Chair, Haringey CCG Strategy and Finance Committee and North East GP Lead. Chair, Islington CCG Strategy and Finance Committee and Lay Member

Transcription

1 Minutes Meeting of the Haringey CCG and Islington CCG Strategy and Finance Committee in Common Thursday, 30 August 2018 at 1pm Clerkenwell Room, Laycock Professional Development Centre Present: Dr John Rohan Helen Pettersen Sorrel Brookes Dr Jo Sauvage Dr Dina Dhorajiwala Dr Rathini Ratnavel Adam Sharples Tony Hoolaghan Simon Goodwin Eileen Fiori Alex Smith Sue Richards Haider Al-Shamary Sarah Rothenberg In attendance: Charlotte Ashton John O Reilly Julian Hartley Rachael Campbell Dan Windross Andrew Broddle Seonaid Henderson Alice Tertois Steve Beeho Chair, Haringey CCG Strategy and Finance Committee and North East GP Lead Accountable Officer, NCL CCGs Chair, Islington CCG Strategy and Finance Committee and Lay Member Chair, Islington CCG West GP Member, Haringey CCG Elected South East Locality Member, Islington CCG Lay Member, Haringey CCG Chief Operating Officer, Haringey CCG and Islington CCG Chief Finance Officer, North Central London CCGs Director of Acute Commissioning, North Central London CCGs Director of Planning, Performance and Delivery, Haringey CCG and Islington CCG Patient Representative, Islington CCG Assistant Director of Delivery, Haringey and Islington CCGs NCL POD Director, NELCSU Consultant in Public Health, Camden and Islington Public Health Head of Finance, Islington CCG Assistant Director of Contracts Haringey MDT, NELCSU System Resilience Programme Manager, Haringey CCG Assistant Director, Integrated Care Head of Performance and Planning, Islington CCG Head of Planning and Performance, Haringey CCG Assistant Director of Contracts Islington MDT, NELCSU Board Secretary, Haringey CCG (minutes)

2 1. INTRODUCTION 1.1 Present and Apologies John Rohan welcomed everybody to the meeting of the Haringey CCG and Islington CCG Strategy and Finance Committee in Common. Apologies had been received from Lucy De Groot, Clare Henderson and Anthony Browne. It was also noted that Jo Sauvage would be joining the meeting at 2.30pm. 1.2 Declarations of Interest The Committee NOTED the Register of Interests. 1.3 Minutes from Previous Meeting The Committee AGREED the minutes of the previous meeting. 1.4 Matters Arising and Action Log The Committee NOTED that the actions from the previous meeting had been discharged and that reports addressing actions 26/10-2 and 18/5-4, 5 and 6 which had been carried over from the Islington Strategy and Finance Committee would be brought to the next meeting. Tony Hoolaghan confirmed that the Memorandum of Understanding for the Islington CCG CSU re-staffing proposal was being re-drafted and therefore this should remain on the action log. The Committee also noted with regards to action 18/5-7 that Better Care Fund brokerage arrangements will be kept under review and brought back to the committee as and when a decision is required, and it was therefore agreed that the formal action should be closed. 2. Update on Contracts 2.1 Alice Tertois provided an overview of the paper, highlighting the following points: Haringey CCG acute contracts were overperforming by 13.8m at month 4, primarily due to overperformance at NMUH, Whittington Health and UCLH This position was inclusive of additional out of contract QIPP of 11.7m that had not been included within the signed contracts. The reported position against agreed contract values was 2.1m overperformance Islington CCG s acute contracts were overperforming by 4.7m in month 4, primarily due to overperformance at Whittington Health, UCLH and Royal Free London This position was inclusive of additional out of contract QIPP of 6.3m that had not been included within the signed contracts values. The reported position against agreed contract values was 1.6m underperformance. The 4.3m overperformance seen within the Haringey Non-Elective POD was largely driven by overperformance at NMUH, Royal Free London and Barts Health. At specialty level overperformance was seen within Accident and Emergency, Nephrology, Stroke Medicine and Cardiology, partially offset by an underspend in Paediatrics. Coding issues relating to Accident and Emergency, as well as Stroke Medicine overperformance had been identified as potential contributory factors and are being discussed with the Trusts 2

