71633548c5390f9d8a76 …… · AGENDA NHS Leeds CCG Governing Body Meeting Date: Wednesday 28...

AGENDA

NHS Leeds CCG Governing Body Meeting

Date: Wednesday 28 November 2018

Time: 13:30 – 16:30

Venue: The Old Fire Station, Gipton, Leeds, LS9 6LN

Please note: agenda timings are approximate

Item Description Lead Paper Time

GB 18/83

Welcome and Apologies Purpose: To record apologies for absence and confirm the meeting is quorate.

Gordon Sinclair

N

13:30

GB 18/84

Declarations of Interest Purpose: To record any Declarations of Interest relating to items on the agenda: a) Financial Interest

Where an individual may get direct financial benefit from the consequences of a decision they are involved in making;

b) Non-Financial professional interest Where an individual may obtain a non-financial professional benefit from the consequences of a decision they are involved in making;

c) Non-financial personal interest Where an individual may benefit personally in ways that are not directly linked to their professional career and do not give rise to a direct financial benefit, because of the decisions they are involved in making; and

d) Indirect Interests Where an individual has a close association with another individual who has a financial interest, a non-financial professional interest or a non-financial personal interest who would stand to benefit from a decision they are involved in making.

Gordon Sinclair

N

GB 18/85

Questions from Members of the Public Purpose: To receive questions from members of the public

Gordon Sinclair

N 13:35

GB 18/86

Minutes of both the Governing Body & Annual General meeting held on 26 September 2018 Purpose: To receive the minutes for approval

Gordon Sinclair Y 13:45

GB 18/87

Matters Arising Gordon Sinclair N


Purpose: To consider any matters arising that are not considered elsewhere on the agenda

GB 18/88

Action Log Purpose: To review the outstanding actions


RISK GB 18/89

Corporate Risk Register Purpose: To receive the corporate risks for review

Sabrina Armstrong

Y 13:55

GB 18/90

Governing Body Assurance Framework Purpose: To receive the Governing Body Assurance Framework for review

Sabrina Armstrong

Y 14:05

STRATEGY GB 18/91

Strategic Review Purpose: To receive a briefing in relation to the West Yorkshire & Harrogate STP, Leeds Health & Care Plan and CCG Strategy

Tim Ryley Y 14:15

COMMITTEE CHAIRS SUMMARIES GB 18/92

Primary Care Commissioning Committee – 27 September 2018 Purpose: To receive the summary for information and assurance

Sam Senior Y 14:30

GB 18/93

Audit Committee – 24 October 2018 Purpose: To receive the summary for information and assurance

Peter Myers Y

GB 18/94

Remuneration & Nomination Committee – 17 October 2018 Purpose: To receive the summary for information and assurance

Sam Senior Y

GB 18/95

Quality & Performance Committee – 14 November 2018 Purpose: To receive the summary for information and assurance

Stephen Ledger Y

COMMISSIONING & FINANCE GB 18/96

Integrated Quality & Performance Report (IQPR) Purpose: To receive the IQPR and consider any issues escalated by the Quality & Performance Committee

Tim Ryley / Jo Harding

Y 14:45

BREAK FOR 5 MINUTES GB 18/97

Finance Report Purpose: To receive the finance report for information

Visseh Pejhan-Sykes

Y 15:00


GB 18/98

CCG Financial Control, Planning and Governance Self-Assessment Purpose: To receive the assessment for information

Visseh Pejhan-Sykes

Y 15:10

GB 18/99

Chief Executive’s Report Purpose: To receive an update on key issues from the CCG’s Chief Executive

Phil Corrigan Y 15:15

GOVERNANCE GB 18/100

Policy Approval: i) Review of Operational Scheme of Delegation

Purpose: To receive the operational scheme of delegation for review ii) Procurement Policy Purpose: To receive the policy for approval iii) Standards of Business Conduct Purpose: To receive the policy for approval

Visseh Pejhan-Sykes Visseh Pejhan-Sykes Sabrina Armstrong

Y

Y

Y

15:30

GB 18/101

Questions from Members of the Public Purpose: To receive questions from members of the public

Gordon Sinclair N 15:40

GB 18/102

Forward Work Programme 2018/19 Purpose: To receive the programme and Committee Meeting dates for 2019/20

Gordon Sinclair Y

15:50

GB 18/103

Any Other Business Gordon Sinclair

N 15:55

Exclusion of the public - it is recommended that the following resolution be passed: "That representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest" GB 18/104

Confidential Minutes of the Governing Body held on 26 September 2018 Purpose: To receive the minutes for approval

Sam Senior Y 16:00

GB 18/105

Procurement Plan Update Purpose: To approve the updated procurement plan

Visseh Pejhan-Sykes

Y 16:05

GB 18/106

Integrated Urgent Care (IUC) Services for Yorkshire & Humber Purpose: To receive and note the process

Phil Corrigan Y 16:15


GB 18/107

Extraordinary Remuneration & Nomination Committee – 28 November 2018 Purpose: To consider the recommendations of the Remuneration & Nomination Committee held on 28 November 2018


ITEMS FOR INFORMATION IFI1i. Minutes of the West Yorkshire & Harrogate Joint

Committee – 4th September 2018 Purpose: To receive the minutes for information

Phil Corrigan

Y N/A

IFI1ii. EPRR Self-Assessment & Business Continuity Plan Purpose: To receive the self-assessment and business continuity plan for information

Sue Robins Y N/A

IFI1iii. Commissioning for Value Update Purpose: To receive the update for information

Tim Ryley Y N/A

Dates of Future Meetings: Wednesday 30 January 2019, 2pm Wednesday 27 March 2019, 2pm

Name Title RolePractice B

Code

Declared Interest- (Name of the

organisation and nature of business)Type of Interest

Is the interest

direct or

indirect?

Interest From Interest Until

Action Taken to Mitigate Risk

Angela Collins Lay Member for Patient

and Public Participation

Governing Body

Member

N/A Nil Declaration

Ben BrowningGP Member

Representative

Governing Body

MemberB86020 GP Partner at Lofthouse Surgery Financial Interest Direct

Declare any potential conflict of interest at

Governing Body/Board, sub committees and relevant

meetings


Representative

Governing Body

MemberB86020

Shareholder in Leodis Care Ltd (now a

dormant and non-trading company)Financial Interest Direct



meetings


Representative

Governing Body

MemberB86020 Member of Leodis LLP (Shell company) Financial Interest Direct



meetings


Representative

Governing Body

MemberB86020 Spouse is a GP Partner in Lofthouse surgery Financial Interest Indirect



meetings


Representative

Governing Body

MemberB86020

Spouse is city-wide lead for Learning

Disability servicesFinancial Interest Indirect



meetings Gordon Sinclair GP Partner / Clinical Chair Governing Body

Member

B86030 GP Partner at Burton Croft Surgery Financial Interest Direct Ongoing Declare conflict or perceived conflict within context

of any relevant meeting or project workGordon Sinclair GP Partner / Clinical Chair Governing Body

Member

B86030 Director of Sinclair Healthcare (Sole) Financial Interest Direct Ongoing Declare conflict or perceived conflict within context


Member

B86030 Partner of Viva Healthcare LLP Financial Interest Direct Ongoing Declare conflict or perceived conflict within context


Member

B86030 Headingley Pharmacy LLP – Viva Healthcare

has a 25% interest

Financial Interest Direct Ongoing Declare conflict or perceived conflict within context

of any relevant meeting or project work

Ian CameronSecondary Care

Consultant

Governing Body

MemberN/A Substantively employed by Leeds City Council Financial Interest Direct 01-Apr-16 Ongoing

To declare any conflict or perceived conflict and in

particular any decisions affecting joint working with

Leeds City Council including policy and resource

decisions

Jason Broch Assistant Clinical Chair Governing Body

Member

B86022 Partner Oakwood Lane Medical Practice Financial Interest Direct10.05.2012

Ongoing Declare any potential conflict of interest at


meetings Jason Broch Assistant Clinical Chair Governing Body

Member

B86022 Director Jemjo Healthcare Ltd Financial Interest Direct10.05.2012




Member

B86022 Spouse business Airtight International Ltd Financial Interest Indirect10.05.2012




Member

B86022 Spouse business Nails 17 Ltd Non-Financial Personal Interest Indirect10.05.2012




Member

B86022 Director Leeds Jewish free school Non-Financial Personal Interest Direct16.01.2014




Member

B86022 Director Brodetsky Primary School

Foundation

Non-Financial Professional

Interest

Direct17.06.2014




Member

B86022 Chair of Governor's Brodetsky Primary School Financial Interest Direct01.09.2012




Member

B86022 Founding Fellow of the Faculty of Clinical

Informatics

Financial Interest Direct01.05.2018



meetings

Governing Body Declarations (November 2018)

Jason Broch Assistant Clinical Chair Governing Body

Member

B86022 Gartner UK - Clinical Advisor Non-Financial Personal Interest Direct01.05.2018




Member

B86022 Oakwood Lane Medical Practice is a

shareholder of Calibre Care Partners Ltd (GP

Federation)


Interest

Direct01.05.2018




Member

B86022 Shareholder / Director Chapeloak

Investments Ltd


Interest

Direct15.02.2013




Member

B86022 Father’s business - Leeds Acupuncture Clinic Financial Interest Indirect10.05.2012 Ongoing




Member

B86022 General Practice work with IMH Group Financial Interest Direct13.06.18



meetings Joanne Harding Director of Nursing and

Quality

Governing Body

Member

N/A Nil Declaration

Julianne Lyons GP Member

Representative

Governing Body

Member

B86110 GP Partner at Leeds Student Medical Practice Financial Interest DirectOngoing



meetings Julianne Lyons GP Member

Representative

Governing Body

Member

B86110 Leeds Local Medical Committee Member Financial Interest DirectOngoing




Representative

Governing Body

Member

B86110 Spouse is a Director of Leeds Haematology

plc

Financial Interest IndirectOngoing




Representative

Governing Body

Member

B86110 Spouse is a trustee of the British Society for

Haematology


Interest

IndirectOngoing




Representative

Governing Body

Member

B86110 Spouse is a trustee of UK Myeloma Forum Non-Financial Professional

Interest

IndirectOngoing




Representative

Governing Body

Member

B86110 Spouse is an employee of the University of

Leeds





Representative

Governing Body

Member

B86110 Spouse has an honorary contract with Leeds

Teaching Hospitals NHS Trust





Representative

Governing Body

Member

B86110 Shareholder of Leeds West Primary Care

Limited

Financial Interest DirectOngoing



meetings

Keith MillerGP Member

Representative

Governing Body

MemberN/A GP Partner, Kirstall Lane Medical Centre Financial Interest Indirect 01-Jan-12 Ongoing

Keith MillerGP Member

Representative

Governing Body

MemberN/A

Spouse - Sarah Miller, Advanced Nurse

Practitioner, LTHTFinancial Interest Indirect Ongoing

Peter Myers Lay Member for Audit and

Conflict Matters

Governing Body

Member

N/A Director Finance Yorkshire Ltd Financial Interest Indirect 05/08/2015 Declare conflict or perceived conflict within context

of any relevant meeting or project workPeter Myers Lay Member for Audit and

Conflict Matters

Governing Body

Member

N/A Chairman of the Equine and Livestock

Insurance Group

Financial Interest Indirect 03-Aug-17 Unlikely to cause conflict due to nature of interest. If

conflict arises to declare and withdraw if a decision is

being taken.Phil Ayres Secondary Care

Consultant

Governing Body

Member

N/A I have established a coaching and facilitation

business for doctors and their teams. The

purpose of my business is to improve

effectiveness as leaders and professionals.

Financial Interest Direct

01-Oct-18 Ongoing Maintain awareness of potential influence over

decisions I may take as independent practitioner.

Abide by GMC code of conduct. Declare this interest

at relevant meetings.

Phil Ayres Secondary Care

Consultant

Governing Body

Member

N/A I have commenced a contract with Leeds

Community Healthcare in my business as

facilitator and coach.Financial Interest Direct

01-Nov-18 31/03/2019 Maintain awareness of potential influence over

decisions I may take as independent practitioner.

Abide by GMC code of conduct. Declare this interest

at relevant meetings.

Philomena Corrigan Chief Executive Governing Body

Member

N/A Trustee for the Foundation of Nursing Non-Financial Professional

Interest

Direct 01-Dec-15 Ongoing Declare any potential conflict of interest at


meetings

Sabrina ArmstrongDirector of Corporate

Services

Governing Body

MemberN/A substantively employed by NHS England Financial Interest Direct 01-Oct-14 Ongoing



meetings Sam Senior Lay Member for Primary

Care Co-Commissioning

Governing Body

Member

N/A Lay Member for Primary Care Bassetlaw CCG Financial Interest Direct 01-Sep-17 Ongoing Declare conflict or perceived conflict within context

of any relevant meeting or project workSam Senior Lay Member for Primary


Governing Body

Member

N/A Lay Representative National School of

Healthcare Science

Financial Interest Direct 01-May-16 Ongoing Declare conflict or perceived conflict within context



Governing Body

Member

N/A Lay Advisor Health Education England (West

Midlands)

Financial Interest Direct 01-May-16 Ongoing Declare conflict or perceived conflict within context



Governing Body

Member

N/A Patient and Public Panel Member - National

Institute Health Research

Financial Interest Direct 01-Apr-17 Ongoing Declare conflict or perceived conflict within context



Governing Body

Member

N/A Chairperson - Brampton United Junior

Football Club (S63 6BB)

Non-Financial Personal Interest Direct 01-May-13 Ongoing Declare conflict or perceived conflict within context

of any relevant meeting or project workSimon Stockill Medical Director Governing Body

Member

N/A Partner at Sleights and Sandsend Medical

Practice, Whitby (Hambleton, Richmondshire

& Whitby CCG)

Financial Interest Direct 01-Apr-16 Ongoing Declare conflict or perceived conflict within context


Simon Stockill Medical Director Governing Body

Member

N/A GP Appraiser, NHS England (Yorkshire &

Humber)

Financial Interest Direct 01-Dec-13 Ongoing Declare conflict or perceived conflict within context

of any relevant meeting or project workSimon Stockill Medical Director Governing Body

Member

N/A Clinical Lead for Quality Improvement Ready

Programme, Royal College of GPs

Financial Interest Direct 01-Sep-16 Ongoing Declare conflict or perceived conflict within context


Stephen LedgerLay Member for

Assurance

Governing Body

Member

N/A Nil Declaration

Sue Robins Director of Operational

Delivery

Governing Body

Member

N/A Nil Declaration

Tim RyleyDirector of Strategy,

Planning & Performance

Governing Body

Member N/A Nil Declaration

Visseh Pejhan-Sykes Chief Finance Officer Governing Body

Member

N/A Niece works for CCG as Digital

Communications Officer

Non-Financial Personal Interest Indirect 11-Dec-17 Ongoing Not to participate in any decisions which may affect

this post, e.g. cut budget

THIS PAGE IS INTENTIONALLY BLANK

1

Minutes NHS Leeds CCG – Governing Body Meeting

Wednesday 26 September 2018 1.00pm – 4.00pm

St George’s Centre, 60 Great George Street, Leeds, LS1 3DL

Members Initials Role Present Apologies

Dr Gordon Sinclair (Chair) GS Clinical Chair

Dr Jason Broch JB Assistant Clinical Chair

Dr Ben Browning BB Member Representative

Angela Collins AC Lay Member – Patient & Public Involvement

Philomena Corrigan PC Chief Executive

Jo Harding JH Director of Quality & Safety

Dr Stephen Ledger SL Lay Member – Assurance

Dr Julianne Lyons JL Member Representative

Dr Keith Miller KM Member Representative

Peter Myers PM Lay Member – Governance

Visseh Pejhan-Sykes VPS Chief Finance Officer

Samantha Senior (Deputy Chair)

SS Lay Member – Primary Care Co-Commissioning

Tim Ryley TR Director of Strategy, Performance &

Planning

Dr Phil Ayres PA Secondary Care Specialist Doctor

Dr Simon Stockill SSt Medical Director

Additional Attendees

Susan Robins SR Director of Operational Delivery

Dr Ian Cameron IC Consultant in Public Health Medicine

Sabrina Armstrong SA Director of Corporate Services

John Scott JS

Head of People & OD and Office Services

(until item 68)

Laura Parsons LP Head of Corporate Governance & Risk

Sam Ramsey (Minutes) SRa Corporate Governance Manager

Members of the Public Observing the Meeting - 3

2

No. Agenda Item Action

GB

18/60

Welcome and Apologies GS welcomed everyone to the Governing Body meeting. Apologies had been received on behalf of Peter Myers. The Chair confirmed that the meeting was quorate. GS formally welcomed Phil Ayres as a new member to the Governing Body.

GB

18/61

Declarations of interest Members were asked to raise any declarations of interest in relation to agenda items. With reference to item GB 18/68, Julianne Lyons declared a non-financial professional interest in terms of workforce due to her role as the lead GP for the Leeds Advanced Training Practice Hub. It was agreed that JL could remain in the room for the discussion in relation to this agenda item.

GB

18/62

Questions from Members of the Public The meeting was opened up to the public to take any questions they had at this stage. No questions were asked.

GB 18/63

Minutes from Previous Meetings GS presented the minutes from the NHS Leeds Governing Body meeting held on 25 July 2018 for approval. The Governing Body:

a) approved the minutes of the NHS Leeds Governing Body meeting held on 25 July 2018.

GB 18/64

Matters Arising There were no matters arising.

GB 18/65

Action Log The Governing Body reviewed the action log and noted the following updates: 18/40-3 - Workshop in relation to risk agenda has been scheduled onto the forward plan for Governing Body Workshop in December 2018. GS confirmed that all other actions had been completed.

