GBP/1920/ 203: Welcome, Apologies & Quoracy

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

Apologies were received from Dean Wallace, Richard Chapman and Dr Bruce Braithwaite.

It was confirmed that the meeting was quorate.

GBP/1920/204: Questions from members of the public

None received.

GBP/1920/ 205: 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.

Items 217 and 218 – Engagement Committee Assurance Report / PCCC Assurance Report – Dr Ruth Cooper (RC) declared an interest in the Pilsley Surgery branch closure item. As the decision is being made outside of the Governing Body it was agreed that RC would remain in the room for this discussion.

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

GBP/1920/206: Chair’s Report

AB provided a written report, a copy of which was circulated with the

papers. The report was taken as read and no questions were raised.

The Governing Body RECEIVED and NOTED the report

GBP/1920/ 207: Chief Executive Officer’s Report

Dr Chris Clayton (CC) provided a written report, a copy of which was circulated with the papers. The report includes local, regional and national issues not covered on the agenda which may be of interest to the Governing Body. The report was taken as read and the following request was made:

Time to talk day 2020 – Martin Whittle (MWh) requested feedback from this initiative. CC agreed to obtain this for presentation to the Engagement Committee.

Action: CC

The Governing Body RECEIVED and NOTED the report

GBP/1920/208: The Light House Consultation Report

This paper builds on the previous paper presented to the Governing Body on 1st August 2019 where a public consultation into the long term service model of the Light House children’s residential short break service was approved; the consultation ran from 5th September to 3rd December 2019. The outcome of the consultation was taken to both the Engagement Committee and the Clinical and Lay Commissioning Committee (CLCC) meetings in January 2020. Both Committees were assured that appropriate engagement had taken place and robust processes, with mitigations, were in place to address any issues raised by the members of the public and professionals.

Zara Jones (ZJ) advised that the pre-consultation and formal consultation details were included in the meeting papers. Zara confirmed that all social and health care needs will be met by care staff trained in child specific interventions and supervised by nurses. The children with the most complex needs will have a specific package of care set out by a panel of professionals to meet their needs on an individual basis. There is a need for some social care staff to be upskilled to undertake delegated health tasks, under the guidance of a CQC registered trainer and assessor, who will support them with training, governance and assurance thus ensuring the delivery of safe care.

It was recommended to the Governing Body that the new model be implemented immediately as part of a detailed plan with an intention that it will be fully embedded by 1st April 2020. As the 1st April 2020 is a tight timescale, CC requested that the Governing Body also agree to allow the interim model to continue for longer if deemed necessary; the Governing Body were in agreement with this request.

Gill Orwin (GO) confirmed that both the CLCC and Engagement Committee worked through this piece of work and considered it to be an exemplary example of how people’s needs are being listened to, with parents and families involved at all levels.

The Governing Body:

NOTED the progress with implementing the interim arrangements in Section 1

Were ASSURED of the progress on the governance arrangements and process to review the health needs of children attending The Light House in Section 2

APPROVED the proposed future model of The Light House children’s residential short breaks service which for most children will be care led in Section 3

AGREED to the continuation of the interim model as a contingency arrangement should it be deemed necessary

CCG Governing Body - 6 February 2020 - Lighthouse Paper

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GBP/1920/ 209: Corporate Committees Terms of Reference Review

Helen Dillistone (HD) advised that as part of the Governing Body’s six month review of all Corporate Committees’ Terms of Reference, each Corporate Committee has reviewed and amended its own Terms of Reference where necessary. Any amendments and additions have been agreed by the Committees and highlighted for information. It was confirmed that the Governing Body Members’ survey had influenced this process.

The following Corporate Committees’ Terms of References were presented for approval:

Audit Committee

Clinical and Lay Commissioning Committee

Finance Committee

Governance Committee

Primary Care Commissioning Committee

Quality and Performance Committee.

Jill Dentith (JD) stated that the CLCC Terms of Reference have been amended to refer to savings rather than QIPP and asked that the other committee Terms of References are also amended to ensure consistency.

Action: SP

The Governing Body APPROVED the amended Corporate Committees’ Terms of Reference.