3 The 1.7m overperformance seen within the Haringey Outpatients POD was largely driven by overperformance at Whittington Health and UCLH. The Whittington Health cost increase was mainly driven by a contractual move from the 2017/18 position of a block contract for Ambulatory Care to a cost and volume contract for 2018/19. UCLH overperformance had mainly been caused by the adult ENT waiting list backlog being reduced at a faster rate than forecast. The Critical Care, Maternity and Patient Transport PODs were forecast to underperform across all Providers for Islington CCG, whereas the A&E, Diagnostic Imagining, Drugs and Devices, Elective, Non-Elective and Outpatients PODs were forecast to overperform across all Providers. The overperformance within the Islington CCG Outpatients POD was caused primarily by overperformance at UCLH and Whittington Health ( 0.2m). 2.2 The Committee then discussed the report, making the following points: The move to exception reporting was welcomed It was suggested that consideration should be given to combining this report with the Finance Report, given the degree of overlap between them The heading for section 2 should refer to 2018/19, rather than 2017/18 Due to the overperformance against its acute contracts Haringey CCG would still be overspending even if the QIPP figures were excluded Three-quarters of Haringey CCG s acute QIPP target was not included in the contract baselines Overperformance at NMUH and Barts was largely caused by the knock-on effects of an extended winter Without all parties being signed up to achieve the challenging QIPP targets it will be extremely difficult to deliver them It was agreed that John O Reilly would provide more clarity outside the meeting regarding the predicted 2m underspend on Community Services in Haringey Contract reports should focus more on activity Helen Pettersen and Simon Goodwin were attending all NCL Finance and Performance Committee meetings in recognition of the challenging position across NCL The Strategy and Finance Committee in Common NOTED the contracts update. ACTION: John O Reilly to provide more details about the predicted 2m underspend on Haringey Community Services. 3. Winter Planning Update Rachael Campbell provided an overview of the report which detailed the winter planning requirements for Haringey and Islington CCGs in 2018/19, a gap analysis against national LOS requirements and proposals for winter system resilience funding. The report outlined how both CCGs are performing against key areas. Each CCG was broadly performing well, although there was still room for improvement. This analysis had been used to inform the respective funding priorities. 3

4 Enfield CCG s funding proposals had been included in the paper alongside Haringey and Islington s to provide a broader picture of how the boroughs are working together. The differences between the CCGs funding reflected variations in funding allocations. It was noted that multi-agency planning meetings are taking place in Haringey and Enfield (for NMUH) and Haringey and Islington (for Whittington Health) in September 2018, to refine plans further and enable organisations to agree mitigations to any emerging risks. Alex Smith highlighted that NHS England had informed Trusts that they would be required to meet all winter staffing costs that relate to staff employed by acute hospitals and therefore commissioners will need to obtain assurance that the necessary additional consultants and discharge support staff will be in post by 1 November No challenges had been expressed to this funding request at the recent A&E Delivery Board meetings. The level of support that the Trusts were being asked to put in place was similar to the previous year. It was anticipated that the majority of the staff would be recruited via the Temporary Staffing Bank. Adam Sharples queried why Haringey CCG was spending more on winter planning than Enfield and Islington CCGs and questioned whether this was affordable, given the CCG s financial position. He also highlighted that in the length of stay gap analysis Haringey was rated red for 7 day working in care homes. Alex Smith observed that the use of the Better Care Fund (BCF) somewhat muddied the situation, as Whittington Health has historically received more funding from BCF for system resilience, so it was necessary to consider the proposals in this light when ensuring value for money. He also noted that although CCGs have discretion over how they spend their money, there would be material risks to patient safety and the CCGs reputations if appropriate funding was not in place. He noted that Enfield CCG also faced significant financial challenges. Alex Smith then clarified that the care home workforce recruitment was a national issue, and the fact that Islington CCG is meeting this standard was an exception to the rule. He highlighted that CCGs are working hard to ensure that a lead GP is allocated to each care home and assured the committee that the situation is monitored closely by a group of Directors of Social Care who meet regularly as part of of the STP to review this. The committee then discussed the scope for reviewing the proposed funding in light of the CCGs financial positions. It was agreed that the funding needed to be reviewed within the context of the CCGs wider investments as this constituted discretionary spend. However, patient safety needed to be integral to this discussion so it was imperative that the lead urgent care GPs for each CCG were involved. It was therefore agreed that Jennie Williams, Simon Caplan, Jo Sauvage, Alex Smith and Anthony Browne would review the proposals as a matter of urgency. 4