GB 18/66

Corporate Risk Register SA presented the corporate risk register highlighting the current red risks on the register. Members noted that there were now three red risks on the register. This was an increase from two to three since the last report as a result of Risk 532 being split into three separate risks, to align with national reporting. Two of these risks retained a score of red 16 (Risk 679 and Risk

3


680). The Governing Body was asked to review the risks on the corporate risk register, including the controls and assurances from the committees.

The Governing Body noted that the financial risks had been reduced moving into the second half of the financial year. Members were asked to recognise that there was no assumption of a permanent reduction, but was a reflection of the start of the financial year and the current position. The Governing Body:

a) reviewed the corporate risk register and reviewed the controls, assurances and mitigating actions in place to manage the risks.

GB 18/67

Governing Body Assurance Framework (GBAF) SA presented the GBAF for the Governing Body to review, highlighting that the GBAF provides a structure and process to enable the CCG to focus on risks to achieving its strategic commitments and assurance that the adequate controls are in place to reduce these risks. Each risk had been reviewed and updated by the lead Director in advance of the Governing Body. The Committee noted that the risk associated with financial stability had been reduced based on an improved forecast position; however this was a temporary reflection on the longer term position. A query was raised in relation to risk 4 highlighting the need for clinicians and individual agendas to have a shared focus and what the CCGs mitigating risk would be to ensure providers are communicating with each other. Members acknowledged that through commissioning for outcomes the CCG should be clear on expected outcomes and goals which in turn would drive joint conversations. The Chair highlighted that this sits across both risks 4 and 7 in relation to the clinical engagement and their contribution. A further query was raised in relation to the current legal frameworks that can create barriers at a national level. Members recognised that there was no national solution and there would be a need to work through these and look at pragmatic solutions and develop these at a local level with a risk based approach. In relation to risk 5, PA was pleased to note the CCG position with regards to its intention to tackle health inequalities. The Governing Body:

a) received the Governing Body Assurance Framework.

GB 18/68

People & Organisational Development (OD) Strategy SA presented the People and OD Strategy, alongside John Scott, Head of People & OD, outlining the purpose to provide a framework for developing the

4


CCG and its staff. The strategy sets out how the organisation is expected to continue to change over the next three years and how staff are supported to deliver in this changing and developing environment. The strategy had been discussed at the Governing Body Workshop in August 2018 and the changes had been made to the document in line with the discussions held, particularly in relation to the 6 people ambitions and the 8 themes. SA highlighted to members that the language had been amended to be more inclusive and more explicit in terms of expectations of staff. The Governing Body was asked to approve the People & OD Strategy. Clarification was sought in relation to the inclusion of health and wellbeing of staff and supporting the diversity of staff. Staff networks were highlighted and the work of the Workforce and Diversity Group which meets 6 weekly. Members recognised the benefits of network groups, however due to the size of the CCG this may be a challenge but could be an option to be proactive in wider networks. Further information was sought in relation to the CCGs position as a responsible recruiter across the system and it was agreed that this would be reflected within the resourcing section of the strategy. It was agreed that the reworded section of the strategy in relation to these points would be shared with the Governing Body – ACTION. A query was raised in relation to volunteers, their development and where this fits within the strategy. Members acknowledged that the engagement team works specifically with the CCG volunteers; however it was noted to make reference to patient volunteers within the strategy. Members noted that provider organisations would have their own volunteer strategy. A further query was raised as to whether updates would be brought to Governing Body on achievements that had been made. This was acknowledged and thoughts would be made on the most appropriate way to present this. Members noted that this was an evolving document and approved the People and OD Strategy on the proviso that the amendments highlighted were made. The Governing Body:

a) approved the People & OD Strategy

GB 18/69

Committee Chair’s Summary - Primary Care Commissioning Committee – 26 July 2018 SS presented the Committee Chair Summary for the Primary Care Commissioning Committee held on 26 July 2018 for information. SS highlighted that a risk workshop would be taking place in advance of the Primary Care Commissioning Committee on 27th September to consider each

5


Primary Care risk so that the Committee had full clarity on each risk. The Governing Body: a) received the report.

GB 18/70

Committee Chair’s Summary – Quality & Performance Committee – 19 September 2018 SL presented the Committee Chair’s Summary for the Quality & Performance Committee held on 19 September 2018 for information. The Quality and Performance Committee raised the issue in relation to 52 week waits, however the Committee had been assured that Leeds CCG understood the issue and the data, and was working collaboratively across the system and with NHS England to manage reputational impact. Clear action plans are in place, however there was no assurance that these would deliver. SL informed the Governing Body of a proposal in relation to the future reporting for quality and performance. This would link to our strategic objectives, health outcomes and should help influence our planning and future commissioning intentions. The risk review process had been raised by members of the Quality & Performance Committee in relation to consistency when assessing risks. The Risk Manager would be working with teams on a scoring methodology and that there was further work to be done across teams. The Committee was pleased to see the significant process made in relation to autism and ADHD assessments. The Governing Body:

a) received the report.

GB 18/71

Integrated Quality & Performance Report (IQPR) TR presented the Integrated Quality & Performance Report (IQPR) and confirmed to members that this had been reviewed in detail by the Quality & Performance Committee. Members noted that in relation to 52 week waits, the target was unlikely to be achieved due to capacity issues within the current system. This would be challenging for NHS Leeds CCG. The Governing Body acknowledged the work done by Newton Europe in relation to Unplanned Care and was aware of the challenges faced over the next few months. In relation to IAPT, members noted that there is a medium to long term plan in relation to the procurement of a new service, however to address the current level of underperformance, a recovery plan had been implemented. SL raised

6


the discussion that had taken place at the Quality & Performance Committee in relation to access rates and that the Committee had been assured that there were plans in place to achieve an improvement of this over the next 6-12 months. It was also highlighted to the Governing Body that schools would soon have the ability to directly refer into the Mental Health service. Members were informed of a Never Event Workshop due to take place with LTHT on 4th October 2018. LTHT would present clinical details of never events that have taken place with a collective critical review and reflection. There was an open invitation to members of the Governing Body. A discussion took place in relation to 2 week waits for breast cancer referrals and the figures presented within the IQPR. Members were informed that the Planned Care team are working with LTHT to seek additional capacity where it is appropriate. A query was raised in relation to the figures and the delay in receiving these. Members were assured that informal figures were discussed on a regular basis, however the formal figures were on a retrospective basis to ensure they had been validated. A suggestion was made for the un-validated data to be presented to the Quality & Performance Committee and discussed in further detail for assurance on the most up to date figures. The Governing Body agreed that the Committee should consider both suspected and less suspicious referrals and also consider the delay in seeing patients to put the figures into context – ACTION. The Governing Body:

a) received and reviewed the IQPR dashboards; discussed the information and noted the current areas of underperformance.

GB 18/72

(a) Finance Report VPS presented the finance report for the five months to 31st August 2018. Members noted that for 2018-19, a risk reserve is held in order to mitigate slippage. The Governing Body noted that the financial risks had been reduced moving into the second half of the financial year. Members were asked to recognise that there was no assumption of a permanent reduction, but was a reflection of the start of the financial year and the current position. A query was raised in relation to QIPP and whether this was a reasonable trajectory. VPS informed members that some of the risk had been mitigated, however it was anticipated that QIPP targets totalling £25m may not be met, however there would be reserves in place to mitigate this. VPS provided further detail on commissioning plans and considering the financial outcomes of these. Members acknowledged the importance of ensuring the best value for the pound that we are investing and further work on commissioning intentions would be taken to the next Governing Body Workshop.

7


The Governing Body: a) noted the month 5 financial position; b) discussed, commented and highlighted actions required to progress

and report to the next meeting of the Executive Management Team. (b) Aligned Incentive Contract Update In relation to the progress of the Aligned Incentive Contract, a summary was provided as a mid-point of the year. The Committee noted that there had been more of a difference than anticipated in relation to change in behaviours and engagement. The Committee supported the extension of the arrangements for the 2019/20 contracting round. A query was raised in relation to the difference that it has made. Members were informed that it had enabled clinician time to be freed to give care to those who need it, and had brought forward ideas from clinicians on how to do things differently. There had been a breadth of engagement from staff and a number of schemes suggested. The monitoring of primary care was raised and whether there had been an increase in referrals. VPS confirmed that it had been a two-way discussion with primary care involved in the pathway conversations. Members requested that further opportunities outside of LTHT were explored to be able to model and understand this elsewhere across the system. This was noted by the Chief Finance Officer. The Governing Body: (a) noted the findings from the introduction of an Aligned Incentive Contract in Leeds at the mid-way point in the financial year; and (b) supported the extension of the arrangements for 2019/20 Contracting Round

GB 18/73

Chief Executive’s Report PC presented the Chief Executive’s Report highlighting the key areas within the report. Members were informed of the current engagement and consultation in relation to the Primary Care Mental Health service and the development of a diabetes strategy across the city. Members noted the current CQC local system review of health and social care in Leeds, with a particular focus on people over 65 years old. This would be a comprehensive process to include a full report at the end. The Governing Body would be kept informed throughout the process.

8


In relation to Mental Health, members acknowledged that the current Mental Health Strategy needs reshaping for the city. The Governing Body recommended that there is a need to reconsider the Mental Health Strategy including consideration of the mental health needs of the student population. The Governing Body:

a) received the Chief Executive’s report b) recommended NHS Leeds CCG to reconsider the Mental Health

Strategy including the consideration of the mental health needs of the student population

GB 18/74

West Yorkshire & Harrogate Health & Care Partnership Memorandum Of Understanding The Memorandum of Understanding for the West Yorkshire and Harrogate Health & Care Partnership was presented to the Governing Body for approval of the MOU and authorisation for the Chief Executive to sign the MOU. The Chair informed members that the MOU is to formalise working across the wider footing of West Yorkshire and Harrogate. PC provided a summary of the current situation and highlighted that the MOU is not a legal agreement but an agreement on how to work together, building on the work that had been done. The MOU provides a platform for a refresh of the Governance arrangements for the partnership. Members noted that the MOU had been through legal opinion to ensure the MOU was sound. The Governing Body acknowledged that 90% of what is done in Leeds is place based; however there are commitments to work together at a West Yorkshire level. A query was raised as to whether there would be any explicit risks by entering into the agreement and members recognised that there would be no risk only potential varied opinions across CCGs on specific policies. The Governing Body noted that the Local Authority had also approved and signed the MOU. A query was raised in relation to patient experience and patient care. Members were informed that there is a mechanism in place to monitor patient experience and that the four workstreams have in built patient experience. It was highlighted within the document that the definition of GP was General Practice and General Practitioner and could therefore cause confusion. PC noted and would feed back - ACTION A further query was raised in relation to Health & Wellbeing Boards and their involvement. PC informed members that the agreement with the Board is to continue to keep them informed and review. It was also highlighted that the Chairs of the Health & Wellbeing Boards meet.

9


The Governing Body noted that the remit and functions could change in the future if powers are delegated to ICSs from NHS England and NHS Improvement and further discussions would be required to take place at the Governing Body. The MOU was approved by the Governing Body and authorisation given to the Chief Executive to sign the MOU. The Governing Body: (a) approved the MOU; and (b) authorised the Chief Executive to sign the MOU

GB 18/75

CCG Delegation of Commissioning Function for a new model for management of Excess Treatment Costs SSt presented the report and highlighted to the Governing Body that CCGs have a responsibility via the Government’s mandate to NHS England to meet the costs of ETCs in relation to non-commercial research through normal commissioning arrangements. Members noted that CCGs are unable to delegate their commissioning functions to the National Institute for Health Research (NIHR) and LCRNs, however can delegate their functions to another CCG to exercise and for that reason, the Governing Body was requested to delegate the commissioning function for ETCs to NHS Bradford Districts CCG, the lead CCG for ETC commissioning for the Yorkshire and Humber LCRN region. The Governing Body: (a) approved the delegation of the commissioning function for ETCs to NHS Bradford District CCG.

GB 18/76

Policy Approval Overarching IFR Policy The Overarching IFR Policy was presented for approval and members noted that the policy had been updated and streamlined to be approved as an NHS Leeds CCG policy. SSt highlighted that the policy had now clarified the role of the designated decision maker who makes the final decision in relation to IFRs. A query was raised in relation to the training of decision makers, and SSt confirmed that specific training must take place including legal training and that a lay member was on the panel. VPS informed members that the policy had also been through legal review. The amended policy was approved by the Governing Body. The Governing Body:

a) approved the policy.

10


GB 18/77

Questions from Members of the Public The meeting was opened up to the public to take any questions they had at this stage. A query was raised from a member of the public in relation to the MOU agenda item and worries with regards to this in organisations holding each other to account. PC confirmed that the sovereignty of the Governing Body remains and therefore they cannot force decisions upon the CCG. The Chair highlighted that all partnerships do believe there would be a collective benefit, however overall we would still be place based. In relation to health inequalities, IC shared that it is the responsibility of workstream leads to highlight this issues and for programmes to articulate what can be done about health inequalities.

GB 18/78

Forward Work Programme 2018/19 The Governing Body’s work programme was presented for information. The Governing Body:

a) received the forward work programme.

GB 18/79

Any Other Business None noted.

Date of next meeting: 28th November 2018, 2.00 – 5.00pm

IFI1. For information i) Minutes of the West Yorkshire & Harrogate Joint Committee – 5 June 2018 The Governing Body received the minutes of the West Yorkshire & Harrogate Joint Committee held on 5th June 2018 for information ii) Strategic Review The Governing Body received a briefing in relation to the West Yorkshire & Harrogate STP and Leeds Health & Care Plan iii) Commissioning for Value Update The Governing Body received an update on the Commissioning for Value Framework and current schemes

Approved and signed by: Dr Gordon Sinclair, Clinical Chair, NHS Leeds CCG Date:

1

Minutes NHS Leeds CCG – Annual General Meeting (AGM)

Wednesday 26 September 2018 16:00 – 17:30

The Hemming Suite, St George’s Centre, 60 Great George Street, Leeds, LS1 3DL

Members Initials Role Present Apologies

Dr Gordon Sinclair GS Clinical Chair

Dr Jason Broch JB Assistant Clinical Chair

Dr Ben Browning BB Member Representative

Angela Collins AC Lay Member – Patient & Public Involvement

Philomena Corrigan PC Chief Executive

Jo Harding JH Director of Quality & Safety

Dr Stephen Ledger SL Lay Member – Assurance

Dr Julianne Lyons JL Member Representative

Dr Keith Miller KM Member Representative

Peter Myers PM Lay Member – Governance

Visseh Pejhan-Sykes VPS Chief Finance Officer

Samantha Senior SS Lay Member – Primary Care Co-Commissioning

Tim Ryley TR Director of Strategy, Performance &

Planning

Dr Phil Ayres PA Secondary Care Specialist Doctor

Dr Simon Stockill SSt Medical Director

Additional Attendees

Susan Robins SR Director of Operational Delivery

Dr Ian Cameron IC Consultant in Public Health Medicine

Sabrina Armstrong SA Director of Corporate Services

John Scott JS Head of People & OD and Office Services

Laura Parsons LP Head of Corporate Governance & Risk

Sam Ramsey SRa Corporate Governance Manager

Karen Lambe (Minutes) KL Corporate Governance Officer

Suzi Lofthouse SL Corporate Governance & Risk Administrator

Members of the public in attendance - 21

2

Item. Notes Action

1 Welcome & Introductions Gordon Sinclair (GS), Chair welcomed everyone to the meeting and proffered thanks to CCG staff, CCG member practices, volunteers and partners in external agencies who had supported the CCG throughout the merger.

2 Review of Achievements 2017-2018 Phil Corrigan (PC) provided an overview of the three CCGs for the previous year. All three CCGs had achieved a rating of ‘Good’ in the year 2017-2018. A video was shown which highlighted achievements to date. These included:

Cancer (ACE) – a pilot scheme identifying early stages of cancer in people in areas of deprivation;

Mental Health – support for people with dementia, e.g. 47 Memory cafes;

Primary Care – 7 day access and bowel cancer screening;

Successful bid for diabetes funding – aim to reduce amputations;

Patient Participation Groups (PPGs) – city-wide conference and developed network;

Social prescribing – addressing people with complex needs;

Winter preparedness – working with partners to discharge people quickly.

3 Financial Review 2017-2018 Visseh Pejhan-Sykes (VPS) presented a review of the finances of the three predecessor CCGs. All three had remained within their budgets, with 95% of creditors being paid within the required 90 days. Spending for the three CCGs 2017-2018 comprised:

Leeds West – £476.3m

Leeds North - £290.6m

Leeds South & East – £421.6m All three CCGs were reported as being financially viable. VPS stressed the opportunities that the merger had brought about, with regards to having a combined budget of £1.2bn and a single strategy.

4 Adoption of Annual Report and Accounts 2017 – 2018 GS presented the Annual Report and Accounts 2017-18 for adoption.

3

Item. Notes Action

5 Questions & Answers Attendees were invited to pose questions to the CCG’s Governing Body:

1. How does senior management ensure CCG engagement with the public?

Sabrina Armstrong (SA) explained that there was a CCG Engagement Team whose remit was to ensure this. Committee papers and reports were published on the CCG website and the Governing Body included a Lay member for Public & Public Involvement. PC added that, due to the challenge of engaging with certain key populations, faith and community groups had been contacted and acted as a conduit with the CCG. An attendee expressed concern that his group’s experience of communicating with the CCG had been mostly negative, when a large meeting was cancelled with one hour’s notice. PC apologised for this experience and encouraged the group to continue to work with the CCG.

2. How are health inequalities to be addressed, given that Leeds has the worst infant mortality rate in the UK?

Ian Cameron (IC) stressed that levels of infant mortality in Leeds had been a concern ten years earlier when they had dropped below the national average, but that this was no longer the case. He highlighted the need to continue focussing on the first two years of life with Best Start.

