Derby and Derbyshire CCG Governing Body Meeting in Public
Held on 6th August 2020
CONFIRMED

Present

Dr Avi Bhatia AB Clinical Chair

Dr Bruce Braithwaite BB Secondary Care Consultant

Dr Chris Clayton CC Chief Executive Officer

Dr Ruth Cooper RC Governing Body GP

Jill Dentith JD Lay Member for Governance

Dr Robyn Dewis RD Acting Director of Public Health – Derby City Council

Helen Dillistone HD Executive Director of Corporate Strategy and Delivery

Ian Gibbard IG Lay Member for Audit

Zara Jones ZJ Executive Director of Commissioning Operations

Dr Steven Lloyd SL Medical Director

Simon McCandlish SM Lay Member for Patient and Public Involvement

Andrew Middleton AM Lay Member for Finance

Dr Emma Pizzey EP Governing Body GP

Brigid Stacey BS Chief Nursing Officer

Dr Greg Strachan GS Governing Body GP

Dean Wallace DW Director of Public Health – Derbyshire County Council

Dr Merryl Watkins MW Governing Body GP

Martin Whittle MWh Lay Member for Patient and Public Involvement

Apologies

Dr Penny Blackwell PB Governing Body GP

Richard Chapman RCp Chief Finance Officer

Dr Buk Dhadda BD Governing Body GP

Professor Ian Shaw IS Lay Member for Primary Care Commissioning

In attendance

Niki Bridge NB Deputy Chief Finance Officer

Dawn Litchfield DL Executive Assistant to the Governing Body / Minute Taker

Suzanne Pickering SP Head of Governance

Sean Thornton ST Assistant Director of Communications and Engagement

GBP/2021/021: Welcome, Apologies & Quoracy

Dr Avi Bhatia (AB) welcomed members to the meeting.

Apologies were received as above.

It was confirmed that the meeting was quorate.

GBP/2021/022: Questions from members of the public

AB advised that the following question has been received from a member

of the public and confirmed that the response will be included in the

minutes and provided directly to the individual concerned.

Question 1 – I would like to ask the board to comment on the state of the Medicines Management budget and the risk of over spend to the CCG.

Response – The CCG is operating in a very different financial regime than previous financial years as a result of the COVID-19 pandemic, and prescribing is just one aspect of the overall budget and expenditure. Budget allocations have been set nationally by NHSEI and are currently only known to the end of July 2020. The CCG actively monitors prescribing expenditure and any risks are identified, managed and reported to the Governing Body and NHSEI.

The Governing Body NOTED the question raised

GBP/2021/ 023: Declarations of Interest

AB reminded committee members and visiting delegates of their obligation to declare any interests that they may have on any issues arising at Committee meetings which might conflict with the business of the CCG.

Declarations declared by members of the Governing Body are listed in the CCG’s Register of Interests and included with the meeting papers. The Register is also available either via the Executive Assistant to the Governing Body or the CCG website at the following link: www.derbyandderbyshireccg.nhs.uk.

GBP/2021/032 – Primary Care Commissioning Committee Assurance Report – Dr Ruth Cooper (RC) declared an interest in this item which included an update on the impact on patients following the closure of the Pilsley Branch Surgery. As no decisions were to be made it was agreed that RC would remain in the room for this item.

No further declarations of interest were made and no changes were requested to the Register of Interests.

GBP/2021/024: Chair’s Report

AB provided a written report, a copy of which was circulated with the papers; the report was taken as read and the following points of note were made:

The CCG is now in the Restoration and Recovery phase, progressing towards a ‘new normal’.

The Governing Body is returning to a more formal pattern, with Development Sessions being reinstated following Governing Body meetings from September onwards.

The health and care system in Derbyshire is working jointly to review the impact and learning from the COVID-19 pandemic in its journey towards becoming an Integrated Care System (ICS).

Dr Chris Clayton (CC) continues to undertake membership briefings, with General Practices and will continue to do so in a way which best helps and informs members, modifying the agenda from COVID specific to include a wider spectrum of general practice related items.

The Governing Body NOTED the contents of the report

GBP/2021/025: Chief Executive Officer’s Report

CC provided a written report, a copy of which was circulated with the papers. The following points of note were made:

This would normally be the month when a verbal report was provided however given the current position it was felt necessary for a written report to be presented in order to demonstrate the amount of work being undertaken throughout the Restoration and Recovery phase.

