Governing body meeting - 7 April, 2022

GBP/2223/001: Welcome, Apologies & Quoracy

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

Apologies were noted as above.

It was confirmed that the meeting was quorate

GBP/2223/002: Questions received from members of the public

No questions were received from members of the public.

GBP/2223/003: 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

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

GBP/2223/004: Chair’s Report – March 2022

AB presented a report, a copy of which was circulated with the meeting papers; the report was taken as read and no questions were raised.

The Governing Body NOTED the content of the report provided

GBP/2223/005: Chief Executive Officer’s Report – March 2022

Dr Chris Clayton’s (CC) presented a report, a copy of which was circulated with the meeting papers. The report was taken as read and the following points of note were made:

• The Derbyshire Health Care System continues to remain challenged; the strong System partnership meets on a regular basis to work through resolving these challenges.
• CC welcomed the new ICB Non-Executive Members to observe the Governing Body; during the first quarter of this financial year this will form an active part of the transition in preparation for the ICB taking over the CCG’s statutory duties on 1st July.
• CC recently spent time with the High Peak Place Alliance Group, which now includes Glossop. The changes which will occur in terms of the integration of Glossop Dale Primary Care Network (PCN) into the High Peak Place Alliance are being worked through positively and constructively; CC is looking forward to seeing where these conversations go.
• A focus on Population Health Management was recently launched; this will help planners and frontline teams across the System understand current health and care needs and help to predict the future needs of the local population. This data will provide a better understanding of what long-term challenges need to be addressed; the outputs will be presented to the Governing Body in due course.
• Section 2 provided details of the meetings attended by CC on behalf of the Governing Body and the Derbyshire System.
• Section 3 provided information of national developments, research and reports. CC highlighted the commencement of the Spring booster COVID vaccinations, including the vaccination of 5–11-year-olds.
• Section 4 provided information on local developments including the important work being undertaken by Joined Up Care Derbyshire (JUCD) to understand the different roles that General Practices undertake. A national piece of work is also underway on the future roles of PCNs. There are ongoing campaigns to encourage the appropriate use of NHS111 and Urgent Treatment Centres.

The following questions were raised:

• It was stated in the report that ‘Population Health Management will help tailor care more effectively’ which is something discussed previously by the Governing Body. It was enquired how this might result in the reconfiguration of how care is delivered. CC responded that this is an important philosophy and signals that Population Health Management, looking at the true cause of presentations into the NHS, now needs to be the fundamental mainstream of the business. Population Health Management is not an add on to the urgent care pathway, it needs to become a fundamental part of its management. Understanding why people choose different ways of presentation is fundamental to tackling the urgent care challenges. A strategic shift is required to see this as an integral part of the System. The NHS and Care System is used to managing what is happening at that particular moment, however there is also a need to manage upstream as part of the plan. The strategic intent approach is currently being formulated; before the end of the CCG and the start of the ICB, the outputs will be available in the form of commissioning intensions.
• In March PCNs received a ‘tackling neighbourhood health inequalities PCN plan’ form to complete. Each PCN was requested to identify the population within its PCN experiencing inequality in health provision. It was considered that there is more work to do to join this up at a strategic level, as the Public Health Directors were unaware of this ask. CC agreed that there is more work to do on the integration of ideas and operationalising them through a joint strategic intent approach, inclusive of both health and social care. 

There is a need for senior leadership to think about how to connect and integrate. It was commented that this could have been a Place ask, enabling the PCN to work within their Place Alliance to ensure connectivity, bringing in Public Health support. CC stated that the boundary between PCNs and Place is important and will be different in different areas based on how they are configured. The national asks of PCNs going forward will require consideration as to whether they sit with PCNs or Places. PCN asks may come through the General Practice contractual route, which is the mechanism for investment and spend i.e., enhanced services. Dr Steve Lloyd (SL) agreed to discuss the matter offline to understand whether the request has come from Region as part of the core plus work.

