Minutes of the Meeting of the Haringey Clinical Commissioning Group Governing Body

Wednesday 1 February 2017 at 1.30pm Cypriot Centre, Earlham Grove

Present:

Dr Peter Christian PC Chair of Haringey CCG, West Lead

Sarah Price SP Chief Officer, Haringey CCG

Dr Gino Amato GA GP Governing Body Member, North East

Dr Jeanelle De Gruchy JDG Director of Public Health, Haringey Council

Dr Dina Dhorajiwala DD GP Governing Body Member, West (from item 4.1)

Catherine Herman CH Lay Member and Vice Chair, Haringey CCG

David Maloney DM Chief Finance Officer, Haringey CCG

Dr David Masters DMa GP Governing Body Member, West

Dr Sheena Patel SPa GP Governing Body Member, Central Lead

Dr John Rohan JR GP Governing Body Member, North East Lead

Sharon Seber SS South East Primary Care Health Professional Member, Haringey CCG

Adam Sharples AS Lay Member, Haringey CCG

Dr Dai Tan DT Salaried/Sessional GP Governing Body Member

Sarah Timms STi Nurse Member, Haringey CCG

In attendance:

Jill Shattock JS Director of Performance, Haringey CCG

Jennie Williams JW Executive Nurse and Director of Quality and Integrated Governance, Haringey CCG

Sharon Grant SG Chair, Heathwatch Haringey (Observer with speaking rights)

Tamara Djuretic TD Consultant in Public Health, Haringey Council (item 3.1)

Steve Beeho SB Head of Integrated Governance, Haringey CCG (minutes)

1. INTRODUCTION Action

1.1 Apologies for Absence

1.1.1 Apologies were received from Simon Caplan, Rachel Lissauer and Lionel Sherman. Dina Dhorajiwala would be joining the meeting in due course. Tamara Djuretic would be joining the meeting to present item 3.1, so this item would be deferred until her arrival.

1.2 Declarations of Interest

1.2.1 The Governing Body NOTED the updated Declarations of Interest.

1.3 Chair’s Introduction and Opening Remarks

1.3.1 The Chair formally welcomed all present to the meeting.

1.4 Minutes of the Previous Meeting

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1.4.1 The Governing Body APPROVED the minutes of the meeting held on 30 November 2016 as an accurate record.

1.5 Matters Arising

1.5.1 The Governing Body noted the information from Susan Otiti regarding the role of midwives at children centres in Newham but it was agreed that it did not fully address the original action. It was agreed that Jeanelle De Gruchy would arrange for more information to be provided about their actual impact, if it was available.

1.5.2 David Masters noted that obtaining clearer referral data for practices, particularly surgical and medical referrals, remains a work in progress. Sarah Price observed that this is affected in part by the restrictions on the data which the CCG can access.

1.5.3 The Governing Body NOTED the action log.

1.5.4 ACTION 1/2-1: To arrange for Susan Otiti to provide further information about the impact in Newham of having a named midwife in children’s centres.

JDG

1.6 Questions From the Public

1.6.1 No questions had been received.

2. Overview Reports

2.1 Chief Officer’s Report

2.1.1 Sarah Price highlighted a number of items in the Chief Officer’s Report.

2.1.2 Helen Pettersen had been appointed as Accountable Officer for Haringey CCG and the other four CCGs in North Central London (NCL). Helen has a wealth of local experience, including helping to set up the Haringey and Islington Integrated Care Organisation when she was at Islington PCT, and a myriad of expertise in delivering challenging roles, including a number of NCL-wide positions. It is hoped that she will take up her new post in April, subject to the completion of the merger between NELCSU and South East CSU.

2.1.3 Alison Blair, currently Chief Officer at Islington CCG, has agreed to also cover the Chief Officer role at Haringey CCG until June 2017. Ahmet Koray, the current Chief Finance Officer at Islington CCG, has similarly agreed to cover the Chief Finance Officer role at Haringey CCG until June 2017. It is hoped that the continuity provided by this arrangement will provide assurance to staff during the transition.

2.1.4 The recently-completed contracting round had been particularly challenging in terms of timescales, meeting expectations and the requirement to agree two year deals, alongside the need for the various parties to develop new ways of working, and she paid tribute to the huge efforts of everybody involved in the process. It was encouraging to see signs of a new culture already beginning to emerge among commissioners and providers.