5 The Strategy and Finance Committee in Common NOTED the provisional winter plans being discussed at AEDBs and multi-agency planning sessions. ACTION: Jennie Williams, Simon Caplan, Jo Sauvage, Alex Smith and Anthony Browne to review the winter funding proposals as a matter of urgency. Jo Sauvage joined the meeting at this point and it was agreed to take item 5 next /19 Month 4 Finance Update 5.1 Simon Goodwin provided an overview of the papers. He highlighted that Haringey CCG currently had a 6m - 9m financial gap, primarily due to unidentified QIPP savings and overperformance against its acute contracts. Of the NCL CCGs, only Enfield CCG was in a more challenging position. If the position did not change over the next few months, the CCG would need to declare that it would be unable to meet its control total. He and Helen Pettersen would shortly be meeting NHS England, where it would be necessary to inform NHS England that the NCL CCGs would be unable as a whole to meet the overall control total. If Haringey CCG is unable to meet its control total, this will trigger unpalatable interventions from NHS England. In light of this, all new and existing expenditure in Haringey would need to be reconsidered as a priority. 5.2 Although Islington CCG was not in such a challenging financial position, Jo Sauvage noted that it too had unidentified QIPP savings to meet, so the CCG s position could yet deteriorate further. 5.3 Adam Sharples observed that it was unrealistic to hope that Haringey CCG could implement QIPP savings on the scale required, so advice was required on the potential options to reduce the volume of current activity by a sufficient scale to reduce the deficit. 5.4 Helen Pettersen noted that both CCGs need to review uncommitted budgets to see what planned activity can be halted or reduced, while ensuring that quality and patient safety are taken fully into account. It was important that both CCGs do the best that they can for their populations, with the money that they have. Any proposals will be shared transparently with both Governing Bodies. 5.5 John Rohan expressed concern about the fact that at the end of the previous financial year Haringey CCG had had to absorb part of the overspend on its acute contracts, as Trusts invariably spend up to the limit of their contracts irrespective of QIPP targets, knowing that the CCG will be required to pay for 50% of the overspend. 5.6 Tony Hoolaghan assured the Committee that the CCGs have been aware of the worsening financial positions for some time and work was therefore already underway on reviewing every element of the CCGs expenditure as part of their recovery plans, which includes re-looking at all QIPP schemes in terms of whether they will deliver the planned savings and whether they warrant future investment. This would inevitably require difficult decisions to be taken and the Senior Management Team was discussing how the situation should be communicated to staff. 5