The Governing Body NOTED the content of the report provided

GBP/2223/006: Joined-Up Care Derbyshire ICS Green Plan

Chrissy Tucker (CT) presented the Derbyshire ICS Green Plan for approval; significant work has been undertaken over the past few months to compile this System wide plan. In 2020, the NHS launched the campaign “For a Greener NHS ” and an Expert Panel set out a practical, evidence-based and quantified path to a ‘Net Zero’ NHS.

The ICS was requested to develop a regional level approach to sustainability; a Derbyshire ICS Greener NHS Delivery Group has been formed, chaired by Helen Dillistone, allowing organisations to work together, with support from an external consultancy, to develop the Plan. A clear brief was provided that the Plan should have Derbyshire System oversight and accountably for achieving the carbon reduction targets against the NHS carbon footprint and facilitate the monitoring of progress against expected trajectories. All partner organisations are represented on the Delivery Group, with workstream leads allocated to each initiative. A workshop was held in December to look at individual organisational Green Plans and define a Derbyshire-wide Plan which supports the ICS objectives on health improvement, patient care, addressing health inequalities, green space and building a resilient health care System for the future. The plan outlined the priorities for the next 3 years.

Regional level carbon footprint data is included in the plan, as is an overall commitment to sustainability. The 11 required interventions were described in detail, the delivery of which will be coordinated through the Derbyshire ICS Greener Delivery Group. There are 5 key actions to be prioritised in 2022/23 to obtain ‘quick wins’, some of which may require Business Cases; any investment / resource requirements will go through the appropriate governance and approval processes in due course. Funding may be available nationally however there is no confirmation of this as yet.

The following questions were raised:

• It was noted that the building industry is a large carbon emitter; therefore, stopping building will reduce carbon emissions. Maximising the use of existing estate, by repurposing will prevent the need for capital investment. The change of working practices seen during lockdown, using Microsoft Teams instead of travelling, with no productivity loss, saved 90% of vehicle carbon emissions and 50% of building emissions; it was queried what the flexible workforce strategy will be going forward. It was also suggested that Microsoft Teams be set as the default position for meetings and face to face meetings only be held when absolutely necessary. It was also queried how much more clinical practice could be undertaken remotely. Between 2019-20 it was noted that the NHS reduced its emissions by 62%, it would be interesting to know how this was achieved. CT responded that the silver lining of COVID has been sustainability through the reduction in travel and building use. A hybrid working model has now been agreed whereby, COVID permitting, staff will be able to work in the office should they wish to do so; as many staff enjoy working from home and prefer to continue to do so, the existing office space may be reduced. This will be monitored to understand how it affects the sustainability plan. Regarding estates, there are difficulties around acceptable building temperatures and how to address this in a sustainable way. COVID has given General Practices confidence in undertaking more digital practice. AB added that it is best practice that, should there be any clinical concerns, patients be seen in person as soon as practically possible.
• The actual mechanism to ensure that the actions are embedded sustainability throughout the ICS needs to be better defined. Following a recent green audit, it was suggested that all printers be set to double-sided printing by default; this could be actioned at a System level in order to save costs. CT agreed to pick this up as part of the plan.
• It was suggested that all food waste should be disposed of appropriately to prevent it going into land fill, as currently happens in some cases. It was enquired whether District Councils are linked into the plan for the overseeing of waste management. Suzanne Pickering (SP) confirmed that there are direct links with all partners and this issue will be picked up. Some of the individual workstreams will be considering the setting up of specific pilots across the different areas. The Governing Body APPROVED the Joined-Up Care Derbyshire ICS Green Plan

The Governing Body APPROVED the Joined-Up Care Derbyshire ICS Green Plan

GBP/2223/007: 2022-23 Operational Plan – Draft Submission

Zara Jones (ZJ) presented the draft 2022-23 Operational Plan, advising that a tremendous amount of positive work has been undertaken across the System to manager a challenging operational picture; the work of the teams to collectively keep patients safe, deliver high quality care wherever possible and grapple with the current ‘wicked’ issues in the System, was acknowledged. A draft version of the Plan has already been submitted to the Regional NHSE; as part of the governance process, assurance checks have been undertaken across System groups and Delivery Boards, as well as within the CCG, ahead of the final submission on 28th April 2022. The following key areas were highlighted:

• Elective position – The Governing Body has been well sighted on the issues around the waiting list position, particularly around the long waiters and the cancer targets. In terms of restoring elective activity to pre-pandemic levels (2019/20), the Plan submitted to NHSE was not at the required level to meet the national requirements against the 104% target. Since the submission was made, work has been undertaken with the responsible Lead Officers for the elective positions to bridge the gap. Assurance was provided that the position has improved since last month. Additional theatre productivity and waiting list initiatives are being considered to ascertain how to bridge the gap further whilst being mindful of the things that are restricting the ability to deliver the required activity, including COVID which is still prevalent. This is a moving picture however good progress is being made.
• Long waiting times – The 104-week wait is a key target to eliminate as soon as possible. There is a positive position in relation to the milestones set against the trajectory, for both UHDBFT and CRHFT. The interrelationship between emergency and elective care is a fragile position in terms of bed availability; the teams will work hard to reach the next milestone to eliminate the long waiters by the end of June. There is a robust trajectory to do this which will be demonstrated in the final plan.
• Cancer – This is now showing a more positive position, due to the consistent approach undertaken to clinical prioritisation. The waiting list will be held at the February 2020 position, in line with the national requirement.
• Diagnostics – The constraints around the workforce, due to COVID, have had an impact on the ability to meet key diagnostic targets. More work is to be done to try to pin down what the position is, as additional capacity will be available; diagnostic hubs are to be set up to help recover the position. If the diagnostic position does not improve it will have an impact on the wider pathway.
• Urgent and Emergency Care – Important targets include the elimination of 12-hour trolley breaches and ambulance handover delays in ED units which are having a knock-on impact of crews not being freed up to respond to urgent calls; there is concern about this national position. Derbyshire is the coordinating commissioner for EMAS and has responsibility for managing the difficult regional position across the East Midlands. The ambition is to reduce the breaches and return to the target level response times to treat patients quickly and safely. It will not be possible to eliminate these issues rapidly. Further work is being undertaken to target the actions that will have the biggest impact. Strategic conversations are being held with Local Authorities around complex discharges to free up acute bed capacity. Should the beds not be freed up, this will impact on the elective position.
• Mental Health, Learning Disabilities and Autism – A phenomenal amount of work has been undertaken through the Mental Health Delivery Board to perform well against the targets set. Trajectories have already been agreed for Transforming Care with NHSE. There is ongoing work around perinatal and employment support for people with mental health conditions in order to increase activity numbers and meet the higher level of need caused by the pandemic. The dementia diagnosis target and improving dementia diagnoses are also important targets. It needs to be ensured that the Learning Disabilities annual health checks are undertaken, and the data captured.
• Workforce – This is a driving risk. There is a System level plan to support existing staff and grow our own workforce in order to transform and deliver integrated care. Whilst at a System level there are good plans and engagement in place, there is a need to be mindful of the risks. The COVID position is being monitored to ascertain the impact and pressures on the workforce.
• Finance – There is a link between the financial position and the elective position. The System could receive additional funding, through the Elective Recovery Fund, if it meets the set targets; there is a need to triangulate the finances, workforce and operational delivery to drive elective activity and deliver more income into the System.

This is a robust System plan, with further work to be undertaken to target the actions and mitigate the risks before final submission on 28th April 2022. A copy of the final plan will be presented the Governing Body in May. A meeting was held with the Regional NHSEI Team yesterday to receive feedback on the draft Plan. Derbyshire’s Plan was thought to be positive. The health inequalities work was held up as being one of the strongest draft submissions received to date. Although there is more work to do, this is a strong position to be in. Derbyshire is not at the highest level of escalation; it has been placed in the middle tier, which is testament to the amount of work being undertaken.