GBP/1920/ 210: Change of Scheme of Reservation and Delegation

As the CCG has now been operating for 9 months, a review of its Constitution, Annex 1: Decisions, Authorities and Duties Delegated to Officers of the CCG Governing Body has been undertaken. Niki Bridge (NB) advised that the review highlighted the inappropriately low level of delegated authority given to the Executive Director of Commissioning Operations with regard to the signing of healthcare contracts. It is recommended that the level of authority delegated to this Officer be increased to £1m, in line with the Chief Finance Officer’s level of delegated authority. All other delegated limits remain unchanged and the Chief Finance Officer and Chief Executive Officer will be required to sign off all contracts valued over £1m.

Andrew Middleton (AM), as Chair of the Finance Committee, confirmed that this paper has been reviewed by the Finance and Audit Committees, and both were recommended to the Governing Body for approval.

The Governing Body APPROVED the proposed change to the Scheme of Delegation to increase the delegated authority of the Executive Director of Commissioning Operations to £1m when signing healthcare contracts.

GBP/1920/ 211: Dying to Work Charter

‘Dying to Work’ is a voluntary charter developed to protect and support terminally ill employees; its aim is to remove any additional stress and worry relating to continued employment, by treating employees with dignity and respect and having processes in place to deal sensitively with their needs, and not dismissing them due to their condition. As much support, advice and guidance as possible will be offered to employees in each case.

HD confirmed that the Executive Team and Governance Committee supported this Charter and recommended that the Governing Body signed up to it.

Dr Merryl Watkins (MWa) supported this however raised concern in relation to those people that do not have mental capacity. It was confirmed that cases will be reviewed on a case by case basis.

The Governing Body APPROVED the CCG signing up to the Dying to Work Charter.

GBP/1920/ 212: Finance and Savings Report – Month 9

NB confirmed that as at Month 9 the CCG is reporting year to date and

forecast positions which are in line with the plan and remains on course to achieve the control total. The following points of note were made:

The year to date and forecast overspend positions of £11.484m and

£18.850m respectively are in line with the Commissioner Sustainability Funding (CSF) adjusted control total.

The year to date position includes a savings under delivery of

£10.620m and the forecast year end position includes a savings under delivery of £22.418m.

The CCG’s running costs budget reflects savings and efficiencies; the CCG remains within its cash limit and has achieved the Better Payment Practice Code.

To aid the financial position, year end settlements have been agreed for acute contracts in order to provide added security and confidence.

There is continued pressure on the Mental Health budget mainly relating to high cost patients and Section 117 cases. Work is being undertaken to reduce overspend within this area.

Primary care prescribing continues to demonstrate an overspend mainly due to cost pressures relating to Category M drugs, along with cost and volume variances.

The CCG is reporting a fully mitigated risk position and cost pressures continue to be covered with reserves and contingency.

Sandy Hogg (SH) advised that there has been a deterioration in the savings positon of £1.1m due to adverse movement between Months 7 and 8, and Months 8 and 9 which is of significant concern to the leadership. The Month 9 savings information demonstrates a year to date delivery of £36.8m (against a phased plan of £47.3m) and a forecast savings delivery of £47.1m (against a planned total of £69.5m -a deficit of £22.4m). As a consequence, a leadership review is to be conducted and actions agreed. The key areas of deterioration are medicines management and primary care; deep dives are to be undertaken into these areas to understand what has occurred. A full year review is to be undertaken to assess how to reduce spend safely without impacting on patient care. Recommendations are to be made to the CEO in preparation for the review, which will take place next week. A financial recovery approach is to be applied in the CCG. A review has been initiated into all commitments and invoice approvals, and a review of all operational areas is to be undertaken. The whole leadership team will be involved in minimising spend. The underlying deficit needs to be a low as possible as the CCG will be expected to recover it next year.