Action: DL

CC wrote to the GP membership to request the stepping down of the weekly membership briefings and implementing monthly ones in their place; feedback was received that this would be a reasonable position. CC will request the input of Governing Body GPs as to how these meetings continue to be relevant to all General Practices.

A letter was received this week from Sir Simon Stevens and Amanda Pritchard on the Phase 3 Recovery Response to COVID-19; a copy of this letter will be circulated to Governing Body members.

The health care system is working through Phase 2 of the recovery and restoration work to restore services, and continues to make good progress, particularly in cancer services.

CC is pleased by the support received from the whole health and social care system in response to the pandemic. He gave particular thanks to Public Health for their input into the System Executive Call.

The Governing Body NOTED the contents of the report

GBP/2021/ 026: Constitution Changes

Helen Dillistone (HD) presented a paper detailing 5 amendments to the CCG’s Constitution for consideration / approval by the Governing Body.

1. Removal of the Turnaround Director (TD) post from the composition of Governing Body – The TD was a member of the Governing Body and a key part of the Senior Leadership Team for the CCG. It was recognised that this post was fixed term and that it was terminated at the end of July. It is now necessary to amend the Constitution to reflect this – Agreed.

2. To return to formal Governing Body quoracy as per section 3.6, Appendix 3 of the Constitution to include:

Clinical Chair or Vice Chair (PPI Lay Member);

1 x CCG Officer (Accountable Officer, or Chief Finance Officer or Chief Nurse Officer);

2 x Lay Members;

4 x Voting Clinicians (to include GP Members and or Secondary Care Clinician).

Jill Dentith (JD) requested confirmation that it was previously agreed that quoracy would be 8 Governing Body members in attendance at meetings, with Dr Bhatia not being included in the 4 voting clinicians; HD confirmed that this was the case.

JD also enquired whether, if there became a need for the CCG to return to increased escalation levels, a proviso should be added to allow the CCG to do so without obtaining further Governing Body

approval. HD considered that if this scenario were to arise, Governing Body oversight would be required; however there is provision within the CCG’s Constitution, under extraordinary powers for escalation through the different Business Continuity Levels, if it is not possible to obtain Governing Body approval within the required timescales; this may be implemented by the CEO and Lay Members, and presented to the Governing Body retrospectively for decision making.

CC requested that further thought be given to consideration of the Executive Director (ED) element of the voting membership now that the TD post has been removed from the permanent CCG establishment. There are currently 2 ED’s that are not Governing Body voting members (Helen Dillistone (HD) and Zara Jones (ZJ)) and CC would like to ask the Governing Body to consider making them both voting members in line with new quoracy arrangements. It was requested that a paper be brought back to the next meeting on this matter for further consideration, bearing in mind the professional portfolio conflicts of interest that will arise for each of these EDs; it is important to note that these are not personal conflicts of interest.

Dr Greg Strachan (GS) enquired what regimes other CCGs have implemented regarding voting EDs on Governing Bodies. HD confirmed that there is a mixture of Executive and Non-Executive members having voting rights for all CCGs. GS also stated that careful consideration would be required of any professional portfolio conflicts of interest as and when they arise on the agenda.

1. To return to the formal Audit Committee membership of 3 Lay Members – Agreed.

2. From 1st August 2020, the permanent governance arrangements in respect of invoice approval will be reinstituted – Agreed.

3. From 1st August 2020, all temporary approval limits for members of the finance team that were agreed by the Finance Committee will be removed and the original approval limits will be restored – Agreed.

The Governing Body APPROVED the following changes to the CCG’s Constitution:

Removal of the Turnaround Director post from the composition of Governing Body.

To return to the formal Audit Committee membership of 3 Lay Members.

From 1st August 2020, the permanent governance arrangements in respect of invoice approval will be reinstituted.

From 1st August 2020, all temporary approval limits for members of the finance team that were agreed by the Finance Committee will be removed and the original approval limits will be restored.