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2.1.5 Sarah Price commended the key part played by Caroline Rowe and her team in enabling Haringey CCG to become the first CCG to receive ‘Achievement’ level in the London Healthy Workplace Charter which is endorsed by the Mayor of London. She also thanked Haringey Council for the support that they had provided to the CCG in achieving this award.

2.1.6 Sarah Price then paid tribute on behalf of the Governing Body to David Maloney, who would be leaving the CCG at the end of the following week. She said that he should be proud of what he had achieved during his time at the CCG, in particular ensuring that the CCG hit its financial targets four years running, and will this year meet Business Rules for the first time. To underline this, the CCG had had a notably positive financial assurance meeting with NHS England and NHS Improvement the previous week.

2.1.7 Jeanelle De Gruchy noted that Zina Etheridge will be the Acting Chief Executive at Haringey Council until Nick Walkley’s successor has been appointed. This will have internal implications as Jeanelle and Beverley Tarka will be covering some of Zina’s current duties.

2.1.8 The Governing Body NOTED the Chief Officer’s Report, AGREED to DELEGATE decision-making authority to the Remuneration Committee which would be meeting in common with the other NCL CCGs’ Remuneration Committees on 9 February 2017 and AGREED to DELEGATE final approval of the Conflicts of Interest Policy to the Audit Committee.

3. DISCUSSION

3.1 Mental Health and Wellbeing

3.1.1 (This item was taken after item 5.2).

3.1.2 Tamara Djuretic provided an overview of the implementation of the Joint Mental Health and Wellbeing Framework. Significant progress had been made over the past 18 months since its launch, including 30 community groups and 700 individuals signing up for the Mental Health Network, Mental Health First Aid Training being delivered to over 300 people trained in mental health and the establishment of a multi-agency suicide prevention group. Preliminary evaluation suggested that the welfare hubs co-located at GP practices have contributed to a reduction in time spent on GP consultations. The uptake of the Big White Wall service in Haringey has been among the highest in London.

3.1.3 The focus for 2017 will include delivering the devolution pilot on mental health and employment and embedding existing work across the Haringey and Islington Wellbeing Partnership.

3.1.4 The Governing Body then discussed the issues raised by the presentation. Tamara Djuretic acknowledged that Public Health funding for mental health is relatively low compared to the CCG, but it is hoped that the Section 75 agreement between the CCG and Haringey Council will facilitate ‘whole system’ commissioning and be more effective.

3.1.5 Jeanelle De Gruchy noted that Public Health have been working with the CCG and Social Care as part of the transformation work looking at how the wider system can prevent people from requiring acute care and enable them to lead fulfilling lives.

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3.1.6 Sarah Price welcomed the fact that the Governing Body was having this discussion at this juncture. A huge amount of work had gone into developing the framework in Haringey, so it was timely to be looking at the progress which had been made, with a focus on what the CCG wants it to achieve, as well as considering what has not had the desired impact. These issues should all be considered within the wider context of the Sustainability and Transformation Plan (STP).

3.1.7 David Masters suggested that there is scope for improved Crisis Care co-ordination within the STP.

3.1.8 Tamara Djuretic noted that the STP includes a bid for funding for mental health patients with long term conditions and it is hoped that this bid will be successful.

3.1.9 Catherine Herman welcomed the focus on integrated commissioning within the STP, especially with regards to homelessness and unemployment, and she looked forward to receiving feedback on these initiatives going forward. She also welcomed the work on stigma reduction, which is having a positive impact on the level of reporting.

3.1.10 In response to a query from Dina Dhorajiwala, Tamara Djuretic noted that the Section 75 agreement will facilitate the alignment of the system, with agreed outcome measures, such as admissions to mental health trusts. Assigning measures to system changes us more challenging.

3.1.11 Gino Amato welcomed the fact that according to the figures for the various measures in the presentation Haringey generally performs better than other London boroughs and its statistical neighbours but asked if it would be possible to have a breakdown for different parts of the borough.

3.1.12 Tamara Djuretic agreed that Haringey performs fairly well in terms of outcomes compared to other boroughs, with an overall level of “moderate happiness”. People aged over 65, with two or more long term conditions, tend to be the least happy but in general the degree of geographical variation is relatively low and is not necessarily related to the level of deprivation.