Ian Gibbard IG) highlighted the fact that Continuing Healthcare (CHC) is a good news story to some extent with a forecast annual underspend overall of £7m expected; however there have been some changes in the climate recently. Assurance was requested around the cost sharing with Local Authorities and whether this presents any further risk. Ian asked if there is anything else that could be done to manage costs. Brigid Stacey (BS) stated that bringing the expenditure into line was a success story for the CCG however there has been some recent variability. Provision was made for the challenges faced last year and it was hoped that the issues with the Local Authority, which caused the deviation, had been rectified however a further deviation occurred this month. NB confirmed that this was a timing issue. A change in forecast of £2m was notified with a

further pressure of £1m. A meeting has been arranged to discuss this

matter and broker a deal.

AM confirmed that a new CHC policy is in place and enquired if this will provide more certainty as to what could be included in a package. Next month a robust process is required for bringing costs in to line and defining what will be funded, in line with statutory responsibilities. This will be presented to the Governing Body.

It was considered that closing down the contracts at year end was the right thing to do in order to reduce the overall risk in Derbyshire; if they were to be re-opened it would expose more risk. The non-Derbyshire contracts are also being examined. CC confirmed that the principle of shutting down contracts outweighs the risk for Commissioners and Providers. The resources saved will go into agreeing next year’s contracts.

The Governing Body NOTED the Finance and Savings report.

GBP/1920/ 213: Finance Committee Assurance Report – January 2020

AM provided a verbal update following the Finance Committee meeting held on 30th January 2020. The following points of note were made:

The CCG must meet the £29m control total; the Committee were reassured that this will be done.

It is pleasing to hear that an extra £1m – £2m can be accommodated and that the Executive Team has been looking for risks and setting contingencies.

Excellent work has been undertaken by the CCG in both CHC and Medicines Management in order to achieve a significant quantum of savings.

AM believed that it is right to close down the contracts early to prevent extra demand.

Disappointment was expressed on the slippage of the savings programmes but it was recognised that the majority of the slippage is within the system space; the proactive way the leadership is influencing the system to get ahead of the challenge was recognised and commended.

A fundamental rethink on the design of secondary and primary care pathways is required; the CCG and the system are facing a massive challenge next year. Demand is rising year on year and the costs are increasing without the budget to manage it.

CC confirmed that the deep dive review will be on the shift in position of

£1.1m during September/October and not on the totality, as system transformation schemes have already been locked down; the gearing in the system to understand the challenge is underway.

The Governing Body RECEIVED and NOTED the Month 8 Finance and Savings report.

GBP/1920/ 214: Quality and Performance Committee Assurance Report – Month 8

Dr Buk Dhadda (BD) provided an update on the discussions held at the Quality and Performance Committee meeting on 30th January. The

report was taken as read and the following points of note were made:

An interim agreement has been made with practices on wound care.

IG highlighted an increased acuity of patients presenting at A&E, as demonstrated in the report. He enquired if the hospitals are getting better at triaging or whether other factors were involved. BD confirmed that the Committee received the findings of a deep dive on A&E which showed that there is no singular issue contributing to the A&E issues but many factors. More people are presenting with a higher level of acuity and not as many people are arriving who should not be there. 1:4 attendances result in an admission.

The Governing Body RECEIVED and NOTED the Quality and Performance Committee Assurance Report.

GBP/1920/ 215: Audit Committee Assurance Report – January 2020

IG presented this report which was taken as read. The following points of note were made:

The results of a Governing Body Members’ survey on risk management and the operation of the Governing Body Assurance Framework (GBAF) were discussed at the meeting. 17 responses were received giving a 74% response rate; the overall response was very positive and the results will form part of the Head Of Internal Audit’s control arrangements. The Committee agreed that it could be useful for the Governing Body to look at its own effectiveness as part of a future Development Session.

The extent to which people felt confident on system working and partners’ delivering strategic objectives is to be discussed further by the Audit Committee.

A review was undertaken to assess the effectiveness of the Joined Up Care Derbyshire (JUCD) operational planning process in 2019/20 in order to inform the process for 2020/21. The Audit Committee were confident that lessons could be learnt going forward. The report contained key messages which the Governing Body need to take on board. The report will be presented to the STP and other partner agencies for consideration.