Further consideration is to be given to returning to the formal Governing Body quoracy in the Constitution. Thought to be given to

providing the Executive Director of Commissioning and the Executive Director of Corporate Strategy and Delivery with voting membership of the Governing Body; however there is a need to ensure that the Executive voting membership does not exceed clinical and Non-Executive voting membership. It was agreed that a paper would be presented to the September meeting for further consideration.

Action: HD

GBP/2021/ 027: COVID-19 Outbreak – Management and Lessons Learnt

Dr Robyn Dewis (RD) and Dean Wallace (DW) gave a presentation on COVID-19 outbreak management and the lessons learnt, a copy of which will be circulated post meeting for information. The following points of note were made:

Concern was expressed that some people are not able to read in their own language and are therefore not receiving the COVID-19 stay safe messages. It was enquired how messages are being communicated to this cohort of people. RD confirmed that various methods are being used including the close relationship with the Iman at the local mosque. The Friday before Eid the Iman read out relevant information in order to catch a large cohort of people. Social media has been used to reach the Eastern European element of the local population who actively use online applications. A conscious effort has also been made to contact the deaf signing community to include them in all communications. DW confirmed that the CCG’s communications team has been involved in covering all cultural and language aspects, both written and verbal.

Work has been undertaken with employers across the county in order

to be proactive and create links.

It was asked if the messages being given are being believed. The experience with the Muslim community in particular was that, in the early stage of the pandemic, they were incredibly impacted and suffered a significant number of deaths; they are therefore very open to hearing the messages being given and take action.

Andrew Middleton (AM) enquired if the learning from the previous few months will help with any sudden surges or increase in cases. It was confirmed that the system is in a better position now, having better, more timely data available. One-off funding has been built in to Public Health budgets this year; Public Health are still in response mode and this funding will be used to continue to build systems and networks going forward.

Dr Merryl Watkins (MW) asked what the CCG could change to improve the health and wellbeing of those families living together in close proximity, some of whom are key workers, some are on zero hours contracts and do not receive sick pay and do not feel they can be absent from work as they will not be paid. Although these problems are well identified there is little information on what action is being taken to tackle them. RD agreed that the health inequalities have been made stark; DW and RD plan to keep on with this message nationally. They both link into weekly Public Health England meetings where issues are shared and pushed forward nationally, as there is only so much that can be done locally.

Dr Emma Pizzey (EP) asked if there is a reluctance to engage with the

Test and Trace programme due to the knock on effects of not being able to work and shop if self-isolating, or if the issue of not hitting the

targets relates to the system itself. RD considered the issues to be due to the Test and Trace system itself, which ideally should have been established locally in order to develop local responses.

Action: RD

CC noted that, as a system, real learning has been achieved from this pandemic on how to approach a public health emergency. A lot has been learnt about connectivity into multiple communities via Public Health inroads. The connectivity between health and social care systems is important and helpful in terms of relationships and working with data out with the formal route. The health and housing issues have been known for some time; the Governing Body have previously held sessions on health inequalities, however these inequalities have been further exposed by COVID-19. Further thought is to be given to understanding the issues by working together as a system in order to influence the wider determinants of health.

Dr Ruth Cooper (RC) considered that, in relation to the health and housing aspect, the situation has worsened with the increase in private rental; this has created many individuals having no powers to change their situations.

Learning from other regions has helped identify high risk employers in Derbyshire; closer working has been established with these organisations by Environmental Health Teams across both the City and County. RC requested that this information be shared with General Practices.

Ian Gibbard (IG) requested sight of the plans implemented to deal with local outbreaks, particularly in view of the imminent opening of schools in September. RD advised that every new area opening up increases the number of potential contacts and transmissions; schools have done a lot of work to minimise any potential transmission risks. Many schools are now academies, of which the Local Authorities has no oversight. Parents congregating outside of schools, car sharing, children playing together outside schools and people going back to work will also increase transmission. There is evidence that younger children transmit to each other but not to adults in the school setting.

The Governing Body RECEIVED and NOTED this presentation.

GBP/2021/ 028: Finance Report – Month 3

Niki Bridge (NB) presented the Month 3 Finance Report. The following points of note were made:

The CCG has been working under a temporary financial regime from 1st April to 31st July 2020.

The year to date overspend is £12.432m, as at Month 3. The forecast year-end overspend as at the end of July 2020 is £20.477m.

Some requested amendments have been received to help bring to the CCG to a breakeven position.