3.1.13 Jennie Williams highlighted that a large proportion of NMUH staff live locally and she asked if it would be possible for Public Health to provide support to NMUH via their HR department.

3.1.14 It was agreed that Jennie Williams would raise this issue at the next CQRG meeting.

3.1.15 Sharon Grant highlighted a recent useful workshop developing Haringey Council’s plans for a local area co-ordination model, which included a good deal of social prescribing and queried whether the CCG is involved with this.

3.1.16 Tamara Djuretic confirmed that CCG officers working with primary care and the Better Care Fund have been involved in this. More information would be shared with the Governing Body as part of a future community wellbeing presentation.

3.1.17 Sharon Seber observed that practices had been receiving good clinical feedback around the Big White Wall project but specific feedback from black and minority ethnic (BME) communities would also be helpful.

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3.1.18 Tamara Djuretic confirmed that she would be happy to circulate quarterly Big White Wall reports to the Governing Body but noted that BME communities are under-represented in this intervention. Jeanelle De Gruchy observed that there is a London-wide digital solution that will be looking into specific BME groups and what solutions would work best to access these population groups.

3.1.19 ACTION 1/2-2: To raise the possibility of Public Health providing support to the NMUH HR department at the next CQRG meeting.

JW

3.1.20 ACTION 1/2-3: To circulate quarterly Big White Wall reports to the Governing Body. TD

4. Strategy and Development

4.1 Sustainability and Transformation Plan (STP) and Local Priorities

4.1.1 Sarah Price provided an overview of the paper setting out how the local priorities as identified by the Governing Body align with initiatives identified in the NCL STP. There are already many areas of clear alignment and the work currently underway locally and as part of the Haringey and Islington Wellbeing Partnership put the CCG in a strong position to deliver the aims of the STP. Discussions have taken place at Governing Body seminars regarding what will be delivered locally and there will be further discussions with Islington CCG going forward.

4.1.2 The diagram on page five of the document highlighted the main focus areas, followed by a more detailed breakdown of how the existing projects fit into the key areas of the STP.

4.1.3 Sheena Patel welcomed the summary and suggested that it would be helpful for the document to be shared with the Clinical Cabinet.

4.1.4 Catherine Herman welcomed the clarity of the paper, especially regarding alignment. However, she expressed concern about the A&E figures across the STP patch and sought assurance that there will be a whole system approach to relieve the long-term pressures.

4.1.5 Gino Amato noted the particular focus on Care Closer to Home Integrated Networks (CHINs) but suggested that the document would benefit from more details of the teams who will be making decisions and driving things forward.

4.1.6 Catherine Herman clarified that the thrust of her question had been about the resource will be shifted but she agreed that having the appropriate workforce in place will be key to this.

4.1.7 Adam Sharples also welcomed the paper but commented that the lack of measures of success remain an underlying weakness. He suggested that the CCG should be asking what success would look like in terms of the patient experience and then put annual measures in place to gauge this.

4.1.8 Dina Dhorajiwala agreed with Gino Amato’s comment and said that she would bring this up at the Reference Group.

4.1.9 Peter Christian noted that the main STP document is relatively top-level, so it was extremely useful to have a localised version to share.

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4.1.10 Sharon Grant observed that there had been little patient and public engagement to date and she had written to Peter Christian to express concern about the level of representation for Healthwatch at NCL-level, given their limited resource. Issues of accountability remained a concern and she queried as an example who people would need to contact if they wished to complain about an NCL-level commissioned service.

4.1.11 Jennie Williams confirmed that the current complaints system will remain in place, as the five NCL CCGs will continue to hold this responsibility as the statutory bodies.

4.1.12 Peter Christian highlighted that a large number of Haringey residents work in the healthcare sector, so it is important that workforce engagement continues and people are able to reflect on the potentially large changes envisaged under the STP.

4.1.13 Catherine Herman noted that although the CCG has not held a specific public meeting on the STP, it had been a strand at the CCG’s public meetings. The CCG also holds regular CCG Engagement Network meetings, the membership of which had been extended for discussions on the STP and Well Being Partnership to the wider Voluntary and Community networks coordinated by the Bridge Renewal Trust.

4.1.14 Sharon Grant acknowledged that there had been some discussion of the STP at CCG engagement events but at the time there had been comparatively little information which could be shared and things have clearly moved on since.