3. How is social prescribing being developed and what does it include? PC explained how social prescribing recognised and addressed some of the root causes of ill health, such as redundancy, alcohol abuse and depression. She described how a case worker would engage with an individual and, working with different agencies, help them to set individual goals, rather than health professional goals. PC stressed that the evaluation had focussed on case studies and had been very positive. £2.5m had been invested in the scheme, which was bespoke and local.

4. Given limited financial resources, what are the priorities for Leeds CCG?

PC identified poverty and employment as key priorities which were being addressed by Leeds City Council’s social inclusion and growth programme.

4

Item. Notes Action

Other priorities included children’s mental and physical health as well as the need to focus on achieving parity between mental and physical health. PC stressed the need to improve the health of the poorest fastest.

5. What has been the net effect on staffing resources since the merger of the three CCGs?

VPS explained that, following the redeployment of CCG staff, the target of a 20% reduction in running costs will be achieved by April 2019.

6. Given the cost to hospitals of admitting patients who have been medicating incorrectly, are pharmacy checks being carried out and are they being monitored?

Simon Stockill (SS) shared that GPs work with pharmacists to ensure cost effective prescribing and correct self-medication for people. He added that indicators suggested that Leeds was performing very well in terms of expenditure and cost effectiveness.

7. An attendee acknowledged the local networks and social prescribing as beneficial to mental health provision.

PC informed the meeting that the CCG’s Mental Health strategy had expired and a new strategy was in development. She identified Improving Access to Psychological Therapies (IAPT) as the nationally mandated point of referral for mental health and anticipated that the new model would address the gaps in current provision. There would be increased focus on suicide prevention strategies, community provision for people in dementia wards and better provision for a broader range of people than was currently on offer. PC added that a community strategy was required to address the problem of too many people staying for unnecessarily long periods of time in hospital. She welcomed community input into the strategy.

8. When would the consultation be completed for primary care mental health?

PC responded that the consultation would end in two weeks and the findings would be presented.

5

Item. Notes Action

9. Given that the rollout of Universal Credit is imminent, what are the related health issues?

IC identified child poverty as being inherent in health inequalities. He acknowledged the negative reports of Universal Credit and felt that the rollout would require careful monitoring.

10. The Burmantofts Health Centre building is not fit for purpose. Despite funding being agreed some time ago, nothing has happened and services are being removed.

GC explained that, while funding had been agreed in principle, the business case for the practice needed to be further developed. She acknowledged the challenges for the practice, but emphasised how Leeds Council and the CCG are committed to its redevelopment as a community hub with expanded services. GC expected the case to be agreed by the end of the year.

GS thanked all for their questions and contributions to the meeting. The AGM closed at 5.50pm.

MINUTES ACTION LOG – GOVERNING BODY

1

ITEM NO:

ACTION NO:

ACTION: ACTION BY: COMPLETED/UPDATE

25 July 2018

GB

18/40

3 Workshop to take place for Governing Body members in relation to the risk agenda, specifically on strategic level risks and operational risks

GS/SA/LP Complete. On forward plan for December workshop.

26 September 2018

GB 18/68

1 People & OD Strategy Highlighted the need to demonstrate responsible recruiter across organisations. Agreement to be explicit in strategy under resourcing section. Reworded section of strategy to be shared with Governing Body.

SA/JS Complete. Reworded strategy circulated to Governing Body members for information.

GB 18/71

1 IQPR Further detailed data requested to go to Quality & Performance Committee in relation to 2 week wait for breast referrals. Most up to date data (not validated) to be taken to Q & P Committee for discussion.

SL/SR Complete. Quality & Performance Committee to receive data for discussion and feed back to November Governing Body meeting as part of the Action Log agenda item.

GB 18/73

1 Chief Executives Report Governing Body recommendation to reconsider the Mental Health Strategy including consideration of the mental health needs of the student population.

PC

In progress. To be updated through Chief Executive.

GB 18/74

1 WY&H Memorandum Of Understanding Definition of GP is stated both General Practice and General Practitioner and therefore causes confusion. PC to raise this at West Yorkshire level.

PC Complete.

1

Leeds Health & Wellbeing Strategy Outcomes – that this report relates to:

1. People will live longer and have healthier lives

2. People will live full, active and independent lives

3. People’s quality of life will be improved by access to quality services

4. People will be actively involved in their health and their care

5. People will live in healthy, safe and sustainable communities

NHS Leeds CCG Strategic Commitments We will focus resources to:

1. Deliver better outcomes for people’s health and wellbeing

2. Reduce health inequalities across our city

We will work with our partners and the people of Leeds to:

3. Support a greater focus on the wider determinants of health

4. Increase their confidence to manage their own health and wellbeing

5. Achieve better integrated care for the population of Leeds

6. Create the conditions for health and care needs to be addressed around local neighbourhoods

Assurance Framework – which risks on the GBAF does this report relate to: 1. Inadequate patient and public engagement results in ineffective decisions and challenge

2. Failure to assure the delivery of high quality services, leading to commissioned services not reflecting best practice and improving care

3. Failure to achieve financial stability and sustainability

4. Lack of provider and clinical support for change will impact on the development and implementation of the CCG strategy

5. Resources are not targeted effectively to areas of most need, leading to failure to improve health in the poorest areas

6. Insufficient workforce capacity, capability and adaptability to deliver the ambitions

7. Failure to enable partners to work together to deliver the CCG commitments

8. Failure of system to be adaptable and resilient in the event of a significant event

Agenda Item: GB 18/89 FOI Exempt: N


Date of meeting: 28 November 2018

Title: Corporate Risk Register November 2018

Lead Governing Body Member: Sabrina Armstrong, Director of Corporate Services

Category of Paper Tick as

appropriate

()

Report Author: Anne Ellis Playfair, Risk Manager

Decision

Reviewed by EMT/SMT/Date: by email 25 October 2018

Discussion

Reviewed by Committee/Date: Quality & Performance Committee 14 November 2018

Information

Checked by Finance (Y/N/N/A - Date): N/A

Approved by Lead Governing Body member (Y/N): Y

2

EXECUTIVE SUMMARY: The CCG uses Datix as an internal risk management system which enables risks to be recorded and managed by all members of staff. Risks are aligned to the appropriate CCG committee for overview and scrutiny. The risks are included on the CCG operational risk register and reviewed within individual directorates and by the executive management team. As per the CCG risk management strategy, all risks at a score of 12 and above are presented to the relevant CCG committee for review and assurance. Assurance on areas of concern is reported from the CCG committees to the Governing Body via the CCG committee chair report. The Governing Body receives the Corporate Risk Register (all red risks scored at 15 and above) for review at each meeting and is supported by the CCG committee chair updates. The CCG Governing Body Assurance Framework is presented as a separate agenda item. There are currently 60 active risks on the CCG risk register, three of which have been escalated to the CCG Corporate Risk Register as they have a score of red 16. There is no change to the Corporate Risk Register since the last report to the Governing Body in September 2018. Red risks (Corporate Risks) Risk ID

Risk Title Current Risk Score (LxI)

Risk Movement in last 12 months

Current Position

339 Cancer Underachievement of 62 day urgent GP referral to treatment standard overall at LTHT.

16 (4x4)

Static Performance has deteriorated in recent months for a variety of reasons. The main issue has been the increase in patients requiring treatment for prostate cancer, following a surge in prostate referrals. Although LTHT has increased slightly its surgical capacity, because the preferred treatment is robotic, there is a very limited ability to create additional slots in sufficient numbers to pull back performance.

679 RTT – Incomplete Pathway (number of patients waiting)

16 (4x4)

Added 24/8/18 (Split out from Risk 532)

May be difficult to achieve because LTHT’s total waiting list size was at its lowest point in March 2018 following significant redesign work. All teams have been focusing on inpatients during summer and then outpatients in winter months which are higher volume. Some growth is seasonal (e.g. dermatology) and will reduce when demand goes down in the Autumn.

680 RTT – 52 Week Waits

16 (4x4)

Added 24/8/18

Key risk areas are colorectal surgery and spinal surgery. There is some improvement

3

(Split out from Risk 532)

on colorectal surgery, but spinal surgery capacity is very problematic. NHSE is brokering a regional approach to trying to identify further capacity, particularly for the most complex patients who need treatment at a specialist centre. Independent Sector capacity is now being fully utilised but is not suitable for the majority of patients due to complexity of patients or procedure. Discussions are underway with Calderdale and Huddersfield NHS Foundation Trust (CHFT) and some other providers in the Midlands and elsewhere. Progress is being made on the other pathways with small numbers of over 52 week waiters remaining and reductions in over 38 weeks (mainly paediatric and mainly NHSE commissioned).

The Corporate Risk Register can be found at Appendix 1 and provides a summary of the current controls and assurances in place to mitigate each risk. The risk score for one red risk (339) has remained static over the last 12 months; the consistency of risk scores and effectiveness of actions to manage risks is being reviewed by CCG Teams and Risk Owners, supported by the Risk Manager. The Governing Body is asked to review the risks on the Corporate Risk Register, including the controls and as the supporting information from the committees which can be found within the committee assurances, as well chair summaries. Whilst some areas of performance and quality are not in line with agreed targets there is reasonable mitigation and action being taken to rectify the issues as well as established risk management systems and processes in place within the CCG.

NEXT STEPS:

All risks will be reviewed as per the bi-monthly cycle in accordance with the CCG risk management strategy and presented to the assigned committee for review.

Work is underway to review the consistency of the application of the risk scoring methodology and this will feed into the risk reporting cycle.

The Corporate Risk Register will be presented to the CCG Governing Body at each meeting.

RECOMMENDATION: The Governing Body is asked to:

a) REVIEW the Corporate Risk Register; and b) REVIEW the controls, assurances and mitigating actions in place to manage the risks

and confirm if any further assurance or action is required.

ID

Rev

iew

dat

eTitle Description Secondary Risks

Co

nse

qu

ence

(in

itia

l)

Like

liho

od

(in

itia

l)

Rat

ing

(in

itia

l)

Controls Gaps in controls

Co

mm

itte

e

Res

po

nsi

ble

Acc

ou

nta

ble

Dir

ecto

r

Man

ager

Costs Assurance Gaps in assurance Current Position

Co

nse

qu

ence

(cu

rren

t)

Like

liho

od

(cu

rren

t)

Rat

ing

(cu

rren

t)

67

9

10

/10

/20

18

RTT - Incomplete

Pathway (number of

patients waiting)

Failure to maintain or

improve total waiting list

size from March 2018

position

Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t

wee

kly.

Lik

ely

to o

ccu

r.

16

Clearance plans developed for highest volume

specialties

Qu

alit

y an

d P

erfo

rman

ce

Co

mm

itte

e

Susa

n R

ob

ins

- D

irec

tor

of

Co

mm

issi

on

ing

Lew

is,

Hel

en

Agreed as part of

contract

Monthly update at joint LTHT

/CCG Elective Care Working

Group to review progress and

identify any further actions that

can be taken by CCGs

May be difficult to achieve because LTHT total WL size at lowest point in March 18

following significant redesign work. All teams focusing on inpatients during summer and

then outpatients in winter months which are higher volume. Some growth is seasonal

(e.g. dermatology) and will reduce when demand goes down in the Autumn. Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t

wee

kly.

Lik

ely

to o

ccu

r.

16

68

0

10

/10

/20

18

RTT - 52 Week

Waits

Failure to at minimum

halve the numbers of

patients over 52 weeks

from March 18 to March

19 and to reduce as far

as possible below that.

Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t w

eekl

y.

Like

ly t

o o

ccu

r.

16

Managed through internal LTHT processes

overseen by Planned Care working group

subgroup of Contract Management Board

Qu

alit

y an

d P

erfo

rman

ce

Susa

n R

ob

ins

- D

irec

tor

of

Co

mm

issi

on

ing

Lew

is,

Hel

en

Agreed as part of

contract

Monthly update at joint LTHT

/CCG Elective Care Working

Group to review progress and

identify any further actions that

can be taken by CCGs

unable to control

availability of

services at other

providers,

particularly in the IS

Key risk areas are colorectal surgery and spinal surgery. There is some improvement on

colorectal surgery, but spinal surgery capacity is very problematic. NHSE is brokering a

regional approach to trying to identify further capacity, particularly for the most complex

patients who need treatment at a specialist centre. Independent Sector capacity is now

being fully utilised but is not suitable for the majority of patients due to complexity of

patients or procedure. Discussions are underway with CHFT and some other providers in

the Midlands and elsewhere. Progress is being made on the other pathways with small

numbers of over 52 week waiters remaining and reductions in over 38 weeks (mainly

paediatric and mainly NHSE commissioned)

Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t w

eekl

y.

Like

ly t

o o

ccu

r.

16

33

9

10

/10

/20

18

Cancer under

achievement of 62

day urgent GP

referral to

treatment standard

overall at LTHT

Cancer waiting times -

under achievement of

overall performance 62

days urgent GP referral

to treatment of all

cancers, LTHT total.

Failure to deliver NHS

Constitution standards

required nationally. Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t d

aily

.

Mo

re li

kely

to

occ

ur

than

no

t.

20

LTHT have weekly Access Meetings to monitor. All

patients tracked and clinically prioritised. Reports

received by LTHT Cancer Board.

Limited ability to influence

pathways in referring trusts,

leading to higher proportions of

patients referred later than day

38.

Qu

alit

y an

d P

erfo

rman

ce

Co

mm

itte

e

Susa

n R

ob

ins

- D

irec

tor

of

Co

mm

issi

on

ing

Lew

is,

Hel

en

We await conclusion

of national work on

breach allocation.

Performance monitored monthly

at Elective Care Working Group

and actioned appropriately. LTHT

has a Cancer Board to oversee

delivery of recovery plans.

reporting to LTHT Trust Board.

West Yorkshire actions being

developed.

Performance has deteriorated in recent months for a variety of reasons. The main issue

has been the very big increase in patients requiring treatment for prostate cancer,

following a surge in prostate referrals. Although LTHT has increased slightly its surgical

capacity, because the preferred treatment is robotic, there is a very limited ability to

create additional slots in sufficient numbers to pull back performance.

Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t w

eekl

y.

Like

ly t

o o

ccu

r.

16

1


























Title: Governing Body Assurance Framework



appropriate

()

Report Author: Anne Ellis Playfair, Risk Manager

Decision

Reviewed by EMT/ Date: by email 25 October 2018

Discussion

Reviewed by Committee/Date: N/A

Information



2

EXECUTIVE SUMMARY: 1. The Governing Body Assurance Framework (GBAF) provides a structure and process

that enables the CCG to focus on the principal risks to achieving its strategic commitments and be assured that adequate controls are operating to reduce these risks to acceptable levels (the risk appetite).

2. The GBAF format enables the Governing Body to review each of the risks, analyse the controls and assurances, clearly identify any gaps and the actions needed to address them. The graph illustrates the movement of the risk score throughout the year in relation to the risk appetite. Risk appetite is the total impact of risk the CCG is prepared to accept in pursuit of its strategic objectives and has been agreed for each risk. The format has been amended to separate out internal and independent assurances and to align to the internal audit plan for 2018/19.

3. As part of the review cycle, each of the principal risks have been reviewed and updated

by the director leads. Updates made since the previous version are highlighted in bold italics.

4. There are currently a number of risks in which the CCG is operating above the agreed risk appetite. For these risks a number of mitigating actions have been identified and once implemented, the risk level should reduce to the level of risk appetite the CCG has agreed to tolerate.

NEXT STEPS: 5. The Governing Body will continue to review the GBAF at each meeting and directors will

continually monitor and update their risks accordingly.


a) RECEIVE the Governing Body Assurance Framework.

1

Governing Body Assurance Framework (GBAF) 2018-2019

Introduction

The Governing Body Assurance Framework (GBAF) sets out how the CCG will manage the principal risks to delivering the strategic objectives. The GBAF enables the Governing Body to corporately assure itself (gain confidence, based on evidence). The framework aligns risks, key controls and assurances alongside each objective.

Where gaps are identified, or key controls and assurances are insufficient to reduce the risk of non-delivery, action needs to be taken. Planned actions will enable the Governing Body to monitor progress in addressing gaps or weaknesses and to ensure that resources are allocated appropriately. Governing Body responsibility for the GBAF

It is for the Governing Body to:

Establish strategic objectives.

Identify the principal risks that threaten the achievement of these aims.

Identify and evaluate the design of key controls intended to manage these principal risks.

Set out the arrangements for obtaining assurance on the effectiveness of key controls across all areas of principal risk.

Evaluate the assurance across all areas of principal risk.

Identify positive assurances and areas where there are gaps in controls and / or assurances

Put in place plans to take corrective action where gaps have been identified in relation to principal risks.

Maintain dynamic risk management arrangements including a well-founded risk register.

Assurance

The GBAF provides the basis for the preparation of a fair and representative Annual Governance Statement. It is the subject of annual review by both Internal and External Audit. CCG Commitments: We will focus our resources to -

Deliver better outcomes for people’s health and well-being

Reduce health inequalities across our city

We will work with our partners and the people of Leeds to -

Support a greater focus on the wider determinants of health

Increase their confidence to manage their own health and well-being

Achieve better integrated care for the population of Leeds

Create the conditions for health and care needs to be addressed around local neighbourhoods

Appendix 1

2

Summary of strategic risks

Ref Risk to delivering the CCG commitments Initial Score

Current Score

Risk appetite Key changes since last review

1 Inadequate patient and public engagement results in ineffective decisions and challenge 20 4 4

No change to current score. Mitigating actions updated.

2 Failure to assure the delivery of high quality services, leading to commissioned services not reflecting best practice and improving care

20 8 8 No change to current score. Mitigating actions not yet due.

3 Failure to achieve financial stability and sustainability

20 12 8 No change to current score.

4 Lack of provider and clinical support for change will impact on the development and implementation of the CCG strategy 16 12 8

No change to current score. Additional controls and assurances added. Mitigating actions updated.