6 5.7 As part of this work both CCGs had been liaising with the NHS England Right Care team to undertake benchmarking at a local level to identify potential savings. Alex Smith noted that he would be meeting the Right Care team in mid-september to discuss their analysis. 5.8 The Committee then discussed the potential value of bringing the monthly Right Care reports to future committee meetings. Alex Smith confirmed that the report would be taken initially to the QIPP Development Group meeting if it was considered useful, and then brought as an appendix to the main Finance Reports presented to the committee. He also drew members attention to the sections in both Finance Reports which highlighted the barriers to achieving QIPP savings and the actions being taken to address these. 5.9 The Strategy and Finance Committee in Common NOTED the Month 4 financial positions for Haringey and Islington CCGs. 4. Care Homes Support and Trusted Assessor Business Case and Impact Analysis 4.1 Haider Al-Shamary introduced the business case to improve the quality of care in care homes and to provide Trusted Assessments on behalf of care home managers. The proposed model would provide proactive healthcare and ensure coordinated and effective use of community services. Additional support to care homes was expected to improve the quality of life for care home residents and avoid unnecessary unplanned admissions, and the provision of Trusted Assessments on behalf of care home managers was expected to improve the quality of transfers between care settings. The proposed model required investment for components not currently commissioned by Haringey CCG, whilst a number of commissioned services would be aligned and coordinated to provide full Multi-Disciplinary Team (MDT) support for the care homes. 4.2 It was noted that care home admissions and discharges were frequently challenging over the winter period due to issues relating to the availability of beds and patient flow, resulting in delayed discharges and assessments. Unlike other areas, Haringey did not currently take an MDT approach and it was an outlier for non-elective admissions and A&E attendance for care home residents. The scheme therefore reflected the strong need for a sustainable long-term model. While the implementation of the model was anticipated to be cost-neutral in 2018/19, significant recurrent savings were anticipated after it had been embedded. 4.3 John Rohan observed that the projected savings did not seem sufficient to warrant the planned investment, given the CCG s financial position. He also queried whether the start date could be pushed back to April Alex Smith clarified that it would be funding from the resilience budget that would enable the scheme to commence (beyond the pilot stage) from November 2018, ahead of recurrent planned investment in 2019/ Helen Pettersen commented that the projected savings set out in the paper are cautious compared to what the model should be seeking to deliver. The evidence from a similar initiative implemented by Sutton CCG was extremely impressive and ought to be taken into consideration. 6

7 4.5 Jo Sauvage observed that from a clinical perspective accessible pro-active care is important in the early identification of symptoms which can lead to falls or mobility issues that is not traditionally done when GPs visit care homes. The proposed model therefore represented a more systematic and effective way of addressing a cohort of patients with clinical needs. 4.6 Adam Sharples highlighted that the results of the pilot schemes carried out at two care homes differed significantly and queried whether this might reflect differences in management response. John Rohan observed that the two care homes were very different, so the data did not really compare like with like. 4.7 The Committee agreed that Tony Hoolaghan should carry out in his capacity as Chief Operating Officer an overview of the savings assumptions outside the meeting, taking into account the approach followed in Sutton to ensure that a similar model was being proposed in Haringey, while also focusing on where the largest gains can be made. Assuming that Tony Hoolaghan was satisfied with the case for proceeding, he would write to John Rohan, recommending that approval of the business case via Chair s Action, in accordance with the committee s Terms of Reference. 4.8 Jo Sauvage noted that Islington had seen a significant reduction in A&E attendance following the introduction of the Integrated Community Ageing Team. She also observed that Whittington Health already had a virtual ward in place, so the interface between the proposed model and Community Services would be fairly straightforward. 4.9 The Haringey CCG Strategy and Finance Committee NOTED the Care Homes Support and Trusted Assessor Business Case and Impact Analysis ACTION: Tony Hoolaghan to review the savings assumptions behind the Care Homes Support and Trusted Assessor Business Case in light of the savings delivered by the model implemented by Sutton CCG and if appropriate, recommend to John Rohan outside the meeting that the business case should be approved via Chair s Action. 6. System Intentions for 2019/ Seonaid Henderson provided an overview of the provisional Haringey and Islington acute and community commissioning intentions for 2019/20 and the backdrop to the development of North Central London System Intentions for 2019/ Adam Sharples observed that the document contained an attractive list of proposals but queried where they had emanated from. He also highlighted that the document lacked a breakdown of the financial implications. 6.3 Alex Smith clarified that the majority of the intentions represented QIPP pathways and reflected the need for commissioners to work jointly with providers to deliver sustainability within the system. It would therefore be imperative that the CCG is very clear on the messages it gives to providers. 6.4 Jo Sauvage agreed on the importance of moving to a meaningful new way of working. As part of this, discussions would need to take place within the Haringey and Islington Wellbeing Partnership about risk share, over and above the discussions that occur at PID level. 7