4.1.15 Catherine Herman clarified that the most recent of these meetings had been held the previous week. The CCG will continue its engagement on the STP but there had been feedback that, for now, the Engagement Network felt that the information provided was sufficient until more detail on delivery was available.

4.1.16 Sharon Grant encouraged the CCG to continue to plan for more events, given that the changes driven by the STP would soon be starting to affect service users.

4.1.17 Sarah Price highlighted that some STPs, which were published much earlier than the NCL one, contained more specific detail. Responding to Catherine Herman’s query about A&E pressures, she noted that modelling will be required as a prelude to transferring activity from the acute trusts into community services. This will need to be done at a significant scale in order to achieve real savings. Money for investment has been set aside in the STP in areas such as Care Closer to Home to support this.

4.1.18 Jill Shattock commented that there will be a greater focus on CHINs going forward to develop services closer to patients’ home environments. This will need to be worked up in more detail.

4.1.19 Jeanelle De Gruchy noted that there had been a productive STP discussion focusing on sustainability and transformation at the Joint Haringey and Islington Health and Wellbeing Board meeting the previous day. She agreed with Catherine Herman on the importance of ensuring that the STP is communicated in a way that makes sense to people and suggested that a similar approach is needed regarding social care transformation.

4.1.20 David Maloney cautioned that the scale of any change needs to be sufficiently transformational to assuage trusts’ concerns about being potentially left with ‘stranded costs’. A significant amount of the existing costs needs to be taken out of the current NCL system and at present there is a financial gap of £130m, largely in the provider sector.

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4.1.21 Jeanelle De Gruchy said that this underlined why patient engagement and political engagement form a key part of this work.

4.1.22 Peter Christian expressed concern about the continuing growth in activity in primary and secondary care which shows no sign of abating and is imposing a significant pressure on resources.

4.1.23 David Masters observed that the expensive nature of medical advances is also an important factor.

4.1.24 David Maloney concurred that growth in demand only represents part of the financial challenge confronting CCGs. An ageing population and the cost of treatment are also crucial factors.

4.1.25 The Governing Body agreed that the paper should be taken to the Clinical Cabinet as the beginning of a wider discussion with the CCG membership. Consideration would also be given to future engagement. It was agreed that Sarah Price would investigate how engagement has been taken forward in Manchester so that the CCG can build upon this.

4.1.26 Adam Sharples reiterated the importance of ensuring that any changes are meaningful to the population and the results are quantifiable.

4.1.27 Catherine Herman emphasised the importance of the CCG being clear about when it is informing the public and when it is consulting them. She accepted that the layers of communication are challenging and will require careful handling.

4.1.28 Sharon Grant recommended producing generic communication material to explain the changes and encourage people to access services appropriately. Although this might appear expensive it would be a worthwhile investment in the long run.

4.1.29 Peter Christian and Catherine Herman welcomed this suggestion, although it would require further thought, as there was a risk of generic material failing to have an immediate impact, so a range of communication approaches us required for different audiences. Ultimately a more ‘ingrained’ approach is required to address health inequalities.

4.1.30 The Governing Body NOTED the report on the alignment of the Sustainability and Transformation Plan and Haringey CCG Local Priorities.

4.1.31 ACTION 1/2-4: To arrange for the report to be shared with the Clinical Cabinet. RL

4.1.32 ACTION 1/2-5: To investigate how public engagement over the STP has been taken forward previously in Manchester.

SP

5. Business, Quality and Integrated Performance

5.1 Finance Report

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5.1.1 David Maloney introduced the Month 9 Finance Report, which had previously been presented at the Finance and Performance Committee. He highlighted that the CCG is continuing to forecast in-year financial balance for 2016/17, in accordance with its financial plan. As the CCG is not allowed to access 1% of its budget (as mandated by NHS England), if the CCG achieves its financial plan this will represent the first time that it has achieved a financial surplus.

5.1.2 The acute overspend at month 9 is approximately £6.3m year to date and a full year forecast of £8.8m. This is an improvement on the position reported to the Governing Body in November. Good progress has been made with closing down contractual positions with local providers which means that 80% of the CCG’s acute expenditure has now been ‘fixed’ for the remainder of the financial year.