Scenario modelling has been undertaken for the full financial year based on 7 and 12 months respectively, details of which were provided for information. Scenario 1 is for block contract arrangements to remain in place until 31st October 2020 and Scenario 2 is for block contract arrangements to remain in place until 31st March 2021.

Not all contracts are covered by block arrangements and therefore

there are still some risks to the CCG of overspends in certain areas. Work is being undertaken to mitigate any risks to the CCG – further guidance is expected shortly.

There remains, as yet, no robust intelligence as to the likely final revenue resource limit for the full financial year.

Some expected allocations are still outstanding, including co-commissioning GP contract monies, the Free Nursing Care money uplift and money for investment into the mental health services; if received, these would bring the forecast outturn deficit to £3.7m year to date and £4.8m as at Month 4.

Post-anticipated allocation corrections have been flagged up around running costs and non-recurrent programme QIPP in the baseline. If refunded, this would bring the deficit to £0.497m at Month 3 and a forecast year-end overspend of £0.559m.

An allocation of £9.046m was received in Month 3 to cover the identified COVID-19 costs which were incurred necessarily and exclusively for the purpose of servicing the emergency.

Under the current financial regime it will be ensured that the CCG will receive support to breakeven.

Dr Bruce Brathwaite (BB) queried why the overspend for care services is so high when activity has reduced during the pandemic; he asked why expenditure has exceeded budget. Dr Steve Lloyd (SL) confirmed that the Primary Care budget contains a prescribing overspend of £5m, £1.5m of which relates to March 2020, for which the CCG has now been reimbursed. A 5% growth in prescribing for Category M drugs was expected however a 10% growth has actually materialised. COVID-19 has also had an impact on the delivery of savings programmes which are currently under-achieving. There is a block contract in place for prescribing within the Acute hospital setting therefore no overspend has been demonstrated in that area. An overspend has however been seen for Sertraline.

GS enquired if the costs relating to the increased prescribing of Sertraline could be moderated through the use of an alternative first line antidepressant. SL advised that part of the problem is that prescribing data is only available up to May 2020. It is therefore difficult to implement rapid changes; however the situation is being continually monitored.

IG raised a concern in relation to the CCG’s governance structure in that the CCG is currently operating with no budget beyond Month 4. He requested that the Governing Body provides some direction for the Executives to follow in terms of operating within budget for this financial year based on forecast outturn, pending clarification. NB confirmed that guidance was provided in the Phase 3 letter received this week. Confirmation was given for Months 5 and 6, and a high level outline for Months 6 to 12 is being developed. There is a move towards a system control total, with the CCG managing budget allocations, and block contracts implemented to provide certainty for the NHS. There are expectations that activity will start to resume, with top ups given to Providers, and a non-recurrent COVID budget implemented which will not be retrospective. NB advised that discussions were held at the Senior Leadership Team meeting yesterday and weekly strategy meetings are also being held on how to achieve a system control total.

MWh raised a concern that, although block contracts improve position, the

problems do not go away – they are just moved to other parts of the system; there is a need to reflect on this. NB advised that there is work to be done underneath the block contracts, linked to recovery, in order to better understand demand and capacity. The block contracts were flexed on anticipation of restoring activity and building upon them for the next financial year. There is no information as yet available for March 2021 onwards. If the situation continues there will be a need to know how to set the blocks and also to understand where non-recurrent monies sit within Trusts.

The Governing Body NOTED the following:

There is a temporary financial regime in place for the period 1st April to 31st July 2020

At Month 3 the year to date overspend is £12.431m

The forecast position for the 4 months of April to July 2020 is an overspend of £20.477m

Some expected amendments to the allocations have now been received

Scenario models have been produced for the full year position based on a 7 month and 12 month block scenarios

GBP/2021/ 029: Engagement Committee Assurance Report

Martin Whittle (MWh) presented the Engagement Committee Assurance Report. The following points of note were made:

The Engagement Committee is now a joint Joined Up Care Derbyshire

/ DDCCG Committee with a combined agenda.

A University Hospital of Derby and Burton Foundation Trust Governor is now included within the Committee’s membership to match representation from other local Trusts.

