Derby and Derbyshire CCG Governing Body Meeting in Public
Held on 9th January 2020
CONFIRMED

Present

Dr Avi Bhatia AB Chair

Dr Penny Blackwell PB Governing Body GP

Richard Chapman RCp Chief Finance Officer

Dr Chris Clayton CC Chief Executive Officer

Dr Ruth Cooper RC Governing Body GP

Dr Robyn Dewis RD Acting Director of Public Health

Helen Dillistone HD Executive Director of Corporate Strategy and Delivery

Ian Gibbard IG Lay Member for Audit

Sandy Hogg SH Executive Turnaround Director

Zara Jones ZJ Executive Director of Commissioning Operations

Dr Steven Lloyd SL Medical Director

Andrew Middleton AM Lay Member for Finance

Gill Orwin GO Lay Member for Patient and Public Involvement

Professor Ian Shaw IS Lay Member for Primary Care Commissioning

Brigid Stacey BS Chief Nursing Officer

Dr Greg Strachan GS Governing Body GP

Dr Merryl Watkins MWa Governing Body GP

Martin Whittle MWh Lay Member for Patient and Public Involvement

Apologies

Dr Bruce Braithwaite BB Secondary Care Consultant

Jill Dentith JD Lay Member for Governance

Dr Buk Dhadda BD Governing Body GP

Dr Emma Pizzey EP Governing Body GP

Dean Wallace DW Director of Public Health, Derbyshire County Council

In attendance:

Leni Robson LR Office Manager/ Minute Taker

Suzanne Pickering SP Head of Governance

Dawn Litchfield DL Governing Body secretary

GBP/1920/ 182: Welcome, Apologies & Quoracy

Apologies were received from Jill Dentith, Dr Bruce Braithwaite, Dean Wallace, Dr Buk Dhadda and Dr Emma Pizzey.

Quoracy was confirmed.

GBP/ 1920/184: Questions from members of the public

No questions pertaining to the agenda were raised.

GBP/ 1920/183: Declarations of Interest

Dr Avi Bhatia (AB) reminded committee members of their obligation to declare any interests they may have on any issues arising from committee meetings which might conflict with the business of the governing bodies. Any declarations made by the members of the governing bodies are listed in the individual CCG’s Register of Interests.

There were no changes requested to the Register of Interest and no further declarations of interest were reported.

GBP/ 1920/184: Chair’s Report

AB presented his report to the Governing Body which was taken as read. He invited questions.

Andrew Middleton (AM) asked what the Governing Body had had sight of in regards to workforce. Dr Ruth Cooper (RC) confirmed that there had been a discussion and Linda Garnett, Workforce and OD Lead for Joined Up Care had presented at a previous Governing Body in September. No specific data had been seen but RC stated that this could be brought back to Governing Body.

AM stated that the Governing Body’s and CCG’s role regarding providing impetus to the workforce issues was not clear. Current reporting showed that workforce was a constraint against effectiveness and delivery.

Dr Chris Clayton (CC) confirmed that there had been an in-depth session and that Helen Dillistone (HD) was the CCG’s Director representative on the Local Workforce Action Board (LWAB). It was agreed that the presentation would be recirculated and the minutes checked to ensure that the discussion around how the Commissioner role works within the LWAB is being reflected. No updates have been seen since the presentation and HD will bring further reports to future Governing Bodies and ensure all actions are in progress.

ACTION: Further detailed report with regards to workforce will be included on Governing Body agendas.

Action: HD

AB agreed that the workforce was a huge challenge that is reflected in other areas such as activity data. As such it is a system issue.

Dr Penny Blackwell (PB) raised the new Primary Care Network information that has been circulated in the last week. Concerns had been raised around the resourcing of this. It would be useful for the Governing Body to have sight of where the resource was coming from. CC will pick this up in his verbal update.

AB reassured the Governing Body that this information is being covered thoroughly at the next GP Leadership team meeting.

The Governing Body RECEIVED and NOTED the report of the Chair.