5.1.3 The Governing Body was also asked to note that the CCG’s financial position assumes a net receipt of £1.0m from the 2016/17 NCL Financial Strategy. Work is progressing to agree the Strategy but that the agreement has yet to be finalised. He assured the Governing Body that there is a strong commitment across the NCL CCGs to make this happen.

5.1.4 In response to a query from David Masters, David Maloney explained that the impact of releasing the 1% reserve would be to generate a year-end surplus in the annual accounts, thus enabling the CCG to achieve Business Rules. This surplus would be returned to the CCG in the following financial year which would be the mechanism for the CCG delivering Business Rules in 2017/18 onwards. The CCG is not able to spend this money but its return facilitates the delivery of an annual surplus.

5.1.5 Adam Sharples asked how it was envisaged that things would work next year when the CCG hands over half of its budget to NCL and there is a single Chief Finance Officer working across NCL.

5.1.6 David Maloney confirmed that the future financial governance arrangements are yet to be determined. It was important that the sharing of financial risk and any overspends/underspends is transparent. He hoped that the management of risk could be done at NCL-level, as this will help to minimise some of the difficulties which will need to be resolved.

5.1.7 Sarah Price assured Adam Sharples that any financial decisions made on behalf of Haringey will need to be approved by the Governing Body. The Accountable Officer and Chief Finance Officer would not be able to take decisions above their heads.

5.1.8 John Rohan observed that a bigger challenge going forward would be the possibility of a ‘disconnect’ between the central team and the CCGs, so maintaining a strong dialogue would be particularly important.

5.1.9 David Maloney said that the Governing Body will need to ensure that the Accountable Officer and Chief Finance Officer do not lose sight of local issues which require attention.

5.1.10 Adam Sharples agreed and cautioned that in the past the CCG has relied on Sarah Price and David Maloney to be their advocates, whereas their successors will have different responsibilities and a different relationship with the Governing Body.

5.1.11 Gino Amato suggested that it would be short-sighted for the predicted surplus to be ‘banked’ when there is a pressing need to invest in services.

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5.1.12 The Governing Body NOTED the Finance Report.

5.1.13 John Rohan thanked David Maloney on behalf of the Governing Body for the huge contribution he had made to the CCG as Chief Finance Officer.

5.2 Performance and Quality Summary Report

5.2.1 Jill Shattock observed that acute trusts in NCL had faced significant pressures over Christmas from 20 December 2016 onwards, compounded by incidences of flu. However, NMUH had reported a large cohort of ‘working age’ patients rather than the elderly presenting or being admitted. NMUH had experienced particularly high pressure on capacity over the New Year weekend and as a result it had declared an internal incident and cancelled non-essential activity, as well as postponing elective surgery. An Extraordinary A&E Delivery Board was convened, with regular teleconferences taking place to enable partners to provide support where possible.

5.2.2 Other key parts of the report were highlighted. Concerns remain regarding the performance of the London Ambulance Service (LAS). The NCL Integrated Urgent Care service had now gone live after a smooth transition. Full reporting schedules are currently being developed which will enable reporting of the service at individual Borough level.

5.2.3 NMUH failed to achieve the 6 week diagnostic wait target in October 2016 due to endoscopy performance. The CCG is working with the Trust to turn this around.

5.2.4 The CCG achieved five out of the eight national cancer standards in October 2016. The under-achievements in the 31 Day Subsequent Treatment (Chemotherapy), 62-day GP referral standards and 62-day Screening standards were due to performance challenges at NMUH, Royal Free and UCLH.

5.2.5 Jennie Williams gave assurance that harm reviews of all cancer breaches have been undertaken by NMUH and reviewed by commissioners. The Trust has now agreed to provide a quarterly report to the CQRG on harm reviews where appropriate.

5.2.6 Jennie Williams then provided an overview of the CQC inspection report on NMUH which had been published in December 2016. The overall rating for the Trust was “requires improvement”, particularly in maternity and end of life care. As a result, an enforcement notice had been issued regarding end of life care and the ensuing improvement plan, which had been shared with the CQC and stakeholders in January 2017, will be reviewed by the Clinical Quality Review Group (CQRG) going forward. The CQC also reported “substantial improvements” in the A&E department since their previous unannounced inspection in May 2016.