The COVID-19 Communications and Engagement Strategy sets out a proposal for a ‘system’ approach to consultation and engagement during the restoration and recovery period. An audit of all changes to services will be undertaken with a view to establishing where engagement is required; this will include ensuring equitable access to engagement opportunities.

A system-wide Insight Group has been convened to collect, collate and share insight activity across partner organisations, and to agree priorities for additional work to support decision making. The strategy had been agreed by the System Escalation Call and investment has been secured to commence a broad piece of research to understand population health behaviours and preferences during the pandemic; the survey will commence during July 2020.

The Governing Body NOTED the contents of this report for assurance purposes, including the assurances given on progress made with the Restoration and Recovery activity

GBP/2021/: Finance Committee Assurance Report

30:

Andrew Middleton (AM) provided a verbal update following the Finance

Committee meeting held on 30th July 2020. The following points of note

were made:

AM thanked NB for the comprehensive financial report provided.

What will be will be this year. Even though the Governing Body has been provided with high level assurances, this year is still an abnormal scenario. The key is to undertake the ground work in preparation for next year.

Assurance was provided that the Quality and Performance Committee and the Finance Committee are both capturing the beneficial gains made during the pandemic in order to ensure that they are not lost.

Notwithstanding the breakeven position promised, the system went into this year with an underlying efficiency challenge of >£100m.

The System Finance Oversight Group will reconvene on 4th September.

100% of suppliers continue to be paid within the required timescale.

The Governing Body NOTED the contents of this update for assurance purposes

GBP/2021/ 031: Governance Committee Assurance Report

Jill Dentith (JD) provided an update on the discussions undertaken at the

Governance Committee meeting held on 9th July 2020. The following policies and reports were noted and approved:

The Policy Management Framework

The Managing Conflicts of Interest Policy

The Gifts and Hospitality Policy

The Procurement Policy

The Cyber Operational Readiness Support (CORS) Audit and Action Plan was noted.

It was good to note that Freedom Of information requests were compliant with the response deadlines and met during the pandemic.

An Information Governance Control of Patient Information (COPI) notice was issued to support health and care organisations in sharing data where this would benefit system management, and a combined response. The COPI notice is authorised until the end of September 2020, however this may be rescinded prior to this time, or extended beyond this time, dependent upon the continuation of the COVID-19 response.

The Committee received assurances on the CCG’s health and safety regarding working arrangements during the pandemic at home, in the office and within clinical settings.

The Governing Body NOTED the contents of this report for assurance purposes

GBP/2021/ 032: Primary Care Commissioning Committee Assurance Report

RC raised a conflict of interest in relation to the update on the Pilsley Branch Surgery closure update.

Dr Steve Lloyd (SL) provided an update on the discussions held at the Primary Care Commissioning Committee meeting held on 22nd July 2020. The following points of note were made:

No decisions were made at the July meeting.

A quarterly assurance report was received relating to the closure of the Pilsley branch surgery of Staffa Health, which was approved by the Committee in February. One of the mitigating actions was for the Committee to be assured of patient access to primary care services. A request was made for the next report to include details of how the practice plans to feedback and engage with patients on the changes made to access primary care services as part of the COVID-19 response and whether video conferencing/telephone triage has mitigated some of the original concerns made by patients.

JD was impressed with the information provided by Staffa Health; it has undertaken a lot of work which will be helpful to both the practice and patients in the longer term.

The Governing Body NOTED the contents of this report for assurance purposes

GBP/2021/ 033: Quality and Performance Committee Assurance Report

Brigid Stacey (BS) provided an update on the discussions held at the Quality and Performance Committee meeting held on 30th July 2020. The following points of note were made:

Cancer / 2 Week Waits – A system plan has been produced to help reduce delays across pathways; this is due out in mid-August and will be presented to the Committee in September.

Safeguarding adults and children – The Committee considered that it has received significant assurance in relation to all safeguarding issues throughout the pandemic, with business as usual being maintained throughout

Continuing Health Care – An update on the restoration was received and welcomed, as was the proactive approach taken.

EMAS – All performance targets were achieved for the first time in a long period.

Terms of Reference – These were amended, agreed and adopted by the Committee. The agenda has been signed off for 3 months in order to ensure consideration of the priorities identified by the Task and Finish Group for Restoration and Recovery. The updated Terms of Reference will be presented to the Governing Body in due course.