MWh queried how CCGs will obtain feedback on the JUCD report from individual Audit Committees and how this will filter down to individual organisations. The CCG and Providers share a common Internal Audit partner who will provide a read across and work in a cooperative manner. This will be progressed as further movement is made into the system space.

AM considered this to be a fruitful area for further investigation. He enquired when it would be an appropriate point to request Internal Auditors to assess system accountability and governance arrangements – this is something that still needs to be agreed. There is a will and intent from the System Finance Oversight Group; it is considering how authority beyond individual organisations could be gained to provide a system first focus. The mechanism sets out to provide an opportunity to bring collective thoughts together and apply learning.

HD advised that the Audit Committee, together with the Remuneration Committee, are the only statutory committees required of the CCG.

This needs thinking through across the system space as there may be some benefit from bringing organisational related tasks together. A national event is scheduled shortly to allow Audit Chairs to contribute to the conversation. 360 Assurance is keen support this process.

Action: IG

SH recently attended the CFO forum where there was quite a lot of debate about system working. Discussions were held on the last planning round and the amount of direct input from those involved.

Action: HD

MWh requested the thoughts of individual organisations on the report be fed back to the Governing Body.

AM stated that having a System Finance Oversight Group was a valuable asset in understanding where partners are coming from. He suggested having an informal gathering of Audit Chairs. IG advised that if system level goals are to be introduced the Governing Body must have a formal recognition that it has the control to deliver its targets; this will not be resolved by discussions without formal structures. The Lead Commissioner needs to set out new strategic directions to ensure delivery.

Dr Penny Blackwell (PB) considered that the Governing Body needs to know that the conversations are being held. Cultures need to be developed to allow mandates to be delivered.

AB concluded that system governance is challenging; there is a need to take both a proactive and reactive approach. Building upon the comments made, a Governing Body development session will be arranged to explore learning and the system position.

The Governing Body RECEIVED and NOTED the report.

GBP/1920/ 216: Governance Committee Assurance Report – January 2020

JD presented this report which was taken as read.

The following information governance policies were approved by the Committee:

IG Strategy

IG Policy

Network, Internet and Email Acceptance Use Policy

Records Management Policy

Information Security Strategy

The following HR policies and procedures were approved by the Committee:

Special Leave Policy

Pay Progression Policy

The Dying to Work Charter was supported and recommended to the Governing Body for approval.

Mandatory training is an important issue and it needs to be ensured that it is undertaken by all staff.

A good conversation was held by the Committee on the 6 risks assigned to it.

The Governing Body RECEIVED and NOTED the report.

GBP/1920/ 217: Engagement Committee Assurance Report – January 2020

RC declared an interest in the consultation to close the Pilsley Branch

Surgery as she is a partner at Staffa Health; however as the decisions are being made elsewhere it was agreed that Dr Cooper would remain in the room for this item.

MWh presented this report which was taken as read. The following points of note were made:

A review in the Committee’s Terms of Reference has commenced in light of the impending changes to the Derbyshire system’s structure with the advent of Integrated Care Partnerships and Primary Care Networks and the links these developments have to the work and membership of the Committee, and the Joined Up Care Derbyshire Board Governance Review currently underway. Appropriate geographical representation needs to be obtained for Committee membership. The Terms of Reference will be presented to the Governing Body in March.

The findings of the consultation to close the Pilsley Branch Surgery were presented to the Committee. The robustness of the engagement process was found to be strong. The comments made during the consultation period have been taken on board by the practice and the Committee endorsed the report.

A revision of the Communications and Engagement Strategy is being considered in connection with Joined Up Care Derbyshire.

JD considered it to be important that individual Corporate Committees gain assurance from the discussions held at other Committees. It was noted that the Pilsley consultation was also considered by the Primary Care Commissioning Committee; there is a need to join these discussions together to prevent duplication and allow robustness of consideration. CC confirmed that each Committee has a particular function and there a mechanism to ensure that all of the different aspects are completed by the Corporate Committees in order to provide adequate assurance.

The Governing Body RECEIVED and NOTED the report.