5 Resources are not targeted effectively to areas of most need, leading to failure to improve health in the poorest areas

20 16 12 No change to current score. Mitigating actions not yet due.

6 Insufficient workforce capacity, capability and adaptability to deliver the ambitions

16 12 9 No change to current score. Additional controls and assurances added. Mitigating actions updated.

7 Failure to enable partners to work together to deliver the CCG commitments

9 9 4 No change to current score. Mitigating actions updated.

8

Failure of system to be adaptable and resilient in the event of a significant event 20 16 8

No change to current score. Mitigating actions updated.

3

Risk 1: Inadequate patient and public engagement results in ineffective decisions Lead Director/risk owner: Sabrina Armstrong, Director of Corporate Services

Relevant commitments: All Date last review: October 2018

Risk Rating (likelihood x consequence) Initial score: 5 x 4 = 20 Current score: 1 x 4 = 4 Risk appetite: 1 x 4 = 4

Rationale for current risk score: All appropriate controls are in place to plan and deliver effective patient and public involvement (PPI). However the consequence of these controls failing has the potential to result in challenge and ultimate referral by Scrutiny board to judicial review. This would impact on the CCG’s reputation as well as delaying

any proposed changes. Rationale for risk appetite: It would not be possible to reduce the risk to a score lower than 4. This is due to the potential consequence of a control failure supplemented by circumstances outside our control.

Controls (what are we currently doing about the risk?):

Remit to CCG volunteer panel (PAG) to provide assurance around engagement

and/or consultation plans. Volunteer panel in place.

Significant and major engagement/consultation plans taken to Scrutiny Board for

discussion and approval to proceed.

CCG has recruited further expertise to the engagement team – a full complement of

staff in place.

The engagement plan template includes the Equality Impact Assessment to identify

impact on protected characteristics and discrete communities.

Contract with Voluntary Action Leeds (VAL) to undertake asset-based engagement in

harder to reach/engage communities. VAL are continuing to recruit to their volunteer

Health Champions.

Monthly VAL contract meetings and VAL KPIs reviewed quarterly.

CCG has a lead role in continuing to develop the citywide engagement hub which

includes engagement colleagues from provider teams.

CCG works closely with Healthwatch as part of the People’s Voice network.

Communications and engagement incorporated into Commissioning for Value (CfV)

template.

CCG community network continues to grow.

Quarterly communications and engagement reports published and shared.

Annual PPI review published in July 2018.

Mitigating actions (what more should we be doing?):

Action Owner Due by

Awareness training commissioned for CfV Board and commissioners on statutory duties; delivered by the Consultation Institute

Communications and Engagement Team

Complete

Assurances (how do we know if the things we are doing are having an impact?): Internal Assurance

Evaluation reports written and provided to commissioning teams to incorporate in their plans and influence service change.

Reports published on the CCG website and shared with members of the public who expressed an interest for further detail: ‘You said, we did’.

Regular liaison with, and attendance as appropriate at, Scrutiny Board to support commissioning colleagues.

Independent Assurance

‘Green’ assessment rating for PPI from NHS England in 2017 (latest rating).

Most recent internal audit assured and rated ‘green’.

An internal audit of Stakeholder Engagement is in progress.

Gaps in assurances (what additional assurances should we seek): Ongoing awareness raising throughout the CCG about statutory duties in relation to patient and public engagement.

Additional Comments:

Link to Risk Register: 656 – Patient & Public Involvement in Primary Care (4 – green)

0

10

20 CurrentScore

RiskAppetite

4

Risk 2: Failure to assure the delivery of high quality services, leading to commissioned services not reflecting best practice and improving care Lead Director/risk owner: Jo Harding, Director of Quality & Safety

Relevant commitments: All Date last review: October 2018

Risk Rating Initial score: 4 x 5 = 20 Current score: 2 x 4 = 8 Risk appetite: 2 x 4 = 8

Rationale for current risk score: The CCG has in place quality standards, and measures quality outcomes via a range of methods and processes to assure the quality of care we commission for our patients. Rationale for risk appetite: A risk appetite of 8 has been applied to this risk as the CCG aims to minimise the likelihood of the risk occurring but the consequence of failure remains high due to the potential impact on patients.


Quality Surveillance tool is being utilised across the CCG (including primary care) to monitor quality and performance of our providers enabling the CCG to identify issues and offer additional support at an early stage to ensure service improvements

Commissioning for Quality and Innovation (CQUIN) framework in place to incentivise providers for quality improvement and includes contract penalties where performance fails

Clear national and local quality expectations and standards agreed and included in contracts

Contractual requirement for providers to provide regular quality performance reports on key quality, safety and experience measures

Bi-monthly CCG Patient Insight Group (PIG) to monitor and review patient experience. Themes and trends identified and actions taken ensuring intelligence supports service improvements and commissioning decisions

Process developed and supporting measures in place to seek assurance on and assess quality impact of provider Cost Improvement Plans

Joint clinical quality review groups held with providers to receive reports on and assess standards of quality, supported by robust system and method of review and challenge

Annual assurance required from providers that Cost Improvement Proposals have been assessed for impact on quality and signed off by provider medical and nursing directors

Quality Impact Assessment tool incorporated into Commissioning for Value toolkit to ascertain risk of commissioning/decommissioning decisions.

Establishment of joint city wide health and local authority care home group to support quality improvement and introduction of supporting and joint processes as outlined in the care home protocol.

Safeguarding Key Performance Indicators and Safeguarding Standards Framework developed to monitor performance of provider organisations in terms of both safeguarding children and adults at risk.

A GP Safeguarding Standards Framework has been developed to monitor annually the performance of primary care in terms of both safeguarding children and adults at risk.

Oversight of Serious Incidents via STEIS and DATIX.


Action Owner Due by

Annual quality visit schedule programme for all providers, including pathway reviews

Head of Quality

August update: Schedule and process drafted. to be presented to Quality and Performance Committee in November


Joint Clinical Quality Review Groups review key quality requirements, expectations and performance requesting remedial action plans where required using a systematic and robust methodology of review and challenge

Primary Care Quality Surveillance group monitors key quality performance information and standards of quality of primary care provision, monitoring remedial action plans where required

Director of Quality and Safety attends West Yorkshire Quality Surveillance Group (QSG) where oversight of quality across West Yorkshire is discussed

Contract Management Board receives quality update briefing from Providers identifying any key areas of concern/under performance and associated remedial actions.

Integrated Quality and Performance Report, including all pathways and primary care, is reported to the CCG Quality and Performance Committee with highlights and exceptions then reported to the Governing Body

Reporting of all providers under enhanced surveillance to the Quality and Performance Committee

Robust governance structure in place within the CCG provides assurance on the quality of services to Governing Body

Safeguarding Team review and monitor the GP Safeguarding Standards Framework on an annual basis, providing advice and support where practices are non-compliant.

Safeguarding Team attend Clinical Quality Review Groups to review and gain assurance in respect of Quarterly Key Performance Indicators and the Annual Safeguarding Standards Framework which includes Section 11 assurance regarding provider safeguarding children responsibilities.

Safeguarding Team is cited on all safeguarding DATIX reports and Serious Incidents. Independent Assurance

CQC inspection programme – reports and action plans are monitored via provider quality meetings

Internal audit of quality information and assurance processes identifies gaps in assurance

Internal audit of Individual Funding Requests provided High assurance.

Gaps in assurances (what additional assurances should we seek):

Review of Quality and Equality Impact Assessment across West Yorkshire and Humber

Additional Comments: Planned internal audits in 2018/19:

Safeguarding (Q4)

Patient Experience (Q4)

Continuing Healthcare (Q4)

Personal Health Budgets (Q3)

Performance Management (Q3)

Link to Risk Register: 576 – Delivery of Patient Advice and Liaison Service to patients in Leeds (6 – amber) 660 – Delivery of high quality primary care services (9 – amber)

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Risk 3: Failure to achieve financial stability and sustainability Lead Director/risk owner: Visseh Pejhan-Sykes, Chief Finance Officer

Relevant commitments: We will focus our resources to - Deliver better outcomes for people’s health and well-being

Reduce health inequalities across our city

Date last review: October 2018


Rationale for current risk score:

Failure to achieve financial stability could lead to a breach in our statutory duties and have an adverse effect on our local population. NHSE is increasingly concerned about rapidly deteriorating finances in CCGs where previously healthy year end projections have spiralled into deficit positions in-year, often due to a lack of scrutiny and understanding of the CCG’s underlying recurrent financial position under its Governance processes.

Whilst the CCG has a number of key financial controls and financial contingencies in place to monitor and deliver financial performance in 2018/19, it’s longer term financial stability is predicated either on the delivery of a significant QIPP programme, or a significant increase in allocations to around 5%+ per annum.

Projections of the CCGs financial plans into the next 5 years suggest that from late 2018/19 and thereafter, the CCG is facing significant financial pressures with cost reduction schemes still to be identified, evaluated and negotiated across the system

Rationale for risk appetite: Commissioners are facing significant and increasing risks from changes to NHS policy such as Transforming Care Partnerships,

as well as demographic challenges at a time where annual investment in the NHS is at its lowest. Our local acute provider has significantly ageing estates stock requiring at least £350m of investments to modernise and ensure that care can be provided in the most effective configuration conducive to patient care. There are simply not enough resources available in Leeds to meet all current needs and demands.

The rationale behind the reduced risk (post assessment of risk appetite) is that Leeds does have the option to consult on rationing the provision of healthcare – a measure that is already being implemented in other areas and Leeds is also making progress on risk alignment across the heath system to change clinical decisions that can improve system efficiency and reduce system costs.

Controls (what are we currently doing about the risk) Balanced Financial Plan for 2018/19 reviewed and accepted by NHSE and the Governing Body noting

contingencies and mitigation for 2018/19 financial balance More in depth and rigorous monthly financial reporting to budget holders, NHS England, the Governing Body

and executives Monthly contract information now extended to include primary care users of data Budgetary and governance control systems for identifying and controlling financial risks Detailed financial policies and budgetary control framework outlines responsibilities and ground rules Commissioning for Value Delivery Board to oversee delivery of QIPP Aligned Incentive Contract with main Acute Provider Regular CFO meetings across Leeds, West Yorkshire and Y&H Detailed scheme of delegation


Action Owner Due by

Developing all aspects of CCG Strategy and priorities including Strategic Estates and Provider landscape as part of funding and QIPP prioritisation process

Governing Body

Complete

5 year planning horizon process for the CCG to include potential and detailed spend reduction plans to be identified, evaluated, consulted on and implemented

Governing Body

March 2019


Monthly finance report to SMT, Audit Committee and Governing Body identifying any current financial risks

Prescribing finance position included in monthly finance updates Escalation of exception reports from Commissioning for Value Delivery Board to Governing Body Procurement Programme monitoring and delivery reporting Monthly budget reports are issued and discussed at budget holder meetings Budgetary control framework in place Scheme of financial delegation and detailed financial policies Lead commissioner monthly forecasts Financial impacts of primary care commissioning appear to be less significant at current stage of planning Independent Assurance

Internal and external audit reports provide high assurance (2017/18)

NHSE assurance meetings

Planned internal audits of financial systems and QIPP in Q3 2018/19.

Gaps in assurances (what additional assurances should we seek) :

Health and social care economy in Leeds is financially challenged and the magnitude of values involved in one of the largest “places” in the UK means that the challenge is of significant financial value (and potentially unmanageable) nationally and locally if the system spirals into deficit.

Within the context of the West Yorkshire and Harrogate Integrated Care System (ICS), Leeds is also one of only 2 places that remains in financial balance and is therefore shouldering the added burden of “propping up” other places by not drawing down on historical surpluses to ease in year financial pressures – albeit non-recurrently.

A shared control total for West Yorkshire and Harrogate does however offer potential (if delivered in its totality) to attract significant transformational resources into the ICS footprint which will benefit all parties to the ICS. Much of this is outside of Leeds’ control to deliver with the added potential burden of having to hold peers to account to ensure securing these funds in addition to “keeping our own house in order”.

The wider Leeds Health and Social Care system is also closely interlinked with the provider landscape potentially suboptimal in its current configuration to deliver the most cost effective and seamless care for service users in Leeds.

Additional Comments: The CCG has to reduce commissioning spend – some relates to areas of limited clinical value, others around more effective commissioning. Some decommissioning of services will need to be considered and this will be overseen by the Commissioning for Value delivery board. However, ownership of these decisions must clearly and visibly sit with the Governing Body. The risks associated with financial stability have been reduced based on an improved forecast position for 2018/19 for the CCG. However, risks still remain across Leeds and we await information around future allocations and revenue requirements for the CCG over the next 10 years – including the cost impact of Agenda for Change settlements for the NHS. The risk reduction is therefore a temporary reflection on the longer term position

Risk register: 609 – Primary Care Payments (4 – green) 550 – Achievement of QIPP (9 – amber) 643 – Continuing Healthcare Financial Pressure and risks (6 – amber) 311 – Learning Disabilities budget overtrade (12 – amber) 316 – Failure of financial IT systems (1 – green) 321 - Financial plans may not be aligned to organisational objectives and priorities (4 – green) 548 - Statutory Financial Duties (4 – green) 551 - Fraud and Corruption (6 – amber) 647 - IR35 Non Compliance (6 – amber) 648 - Risk of non-compliance with VAT rules (6 – amber) 649 - Suppliers/providers paid in advance (9 – amber)

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Risk 4: Lack of provider and clinical support for change will impact on the development and implementation of the CCG strategy Lead Director/risk owner: Tim Ryley, Director of Strategy, Planning & Performance

Relevant commitments: We will focus resources to -

Deliver better outcomes for people’s health and well-being Reduce health inequalities across our city

We will work with our partners and the people of Leeds to - Achieve better integrated care for the population of Leeds Create the conditions for health and care needs to be addressed around local

neighbourhoods.



Rationale for current risk score: Likelihood - through the Provider Partnership Board and supporting clinical strategy groups, there are strong arrangements in place to ensure strategic support and alignment between commissioning priorities and provider development. Whilst there is a positive reception among providers the greater engagement of clinicians and working through of the necessary detail still needs to take place. Consequence - the failure to gain support of all major providers will significantly limit a number of key objectives of the strategy in particular greater integration. Rationale for risk appetite: Provider support for the changes articulated in the CCG strategy is key to delivery. It is unlikely given the range of providers and number of clinicians involved that all opportunities for changes of direction or levels of engagement by one or more can be ruled out entirely and sustained vigilance and supportive action will be ongoing. Though as we work through detail and develop governance risk should further reduce. However, the move in Leeds from an individual organisational focus to system focus means that the development and implementation of the CCG strategy is equally dependent on the alignment of the CCG’s commissioning approach with the Local Authority.


Leaders of main provider organisations are engaged in the development of the CCG Strategic Plan. Regular discussions within the Partnership Executive Group between leaders of commissioning and provider organisations to ensure transparency and system alignment regarding strategic direction of travel as a system.

System Integration Team supporting and facilitating the Provider Partnership Board - a key objective of this group is to ensure provider alignment with commissioning priorities and act as a strategic partner to the Leeds CCG.

Proposal to formalise intra-provider governance arrangements through establishing Committees in Common – this will expedite decision making to respond to the CCG strategy more responsively.

System Integration Team leading key areas of strategy implementation, support for the GP Confederation and Commissioning of Outcomes for frailty – already supported by providers in the city and associated actions being implemented.

Co-production of Aligned Incentive Contract with LTHT reflects provider support to new approaches to contracting as part of wider commissioning strategy.

We have supported the establishment of a formal provider Committee-in-Common (CIC) involving LTHT, LYPFT, LCH and the GP Confederation.


Action Owner Due by

Need to develop further aligned incentive contracts across provider landscape

Visseh Pejhan-Sykes

April 2019

Provider greater clarity on how of strategy through delivery plan to provider greater detail and drive clarity on medium–term commissioning intentions

Tim Ryley October 2018

Further strategic utilisation of resources to create environment in which providers are actively encouraged to work together and innovate

Tim Ryley December 2019


Providers collectively choose to prioritise and focus on work that supports delivery of CCG Strategic Plan e.g. working collectively to deliver system outcomes

Increasing levels of trust between leaders of commissioning and provider organisations in Leeds. Commissioning and Provider leaders proactively engage with each other to inform decision making that will have a system impact.

Clinical and financial risks are shared and managed differently between the CCG and providers and also between providers

The Provider CIC work-plan aligning with the CCG Strategic Plan and Delivery Framework priorities. Independent Assurance

CQC system review feedback due in December 2019


Internal measures and milestones to measure the assurances described.

Additional Comments: Very good progress on reducing the risk with considerable controls in place. Still require a period of time to ensure new arrangements are being fully embedded and that system relationships strengthen further before risk within risk appetite.

Risk register: N/A

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Risk 5: Resources are not targeted effectively to areas of most need, leading to failure to improve health in the poorest areas Lead Director/risk owner: Tim Ryley, Director of Strategy, Planning & Performance

Relevant commitments: We will focus resources to -

Deliver better outcomes for people’s health and well-being Reduce health inequalities across our city



Rationale for current risk score: Commissioned services and programmes may not be designed in a way which meets the needs of groups who have poorer access to services, particularly preventive, proactive and primary care services. This could result in an increase in health inequalities with some patients receiving sub-optimal care and potentially poor patient experience outcomes. Most recent Public Health Annual Report has identified increased inequalities across the city, with more people living in the 10% most deprived wards. Rationale for risk appetite: This strategic aim is a significant challenge, particularly given reductions in funding across the public sector. As such, we need to work with partners to endeavour to make the difference, recognising that focusing CCG resources in the right areas, whilst challenging in itself, will only go so far.


CCG Strategic plan is grounded in the Health and Wellbeing Strategy and reflects the city Joint Strategic Needs Assessment (JSNA) & local health needs with a clear focus on reducing health inequalities.