GBP/ 1920/185: Chief Executive Officer’s Report

CC gave a verbal report to the Governing Body. It was noted that this was the first report of the new year. He talked through the priorities of the Executive Team. There remains three main areas of focus:

1. Stabilisation of the CCG having merged in April

2. Operational Challenges

3. Implementation of the Integrated Care System (ICS) which includes the work of the developing strategic commissioner.

It has been nearly a year since the merger and in terms of the stabilisation of the CCG, there have been significant challenges and the process did not end on completion of the merger. Governing Body through the Organisational Effectiveness Improvement Board has seen significant developments in creating the CCG. It continues to gain assurance, in regards to workforce, strategy, approach and position as a key member of the health and care system.

In terms of operational challenges the CCG has been heavily involved in supporting the system with winter challenges, and throughout the bank holiday. The system remains operationally challenged from an Urgent Care perspective and the Commissioner has done all it can to support the system. CC thanked colleagues, particularly Brigid Stacey, Zara Jones and their teams who are supporting efforts to reduce stay and working with Local Authority (LA) partners in terms of supporting community care approaches.

The other key area of operational challenge is around finance and this will be covered throughout the agenda. At this point in the year focus moves slightly from managing the end of the 2019/20 financial year to looking forward into the next financial year. Governing Body will receive reports in due course with the plans for next year and the approach being taken as a combined health and care system.

All are engaged in supporting the Derbyshire Integrated Care System and part of that is understanding what the role of a strategic commissioner is. Progress is being made and Derbyshire is at the forefront in thinking through the concept. This cannot be done in isolation and work is ongoing with partners to understand the role of a strategic commissioner. This will continue to progress throughout 2020/21 and CC will continue to report back to the Governing Body.

With regards to the Primary Care Network, there will be an enhanced role for both the Commissioners and Providers. CC has been working with providers to understand the role of an Integrated Care Partnership (ICP).

Through the Joined Up Care Board in December, Derbyshire took a preferred view to help the development of four ICP areas, which will be based on the current eight Places. This is with a view for a single Derbyshire ICS, with four ICPs, eight ‘Places’ and 15 PCNs. This was seen to be a manageable amount to ensure a flow of work from Board into communities where most of the actual care takes place.

However there would still be challenges in regards to the interactions and functions that each of those levels would have, so more work is being progressed on this. The PCNs have been developing rapidly and within 12 months it has moved from concept into reality as a formal general practice contract through the DES. The role of the commissioner is to develop a vibrant sustainable General Practice model for Derbyshire and the PCNs create a vehicle for this to happen. The work of the GP Alliance and clinical director leadership also gives opportunity for real progress to be made.

Action: SL

CC acknowledged the challenge having 117 practices across Derbyshire. The work of the Primary Care Leadership group will be key and reports will be brought back to Governing Body.

Dr Steven Lloyd (SL) confirmed that a draft network contract DES has been published and is open for comment. He stated that the last six to nine months have been a formative phase for PCNs. SL also added that the supportive role of the CCG is clearly stated within the DES.

SL talked through the funding and ambition for 2020/21 in the DES, of which there is an additional £552m funding nationally, which will rise to

£1.8b over a 5 year timeframe. This is reflected in the core contract. SL acknowledged that this was a large ask of practices. This is captured in national service specifications through the DES and over the next few months there will be a focus on medicines review, care homes, anticipatory care, personalised care and support in early cancer diagnosis. The purpose of the DES is to get GPs to work together in the PCNs.

Already there is a challenge from colleagues in General Practice through the Local Medical Committee (LMC) regarding the scale of the ambition and whether it is deliverable. The draft will be brought to Governing Body at the next meeting

ACTION: The draft PCN DES will be presented at the February Governing Body.

CC invited questions from the Governing Body.

Gill Orwin (GO) queried whether there were any social prescribers in position and if so whether any feedback had been obtained from them. SL confirmed that the PCNs were only now embarking on recruitment of social prescribers. It is still the formative phase and discussions are ongoing with regards to recruitment. It was also important to recognise the ongoing workforce issue and think about where in the system the additional workforce is recruited from.