GBP/1920/ 218: Primary Care Commissioning Committee Assurance Report –January 2020

RC declared an interest in the consultation to close the Pilsley Branch Surgery as she is a partner at Staffa Health; however as the decisions are being made elsewhere it was agreed that Dr Cooper would remain in the room for this item.

Professor Ian Shaw (IS) presented this item which was taken as read. The following points of note were made:

The following Terms of Reference were received, noted and approved:

Primary Care Leadership Committee

General Practice Digital Steering Group

Primary Care Estates Steering Group

A key item for discussion was the Pilsley Branch Surgery closure. Due to illness there was a delay in getting the papers out to Committee members. As the report was very detailed and members required time to consider the contents, it was agreed that the decision would be deferred to the February meeting.

The Governing Body NOTED the report.

GBP/1920/ 219: Risk Register Report – 31st January 2020

HD presented the Risk Register Report as at 31st January 2020. The report was taken as read and the following points of note were made:

There are 6 very high risks, 14 high risks, 2 moderate risks and 1 low risk being faced by the organisation as at the end of January.

2 new high scoring risks have been identified which have been assigned to the Quality and Performance Committee:

Risk 041 – lack of peer support for nursing home bedside manufacture of syringe drivers after 31.1.2020, following the withdrawal of syringe driver manufacture by University Hospitals Derby and Burton NHS Foundation Trust (UHDB). This risk has been rated at 8. It relates to the workforce and is about ensuring that the right training is provided to staff to allow them to administer syringe drivers.

Risk 042 – Derby City patients with complex wounds will not receive timely care or will face sub-optimal outcomes to their condition. This risk has been rated at 9.

The Governing Body RECEIVED and NOTED:

The Risk Register Report

Appendix 1 as a reflection of the Very High Risks of the organisation as at 31st January 2020

Appendix 2 which summarises the movement of all risks during January 2020

APPROVED the two new Risks 041 and 042, which have been assigned to the Quality & Performance Committee

GBP/1920/ 220: Governing Body Assurance Framework – Quarter 3

HD presented the Quarter 3 Governing Body Assurance Report which provides a structure and process to enable the CCG to focus on the strategic / principal risks that might compromise it in achieving its strategic objectives. It also maps out both the key controls that are in place to manage those objectives and associated strategic risks, providing the Governing Body with sufficient assurance around the

effectiveness of the controls in place. Each risk has been assigned to

one the CCG’s Corporate Committees for oversight and review. Any changes made to the risks have been noted in red in the papers.

Action: RC/HD/ SH

Risk 6 – The Derbyshire health system is unable to manage demand, reduce costs and deliver sufficient savings to enable the system to move to a sustainable financial position – this has been developed in 2 parts. Risk 6A relates to the CCG position; the risk score has reduced from a very high 25 to a very high 16. The rational for the reduction is that as the year end draws nearer, it is clearer where the position is likely to end, and year-end contract positons have been agreed, therefore the risk of not knowing what will happen is reduced. Risk 6B relates to the system element of the risk

Action: RC/HD

On behalf of Richard Chapman (RCp), SH advised that this is not the most up to date position for Risk 6B from the Finance Committee on 30th January 2020. Conversations in relation to risk 6B were held at length around delivering the 2019/20 system finance position. The Governing Body discussed the impact on the UHDBFT position at year end and should in the longer term UHDBFT not have credible plans for 2020/21, the Finance Committee agreed to retain the risk score of 6B at a very high 25. AM confirmed the risk should remain at a risk score of 25. The Finance Committee debated reducing the risk score however was cautious as to what could happen before the end of March.

As a matter of accuracy CC requested that this risk be brought back in due course with the output of the Finance Committee discussion. This is a timing issue related to the close proximately of the Finance Committee and Governing Body dates. There was not enough information available to make a judgement today; system level information is required for consideration.

During March thought will be given on what a system savings plan would look like in reporting and audit terms.

SH suggested that the Finance Committee look in detail at risks 6A/6B and requested that the full system savings report received by the Finance Committee be presented to the Governing Body routinely.