Memorandum of Understanding in place between Leeds CCGs and Leeds City Council to deliver Public Health Healthcare Advisory Service (PHHCAS) with action plan.

CCG is an active member of the Health and Wellbeing Board and other partnership arrangements, e.g. Partnership Executive Group, Leeds Health and Care Plan.

Commissioning for value programme now established to understand how commissioning investments impact on finance, quality and health outcomes.

Primary Care Quality Improvement Schemes – funded on a weighted capitation (but no requirement for all practices to participate).

Joint data analysis team in place across Local Authority and CCG.


Action Owner Due by

Map all existing work to address health of the poorest the fastest and understand the impact

Nichola Stephens March 2019

Build in monitoring impact of actions taken into the IQPR

John Tatton

December 2018

Redesign approach to health inequalities impact assessment

Jo Harding

December 2018

Develop process for differential investments across the city to more effectively meet needs

Tim Ryley December 2018

Assurances (how do we know if the things we are doing are having an impact?): Internal Assurance PHHCAS MOU and annual plan documents and delivery against action plan is monitored at

meetings Regular public health reports to CCG reported every 6 months to CCC 2016 LWCCG PH Profile shows CCG priorities reflect population health needs

Independent Assurance: Internal audits of Business Case Procedures and Performance management are planned in Q3 2018/19; these will provide a level of independent assurance.


Mechanisms to monitor the impact of commissioning decisions on the health of the poorest need to be developed. These then need to be included in the IQPR.

Additional Comments: The CCG is at the early stages of actively implementing this strategic commitment and managing this risk. There is much work to do to build a full understanding of the impact of current work and how we will monitor and measure success.

Risk register: N/A

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Risk 6: Insufficient workforce capacity, capability and adaptability to deliver the ambitions Lead Director/risk owner: Dr Simon Stockill, Medical Director

Relevant commitments:

We will work with our partners and the people of Leeds to -

Achieve better integrated care for the population of Leeds Create the conditions for health and care needs to be addressed around local neighbourhoods.



Rationale for current risk score: Despite the actions taken, the availability of a current and future workforce supply within primary care remains a national issue. Rationale for risk appetite: Ensuring there is sufficient workforce capacity and capability across primary care and Local Care Partnerships is a complex issue that will require continuous strategic and operational focus. The opportunity to work with primary care ‘at scale’ should realise new benefits that are not currently available which should mitigate the overall risk profile.

Controls (what are we currently doing about the risk?): Primary Care Workforce:

A review of the workforce requirements to deliver The Leeds Health and Care Plan has been undertaken. The recommendations have been agreed by the Partnership Executive Group (PEG). This includes the establishment of the Leeds Health and Care Academy.

Investment linked to workforce planning and workforce development into general practice has been made through the Quality Improvement Scheme (QIS); national initiatives e.g. Time to Care; GP Access Fund; and transformation monies.

The CCG actively participates in the West Yorkshire and Harrogate STP workforce workstreams.

Implementation and reporting against GP Forward View (GPFV) workforce trajectories.

BDO commissioned to undertake a review of CCG workforce planning capacity and processes reporting to a newly established Primary Care Workforce Group chaired by Simon Stockill.

The role of the Leeds GP Confederation in relation to workforce planning and workforce development is being described as part of the ‘deliverables’ to be achieved through the transfer of resources to the Confederation.

The CCG is leading a programme of international GP recruitment on behalf of the STP. Vacancies identified for the international GP recruits.

New roles developing within general practice e.g. care navigation; pilot of emergency care practitioners; role of occupational therapists in primary

care pilot; shared roles across a number of practices.

Extended access delivery includes wider workforce and ways of delivering e.g. virtual appointments; pharmacists. Local Care Partnerships (LCPs):

Locality leadership teams are in place across 18 agreed LCP footprints, supported by the investment to release the leaders from clinical practice.

Investment has been made into general practice via the QIS focussed on collaborative working in localities.

The primary care development team has restructured and aligned to 18 LCP footprints and are actively supporting locality leaders.

The Leeds GP Confederation role in supporting the development of LCPs is being articulated as a ‘deliverable’ to be achieved through the transfer of resources to the Confed.

RAIDR dashboards are being developed at a locality level as well as at individual practice level.

Locality health profiles have been produced for each of the 18 LCP footprints to enable a service response based on local need.

Public health is developing locality ‘asset’ profiles for each LCP.

Leaders from adult social care; Leeds Community Healthcare; third sector; and community pharmacy are being identified for the 18 LCPs alongside the general practice leaders.

Leeds has been awarded £844k discretionary transformational funding via the West Yorkshire and Harrogate Integrated Care System for the purpose of accelerating progress in establishing primary care networks (LCPs in Leeds). This allocation will enable an increase in capacity to deliver.

PEG agreed to new leadership and governance arrangements for next phase of developing and delivering LCPs to include the following who will report progress to the newly formed Leeds Provider Integrated Care Collaborative: Clinical Executive Lead – Dr Chris Mills, Senior Executive Sponsorship – Thea Stein.

Tim Ryley to develop the commissioning framework for LCPs on behalf of the Integrated Commissioning Executive.


Action Owner Due by

PEG agreed to review the resources and capacity to develop and deliver LCPs as part of The Leeds Health and Care Plan.

Gaynor Connor

Complete

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Assurances (how do we know if the things we are doing are having an impact?): Internal Assurance Primary Care workforce:

Monitoring of the completion of workforce tool

Reporting against GPFV trajectories to NHS England

Local Care Partnerships:

Evidence of wider partners coming together in LCP meetings across the city.

General Practice locality leaders describing their involvement with wider partners in LCPs at the Leeds GP Confederation Strategic Board.

Strategic support for the LCP vision evident from PEG.

Gaps in assurances (what additional assurances should we seek):

Need to understand the new role for the Advanced Training Practice in Leeds as the Primary Care Workforce Training Hub.

Need increased return rate for the workforce planning tool from practices.

Need to understand the OD capacity required to deliver the necessary leadership training and to facilitate integrated ways of working across organisations in each LCP.

Independent assurance – consider requesting a review by internal audit

Additional Comments Ensuring we have the workforce to deliver a sustainable primary care today and a workforce to deliver a transformed primary care for tomorrow is hugely complex. The establishment of the Leeds GP Confederation brings new opportunity to engage with primary care ‘at scale’ and develop workforce initiatives for general practice across the city e.g. a local ‘bank’ for locum GPs; employment contracts that allow working across a locality; development and support programmes for newly qualified GPs. This is yet to be realised. Developing Local Care Partnerships as the way of delivering integrated local services as described in the Leeds Health and Care Plan is a massive transformational programme for the whole system.

Risk register: 651 – General Practice Workforce & Wider Models of Care (12 - amber) 657 – Capacity to support transformation (6 – amber)

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Risk 7: Failure to enable partners to work together to deliver the CCG commitments Lead Director/risk owner: Phil Corrigan, Chief Executive

Relevant commitments: All


Risk Rating (likelihood x consequence) 3 x 3 = 9 Current score: 3 x 3 = 9 Risk appetite: 2 x 2 = 4

Rationale for current risk score: Changing Governance arrangements across the health and social care economy both within Leeds and West Yorkshire may lead to failure to coordinate actions around shared priorities which could lead to omission or duplication of actions. There are risks around competing priorities between need for placed based services and support to local providers, and the requirement to work at Integrated Care System (ICS)/ West Yorkshire Sustainability and Transformation Partnership (STP) level. Rationale for risk appetite: To minimise this risk we need clear partnership arrangements to ensure all our joint plans are delivered.


Integrated Commissioning Executive (ICE) meetings and Partnership Executive Group meet on a monthly basis.

A new provider Committee in Common meets quarterly with representation from the Local Authority and 3rd sector. Memorandum of Understanding (MOU) for West Yorkshire signed and in place.

Aligned incentives contract in place with Leeds Teaching Hospitals NHS Trust (LTHT) which facilitates alignment of priorities.

Representatives from the GP Confederation attend the Leeds Health and Care Partnership Executive Board. Representation from the Local Authority invited to the Executive Management Team.


Action Owner Due by

Local: Terms of reference for the Committee in Common being developed. A review of health and social care integration is being undertaken by ICE. Aligned incentives contracting approach to be extended across providers and so strengthen alignment.

Phil Corrigan August 2018 Provider Committee in Common in place. The remaining action is superseded by the action below.

Local: A review of health and social care integration is being undertaken by ICE and a Commissioning Framework developed by November 2018. Aligned incentives contracting approach to be extended across providers and so strengthen alignment.

Phil Corrigan March 2019

Joint committee at West Yorkshire developing its role, ensuring Leeds CCG is represented and linked in to sub groups as appropriate. MOU for West Yorkshire will be presented to Governing Body for approval in September.

Phil Corrigan Complete


West Yorkshire minutes and issues are included in the CEO report to the Governing Body, Integrated Commissioning Executive (ICE) and Leeds Health and Care Partnership Executive Board. Issues are reported via the CEO to the Governing Body. The Health and Well Being Board reviews our collective progress every quarter. Independent Assurance An internal audit of Partnership Governance Arrangements is planned in Q3 2018/19


Provider Committee in Common will be reported to the Governing Body, via the CEO Report.

Additional Comments: N/A

Risk register: N/A

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Risk 8: Failure of system to be adaptable and resilient in the event of a significant event Lead Director/risk owner: Sue Robins, Director of Operational Delivery

Relevant commitments: All


Risk Rating (likelihood x consequence) 5 x 4 = 20 Current score: 4 x 4 = 16 Risk appetite: 2 x 4 = 8

Rationale for current risk score: The current capacity and system flow issues within Leeds are year round with particular slow down in patient flow seen during winter. A significant event can be a ‘rising tide’ or a one off event / epidemic, so the resilience mitigations and plans are wide ranging. Most resilience planning is done with other organisations especially Leeds City Council. Rationale for risk appetite: No system can plan for every eventuality, so residual risk will remain.


System Resilience Assurance Board (SRAB) supported by Operational Resilience Group

Engagement at West Yorkshire level with local resilience forum and West Yorkshire urgent care meetings

Leeds Plan has Urgent Care Rapid Response Programme

Surge and escalation plans in place and tested through exercises, plus training

Business continuity plans in place for providers as part of NHS contract, including General practices.

On call systems in all providers plus the CCG, linking to NHS England (NHSE) and region at times of pressure

Weekly situation report (sitrep) meetings across Leeds system planned from Nov 2018

Operational delivery meetings x3 week from Nov 2018

Leeds resilience plan in place - to support system flow.

Winter plans in place, includes primary care and public health / comms actions

Leeds urgent care strategy - in consultation and implementation during 2018/20


Action Owner Due by

Review of Leeds CCG Business Continuity Plan Team Business Impact Assessments are being collated and written into the plan. Testing of the plan can only be undertaken following its approval.

Debra Taylor-Tate

Sept 2018 Oct 2018 Nov 2018

Implement the Leeds resilience plan actions ( Newton Europe recommendations)

SRAB March 2019

Leeds Urgent Care strategy implementation - delivery of urgent treatment centres

Debra Taylor-Tate

Review - March 2019

Review of escalation and mutual aid arrangements

Debra Taylor Tate

Nov 2018

Self-assessment against national EPRR standards Being undertaken alongside the Business Continuity Plan.

Debra Taylor Tate

Sept 2018 Nov 2018


SRAB receives reports from across Leeds system - SRAB dashboard.

Leeds resilience plan has agreed x12 metrics to demonstrate impact from transformation activity.

Daily system and performance reports including A&E attendance - breaches, hospital Delayed Transfers of Care (DTOCs) etc. - all measures of system pressures and system flow.

Urgent care dashboard shows activity and pressures in contracted services e.g. GP out of hours or Yorkshire Ambulance Service (YAS).

CCG IQPR details system performance against a range of measures - presented to Quality & Performance Committee and Governing Body.

Annual self-assessment against national emergency care standards - goes to Governing Body.

Outputs from real or tested scenarios and learning - reports and action plans produced, e.g. LTHT Pathology incident - winter reviews, measles outbreaks etc.

Independent Assurance

NHSE complete an annual CCG assurance assessment through quarterly reviews.

Internal Audit Risk Deep Dive review 2017/18 provided Significant Assurance.


Workforce review for urgent care system sustainability, not yet assuring re: workforce capacity - system wide - being looked at by Workforce group at local and West Yorkshire level

Self-care/ management and access to out of hours (OOH) services for urgent presentation - being addressed through Urgent care strategy.

Additional Comments: N/A

Risk register: 541 – System resilience – maintaining flow during demand and capacity pressures (12 – amber) 659 – System resilience variable risks (12 – amber) 650 – CCG Business Continuity and EPRR Plan (6 – amber) 635 – Failure to meet NHS Constitution Emergency Care Standard (15 – amber)

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Date of meeting: 28th November 2018

Title: Strategic Review

Lead Governing Body Member: Tim Ryley, Director of Strategy, Planning & Performance


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Report Author: Tim Ryley, Director of Strategy, Planning & Performance

Decision

Reviewed by EMT/Date: N/A

Discussion

Reviewed by Committee/Date: N/A

Information

Checked by Finance (Y/N/N/A - Date): Yes (pending)

Approved by Lead Governing Body member (Y/N): Yes

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EXECUTIVE SUMMARY: In July 2018 the CCG Governing Body approved the CCG Strategic Plan. This paper updates the Governing Body on progress to date on developing the underpinning Delivery Framework and delivery of the Strategic Commitments set out in the plan. It starts by providing the Governing Body with an update on the wider strategic context at both the national level and in West Yorkshire. The NHS will announce its refreshed Long-Term Plan along with planning guidance in December 2018. It is expected to cover priorities for Life Course, Clinical Areas and Critical Enablers. During the first half of 2019-20 Leeds will, in response, be expected to contribute a 5 year plan linked to that of West Yorkshire. The CCG is progressing the development of the Delivery Framework by aligning a number of key processes and commencing development of commissioning policies and strategies in key areas. At the same time the CCG is taking forward specific work in a number of areas including: commissioning for outcomes, frailty, long-term conditions, cancer and mental health in a way that aligns to the strategic direction. It is also actively supporting the development of greater provider integration across the city.

NEXT STEPS: No specific actions are required


(a) Note the report

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Strategic Review

1. Summary

In July 2018 the CCG Governing Body approved the CCG Strategic Plan. This paper will update the Governing Body on progress to date on the underpinning Delivery Framework and the delivery of the six strategic commitments set out in the plan. It will start by providing the Governing Body with an update on the wider strategic context at both the national level and in West Yorkshire. The Governing Body is asked to note the report and to set aside adequate time in their forward plan for 2019/20 to allow for approval of the nationally required plans.

2. NHS England Long-Term Plan and National Planning Round

The NHS has been asked by the government to develop a long-term (10year) plan. We are expecting this to be published in late November or early December 2018. In response we will then be expected to produce a one-year operational plan for 2019-20 in line with planning guidance which will also be issued in December. We expect the requirement regarding submission to NHS England to be broadly in line with the current approach to planning. Each Integrated Care System (ICS) will also be expected to develop five-year plans by summer 2019-20. These plans will describe how the NHS will deliver the national plan at a local level. West Yorkshire & Harrogate ICS have indicated that this will be developed on a place-based approach; that is we will be required to have a Leeds five year plan. Again it is expected that there will be national guidance on the content and approach to be taken. In Leeds we will need to give consideration as to how this aligns to the Health & Wellbeing Board Strategy, the CCG Strategic Plan and importantly the Leeds Plan which is likely to be refreshed within a similar period. We will not want to have two Leeds plans and work is in hand to minimise this. The NHS 10 year plan has been developed in conversation with the wider system and we therefore understand the likely structure. We are expecting three themes each with a number of programmes:

Life course programmes will include Prevention and Personal Responsibility; Healthy Childhood and Maternal Health; Integrated and Personalised Care for People with Long-Term Conditions; and the Frail Elderly (including Dementia).

Clinical Priorities are Cancer, Cardiovascular and Respiratory, Learning Disabilities and Autism, and Mental Health.

Enablers will cover Workforce, Training and Leadership; Digital and Technology; Primary Care; Research and Innovation; Clinical Review of Standards; System Architecture; and Engagement.

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We have also been told that NHS England expects to publish five-year commissioner allocations in December 2018 to support planning. Individual control totals are no longer being seen as the best way to manage provider finances. NHS England’s stated medium-term ambition is to return to a position where breaking even is the norm for all organisations. This will negate the need for individual control totals and, in turn, this will allow NHS England to phase out the provider and commissioner sustainability funds; instead, these funds will be rolled into baseline resources. This process will begin in 2019-20 but may take a couple of years to complete. As a CCG Governing Body we will need to build adequate time for review and sign-off into our forward plan to meet the overall timetables once these are published.

3. West Yorkshire and Harrogate ICS

The West Yorkshire and Harrogate Integrated Care System (ICS) has an approach that recognises the importance of place (i.e. Leeds) and the principle of subsidiarity. It has described at a high level this approach and where responsibility for pieces of work is best aligned.

The Joint Committee of the West Yorkshire CCG’s has a work plan reflecting this approach and covering:

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Cancer – developing new and strategic approaches building on the “commissioning for outcomes” work

Mental Health which includes: o agreeing a dingle operating model for acute and psychiatric intensive care

(PICU) beds across West Yorkshire and Harrogate along with a standard commissioning approach; and

o Developing a plan for children and young people inpatient units integrated into local pathways

Stroke – agreeing the configuration of Hyper Acute stroke services

Urgent and Emergency Care focusing on business cases for 111 and GP out-of-hours

Elective care – developing common commissioning policies for pre-surgery optimisation, clinical thresholds and procedures, eliminating unnecessary follow-ups and efficient prescribing.

At the meeting of the CCG Joint Committee held in public on the 6th November 2018 the proposals for Stroke re-configuration were considered in detail. It was agreed that four hyper acute units is the optimal service delivery model and that all commissioners would utilise the agreed hyper acute stroke service specification when commissioning hyper acute care services.