Brigid Stacey (BS) stated that social prescribing within the NHS is a new concept and it was important to learn from LA colleagues who have been working with social prescribers for some time. Dr Greg Strachan (GS) agreed with BS and stated that PCNs are working towards this. Currently the PCN he works within calls social prescribers ‘link workers’ and they work with voluntary sector groups that have experience in the area. He stated that the clinical pharmacist role is much clearer so there needs to be more clarity around the link worker role.

AB recognised that the DES was going to be an important issue going forward and that the Governing Body needs to have a clear view and strategic steer. Potential conflicts of Interest with the GP members of Governing Body were noted and AB and SL will discuss feedback after the PCN Leadership team meeting and this will be brought back to Governing Body.

Action: SL/AB

ACTION: SL/AB to meet following the PCN Leadership team meeting to confirm feedback to the Governing Body.

The Governing Body NOTED the report of the Chief Executive Officer.

GBP/ 1920/186: Planning and Contracting Overview 2020/21

It was noted that this was also going to be covered in the Confidential session with a more strategic steer being given at this time.

Zara Jones (ZJ) presented this first of a series of updates that will be brought to Governing Body and marks the start of the next contracting round.

There have been a number of discussions as a system with NHS partners around recognising the need for bilateral contracts next year and all are keen to work collectively to agree the contractual agreements as soon as possible. This would then allow focus to be on transformation work. The key focus is currently on Joined Up Care, however there are a number of transactional items required to agree the contracts.

The paper set out three main areas:

Affordability

Given the financial position of system, where possible affordable contracts are required..

Transition Arrangements

It was important to mark that this was a transition arrangement as progression is made to a fully-fledged ICS and collaborative ways of working towards this through bilateral contracts.

Performance Improvement

Urgent care is unprecedented even when taking into account the winter pressures. This is not limited to Derbyshire and therefore contractual agreements will need to have a clear theme regarding performance improvement.

Formal planning guidance was awaited and expected imminently, which will set the framework with regards to what needs to be achieved. The usual consultation has been launched around the national tariff and the NHS standard contract. Following a consultation process on the tariff this will be published in February. This will include a 2.5% and a 1.1% efficiency factor.

Within the contract consultation, blended tariffs, and further proposals in terms of targets and performance have been discussed.

A working agreement has been issued by NHS England (NHSE) to try to ensure consistency in each of the relevant systems, and provide assurance that the CCGs will work towards a system trajectory and have transparency around finances with each other. Whilst the paper suggests tactical approaches, detailed conversations between partners are still required.

AM queried whether this would be an agenda item at the System Wide Finance Overview Group. Richard Chapman (RCp) agreed that it does need to be discussed at the Group. Questions are to be agreed with regulators and Governing Bodies throughout the system about what is affordable and what is desirable, and also how the system agrees and buys into this. There are opportunities for very different models of contracting and different models of working as a system. These will then build into the development of the strategic commissioner role in the delivery of healthcare within the constraints of affordability.

Ian Gibbard (IG) queried whether there will be further discussion on system risk share and whether further information would be sighted by Governing Body during this current contracting round. RCp stated that there was further work to be done. There is system risk share in place for this year but RCp did not believe it had delivered all it had been expected to.

PB highlighted that as Place Board Chair, it was a positive move to think about how to contract differently and in a transformative way. It can be difficult to action what is recognised as good transformational thinking.

RCp agreed that this is a real opportunity to set a more rigid risk management framework, which will allow the organisation to move from talking around financial currencies to resource currencies.

In terms of a tactical and strategic direction of travel the Governing Body AGREED the proposals contained within the paper.

GBP/1920/ 188: Finance and Savings Report – Month 8

RCp presented the Finance and Savings Report for month 8. The financial position as reported at month 8 is on target for achieving £29m as planned. Within that position savings are off plan by £21.4m at the end of the year which is a movement of approximately £1m from month 7 to month 8, with the underlying position being off target by £4.7m which increases the financial challenge going forward.