JD queried why risks 3 and 5 were not applicable to strategic objective 2 on the process map; Jill will discuss this further outside of the meeting.

The Governing Body RECEIVED and GAINED ASSURANCE from the Quarter 3 Governing Body Assurance Report.

GBP/1920/ 221: Joined Up Care Derbyshire (JUCD) Board Update Report – January 2020

CC presented the JUCD Board Update Report. The paper sets out the route of the previous discussions in relation to a changing way of working and explains how the operating model in a statutory space will alter. There are significant changes afoot and partners are working hard to achieve them. Financial planning and efficiency generation are making progress. The work on understanding the concepts of demand and resources, the calving up of it and understanding the totality is good. Working through the winter period is helping the preparation for other health and social care challenges. Integrated Care Partnerships are

building on Place, grappling with change and making progress. It is recognised that it will be 2020/21 before all of the creases are ironed out. The Governing Body is asked to achieve a balance between managing uncertainty and working with it.

Action: CC

BD considered the Clinical and Professional Reference Group (CPRG) to be an important driver of transformation; reassurance is attached to making this a driver within the system and having the right people around the table. AB reflected this to be a well-made point however the CPRG is not currently functioning to its best ability. SL and BD recently met with John MacDonald to discuss how to improve its function. Steering group meetings have been held to discuss this further and consider how to alter the membership, tightening it up by having senior clinicians in attendance from each organisation together with General Practice, social care, pharmacy and nursing representation. Organisations will be deferred from sending deputies and delegates will be required to attend 70% of meetings. Whilst the CPRG cannot block anything it is able to have a robust opinion. The dates will be altered to allow better attendance and co-chair arrangements will be implemented between Acute and Commissioning organisations.

JD considered the report helpful to digest; however there may be an opportunity to improve its usefulness by including forward planning and a schedule of forthcoming items which will be beneficial when thinking about reassurance, and not assurance, in order to keep on track and target.

The JUCD Board met in public for the first time in January 2020 which was well received and will continue; not many STPs currently do this.

The East Midlands Ambulance Service NHS Trust has agreed to take the lead on improving air quality on behalf of the system.

The Governing Body NOTED the Joined Up Care Derbyshire Board January 2020 Update

GBP/1920/ 222: Safeguarding Adults Annual Report

The Governing Body RECEIVED the report and ASSURANCE from the Adult Safeguarding work undertaken on behalf of the CCG

GBP/1920/ 223: Derby and Derbyshire Air Quality Strategy and Action Plan

HD was pleased to report that this strategy has been agreed by both Derby City and Derbyshire County Councils and the JUCD Board. A working group has been established to look at how this strategy may be supported.

CC is the sustainability officer for the CCG. The Governing Body will see, through its sub committees, a substantial shift in the use of digital technology in order to reduce mileage. Investment is proposed into video/conferencing facilities; a cultural change is needed to shift to this modality.

The Governing Body RECEIVED the Air Quality Strategy for Joined

Up Care Derbyshire for information and NOTED the process for the development of a delivery plan

GBP/1920/ 224: Ratified Minutes of Corporate Committees:

Audit Committee – 21st November 2019

Governance Committee – 14th November 2019

Engagement Committee – 4th December 2019

Quality and Performance Committee – 19th December 2019

The Governing Body RECEIVED and NOTED these minutes

GBP/1920/ 225: Minutes of the Joined Up Care Derbyshire Board Meeting –December 2019

The Governing Body RECEIVED and NOTED these minutes

GBP/1920/ 226: South Yorkshire & Bassetlaw Joint Committee of CCGs – October 2019 meeting minutes / Progress Report

The Governing Body NOTED these minutes and progress report

GBP/1920/ 227: Minutes of the Derby City Council Health and Wellbeing Board Meeting – November 2019

The Governing Body NOTED these minutes

GBP/1920/ 228: Minutes of the Governing Body meeting held on 9th January 2020

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

GBP/1920/ 229: Matters Arising / Action Log

The action log will be updated and amended accordingly.

GBP/1920/ 230: Forward Planner

Noted for information.

GBP/1920/ 231: Any Other Business

None raised.