The following questions were raised:

• This is an impressively comprehensive and frank Plan, which does not understate the challenges. It is as good a Plan as can be produced given the current circumstances.
• When these aspirations are viewed through the workforce lens it is hard not to be depressed, with colleagues in their 50s leaving the NHS as they have had enough. A recent article advised that when workforce is discussed the focus is predominantly on recruitment, and far less is done about retention; a report has been produced on the many ways to improve retention. Assurance was requested that the workforce strategy group is focusing on the workforce to underpin this Operational Plan, with retention being the route to providing solutions. The breast oncology 2 week wait 15% achievement against a 93% target is also worrying. ZJ responded that the breast pathway is very concerning, and that the Planned Care Delivery Board has implemented actions to improve the position. The workforce risk is also huge. Retention is a key part of the Plan. It was suggested that a further update on the workforce position be presented to the Governing Body / ICB Board in due course, as it is intrinsic to the broader delivery plans.
• The gaps in compliance were noted; this Plan provides a genuine assessment of what can be achieved. The principal driver of the elective backlog is the workload plan and whether it can be achieved. As a System, one of the critical elements is Local Authority partners; assurance was requested that the workload plan in LAs reinforces the ability to create bed spaces in order to handle the backlog. ZJ advised that complex discharges are having an impact on the elective position; however, teams are working hard to deliver as much elective activity as possible. The System Operational Resilience Group, which includes Local Authority representation, is targeting actions to create capacity to care for patients in the community and free up acute beds for elective and emergency care. These problems have been around for some time now but have recently been exacerbated. This is being dealt with at the highest level to help produce strategic solutions.
• Brigid Stacey (BS) provided assurance that the workforce is being addressed both nationally and locally, however the measures will take a while to come to fruition. It is recognised that nursing, midwifery and AHP professionals can retire at 55; this is currently the biggest risk. During the pandemic the pension regulations were relaxed to allow people to return after retirement on a full-time basis, as opposed to part time only; this was due to finish at the end of March, however following a national consultation this has been extended to the end of October. A lot was learnt about the local workforce over the winter; having a more mobile health care assistant population to move into social care would enable flow to be better supported. BS is working with Amanda Rawlings, the ICB’s Chief People Officer, to put something in place and to enable the System’s Chief Nurses to work closer with HR Directors.

The Governing Body NOTED the draft Operational Plan submitted to NHSEI in March and NOTED the current gaps in compliance with NHSEI targets and further work required before the final submission

GBP/2223/008: Finance Report – Month 11

Richard Chapman (RC) provided an update on the financial position as at Month 11 (H2) of 2021/22. The following points of note were made:

• All targets were met at M11 with a year-to-date surplus of £142k.
• A further £1.6m COVID reimbursement is expected, plus just over £1.6m for the Additional Roles Reimbursement Scheme (ARRS).
• The forecast outturn has increased slightly to a £571k surplus from £468k at month 10.
• Running costs remain underspent by just under £1m and should remain underspent by around this amount at year end.
• An extrapolation of the year-to-date expenditure compared to forecast outturn was provided for information; this demonstrated that the key variances are in ARRS and winter access funds in primary care co-commissioning. This extrapolation also included material sums relating to complex care costs in CAHMS, Learning Disabilities and Section 117 spend. The bridge includes a non-recurrent additional contribution to the Better Care Fund as agreed by the Governing Body.