5.2.7 It was noted that the CQRG reviews the Trust’s weekly dashboard, which covers key performance indicators and has also challenged NMUH regarding consultant capacity and the results of grievance surveys.

5.2.8 Jennie Williams noted that the CCG had fed back to the Trust its concerns about the lack of a maternity board, and following discussions about creating one potentially as a sub-board of the CQRG the Trust had agreed to establish one as an internal board which the CCG will be allowed to join and thereby provide appropriate challenge.

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5.2.9 Sarah Timms cautioned that it will be difficult for the NMUH senior leadership to fully address current concerns until long-term solutions have been put in place. Staff retention remains a significant challenge, with high levels of turnover and a large number of agency nurses. Capacity pressures have also resulted in beds having to be set up temporarily outside wards.

5.2.10 Jennie Williams explained to the Governing Body that NMUH have been asked to provide assurance that the extra pressures on the Trust in terms of bed capacity has not had a significant impact on patient safety. During an assessment visit by Jennie Williams and Sarah Timms, the Director of Nursing had confirmed that she is reviewing incidents and will advise the CCG of the outcome in due course.

5.2.11 Adam Sharples expressed disappointment about the lack of detail in the report about the actions being taken to address performance in Community Services at Whittington Health, bearing in mind the concerns voiced at the previous Governing Body meeting and the issues raised by the internal auditors.

5.2.12 Jill Shattock confirmed that performance notices have been issued to the Trust relating to podiatry, MSK and community gynaecology and the CCG will be seeking improvements in these areas. She also noted that the Trust has now agreed that it will begin to summarise other performance lines. This change will be phased in gradually, starting with most acute services. More detail on nursing issues will be included in the next report.

5.2.13 Adam Sharples then highlighted that there had been a further decline in the performance of LAS since the last GB meeting and he hoped that this would be fully addressed in the presentation which LAS were due to provide at the next GB meeting in March. He noted that LAS are seeking significant ‘uplift’ from commissioners for the next financial year, yet the latest figures showed a deterioration in performance even though there had not been a corresponding increase in activity.

5.2.14 Jill Shattock assured the Governing Body that the decline in performance would be raised by Brent CCG, the lead commissioner. A specific action plan for Haringey is due to be available in mid-February 2017.

5.2.15 John Rohan observed that hand-over delays at Barnet Hospital and NMUH are having a significant knock-on effect across NCL and are also impacting on eastern England.

5.2.16 Jill Shattock agreed with Catherine Herman’s suggestion that it would be helpful to submit questions to LAS in advance of the March meeting to ensure that they can be addressed on the day.

5.2.17 Sarah Price noted that the planned Board to Board meeting with NMUH had had to be rescheduled, as the Trust would like their new Chair to be in post by the time of the meeting. An alternative date is therefore currently awaited from NMUH.

5.2.18 The Governing Body NOTED the Performance and Quality Summary Report.

5.3 Developing the Commissioning Arrangements in North Central London

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5.3.1 Sarah Price introduced the paper which summarised the key points raised at the five NCL Governing Body meetings in November and the steps which are being taken to address these. These had been formulated at a workshop held on December 1 2016 attended by members from all five CCGs’ Governing Bodies. A workplan taking the programme forward to April 2017 was also discussed and it was agreed that a Shadow Forum would meet monthly in January, prior to the Joint Committee convening in April.

5.3.2 As a result of the Governing Bodies’ feedback, it was proposed that the number of independent clinical members of the joint committee from two to three, of whom at least one will be a secondary care clinician and one will be a nurse. This differed from the previous governance paper agreed in November 2016.

5.3.3 Referring to a draft governance paper which had been circulated in December, Adam Sharples asked how it was anticipated that the broader governance structure would develop at NCL level.

5.3.4 Peter Christian confirmed that the newly-appointed Accountable Officer will be accountable to CCG Chairs and individual CCGs will retain their accountability. The Joint Commissioning Committee will have delegated powers, but there is still further work to be done to define its precise role and responsibility. He was optimistic that the appointment of Helen Pettersen will instil stability among the CCGs, while working in shadow form will help to address issues as they arise.

5.3.5 Adam Sharples welcomed this but sought clarification of what is proposed for the next governance level, with specific reference to Governing Body committees, as the CCGs will need to identify quickly what arrangements they want to put in place in order to operate more nimbly. He recommended that a working group should be set up with Islington CCG to explore how the two CCGs adapt to the new world, in terms of working more closely together both jointly and across NCL.