AM stated that activity levels in A&E are now nearly normal pre-COVID and asked if patients are still not aware of alternative places for treatment. BS advised that there is more activity now that different parts of the economy are opening up and getting back to normal. Work is ongoing to publicise the right places to access emergency health care.

JD raised a question in relation to the achievement of the cancer 62 day screening standard which appears to have reduced. ZJ confirmed that the national screening programmes have now restarted. The targets were at a low point due to a pause in screening during COVID. This mirrors all aspects of cancer performance and referrals, and the diagnostics position is also reduced, although an upturn in performance is now being seen.

This is being closely monitored, as are recovery plans.

The Governing Body NOTED the key performance and quality highlights and the actions taken to mitigate the risks

GBP/2021/ 034: Draft Governing Body Assurance Framework – Quarter 1 – 2020/21

HD advised that the Governing Body Assurance Framework (GBAF) provides a structure and process that enables the organisation to focus on any strategic/principal risks that might compromise the CCG in achieving its strategic objectives. It also maps out both the key controls in place to manage the objectives and associated strategic risks, and helps to provide the Governing Body with sufficient assurance on the effectiveness of the controls.

HD presented the first draft of the 2020/21 GBAF which identifies seven strategic risks to the achievement of the CCG’s strategic objectives. Further to the discussions held at the last Governing Body meeting, additional work has been undertaken to identify the opening position for 2020/21; this will be further developed through the CCG’s Corporate Committees in order to finalise the Quarter 1 GBAF for presentation at the September meeting.

JD enquired if the initial ratings for the 2020/21 GBAF had been rolled over from 2019/20; HD confirmed that the ratings used were based on last year’s closing position however this position will be subject to review by the Corporate Committees.

The Governing Body DISCUSSED the draft GBAF for 2020/21. It AGREED that the Corporate Risks will be assessed by the Corporate Committees during August and a final version of the GBAF presented to the Governing Body in September for approval

GBP/2021/ 035: Corporate and COVID-19 Risk Register Integration Update Report

HD presented this paper which describes the process used to develop and amalgamate the Corporate and COVID-19 Risk Registers in order to provide an Integrated Risk Report to be worked through by the CCG’s Corporate Committees. Work is being undertaken by the CCG’s Functional Directors, overseen by the Executive Directors, in preparation for presentation to the Governing Body in September.

The Governing Body NOTED this report on the amalgamation process of the COVID-19 and CCG operational Risk Register

GBP/2021/ 036: Ratified Minutes of DDCCG’s Corporate Committees:

Engagement Committee – 17th June 2020

Governance Committee – 12th March 2020

Primary Care Commissioning Committee – 24th June 2020

Quality and Performance Committee – 25th June 2020

The Governing Body RECEIVED and NOTED these minutes

GBP/2021/ 037: Minutes of the Governing Body meeting held on 2nd July 2020

The minutes of the above meeting were agreed as a true and accurate record.

GBP/2021/ 038: Matters Arising / Action Log

The action log will be updated and amended accordingly.

GBP/2021/ 039: Forward Planner

Governing Body Development sessions are to be re-implemented from September onwards.

Winter Planning discussions to be scheduled into the agenda.

GBP/2021/ 040: Any Other Business

Action: ZJ

NHS Rehabilitation Centre – Public Consultation Launch –Nottingham and Nottinghamshire CCG are leading on a consultation, on behalf of all East Midlands CCGs, for the development of a new rehabilitation centre for NHS patients in the East Midlands. It is consulting on whether or not to take forward this opportunity, including the proposed transfer of existing services to the new facility. The funding and land is only available to develop an NHS Rehabilitation Centre (NHSRC) at the Stanford Hall Rehabilitation Estate, therefore this is a single option consultation. The Centre will be purpose built for rehabilitation and will provide an enhanced service for patients, with access to state-of-the-art facilities, enabling a centre of excellence to be created.

The intention is to develop a CCG response to the consultation, which runs from 27th July to 18th September 2020, at the Clinical and Lay Commissioning Group (CLCC); the CLCC will feedback to the Governing Body accordingly. AM enquired if an analysis will be undertaken to ascertain the impact on existing facilities as a result of this new facility. ZJ confirmed that an impact analysis would be undertaken.