The Governing Body NOTED the following:

• Allocations have been received for the full year at £2.102bn
• The YTD reported underspend at month 11 is £0.142m
• Retrospective allocations received for Q1-3 Covid spend on the Hospital Discharge Programme and vaccination inequalities were £7.768m; further funding is expected of £1.591m relating to months 10 and 11
• Additional anticipated funding include: • Elective Recovery Fund reimbursed £0.820m for April to February
• Winter Access fund is forecast to spend and reimbursed and additional £0.964m
• Additional Roles Reimbursement Scheme £1.639m YTD and forecast to spend and receive £5.759m
• The year-end position is forecast at £0.571m underspent

GBP/2223/009: Joint CCG Finance Committee / System Finance and Estates
Committee (SFEC) Assurance Report – March 2022

Andrew Middleton (AM) provided a verbal update following the Joint CCG Finance / SFEC Committee meeting held on 31st March 2022. The following points of note were made:

• The position outlined by RC was confirmed as accurate.
• During the second half of 2021/22 it has become business as usual to forecast breakeven at year end, of which there is high confidence.
• It was confirmed that due diligence on the Glossop area has not discovered any major issues of concern. • The System is also expected to breakeven in 2021/22
• The efforts of the CCG’s finance team were recognised in the latest assessment of financial practices – it is the 4th best out of 109 CCGs.

The Governing Body NOTED the verbal update provided for assurance purposes

GBP/2223/010: Audit Committee Assurance Report – March 2022

Ian Gibbard (IG) provided an update following the Audit Committee meeting held on 17th March 2022. The report was taken as read and the following points of note were made:

• The Committee is not anticipating any issues with the end of year reporting timetable of plans.
  The Interim Head of Internal Audit Opinion has received ‘Significant Assurance’.

The Governing Body NOTED the paper for assurance purposes

GBP/2223/011: Clinical and Lay Commissioning Committee (CLCC) Assurance Report
– March 2022

IG provided an update following the CLCC meeting held on 10th March 2022. The report was taken as read and the following points of note were made:

• A six-month direct award and extension to the contract was made to the
  Innovation Unit for continuity of facilitation and service design for the
  transformation of Community Mental Health Services.
• The Committee ratified a number of clinical policies in relation to
  Glossop; it was good to see how well the Glossop transition is
  progressing.

The Governing Body NOTED the paper for assurance purposes and RATIFIED the decisions made by the CLCC

GBP/2223/012: Derbyshire Engagement Committee Assurance Report – March 2022

Martin Whittle (MWh) provided an update following the Derbyshire Engagement Committee meeting held on 15th March 2022. The following points of note were made:

• Older people mental health wards – The Committee approved the formal report describing the outputs from a period of formal consultation proposing the relocation of existing older people’s mental health provision from existing wards to Kingsway Hospital and Walton Hospital, Chesterfield respectively. The consultation received fewer responses that expected, however there was overwhelming support for the move. The Committee was fully assured of the process undertaken and the use of patient advocates in relation to this vulnerable group of patients.
• Dormitory eradication programme – An update was provided on the proposed measures being taken to eradicate dormitory style provision.
• Equality Delivery System – The Committee reviewed the draft submission of the CCG’s Quality Delivery System for 2021/22; this helps organisations improve the services provided in local communities and offer better working environments for staff. The Committee was assured by the information, which was to be submitted by 31st March.
• ICS Update – This update was provided for information.
• Risk Exception Report / Governing Body Assurance Framework – The Committee received a recommendation to reduce the risk on the adherence to engagement legislation when undertaking service commissioning from 8 to 6 and it was confirmed that it will be closed in April, with evidence provided to the Audit Committee to validate this decision.

The Governing Body NOTED the paper for assurance purposes

GBP/2223/013: Primary Care Commissioning Committee (PCCC) Assurance Report –
March 2022

An update was provided following the PCCC meeting held on 23rd March 2022. The report was taken as read and no questions were raised.

The Governing Body NOTED the paper for assurance purposes

GBP/2223/014: Quality and Performance Committee (Q&PC) Assurance Report –
March 2022

AM provided an update following the Q&PC meeting held on 31st March 2022. The report was taken as read and the following points of note were made:

• The Q&PC covered much of the ground focused on by ZJ earlier in the
  meeting in the 2022/23 Operational Plan item.
• The Committee’s members challenge the information provided, by probing in order to strengthen their understanding; the officers are very good at taking on board these challenges.
• Concern was expressed at the cessation of the Hospital Discharge Fund when COVID is not over and continues to have an impact on the NHS.