5.3.6 Sarah Price noted that Cathy Gritzner, Chief Officer, Barnet CCG, is currently working on a governance paper which will come to the March Governing Body meetings which will provide greater clarity. However, it would be ambitious to think that this level of detail will have been resolved by then. It was important to recognise that apart from acute services, learning disability contracting associated with Transforming Care, integrated urgent care and specialised services not commissioned by NHS England, the CCGs will retain their existing responsibilities.

5.3.7 Peter Christian observed that the logistics and the governance of the new arrangements will require further thought. Sarah Price said that the fact that there will be a single Accountable Officer and Chief Finance Officer across NCL will enable decisions to be made more quickly and enable the CCGs to streamline their processes where possible.

5.3.8 In response to a query from Adam Sharples, Sarah Price confirmed that Cathy Gritzner is leading on future governance arrangements. Adam Sharples noted that the Audit Committee Chairs had not been consulted about this.

5.3.9 Sarah Price said that it will be imperative to ensure that people are properly engaged, so Audit Committee Chairs will need to take a leading role on how they would like Audit Committees to function going forward.

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5.3.10 Sarah Price then noted that the first meeting of the joint Haringey and Islington Wider Leadership Team (WLT) had been held earlier that week, following on from the Haringey and Islington Board to Board meetings. This had been a productive meeting, with positive feedback as well as constructive challenge. The joint WLT will meet monthly in future.

5.3.11 Catherine Herman suggested that it would be helpful if Cathy Gritzner was invited to attend the next meeting of the Audit Committee Chairs.

5.3.12 Adam Sharples asked, in line with the point he had made at the previous Governing Body meeting, if it would be possible to incorporate into the Terms of Reference of the Joint Commissioning Committee words to the effect that the purpose of the committee is to secure excellent health care with equality of standards and access across North Central London.

5.3.13 It was agreed that Sarah Price would raise this with Cathy Gritzner.

5.3.14 In response to a query from Sharon Grant, Peter Christian confirmed that the level of Healthwatch representation on the Joint Commissioning Committee is still under consideration.

5.3.15 The Governing Body APPROVED an increase in the number of independent clinical members of the joint committee from 2 to 3, of whom at least 1 will be a secondary care clinician and 1 will be a nurse and NOTED how each NCL Governing Body resolved against the 21 proposals, and what next steps and further work is underway in response to these.

5.3.16 ACTION 1/2 - 6: To raise with Cathy Gritzner the potential inclusion of equalities as an objective in the Terms of Reference of the Joint Commissioning Committee.

SP

5.4 Primary Care Co-Commissioning

5.4.1 Sarah Price introduced the update report on Primary Care Co-Commissioning. Since the previous Governing Body meeting the governance documentation required to mobilise the agreed Committee-in-Common approach has been developed and outstanding due diligence questions from the NCL CCGs had been sent to NHS England and resolved. Any further queries raised will be managed as part of the mobilisation process. The NCL CCGs have also been working closely with NHS England to agree an approach to the management of the primary care contracting function and associated staff.

5.4.2 The most significant development since the last meeting was the decision by Camden CCG’s Governing Body, in dialogue with its membership and the local LMC, to submit their expression of interest to move to delegated Level 3 commissioning alongside the other four NCL CCGs. Subject to a membership ballot in Camden CCG in the spring, all five CCGs will move forward together as delegated commissioners. The Governing Body was therefore being asked to approve this change.

5.4.3 The Governing Body APPROVED the recommendation that Haringey, Islington, Barnet, Enfield and Camden CCGs mobilise delegated commissioning, assuming that NHS England (London region) and the NCL CCGs agree to the outcome of the NHS England Organisational Development review of staffing, and the ballot being held by Camden CCG is in favour of a move to Level 3 delegated commissioning. (If the ballot is not in favour the other four CCGs will proceed as previously planned).

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5.5 NHS Operational Planning and Contracting Update

5.5.1 David Maloney provided an overview of the paper which built upon previous updates and discussions at the CCG’s Finance and Performance Committee. He noted that the respective plans had been submitted in accordance with NHS England’s timetable. All main provider contracts had been agreed, which was a testament to Sarah Price’s leadership on behalf of the NCL CCGs.