There remains £5.7m of the 0.5% contingency which is not in the forecast outturn position and this is available to mitigate identified risk which is set out within the paper.

The forecast run rate is £3.95m a month rather than £4m from month 2 –8.

Governing Body was asked to note the year to date and forecast outturn position, savings delivery and to note the risks and mitigations in the paper.

Sandy Hogg (SH) stated that the savings position was of a concern and the key risk is around the clinical transformation schemes. She provided assurance to the Governing Body that reflective learning has been done as a system. The system met on 17 December to discuss the system savings plan, and learning has been built into this. They have recognised that there needs to be acknowledgement of ownership in regards to the larger transformational programmes. This will be monitored closely over the next few months and work will be required across the system to deliver the position. She reiterated that the financial targets required have not yet been achieved and focus must not be lost on meeting these.

In regards to the University Hospitals of Derby and Burton NHS Foundation Trust (UHDB), Ian Gibbard (IG) asked whether there is an opportunity to recover credit from transactions in the Year to Date. He also queried whether there was a risk in the current forecast and if this had been identified in the risk position with UHDB.

RCp confirmed that there is a year-end figure in place with UHDB and so that risk is taken out, so there are no unknowns with regards to the figure for this financial year. An element for winter pressures had also been included.

The Governing Body NOTED the Finance report for Month 8.

GBP/1920/ 188: Finance Committee Assurance Report – 2 January 2020

AM assured Governing Body that the report had been thoroughly challenged and the Finance Committee had been fully assured. He agreed with SH that there may still be issues before the end of the financial year. AM stated that the aim should be to surpass the control target, but acknowledged the difficulties around this.

The focus is now on the future and that the change of philosophy and strategy are very important. He complimented the leadership skills of the Executive team and assured the Governing Body of the significance of the System Financial Overview Group.

AM also made Governing Body aware that Ian Gibbard would now be a member of the Finance Committee. The Terms of Reference have been amended and a GP member has been released, subject to governance approval.

He raised two items of discussion that would assist the transformation agenda.

1. As soon as effective system transformation schemes are delivered these could be used as examples

2. Would patient stories, if carefully selected prove useful?

CC concurred with SH that there were concerns over performance. Whilst the projection of £21m is there this is due to over performance in some areas and there needs to be understanding as to how and where this has happened. This is equally as important as understanding where the underperformance has occurred.

It was agreed that the concept of transformation and the challenges involved need to be understood.

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

GBP/1920/ 189: Quality and Performance Committee Assurance Report –19 December 2019

GO presented the paper in Dr Buk Dhadda’s absence. GO reassured the Governing Body that all areas around quality and performance are scrutinised in detail. GO took the paper as read and invited questions.

CC asked about the recovery plans for Cancer and asked for assurance that these were given a level of scrutiny. GO confirmed that these had been looked at in detail on an individual basis, and representatives from UHDB had attended and presented at deep dives. The CCG was not an outlier nationally. It was acknowledged that there was still work to be done as there was concern around the figures provided from UHDB in terms of how they are counted.

ZJ provided assurance at an organisational level. UHDB had a draft recovery action plan, which has been circulated throughout the system and an Executive Cancer Programme Board has now been established to ensure there is scrutiny and leadership around the recovery plan. This will be formally ratified and lead to clear accountability. CC asked whether they would report through the system to Quality and Performance Group. BS confirmed that is the proposal and will be brought to the next Joined Up Care Derbyshire Board.

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

GBP/1920/ 191: Engagement Committee Assurance Report – 4 December 2019

Martin Whittle (MW) presented the Engagement Committee report and

highlighted the following areas:

1. Wound Care

Following a presentation earlier in the year on the implementation of the new wound care pathway across Derbyshire, the Engagement Committee had received an update on progress and impact.

Of the 21 Friends and Family Test forms completed about the service, 17 of those were extremely likely to recommend; three were likely; and one was neither likely nor unlikely. There was still a capacity and demand issue in Derbyshire and work is ongoing to develop an interim model.