4. CCG Delivery Framework Development

a. The Framework

As previously discussed at the Governing Body we are putting in place a delivery framework. This is providing the structure to ensure that the CCG ambition (aligned to the Leeds Health & Wellbeing Strategy) and the six strategic commitments are turned into concrete changes in the landscape of services and deliver tangible improvements in health outcomes across the city. The delivery framework is shown below and operates at three interconnected levels: Macro, Meso and Micro. Whilst it is important that the delivery framework is robustly established, we are clear that this must not result in delays on bringing about necessary improvements on the ground. In this section we will update on both progress in developing the delivery framework and examples of taking concretely forward the principles set out in the Strategic Plan.

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b. Establishing the Delivery Framework

At the Macro-level work we are developing clear policy positions on each of the six strategic commitments and a plan is being put in place for the next 12-18months. These policies reflect the city wide approach and describe the particular CCG contribution. We are designing these so that they shape the Meso-level plans in areas such as Mental Health and are supported by our planning approach and financial strategy. At the Meso-level we are moving further away from short-term and piecemeal funding of projects (micro) and looking to develop, with our partners’, a series of plans and strategies that align with the approach expected to emerge from the NHS 10 year plan. Our approach to this is to develop one-year and five-year plans in line with the NHS England planning timetable described above. In developing these plans we are also adjusting our approach to financial planning, performance and commissioning responsibilities. We are aligning commissioning budgets to the development of these commissioning plans and to ensuring that our investment plans align to addressing the left-shift set out in the Leeds Plan, narrowing health inequalities and developing a population health management approach delivered through Local Care Partnerships (LCP). This builds on work we have already developed in Aligned Incentive Contracts. Similarly, we are reviewing and aligning our approach to planning, performance management and reporting to enable tracking delivery of the strategic plan. Alongside the meso-level planning we are also reviewing the best arrangement and focus of the commissioning teams. This series of strategic alignments and others will be in place for April 2019.

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c. Taking Forward the Strategy

As well as ensuring we put in a place the enabling framework, work is underway in a number of important areas which are reflective of the approach being taken and will contribute to delivery of our commitments. The following examples are illustrative rather than exhaustive.

i. Commissioning for Outcomes

In addition to the specific work set out below the CCG has indicated formally through its commissioning intentions the expectation that in 2019-20 and beyond that we will start moving towards commissioning for outcomes. Discussions have been undertaken with the main NHS providers in Leeds regarding the expectation that in 2019-20, providers will Leeds establish Population Health Management (PHM) capability and infrastructure to enable collective delivery of outcomes in addition to tracking, in shadow form, measures associated with the outcomes framework for frailty and end of life. This will drive provider readiness in order that from 2020-21 the CCG and providers can model and track the impact of contracting for outcomes for the population living with frailty in advance of ‘going live’ in attributing actual payment to the delivery of outcomes from 2021-22.

ii. Frailty and End-of-Life

An outcomes framework for frailty has been developed and a provider-led clinical strategy group (CSG) for frailty and end of life was convened to develop the providers’ optimum model for delivering the framework. The strategy group has led the development of a common understanding across the system of frailty and a model of care for frail and end-of life care. This model includes a number of components and work is underway to implement this approach building on the insights arising from the PHM approach described below. The key components of the model are:

Age Friendly Communities

An Integrated Proactive Community Team

Rapid Response in time of crisis

Virtual Ward

Effective Discharge

The CCG in the planning round for 2019-20 will be looking at making available funding to resource the approach.

iii. Population Health Management (PHM)

As a city system we have been selected as one of four national Population Health Management pilots. This builds on the thinking we have already done locally on outcomes and the work we have led on frailty described above. The pilot will run from December 2018 through to May 2019. We expect the following five outputs:

1. Insights that drive action: Expert analytical insight into current and future

population needs in each participating system, identifying opportunities to

improve the quality, equity or efficiency of care.

2. Supported implementation of targeted interventions. Application of the

population health management cycle around tactical and strategic cohorts

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of patients to implement locally designed personalised interventions for

specific groups of patients with a clear plan in place to evaluate impact.

3. A System Economic and Actuarial model indicating unmitigated and

mitigated trends based on population health analysis to support the

system 2019-20 and five year operating and financial plans.

4. Showcasing your achievements to show others what we can achieve:

At least one case study of the progress made in each system for

presentation to wider audiences and for use across the NHS.

5. A roadmap to underpin and support the spread and scale of population

health management approaches within and across other systems during

2019-20 which supports the vision and priorities of the NHS Long Term

Plan.

iv. Long-Term Conditions

The Leeds Diabetes working group presents an opportunity to consider diabetes related spend along the lines of a population health management model for this patient cohort and in a way that supports greater provider integration and the Leeds left-shift. The CCG LTC commissioning team has been leading on a city-wide piece of work to develop a strategy for the delivery of services to support people with Diabetes and pre-diabetes. This has involved an extensive piece of public engagement and two city-wide workshops with stakeholders to identify priorities for improvement and the shape of the future delivery models. This work will include significant levels of integration between the current LTHT and LCH specialist teams, and in future potentially the transfer of some elements of care into extended primary care within LCPs.

There is also work underway more generally with the Leeds Community Health to move towards outcome rather than activity as the basis for contracting, starting with some of the specialist services for 2019-20.

v. Cancer

The city also already has a well-developed cancer strategy, again developed on a multi-agency basis. Our CCG team is working very closely with primary care, with staff embedded within primary care and the local authority as well as at the CCG to help progress the delivery of our strategy to improve Cancer Outcomes for the city. The Cancer Strategy work is managed through the Leeds Integrated Cancer Services Board, which is beginning to operate along the lines of a population approach to cancer, and being encouraged to consider investment and reinvestment within a single cancer related envelope. There are established working groups on Prevention, Early Diagnosis, living with and beyond cancer, and High Quality Modern services, all with multi-partner representation. The city has benefitted from very significant investments from Macmillan Cancer Support and from Yorkshire Cancer Research (YCR) and is waiting to hear about the next stage of YCR investment which will allow us to further develop our models of cancer aware localities and in particular to further target resources in our most deprived areas where levels of screening and early diagnosis are lowest.

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vi. Provider Integration

One of the CCG’s commitments was to support greater provider integration. The CCG Systems Integration Team has facilitated and enabled provider integration over the last 18 months through the Accountable Care Development Board, Provider Partnership Board and Clinical Strategy Group for Frailty. There is now a city wide Committee-in-Common (CIC) meeting regularly with its own work-plan. This includes the GP Confederation, Leeds Teaching Hospital Trust (LTHT), Leeds Community Health (LCH) and Leeds and York Partnerships Foundation Trust (LYPFT). The local authority and voluntary sector also attend.

Work has progressed in supporting the development of the GP Confederation as approved through a business case at the Governing Body in July, and this in turn has enabled LCH and the GP Confederation to form a second CIC to take forward joint working in primary care.

We have also looked at our approach to procurement. Following an extensive consultation exercise around IAPT re-procurement we have adopted an approach that will support greater provider integration across wider primary care mental health services. We have also included specific evaluation criteria in line with our commitment to greater partnership and integration as well as reducing health inequalities and population outcomes.

5. Conclusion

In approving the CCG Strategic Plan we deliberately chose an approach that supported flexibility in adapting to the emerging city and NHS landscape. In developing the underpinning delivery framework we have built on this agility. We have made progress to date in developing our approach in key areas further, aligning some of the main commissioning processes towards delivery of the strategy and importantly made progress in adopting the new approach in a number of key areas. Further work is required to align our plans to the NHS 10 year plan and to ensure that we are effectively monitoring the implementation and effectiveness of the CCG strategic plan. The Governing Body is asked to: (a) Note the report

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NHS Leeds CCG Governing Body


Title: Chair’s Summary – Primary Care Commissioning Committee

Lead Governing Body Member: Sam Senior, Lay Member and Chair – Primary Care Commissioning Committee

Category of paper

Tick as appropriate

()

Report Author: Sam Senior, Lay Member – Primary Care Commissioning Committee

Decision

Discussion

Information

Approved by Lead Governing Body Member (Y/N) Y

EXECUTIVE SUMMARY: This report provides the NHS Leeds CCG Governing Body with a summary of items discussed and outcomes and risks identified at the Primary Care Commissioning Committee meeting held on 27 September 2018.

RECOMMENDATION: The Governing Body is asked to: (a) RECEIVE the report.

Description of key items of business discussed and key outcomes

1. Please note that this is a brief summary of the items considered and decisions taken at the meeting of the Primary Care Commissioning Committee (PCCC) meeting held on 27 September 2018. Further information can be obtained by reference to the minutes of that meeting.

Chief Executive’s Update on Newton Europe Analysis 2. Members received and discussed a presentation on Newton Europe’s quantitative

analysis into workstreams. The research had examined discharge processes, discharge decision making and community flow. The findings identified how patients may be placed wrongly due to decision makers and clinicians not being fully aware of other services, making assumptions about capacity or being risk-averse. Members felt there needed to be a move towards a smarter live data system to make information on beds more easily accessible.

3. Members discussed how a number of Trusts issued admittance letters to patients and relatives, outlining timescales and the expected movement of patients. The letters had been viewed favourably by patients’ families when surveyed and were recognised as a means of closing the communication gap.

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4. With regard to admission prevention requiring capacity over the winter, the Committee was assured that there would be no change in capacity over the period.

Primary Care Engagement and Patient Participation Groups (PPGs) 5. Members were updated on the first round of PPG funding applications. A total of 37

practices had submitted applications with some localities working together. The total amount of funding agreed was £12,209.63. A second round of applications would be invited for the remaining amount of funding (£12,790.37) at the city-wide Annual PPG event on 18 October 2018. An evaluation of each project would be undertaken by 1 March 2019.

6. With regards to the most recent GP patient survey results, it was noted that the Leeds

response rate was slightly lower than the national average. Overall results for Leeds were encouraging; those practices with a reduced satisfaction rating were being encouraged to develop action plans to address these.

Quality Improvement Scheme – Update on Monitoring 7. The Committee was informed that there had been 100% sign up from the 97 practices

eligible to participate in the scheme. One of the four remaining practices eligible to provide a bespoke scheme had been confirmed in place.

8. Members were assured that monitoring was being carried out by the QIS Steering

Group and results would be brought to the next PCCC meeting on 29 November 2018.

Special Allocation Scheme Policy – Panel Review Process 9. With regards to the Special Allocation Scheme (SAS) for patients who have been

removed from mainstream general practice for aggressive behaviour, the Committee was informed that the CCG was required by NHS England to have an SAS Liaison Team and Review Panel process in place. This was approved by the Committee.

Primary Care Integrated Quality Performance Report (IQPR)

10. Members were presented with the new IQPR which reflected Primary Care priorities for 2018-2019. The report provided a Care Quality Commission (CQC) overview with 100 practices achieving Outstanding or Good ratings, with one practice rated as Requires Improvement.

Primary Care Risk Report

11. Members had participated in a workshop examining all Primary Care risks prior to the PCCC meeting. There were 2 high amber risks post mitigation.

Primary Care Finance Update 12. The Committee was informed of the NHSE announcement regarding the 3% pay

increase for practice staff on Agenda for Change. While NHSE had agreed to fund 2% for Primary Care, the CCG would match the 3% using non recurrent slippage. The contract uplift payment for General Medical Services (GMS) contracts would cost the CCG around £887K. This would be paid in October 2018 and backdated to April 2018. NHSE had also recommended the uplift to be approved for Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS) practices, at a cost to the

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CCG of £553K and £31K respectively. In order to receive the additional 1% funding, practices would be required to pass the increased payment to all current staff and to fully complete the Primary Care workforce survey.

13. With regards to patient payment rates, historic inequities between GMS and PMS

practices remained; these were being discussed with the Local Medical Council and would be brought to a future PCCC meeting.

14. With regards to the Primary Care budget, members noted the unallocated budget of

£1.6M and discussed possible areas for its spending, including innovation seed funding, winter planning involving hubs and workforce issues.

15. The Committee was updated on a number of Estates and Technology Transformation Fund (ETTF) bids where timescales were representing a risk to some practices’ sustainability. One building had been removed from ETTF due to its critical condition. Of the remainder, only two practices were awaiting formal approval, where building plans had been changed significantly.

Strategies/Policies approved

Special Allocation Scheme – Process for Patient Appeal, Provider Challenge or Exceptional Discharge Review Panel

Primary Care Finance - 2% contract uplift for PMS and APMS contracts; and 1% additional uplift to all PMS, APMS and GMS contracts with provisos.

Items of positive assurance or issues to be raised with the NHS Leeds Governing Body

N/A

Any additional comments

N/A

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Agenda Item: GB 18/93 FOI Exempt: No



Title: Chair’s Summary – Audit Committee meeting held on 24 October 2018

Lead Governing Body Member: Peter Myers, Lay Member and Chair – Audit Committee


appropriate

()

Report Author: Peter Myers, Lay Member and Chair – Audit Committee

Decision

Discussion

Information


EXECUTIVE SUMMARY: This report provides the NHS Leeds CCG Governing Body with a summary of items discussed and outcomes and risks identified at the Audit Committee meeting held on 24 October 2018.


Description of key items of business discussed and key outcomes

1. Please note that this is a brief summary of the items considered and decisions taken at the meeting of the Audit Committee meeting held on 24 October 2018. Further information can be obtained by reference to the minutes of that meeting.

Finance 2. The Committee was informed of the CCG’s financial position up to 31 August 2018 and

the expected outturn position for the 2018/2019 financial year. A breakeven position was forecasted with the CCG being on course to achieve key financial targets. There had been a significant reduction in QIPP risks, which had been impacted upon by underspending in areas where forecasted growth activity had not been realised. The QIPP target of £34.3m was acknowledged as always being an ambitious one. Reserves had been held from non-recurrent funds in mitigation to allow for slippage and non-delivery of QIPP in 2018/2019. The position was helped by a number of risks either not crystallising or being deferred into future financial years. However, as reserves applied were essentially non-recurrent, the CCG’s longer term financial viability would still rely either on QIPP being achieved recurrently or risks dropping out of the system on a recurrent basis.

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3. Members were updated on the IFRS16: Accounting for Leases and its possible impact on 3,000-4,000 service contracts. While NHS bodies were being encouraged to prepare for the change, it was recognised that it was difficult to assess the scale of the issue while still awaiting NHSE guidance. Guidance was due to be issued by the end of 2018.

4. The final settlement with HMRC concerning outstanding PAYE liability and NI payments would be £110,000, plus £8,000 interest which was significantly less than anticipated.

5. Members were informed that the national deadline for Making Tax Digital for business (MTDfb) had been moved from 1 April 2019 to 1 October 2019. However, NHS Shared Business Services (SBS) would be ready for 1 April 2019.

6. With regards to the Payment System Reform proposal published by NHSE and NHSI, the CCG was formulating a response to the engagement document.

7. Two issues were highlighted in the Losses and Special Payments report. Firstly, members were informed of an outstanding credit note for £2,357.16 resulting from Tancred Hall being taken into administration. The CCG would register with the administrators and work with SBS to reclaim the amount. It was suggested that higher risk contracts, such as care homes, be assessed on a regular basis, for example each quarter. Secondly, the Committee was updated on an SBS payment of £1,250 that had been paid into the incorrect bank account. The CCG would receive a refund for the payment.

8. With regards to the CCG Financial Control, Planning and Governance Self-assessment, members were informed of the increased number of unplanned cash drawdowns since the merger of the three CCGs and the continued need for drawdowns to assist Leeds Teaching Hospitals Trust (LTHT) with cash flow difficulties. While supplementary cash drawdowns rated as red within the self-assessment, these reflected circumstances rather than problems and guidance indicated the need to manage ‘cash as a place’. The Committee was informed that this would be rated as green within 12 months.

9. Members were updated on the Commissioning for Value (CfV) programme. Of 43 ‘live’ projects, 30 were progressing as planned, with the remaining 13 projects being appropriately challenged. The Committee was informed that the CCG was still some way from achieving its efficiency target of £34.3m, with a forecast of £20m being made. Sample case studies would be brought to the Audit Committee to highlight the qualitative impact of the schemes.

Risk Management 10. Assurance was given to members that the risk management arrangements were

operating according to the current strategy. Risk 544: Conflicts of Interest was reported as being managed to its lowest level possible and had, as a result, achieved its target score of 6. Members felt it would be useful to for the Risk report to include a summary of assurances discussed and given in committee meetings.

11. The Chief Finance Officer informed members that there were two additional risks that were not included on the register. These concerned contracts where there were

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possible tax liabilities. Both risks were non-recurrent issues and External Audit assured the Committee that the figure fell significantly below the materiality limit.

Internal Audit 12. The Committee was presented with two Internal Audit Progress reports. The first

concerned the Management of Conflicts of Interest, which had received a rating of ‘Significant’. Two concerns were noted. Firstly, there were minor gaps in the register relating to actions taken to mitigate risk. In addition, Declaration of Interest (DOI) returns were outstanding for 15 GP Practices. It was felt that this was a low risk due to clinical staff with committee roles being required to complete DOIs for meetings. Since the audit, Practices were being sent pre-filled forms to assist them in the process. The second audit concerned Individual Funding Requests (IFRs), which had received a rating of ‘High’, due to good governance and scrutiny.

13. Jenny Baines provided a verbal update on two outstanding audit recommendations relating to the Business Continuity Plan (BCP). Each team had completed Business Impact Assessments which would be used by the Emergency Preparedness, Resilience and Recovery (EPRR) Steering Group to prioritise the CCG’s key functions following critical incidents. The first version of the BCP would be completed by the end of October 2018, with testing being carried out in January 2019. Members expressed concern that the CCG would be required to refer to the out of date BCP prior to January 2019 and whether the earlier BCP had been subject to recent testing. It was agreed that PM would inform the Governing Body Chair and Chief Executive Officer of the Committee’s concern with regards to current BCP arrangements.