5.5.2 Section 4 of the paper set out the CCG’s financial position following the conclusion of the contracting round. At present there is a financial gap for 2017/18 in the region of £5.5m. Intensive work is underway both in the CCG and through collaborative work across the STP to close this financial gap.

5.5.3 The 2017/18 Financial Plan will be presented to the Finance and Performance Committee and then the Governing Body for approval in March 2017.

5.5.4 Jill Shattock highlighted that the CCG is re-examining the expected performance trajectories from April 2017 and also seeking additional assurances from UCLH and NMUH that their recovery plans are still on track. Depending on the evidence provided the CCG may consider resubmitting its Operating Plan. She also drew the Governing Body’s attention to the two local Quality Premium indicators which had been chosen: a reduction in the number of Out of Area Placements for mental health and an increase in the proportion of people with Atrial fibrillation who are on an anti-coagulant.

5.5.5 The Governing Body NOTED the NHS Operational Planning and Contracting Update.

5.6 North Central London Integrated Urgent Care Report

5.6.1 Jill Shattock provided an overview of the Integrated Urgent Care (IUC) Report. The service, which was launched on 4 October 2016 combines NHS 111 and GP out-of-hours functions into a single integrated model. To date, activity has been broadly above what was forecast, and call answering in 60 seconds performance has been strong. Performance against this measure has only dipped when the calls coming into the service are significantly greater than forecast .Going forward, performance data will be included in the Performance and Quality Report.

5.6.2 Sheena Patel queried why direct booking from the IUC service into NCL Primary Care Hubs is available in Barnet, Islington, Camden and Enfield but has not yet been rolled out to Haringey.

5.6.3 Jill Shattock clarified that this was due to a technical issue and she would provide more detail about this outside the meeting.

5.6.4 Sheena Patel observed that it would also be helpful to know if bringing together the 111 and Out of Hours services has resulted in higher use of the GP Out of Hours service.

5.6.5 It was agreed that Jill Shattock would confirm the position outside the meeting.

5.6.6 The Governing Body NOTED the Integrated Urgent Care Report.

5.6.7 ACTION 1/2-7: To confirm the cause of the delay in the roll-out of direct booking from the Integrated Urgent Care service into the Primary Care Hub in Haringey.

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5.6.8 ACTION 1/2-8: To confirm the impact that the introduction of the Integrated Urgent Care Service has had on the number of patients accessing the GP Out of Hours service.

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6. Governance

6.1 Strategic Risk Report

6.1.1 Jennie Williams provided an overview of the Strategic Risk Report. She highlighted that Risk 37 had been rephrased as: “There is a risk that the uncertainty around the transition to the new NCL commissioning arrangements could adversely affect key CCG functions” and the inherent and residual risk scores had been increased to 20. A new risk (“There is a risk of failing to deliver a balanced Financial Plan in 2017/18”) had also been added.

6.1.2 The Governing Body NOTED the Strategic Risk Report.

6.2 Investment Committee Report

6.2.1 David Maloney introduced the report on the Investment Committee meeting held on 16 January 2017. He noted that the Committee had endorsed the proposal to procure the GP extended access service, enabling access to GP appointments, for patients registered in Haringey, from 8.00am to 8.00pm seven days per week, and had also approved funding for GMS Practices to provide the management of the planned care service.

6.2.2 Adam Sharples highlighted that the funding for GP access has only been agreed at NCL level and the split has not yet been determined. He cautioned that the CCG will therefore need to ensure that the total expenditure does not exceed the allocation.

6.2.3 The Governing Body NOTED the Investment Committee Report.

6.3 Investment Committee Terms of Reference

6.3.1 The Governing Body APPROVED the Terms of Reference.

6.4 Finance and Performance Committee Terms of Reference

6.4.1 The Governing Body APPROVED the Terms of Reference.

7. For Information

7.1 Governing Body Committee minutes

7.1.1 The Governing Body NOTED the agreed minutes for the Clinical Cabinet meeting held on 3 November 2016, the Finance and Performance Committee meeting held on 24 November 2016 and the Quality Committee meeting held on 2 October 2016.

8. Any Other Business

8.1 The Governing Body thanked Sarah Price and David Maloney for their huge contribution to the CCG.

9. Date of Next Meeting

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9.1 Thursday, 30 March 2017