2. Engagement in Belper

The Committee received a briefing on the plans to conduct further engagement with people in Belper following a change of location of the proposed new health development in the town.

Engagement Committee were assured that there had been sufficient staff and community briefings.

3. Citizens Panel

The results from the first official survey held through the Citizens

Panel were presented to the Committee. The survey related to Online Access to Health Services and produced some interesting insights including showing that older users were positive about engaging digitally.

Dr Merryl Watkins (MWa) acknowledged the work by the CCG in regards to wound care and the quality of the work in the city. However she queried whether the patients were asked how long they were waiting to get an appointment and to get treated. CC queried whether the Quality and Performance Committee had looked at this issue and how they were addressing this challenge. ZJ confirmed that the conversation had taken place at Clinical and Lay Commissioning Committee (CLCC) but this will be included in the reporting going forward. The conversation at CLCC was around addressing the clinical issues as well as the contractual side. It had been agreed through the contracting conversation of 2019/20 that wound care would be provided. In terms of Derbyshire results were very positive. There had been a number of issues with practices within the city which included capacity and estates. There are still challenges and it will take some time to rectify permanently however there is a transition plan in place and agreements have been made contractually.

MW agreed that it now needed to move from Engagement Committee to Quality and Performance Committee as the patient experience issues have been addressed.

MWa said that this had addressed her concerns, however it was the patient who was at the heart of the matter. There was funding coming to Primary Care and that was welcome but again there was an issue around staffing and estates. If nurses are appointed from within the system, it will leave a shortage, and this will affect the savings plan.

SL provided assurance that he was working with ZJ and the Primary Care team; and had raised the challenge with the Medical Director of Derbyshire Community Health Services to recognise complex wound care with an ambition that no patient has to wait more than a maximum of 2 weeks. The focus is on the most complex of wounds, and ensuring that when GPs are asked to manage wound care they have the capacity and ability to do this.

GO also acknowledged the work already done and provided assurance that this has been picked up by Quality and Performance Committee. In terms of Derbyshire the feedback has been encouraging and the issues are within the city.

The Governing Body RECEIVED and NOTED the report.

GBP/1920/ 192: Primary Care Commissioning Committee Assurance Report – 18 December 2019

GO presented this report as Professor Ian Shaw had been absent. She highlighted the following:

Overseal Surgery

Overseal Surgery is in the process of closing due to the retirement of the practice doctor. The letter sent to patients was excellent, and made the

reasons for closure clear.

The closure demonstrates the precarious position GP surgeries are in. It has been closed in the most orderly fashion it can be with patients transferred to surrounding practices.

It was noted that there were lessons to be learned and that providing support to General Practices would be led by the PCNs going forward.

AM stated that it was reassuring that the transfer of patients had been managed effectively and asked whether there were any lessons to be learned regarding the transfer mechanisms. However, as the practice had not actually closed, any lessons learnt would be done after the final patients have transferred. Early indications were that it had been well managed and was unavoidable.

AB checked whether the practices who received new patients had had their capacity fully assessed. GO confirmed that there were still questions as this was an ongoing process and there was an ongoing dialogue taking place.

PB made Governing Body aware that the Overseal Surgery had been operating single handed for some time and was unable to obtain support from other practices, due to limited resources across all Derbyshire practices. MWa also agreed with this comment.

SL thanked the Governing Body for their input. Even though this was a small practice, the resource from the Primary Care team into resolving and understanding the issues had been inordinate. Unfortunately list dispersal was the only viable issue, which had been complicated as the area is on a border. The list dispersal will be completed by 31st January 2020. He reiterated that it was not just small practices that were vulnerable, and development of PCNs will aim to give operational support to all practices.

GO queried whether the wider PCN and system have helped this practice with succession planning but stated that the CCG had given a suitable amount of support with this issue.

The Governing Body NOTED the Primary Care Commissioning Committee Assurance Report.