The Governing Body NOTED the paper for assurance purposes

GBP/2223/015: Governing Body Assurance Framework (GBAF) – Quarter 4 – 2021/22

Chrissy Tucker (CT) presented the Governing Body Assurance Framework 2021/22 as at Quarter 4. The Governing Body was requested to approve the risk scores.

A reminder was provided of the strategic objectives agreed for 2021/22 and an update presented from the owners of the risks, as agreed at the Corporate Committee meetings held during January to March 2022. No changes have been made to the risk scores during this quarter.

Meetings are currently being arranged between the Lead Executives and Non-Executive Members of the incoming Committees with existing Committee leads; consideration will be given to the risk scores as part of the closedown process and transfer of the risk position into the ICB.

The Governing Body AGREED the 2021/22 Quarter 4 (January to March 2022) Governing Body Assurance Framework;

GBP/2223/016: CCG Risk Register – March 2022

CT presented a report detailing areas of organisational risk recorded in DDCCG’s Corporate Risk Register as at 31st March 2022. All risks in the Register are allocated to one of the CCG’s Corporate Committees which reviews them on a monthly basis to ascertain whether any amendments in risk score are required. There are currently 24 risks on the register, 7 of which are rated as very high; progress for mitigations against these risks was provided for information.

Risk 27 – A recommendation was made to decrease this risk, relating to safeguarding referral increases, from 12 to 9, due to the easing of lockdown restrictions and more opportunities to work with adults at risk of self-harm, hording, self-neglect, domestic abuse, and scamming. Both Safeguarding Adults Boards have received assurance that referrals have been actioned. The CCG continues to seek assurance from its providers that their statutory duties are being met. This reduction was approved by the Quality and Performance Committee on 31st March 2022.

Risk 24 – The closure of this risk was recommended, around patients deferring seeking medical advice for non-COVID issues. This risk is rated at 6 and met its target risk rating a few months ago. It was recommended that it now be closed and reintroduced if another variant of concern emerges or Government restrictions change. There are still a small number of patients not wishing to enter health care settings. The closure was approved by the Quality and Performance Committee on 31st March 2022.

The Governing Body RECEIVED and NOTED:

• The Risk Register Report
• The DECREASE in score for risk 27 relating to the number of safeguarding referrals
• Appendix 1 as a reflection of the risks facing the organisation as at 31st March 2022
• Appendix 2 which summarises the movement of all risks in March 2022

And APPROVED:

• The CLOSURE of risk 24 relating to patients deferring seeking medical advice for non-COVID issues due to the belief that COVID takes precedence

GBP/2223/017: Health and Wellbeing Board minutes – Derbyshire County Council –
February 2022

CC confirmed that the items on today’s Governing Body agenda fit well with those discussed by the H&WB, demonstrating connectivity between itself, its strategy, and the ICS and its development.

The Governing Body RECEIVED and NOTED these minutes

GBP/2223/018: Ratified Minutes of DDCCG’s Corporate Committees:

• Audit Committee – 20.1.2022
• Derbyshire Engagement Committee – 18.1.2022
• Primary Care Commissioning Committee – 23.2.2022
• Quality and Performance Committee –24.2.2022

The Governing Body RECEIVED and NOTED these minutes

GBP/2223/019: Minutes of the Governing Body meeting in public held on 3rd March, 2022

The minutes of the above meeting were agreed as a true and accurate reflection of the discussions held

GBP/2223/020: Matters Arising / Action Log

Action Log – March 2022 – No outstanding items.

GBP/2223/021: Forward Planner

The Governing Body NOTED the Planner for information

GBP/2223/022: Any Other Business

None raised

Date and time of next meeting 

Thursday 5th May 2022 at 9am via MST

Signed by: …………………………………. Dated: …………………

(Chair)