14. Rob O’Connell updated the Committee on another outstanding audit recommendation relating to a backlog of 486 service users in Adult Continuing Healthcare reviews. Progress had been delayed due to an unprecedented increase in demand, staff shortages and the new National Framework changing its focus from reviewing eligibility to reviewing care packages. A plan had been formulated which entailed recruitment of new staff, movement of existing staff and a ‘cleansing’ of the database to ensure its statistical accuracy. Members were informed of the risks involved in implementing the plan concerning difficulties in recruitment, as well as missing NHSE set targets of 28 days for referrals and 15% assessments being carried out in hospitals. The potential for reputational risk was noted by the Committee.

15. The Committee was presented with the Operational Audit Plan for 2018/2019 and Internal Audit Strategic Plan 2018/2019 – 2019/2020. Following the development of the Governing Body Assurance Framework (GBAF), both plans had been updated to align strategic risks with the audit process.

External Audit 16. Members were presented with the External Audit Technical Update. With reference to

obtaining funds though section 106, the CCG had already explored this with Leeds City Council and had been informed that no money had been pre-determined for health.

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Counter Fraud 17. Three risk areas for the CCG were identified in the Annual Counter Fraud Plan

2018/2019. There were: prescription frauds; mandate frauds; and pre-employment checks. The Committee was assured that these risks were national ones and not confined only to Leeds CCG.

Policy Review

18. The CCG’s Operational Scheme of Delegation was presented to the Committee. Higher tender thresholds for healthcare procurement would enable the CCG to concentrate resources on the higher value/higher risk procurements while still assuring value for money for lower value contracts via Requests for Quotations. Members supported the rationale for the amendments but agreed that it was for the Governing Body to decide the appropriate delegation limits.

19. With regards to the Leeds CCG Procurement policy, members were assured that changes to thresholds made annually by the EU would not apply in the event of a ‘no deal’ after March 2019.

20. The Committee received a number of tender waiver requests where contracts were due to expire by 31 March 2019. These related to: Improving Access to Psychological Therapies (IAPT); social prescribing; Young Person’s Mental Health Service; tier 3 specialist weight management services; and Urgent Treatment Centres (UTCs).

Governance 21. The Committee received the registers of Interests, Gifts & Hospitality and procurement

decisions.


The Audit Committee:

supported the rationale for proposed amendments to the Operational Scheme of Delegation;

endorsed the Procurement policy prior to it being presented to Governing Body for approval; and

recommended the approval of the Standards of Business Conduct policy by the Governing Body.

Items of positive assurance or issues to be raised with the NHS Leeds Governing Body

The Audit Committee highlighted the following:

Failure to achieve the QIPP requirement remained a risk;

Assurance given that the National Audit Office would ensure consistency in IFRS16: Accounting for Leases interpretations;

Risk regarding CCG owing VAT on elements of contracts;

Successful outcome of IFR internal audit;

Risk regarding the BCP as still outstanding;

Care reviews backlog: risk due to unprecedented demand and staff shortages; and

A number of tender waivers had been agreed in line with the CCG’s Procurement policy.

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Any additional comments

There were no additional comments.

1




Title: Chair’s Summary of Remuneration & Nomination Committee Meeting held on 17 October 2018

Lead Governing Body Member: Sam Senior, Lay Member – Primary Care Co-Commissioning / Deputy Chair


appropriate

()

Report Author: Sam Senior, Lay Member – Primary Care Co-Commissioning / Deputy Chair

Decision

Discussion

Information


EXECUTIVE SUMMARY: 1. This report provides the NHS Leeds CCG Governing Body with a summary of items

discussed, outcomes and risks identified at the Remuneration & Nomination Committee meeting held on 17 October 2018.


Description of key items of business discussed

1. Please note that this is a brief summary of the items considered and decisions taken at the meeting of the Remuneration & Nomination Committee on 17 October 2018. Further information can be obtained by reference to the minutes of that meeting (subject to exemptions under the Freedom of Information Act).

Executive Performance Related Pay 2. The Committee agreed that a performance related pay scheme should be developed for

executive directors holding Very Senior Manager (VSM) contracts, and agreed some principles for the scheme which will be presented at the next meeting for approval.

Executive and Non Executive Pay Review 3. The current executive and non executive pay details were presented, alongside

benchmarking from similar sized CCGs and the Yorkshire and Humber region. In comparing the Full Time Equivalent (FTE) rates, it was noted that the CCG’s clinical rates were higher than the executive rates.

4. Members noted the wide variation in pay for some roles when comparing to other CCGs, and the difficulty in establishing an accurate Full Time Equivalent (FTE) rate for clinical roles due to the difference in time commitment. It was agreed that benchmarking information would be taken into account in agreeing remuneration for future clinical appointments.

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Gender Pay Gap 5. Gender Pay Gap data was presented, including the whole organisation (30.8%) and

Governing Body (21.9%). In both cases the gap is higher than the national average of 17.4%.

6. In relation to the Governing Body, there are less females in clinical roles (for example the Member Representatives), therefore there is a need to identify any potential barriers to females applying for these roles.

7. In relation to the wider workforce, the gap is widened due to the low number of males in lower graded roles. The CCG’s Workforce and Diversity Group will consider how to address this.

Agenda for Change Pay Award 8. An update was provided in relation to the impact of the Agenda for Change pay award. The

cost to the CCG is £342k with an allocation of £205k. The finance team has confirmed that the gap can be covered from running costs.

9. The Workforce and Diversity Group will consider the pay progression framework and the implementation of this within the CCG.

Chief Executive Recruitment 10. The Committee approved the indicative timetable for the recruitment of a new Chief

Executive, following Phil Corrigan’s decision to retire from August 2019. An external recruitment agency will be appointed to manage the process.


11. The following HR policies were approved:

Learning and Development;

Acceptable Standards of Behaviour; and

Alcohol, Drugs and Substance Misuse in the Workplace.

12. The following HR policies were ratified, following approval by urgent action:

Annual and Special Leave;

Disciplinary;

Equality and Diversity;

Flexible Working; and

Managing Work Performance.

Items of positive assurance or issues to be raised with the NHS Leeds CCG Governing Body

N/A

Any other Comments

N/A

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Title: Chair’s Summary of Quality & Performance Committee Meeting held on 14 November 2018

Lead Board Member: Dr Steve Ledger, Lay Member, Assurance and Chair – Quality & Performance Committee


appropriate

()

Report Author: Dr Steve Ledger, Lay Member, Assurance and Chair – Quality & Performance Committee

Decision

Discussion

Information

Approved by Lead Board member (Y/N): Y

EXECUTIVE SUMMARY:

1. This report provides the NHS Leeds CCG Governing Body with a summary of items discussed, outcomes and risks identified at the Quality & Performance Committee meeting held on 14 November 2018.


Description of key items of business discussed

1. Please note that this is a brief summary of the items considered and decisions taken at the meeting of the Quality & Performance Committee on 14 November 2018. Further information can be obtained by reference to the minutes of that meeting.

Matters Arising 2. Following a request from the Governing Body on 28 September 2018, the Quality &

Performance Committee received detailed information on the current data issues in relation to national cancer targets, in particular the breast two week wait. The report highlighted that patients being referred from October onwards had been offered appointment dates within 11 days of referral so the expectation was that this would enable delivery of both the 2 week wait targets in October and ongoing. Issues were raised in relation to the 62 day referral target and an area of particular difficulty related to urology.

3. The Committee noted that the debate is still ongoing in relation to performance targets and recommended a level of reasonable assurance in relation to breast cancer targets, however a level of limited assurance was recommended in relation to the 62-day referral to treatment target.

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4. Assurance was requested with respect to prostate cancer, that the younger, higher risk groups of patients were being prioritised for treatment in the event of delayed referral to treatment times overall in this category.

Actions from Previous Meetings

5. The Committee noted that in relation to a previous action whereby a Quality Improvement paper would be presented to the Governing Body meeting in November, the decision had been made by the Chair to defer the paper to a future meeting due to exceptional pressures within the Quality team. This would be presented to the Committee by March 2019.

Integrated Quality & Performance Report (IQPR)

6. The Committee noted that the report was twofold, providing information as standard on the IQPR dashboards, but also further information in relation to the future reporting of quality and performance.

7. In relation to IAPT, the Committee was informed that the national standard for IAPT access is currently not being met, due to workforce capacity being below the level required to reach this target. Additional funding had been provided by the CCG, however the Committee recognised that it may take the reprocurement of services to fully address the gap.

8. The Committee noted the importance of ensuring that the financial investment plan and operational planning are aligned to support target achievements.

9. A query was raised in relation to the assurance levels that are recommended through the IQPR and the Committee agreed to consider these further in future reporting as a whole and on an exception basis.

10. With regards to breech of the A&E target, it was acknowledged this was a barometer of wider system flow issues. The Newton Europe work remains the best way of addressing these, but its potential impact has not, as yet, been fully enacted.

Update on Continuing Healthcare Reviews

11. Following an internal audit of the Continuing Healthcare service, the Audit Committee requested that the Quality & Performance Committee reviewed the current status and required actions in relation to outstanding reviews.

12. The Committee was assured that despite the outstanding reviews, there was no compromise in relation to the care being met. The Committee agreed a reasonable level of assurance in relation to both the financial aspect and the clinical care prioritisation; however with regards to the action plan to clear the backlog, a level of limited assurance was agreed with an action to return to the Quality & Performance Committee in January with an updated trajectory.

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Providers Under Enhanced Surveillance

13. The Committee received a summary of the providers that were currently under Routine+ Surveillance, Enhanced Surveillance and Formal Action, and the actions being taken as a result.

Patient Experience Update – Quarter 2

14. The Committee received the patient experience update for quarter 2, recognising this as a useful cross-organisational tool and a report that develops each quarter. The Committee noted that an extensive piece of work had been completed in relation to the IAPT reprocurement and engagement work had been fed directly into the specification.

CCG Risk Register

15. The risk register was presented. The Committee noted that the full risk register provides controls and assurances.

16. The Committee noted that the report had been revised to highlight a summary of changes to the risk profile with a column to indicate risk movement in the last 12 months.

17. In relation to risk 28, concerns were raised as to the scoring of the risk and it was agreed to be taken back to the Medicines Optimisation team for review.

18. The Committee queried the impact on patients, particularly in relation to risk 680 and the capacity issues in spinal surgery. The Committee was assured that a detailed discussion had taken place at the Clinical Quality Review Group and assurance had been received from LTHT regarding the quality impact of patients waiting.

Complaints Annual Report

19. The Committee received the complaints annual report and agreed that it provided full assurance that there was a robust complaints process in place.

Leeds Safeguarding Adult Board (LSAB) Annual Report 20. The Committee received the LSAB Annual Report and recognised the commitment that

staff had given to the process.

21. The Committee was assured that the health economy in Leeds is working in partnership with the LSAB to achieve the strategic vision for adults with care and support needs.

Independent Investigations, Recommendations & Next Steps 22. Members received a report on three independent investigations that had recently been

conducted involving Leeds providers. The Committee acknowledged that the CCG was fully assured that all requirements had been implemented in terms of provider responses.

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23. The Committee noted the exceptional work that had been undertaken by the Clinical Governance team in reviewing the investigations and providing the assurance statements.

Emergency Planning Statement of Compliance

24. The Committee received the self-assessment as assurance that the CCG has robust EPRR arrangements. Members acknowledged and agreed that the CCG statement of compliance would be submitted as partially assured and agreed the Improvement Plan to move the CCG to full compliance on the 43 standards in 2018-19.

25. In relation to this item, the Quality and Performance Committee would recommend that the Governing Body sign the statement of compliance for submission (attached at Appendix 1).

Business Continuity Plan 26. The Business Continuity Plan was submitted to the Quality & Performance Committee for

approval and sign off as the first version (v1.5). The Committee accepted the plan and noted that it was a living document with clear governance aligned through the Emergency Preparedness Resilience and Response Group.

Individual Funding Request (IFR) Annual Report 27. Members received the IFR annual report and agreed they had full assurance of the IFR

process.

Infertility Policy 28. The Infertility Policy was presented with proposed changes to the Committee for approval.

The Committee acknowledged that the approval of the policy was for Leeds; however it was a West Yorkshire wide policy.

29. The Committee highlighted that there may be potential financial implications and further work would take place in relation to this. The Committee agreed that they would not approve the policy until a full equality and quality impact assessment had taken place.

Non-Medical Prescribing Policy 30. The Committee agreed that approval of this policy should be subject to further

consideration and inclusion of the funding aspects of non-medical prescribers in Primary Care.


Freedom of Information Act and Environmental Information Regulations Policy

Confidentiality and Data Protection Policy

5

Items of positive assurance or issues to be raised with the NHS Leeds CCG Governing Body

Full assurance was agreed for:

Complaints Annual Report

Individual Funding Request Annual Report

Any other Comments

Yorkshire and the Humber Local Health Resilience Partnership (LHRP)

Emergency Preparedness, Resilience and Response (EPRR) assurance 2018-2019

STATEMENT OF COMPLIANCE

NHS Leeds CCG has undertaken a self-assessment against required areas of the EPRR Core standards self-assessment tool v1.0 Where areas require further action, NHS Leeds CCG will meet with the LHRP to review the attached core standards, associated improvement plan and to agree a process ensuring non-compliant standards are regularly monitored until an agreed level of compliance is reached.

Following self-assessment, the organisation has been assigned as an EPRR assurance rating of

Partial (from the four options in the table below) against the core standards.

I confirm that the above level of compliance with the core standards has been agreed by the

organisation’s board / governing body along with the enclosed action plan and governance deep

dive responses.

________________________________________________________________

Signed by the organisation’s Accountable Emergency Officer

____________________________

Date signed

_________________________ ____________________________ ____________________________

Date of Board/governing body meeting

Date presented at Public Board Date published in organisations Annual Report

1


























Title: The Integrated Quality and Performance Report

Lead Governing Body Member: Tim Ryley, Director of Strategy, Performance and Planning Jo Harding, Director of Quality and Safety Sue Robins, Director of Operational Delivery


appropriate

()

Report Author: Various Decision

Reviewed by EMT/Date: n/a Discussion

Reviewed by Committee/Date: Quality & Performance Committee, 19th September 2018

Information

Checked by Finance (Y/N/N/A - Date): n/a


2

EXECUTIVE SUMMARY:

This report provides assurance to the organisation that we are delivering against the requirements of the NHS Mandate and Constitution which embed the priorities of our local populations. Where performance falls below the expected standards, remedial action is described.

The narrative provides an update by exception on key themes and current issues and should be read in conjunction with the dashboards. The dashboards provide a high-level view of how the CCG is progressing in delivering is strategic objectives. The dashboards included with this report are:

NHS Constitution and Operational Planning

Quality and Safety

The indicators and metrics in each dashboard have been chosen to provide a balanced view for each sector. Please note that the metrics are flexible and may change depending on sustained performance.

NEXT STEPS:

The key actions which will be undertaken in relation to performance are as follows:

To continue to closely monitor the commissioner and provider-led actions in relation to areas of underperformance.

The key actions which will be undertaken in relation to the development of the IQPR are as follows:

To continue working closely alongside colleagues in local and citywide commissioning teams, Informatics and Quality in the development of the report and identification of local measures.

RECOMMENDATION:

The Governing Body is asked to:

(a) RECEIVE AND REVIEW the IQPR dashboards; discuss the information, note the current areas of underperformance and mitigating action.

3

1. SUMMARY

1.1 This report provides assurance to the organisation that we are delivering against the requirements of the NHS Mandate and Constitution which embed the priorities of our local populations. Where performance falls below the expected standards, remedial action is described.

1.2 The narrative provides an update by exception on key themes and current issues and should be read in conjunction with the dashboards. The dashboards provide a high-level view of how the CCG is progressing in delivering is strategic objectives. The dashboards included with this report are:

NHS Constitution and Operational Planning

Quality and Safety

1.3 The indicators and metrics in each dashboard have been chosen to provide a balanced view for each sector. Please note that the metrics are flexible and may change depending on sustained performance.

2. SUMMARY OF KEY PERFORMANCE ISSUES

2.1 Planned Care and Long Term Conditions

The CCG continues to marginally underperform against the 92% 18 week RTT waiting time standard. The specialties which continue to predominantly influence performance against this measure are those which are driving the high numbers of patients waiting over 52 weeks ie. spinal surgery and colorectal surgery. Other challenges remain within paediatric services and NHSE commissioned dental services where there has been significant growth.

The total waiting list size (incomplete RTT) has increased slightly since March 2018, although this is only in outpatient specialties, with a consistent reduction in the numbers of patients waiting for inpatient treatment.

Performance associated with two week waits for suspected breast cancer appointments has been underperforming since March 2018 due to a capacity shortfall. This has taken several months to pull back because of the staffing shortages regionally to deliver this pathway but is now resolved and performance is expected to show as being back on track from October 18.

62 day cancer performance has deteriorated further in recent months. A range of issues has impacted upon performance in Q1 with small numbers of breaches across a wide range of specialties. Surgical demand in urology has been particularly challenging, linked to the recent surge in referrals leading to increased numbers of cases requiring treatment. This is positive in relation to early diagnosis and success in encouraging patients to attend, but has impacted on performance.

4

2.2 Unplanned Care

The operational standard for A&E waiting times is that 95% of patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department. However, in February 2018 NHS England announced a temporary suspension of the standard and issued guidance outlining a requirement to achieve 90% between April and September 2018, "...with the majority of providers achieving the 95% standard for the month of March 2019, and that the NHS returns to 95% overall performance within the course of 2019". Therefore, we are currently monitoring performance against a 90% standard. In September 2018, Leeds Teaching Hospitals NHS Trust did not achieve the required 90% performance standard.