GBP/1920/ 193: Risk Register Report – 31st December 2019

Helen Dillistone (HD) presented the Risk Register Report. The following was noted:

No risks have increased in score since the last Governing Body meeting.

No risks have decreased in score since the last Governing Body meeting.

Two risks have been closed since the last report :–

Risk 033 – Lack of engagement in Derbyshire STP refresh in

2019 – The Engagement Committee reviewed this risk at its meeting on 4 December and agreed to close the risk now that the STP Plan Refresh has been submitted.

Risk 035 – The current Gamete Storage policy does not include provision for gamete storage for transgender patients. Transgender is a protected characteristic and under the Equality Act should not be discriminated against.

CLCC ratified the policy on 14th November, which included the protected characteristic. The policy has been uploaded to the website, PALS have been informed and suitable engagement planned.

The Governing Body NOTED the report and APPROVED the closure of Risk 033 and Risk 035.

GBP/1920/ 194: Joined Up Care Board Update Report – December 2019

CC presented the report from the Joined Up Care Board.

A general governance review is underway following the appointment of the new Chair, John MacDonald. CC reiterated the importance of the Quality and Performance Group reviewing the challenges across the system.

CC noted that there has already been comment in this meeting with regards to the finances of the CCG as a sovereign organisation, but that the financial position detailed in this report is in regards to the system.

The report reiterates that there is a strong winter plan which takes a joined up approach, and includes the commitments to work through a new form of regulation.

Dean Wallace (DW) added that the paper that had been sighted by Governing Body in November was presented at the meeting and had been well received.

The Governing Body NOTED the Joined Up Care Board Update.

GBP/1920/ 195: Derby Special Education Needs Inspection (SEND) Written Statement of Action

ZJ stated that due to the limitations in place due to purdah this was being brought back to Governing Body to ensure a full discussion had taken placed. Following a SEND inspection in the city in June 2019, a written Statement of Action was required from the CCG and LA. This has been published and accepted by Ofsted and the Care Quality Commission.

There are detailed plans that sit behind the statement of action to ensure that key areas identified as areas of improvement were covered.

As well as the action plans, strengthened governance has also been actioned, with a new SEND Board, an independent chair and parent representation. Improvements are expected quickly and systematically.

The Governing Body NOTED the Derby Special Education Needs Inspection (SEND) Written Statement of Action.

GBP/1920/ 196: Ratified Minutes of Corporate Committees:

Audit Committee – 19 September 2019

Governance Committee – 12 September 2019

Engagement Committee – 2 October 2019, 6 November 2019

Primary Care Commissioning Committee – 27 November 2019

Quality and Performance Committee – 28 November 2019

The Governing Body RECEIVED and NOTED the minutes of the Corporate Committees

GBP/1920/ 197: Minutes of the Joined Up Care Derbyshire Board Meeting – October and November 2019

The minutes of the Joined Up Care Derbyshire Board Meeting were NOTED by the Governing Body.

GBP/ 1920/198: South Yorkshire & Bassetlaw Integrated Care System (ICS) Health Executive Group – November 2019

These will continue to be brought to this meeting to ensure full sight on any issues that may directly affect the Derbyshire system due to its close proximity.

Governing Body NOTED the minutes of this meeting.

GBP/ 1920/199: Minutes of the Governing Body meeting held on 5 December 2019

The minutes were agreed as a true and accurate record

GBP/ 1920/200: Matters Arising / Action Log

The action log will be updated and amended accordingly.

GBP/ 1920/201: Any Other Business

Dr Greg Strachan raised the issue of date clashes between the Governing Body meeting and the Derbyshire Health and Wellbeing Boards. HD acknowledged this and this has been raised with Dean Wallace. Consideration would be made as to how to ensure there was senior CCG representation at the Health and Wellbeing boards at Director level.

DATE AND TIME OF NEXT MEETING

Thursday 6 February 2020 – 9.15am – Conference Room, Toll Bar House, Ilkeston, DE7 5FH

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

(Chair)