8 6.5 Sorrel Brookes suggested that it would be helpful if future iterations could make it clear when something is mandated. 6.6 Adam Sharples observed that the CCGs need to be prepared to be push back when things are either not clinically worthwhile or affordable. 6.7 Rathini Ratnavel queried who Islington CCG gave notice to in the sentence In 17/18 Islington CCG gave notice that we were seeking to commission a service which is more responsive, will provide a wider range of support (Children's MDTs, CHINs, etc.) and provide better value for money. 6.8 Dan Windross confirmed that this was referring to an integrated network, rather than a specific service as such, and alternative providers were now in existence. This wording would be made clearer in the next version of the document. 6.9 The Strategy and Finance Committee in Common NOTED the reports and on the local Haringey and Islington Commissioning Intentions for 2019/20 and the iteration of the NCL System Intentions for 2019/ ACTION: Dan Windross to make clearer the wording of the first sentence of the eighth bullet point on page five of the Islington System Intentions document. 7. Contract Award Recommendation for PRJ 620 Islington Care Navigation Service 7.1 Dan Windross provided an overview of the report on the decision by Islington CCG to re-commission Age UK to provide the Islington Care Navigation Service, following a procurement process overseen by NELCSU. 7.2 It was noted that Haringey CCG commissions a similar scheme at a smaller scale, via its CHINs. In response to a suggestion that there would be potential economies of scale if the service was jointly commissioned by both CCGs, Tony Hoolaghan observed that this would require a separate tender process but he assured the committee that the general principle would be borne in mind. 7.3 Jo Sauvage said that both CCGs should build on the joint working and crossfertilisation already taking place through the meetings of the Joint QIPP Delivery Group and the Strategy and Finance Committee in Common by considering how else they could maximise productivity and efficiency. As part of this, all procurements ought to be considered for their collaborative potential. 7.4 The Islington CCG Strategy and Finance Committee NOTED the report on the Contract Award Recommendation for PRJ 620 Islington Care Navigation Service. 8. Risk Register Review 8.1 The Committee in Common considered the separate extracts from the Haringey and Islington CCGs risk registers. 8

9 8.2 Adam Sharples suggested that it might now be more appropriate for Risk 10 on the Haringey CCG Risk Register ( There is a risk that the performance against the A&E target at NMUH will not improve in line with the requirements of the planning guidance for 2018/19, NHS Improvement and the A&E Delivery Board ) to be overseen by the Quality and Performance Committee going forward. Alex Smith confirmed that this would be considered by the risk leads as part of a wider review of the assignment of each risk in the next round of reviews. 8.3 Sorrel Brookes expressed concern about the fact that the high score for Risk 437 on the Islington CCG Risk Register, which related to the delivery of the 2018/19 QIPP programme, was not decreasing, despite the range of mitigations being implemented. 8.4 The Haringey CCG Strategy and Finance Committee APPROVED the Haringey Risk Report. 8.5 The Islington CCG Strategy and Finance Committee APPROVED the Islington Risk Report. 8.6 ACTION: Steve Beeho to highlight the need for the assignment of Risk 10 to be considered during the next round of reviews. 9. Any Other Business 9.1 There was no other business. 10. Date of Next Meeting 10.1 Thursday, 25 October