Reasons for this underperformance include sustained high emergency department attendances, increased acute demand on critical care and high acuity, high bed occupancy levels which is impacting on timely flow and continuing high levels of delayed transfers of care and medically optimised patients.

In September-18, Yorkshire Ambulance Service (YAS) failed to meet the 7-minute average for responding to calls from people with life-threatening illnesses or injuries. However, they did manage to respond to this category of call within 15 minutes for 90% of all calls of this type received. YAS failed to meet both the 18-minute average response target and 40-minute response target for 90% of emergency call types.

2.3 Mental Health and Learning Disabilities

The national standard for IAPT access in 2018/19 is for 19% of the prevalent population to access the service in the reporting year. This equates to almost 1.6% of this population accessing IAPT support each month (approximately 1,600 - 1,700 people). Between April and September 2018, just over 6,900 people accessed IAPT support in Leeds - approximately 3,000 fewer than required levels. This is due to workforce capacity being below the level required to reach this target.

The CCG have provided The IAPT Consortium with additional funding to address the waiting list for Step 3 treatment which includes CBT and counselling. The CCG is closely monitoring the work being carried out through established contractual processes and is seeking assurance how soon this waiting list will be addressed and how those waiting are monitored.

In both August and September, the target of 50% of all people completing treatment moving towards recovery was not met. We will continue to monitor performance and explore with the provider if there are reasons for this reduced level which require addressing.

There is a significant risk of not reducing the number of patients reliant on inpatient care by the required level in 2018/19 for places commissioned by the CCG. This is mainly due to an increased demand for support and due to patients in receipt of inpatient care commissioned by NHSE being "stepped-down" to the CCG which has the effect of improving performance for NHSE-level reporting yet worsening performance for CCG-level reporting.

5

As part of an agreed recovery plan our local mental health trust have revised the transforming care cohort to identify which individuals they may be able to support within Leeds - ten patients have since been identified for whom they could potentially support to move back to Leeds.

2.4 Children’s and Maternity

One out of seven young people urgently referred to the CYP eating disorder service in Q1 2018/19 were not seen by the service within one week of referral due to patient choice. Due to the small numbers involved, this led to an underperforming position against this reporting quarter and it is not felt there is a need for further action.

2.5 Continuing Healthcare (CHC)

Reducing the number of full NHS CHC assessments taking place in an acute hospital setting remains to be challenging. The main performance issues are; reduced availability of care homes with nursing capacity for dementia and challenging behaviours; patients and/or their families choosing not to move until the assessment is completed; the requirement to complete referrals within 28 days means that on occasion patients are assessed in hospital to ensure that an outcome is reached within 28 days; and annual leave of staff throughout the summer period in both the Continuing Care Service and independent service providers has reduced capacity within the team and service providers.

2.6 Neighbourhood Care

Since securing the additional funding and extending the focus and responsibilities of the Bed Bureau, significant reductions in delayed discharges have been noted. Similar reductions have been noted in the average length of stay of patients currently resident in the community care beds.

Whilst significant progress has been made in the first few weeks since the role of the Bed Bureau was increased, there is still work to be done to ensure that the CCBs contribute as fully as possible to flow across the system. The reductions in length of stay and delayed discharges are very welcome but significant delays are still prevalent within the system, and it is possible that some of the early progress can be attributed to ‘quick wins’ which may not be replicable.

2.7 Proactive Care and Population Commissioning

Leeds Wheelchair Service have routinely offer Personal Wheelchair Budgets (PWBs) from 1st April 2018. There has been a phased approach to implementation, starting with face-to-face clinics. Approximately half of all new referrals are managed via the telephone; PWBs will be offered via this route once the HR changes and training are complete. Once fully implemented, the PHB numbers will significantly increase to approximately 300 new PHBs per quarter, thereby enabling us to meet our March 2019 target (540 PHBs).

We are currently scoping the provision of PHBs to new patient groups, including renal dialysis transportation to be implemented in 2018/19, and we will be

6

considering the best way of implementation with people in receipt of end of life care and mental health issues in 2019/20.

We are now providing support and experience as part of the National PHB Mentoring programme 2018/19 (partnership between the CCG and wheelchair service) to support the spread of PWBs nationally.

3. NEXT STEPS

3.1 The key actions which will be undertaken in relation to performance are as follows:

To continue to closely monitor the commissioner and provider-led actions in relation to areas of underperformance.

3.2 The key actions which will be undertaken in relation to the development of the IQPR are as

follows:

To continue working closely alongside colleagues in local and citywide commissioning teams, Informatics and Quality in the development of the report and identification of local measures;

3. RECOMMENDATION The Governing Body is asked to: (a) RECEIVE AND REVIEW the IQPR dashboards; discuss the information, note the

current areas of underperformance and mitigating action.

Indicator Tables

NHS Constitution and Operational Planning Measures Page 2‐3

Quality and Safety Page 4

RAG Rating

92.5%

88.0%

85.0%

Interpreting Trends

Sparklines

For example, if the expected Standard is a minimum of 92%...

The Integrated Quality and Performance Report

Report Period: August 2018

Contents

Report Key

Note: The RAG rating applied within this report is based upon calculating a limit

of 5% higher/lower relative to the expected standard/target.

Sparklines have been produced to demonstrate the distance

away from the expected target level, with green representing a

positive position and red representing underperformance.

The most recent period of data is shown furthest to the right in each sparkline.

'Green' performance would be ≥ 92%

'Amber' performance would be 87.4% ≤ x < 92%

'Red' performance would be < 87.4%

Performance measures shown to be 'Amber' should still be interpreted as

underperforming ‐ a RAG rating has only been applied to serve as a visual guide

to understand how close performance is to the expected standard.

They should not be interpreted as being currently within a tolerance level.

Trend analysis is currently based upon comparing the latest performance with

the performance in the previous period.

A green arrow represents an improvement in performance

An amber arrow represents no change in performance

A red arrow represents a deterioration in performance

NHS Constitution and Operational Planning Measures

Measure Target Data Period Current

NHS Constitution

RTT ‐ Incomplete Pathway (18 week wait compliance) 92% Aug‐18 91.0%

RTT ‐ Incomplete Pathway (number of patients waiting)No more than 42,409

by Mar‐19Aug‐18 44,511

RTT ‐ 52 Week WaitsNo more than 23 by

Mar‐19Aug‐18 83

Diagnostic Waiting Times 99% Aug‐18 99.4%

Cancer ‐ 2 Week Wait 93% Aug‐18 85.8%

Cancer ‐ 2 Week Wait (Breast) 93% Aug‐18 46.6%

Cancer ‐ 31 Day First Treatment 96% Aug‐18 95.1%

Cancer ‐ 31 Day Surgery 94% Aug‐18 93.3%

Cancer ‐ 31 Day Drugs 98% Aug‐18 99.6%

Cancer ‐ 31 Day Radiotherapy 94% Aug‐18 99.0%

Cancer ‐ 62 Day GP Referral 85% Aug‐18 71.6%

Cancer ‐ 62 Day Screening 90% Aug‐18 90.9%

Cancer ‐ 62 Day Upgrade 90% Aug‐18 71.9%

A&E

A&E Waiting Times: % 4 hours or less (LTHT ‐ All Types of A&E) 90% until Sept‐18 Sep‐18 85.6%

Mental Health

Dementia ‐ Estimated Diagnosis Rate 66.7% Aug‐18 74.2%

IAPT Access (YTD) 9.5% Sep‐18 6.6%

IAPT Recovery 50% Sep‐18 45.5%

IAPT Waiting Times ‐ 6 Weeks 75% Sep‐18 77.2%

IAPT Waiting Times ‐ 18 Weeks 95% Sep‐18 99.8%

EIP ‐ Psychosis treated within two weeks of referral 53% Aug‐18 65.4%

Improve access rate to CYPMH 32% Aug‐18 13.3%

Waiting Times for Routine Referrals to CYP Eating Disorder Services ‐ Within 4

Weeks (Rolling 12 Months)70% 2018/19 Q1 90.0%

Waiting Times for Urgent Referrals to CYP Eating Disorder Services ‐ Within 1

Week (Rolling 12 Months)95% 2018/19 Q1 85.7%

Learning Disability Target Period Current

Reliance on Inpatient Care for People with LD or Autism ‐ CCGs (All Length of

Stays)11 2018/19 Q2 21

Reliance on Inpatient Care for People with LD or Autism ‐ CCGs (Length of Stay

of 5 Years and Over)9 2018/19 Q2 13

Reliance on Inpatient Care for People with LD or Autism ‐ NHSE All Length of

Stays)19 2018/19 Q2 17

Reliance on Inpatient Care for People with LD or Autism ‐ NHSE (Length of Stay

of 5 Years and Over)11 2018/19 Q2 11

Number of people on GP LD Registers who have received an Annual Health

Check during the year3,722 2018/19 Q1

Other Commitments

e‐Referral Coverage 80% Jul‐18 80.3%

Personal Health Budgets (per 100,000) ‐ YTD 48.5 2018/19 Q2 83.6

Children Waiting no more than 18 Weeks for a Wheelchair 92% 2018/19 Q2 93.5%

Extended access at GP services (Full Provision) 100% by Oct 2018 Sep‐18 100.0%

Performance Measures (1 of 2)

310

Trend

(Difference from Target)

NHS Constitution and Operational Planning Measures

Measure Target Period Current

Quality Premium ‐ Emergency Demand Management Indicators

Type 1 A&E attendancesNo more than 241,592

in 2018/19Aug‐18 18,920

Non elective admissions with zero length of stayNo more than 21,794

in 2018/19Aug‐18 1,648

Non elective admissions with length of stay of 1 day or more No more than 59,550

in 2018/19Aug‐18 4,847

Quality Premium ‐ Quality Indicators

Cancers diagnosed at early stage (detected at stage 1 and 2) At least 54.9% in 201712 months to

2017/18 Q154.3%

Overall experience of making a GP appointment 71.9%2018

(Jan‐Apr 18)68.9%

NHS CHC eligibility decision made within 28 days 80% 2018/19 Q2 49.7%

Full NHS CHC assessments taking place in an acute hospital settingLess than 15% in

2018/192018/19 Q2 23.3%

Recovery rate of people accessing IAPT services identified as BAME 49.8% Sep‐18 37.1%

Proportion of people accessing IAPT services aged 65+ 9.7% Sep‐18 3.6%

Whole health economy ‐ E. coli blood stream infections (12 months)No more than 481 in

2018/19Jul‐18 215

Antibiotic prescribing for UTI in primary care ‐ Trimethoprim: Nitrofurantoin

prescribing ratio*0.51

12 months to

May 20180.35

Antibiotic prescribing for UTI in primary care ‐ number of trimethoprim items

prescribed to patients aged ≥70 years*9,181

12 months to

July 20186,239

Prescribing in primary care ‐ items per STAR‐PU* 0.965 or below12 months to

July 20180.974

Reported to estimated prevalence of hypertension (%) 57.6% 2018/19 Q2 57.9%

Trend

Performance Measures (2 of 2)

in period YTD in period YTD in period YTD in period YTD

Patient Safety

Serious Incidents n/aAug ‐ Sept

201811 39 8 30 2 24 6 18

Never Events n/aAug ‐ Sept

20180 2 0 0 0 0 0 0

Mortality Rate (Standardised Hospital Mortality Index) 1.00Apr 17 to

Mar 181.059

MRSA Blood Stream Infection 0 Aug‐18 0 5

Clostridium difficile Infection (YTD)

(* CCG)97 Aug‐18 27 64

Classic Safety Thermometer (Harm Free Care) 94.3% Sep‐18 95.5% No Data 98.6%

Mental Health Safety Thermometer (% feeling safe) 86.7% Sep‐18 85.2%

Patient Experience

Friends and Family Test (% recommended) ‐ A&E 87.1% Aug‐18 88.5% 88.3%

Friends and Family Test (% recommended) ‐ Inpatient 95.8% Aug‐18 94.0% 93.7%

Friends and Family Test (% recommended) ‐ Outpatient 93.8% Aug‐18 94.5% 94.2%

Friends and Family Test (% recommended) ‐ Maternity Antenatal 95.5% Aug‐18 100% 99.4%

Friends and Family Test (% recommended) ‐ Maternity Birth 96.9% Aug‐18 95.3% 96.2%

Friends and Family Test (% recommended) ‐ Postnatal Ward 95.1% Aug‐18 96.2% 95.8%

Friends and Family Test (% recommended) ‐ Postnatal Ward (Community) 97.9% Aug‐18 95.0% 98.4%

Friends and Family Test (% recommended) ‐ Mental Health 89.1% Aug‐18 91.8% 93.7% 88.1% 84.7%

Friends and Family Test (% recommended) ‐ Community 95.5% Aug‐18 96.8% 96.2%

Friends and Family Test (% recommended) ‐ See and Treat/Non‐Conveyance (YAS) 90.8% Aug‐18 No Data 40%

Friends and Family Test (% recommended) ‐ Patient Transport Service (YAS) 91.3% Aug‐18 No Data No Data

Complaints ‐ Total Received n/a Mar‐18 846 14 204 14 212 15 858 YAS

Staffing

Staff Turnover variable Apr‐18 no data no data 12.50%11.8%

(YAS)

Sickness variable May‐18 3.62% 5.15% 3.61% 5.23% YAS

Performance and Quality Summary Action

LYPFT ‐ Friends and Family Test (FFT)

LYPFT have historically received extremely low returns for the FFT. The Director of Nursing, Quality and Professions for LYPFT has

commissioned an external review of the Trusts Patient Experience team and supporting processes. This will involve a wide ranging review

of how the trust engages with service users and gains feedback and will include the FFT. The CCG also uses all other forms of information

to monitor patient experience such as Patient Opinion, mental health safety thermometer, complaints and incidents to seek assurance

from the Trust that they are reviewing and learning from patient experience.

See and treat/non‐conveyance FFT

Based on the data available to co‐commissioners, the reason for the low response rate is unclear. Although it is noted that this response

rate is historically low.

Patient Transport Service ‐ FFT

According to quarter 2 data available to Leeds CCG, 73 service users responded to the FFT, 1 more than the previous quarter. 90.4% of

those would recommend, 4.1% would not recommend. This is a reduction in recommends and an increase in would not recommend from

the previous quarter.

An update on the work carried out so far will be presented to the CCG Clinical Quality review

meeting in November and the CCG will ensure assurance is gained that the approach to improving

responses to the FFT is part of any recommendations going forward.

We will work with lead commissioners and providers through the 111/999 quality group to

understand the trend in response rates over time, the challenges to improving the response rate

and what is in place to support improvement.

This will continue to be monitored through the 111/999 quality meeting including reasons for the

change and actions in place to address anything that is modifiable.

Performance Measures

Quality and Safety

Measure Target /

Nat Av

Period LTHT LCH LYPFT Other*

1


























Title: Finance Report for 7 months ended 31st October 2018

Lead Governing Body Member: Visseh Pejhan-Sykes, Chief Finance Officer


appropriate

()

Report Author: Judith Williams, Head of Corporate Reporting & Strategic Financial Planning

Decision

Reviewed by EMT/Date: N/A Discussion

Reviewed by Committee/Date: N/A Information

Checked by Finance (Y/N/N/A - Date): Y


2

EXECUTIVE SUMMARY: This report provides an update on the financial performance of NHS Leeds Clinical Commissioning Group for the seven months to 31st October 2018 and the expected outturn position for the 2018-19 financial year. The CCG is on target to achieve its financial control total. Although the CCG is still significantly some way from achieving its £34.3m QIPP target with a forecast of just over £20m, risks identified during the planning stage have now been mitigated or reduced enabling the CCG to achieve its overall in year financial target. Resources are being directed into the Commissioning for Value programme to ensure that there is a robust process in place to review all commissioning expenditure and monitor QIPP plans. QIPP is reported and monitored through the Commissioning for Value Board. An underspend on running costs of £633k has been released in Month 7. The CCG financial plan reflected the part year effect of 20% infrastructure reductions and realignment of staff to system transformation; this was a requirement of the three Leeds CCGs merger plans. This part year effect equated to an expected £2,847k underspend in year on running cost allocation (running costs budgets being set lower than allocation). The CCG plan was on a trajectory in year to the full year effect of 20% £3,480k from 2019/20. In year staff turnover and other earlier than expected reductions in non-pay costs have resulted in the CCG being able to achieve the full year effect trajectory earlier than expected and therefore running costs are forecast to underspend against allocation by a further c£600k in year thereby achieving the full 20% reduction earlier.

NEXT STEPS: Updates on the 2018-19 financial position will continue to be presented to the Governing Body and/or Executive Management Team (EMT) on alternate months to ensure that the CCGs’ financial position is formally reported and reviewed each month under the CCGs’ governance arrangements.


(a) Note the Month 7 financial position (b) Discuss, comment and highlight actions required to progress and report to the next meeting of the Executive Management Team

NHS Leeds Clinical Commissioning Group

Finance Report for the Seven Months ended 31st October 2018

Page 1

Financial Performance Report 31st October 2018


At 31st October

2018 At Year End

2018-19 RAG RAG

CCG Expenditure does not exceed planned level GREEN GREEN

Programme spend less than allocation GREEN GREEN

Running costs spend less than allocation GREEN GREEN

Delegated Co-commissioning less than allocation GREEN GREEN

Planned Surplus in year GREEN GREEN

QIPP AMBER AMBER

Clear identification of risks against financial delivery & mitigations GREEN GREEN

Delivery of Mental Health Investment Standard GREEN GREENBetter Payment Practice Code - to pay 95% of valid invoices by due date or within 30 days of

receipt of a valid invoice, whichever is later GREEN GREENCash at bank balance within 1.25% of the monthly amount requested or £250k, whichever is

greater GREEN GREENAssessment of internal and external audit opinions on the timeliness and quality of returns N/A N/A

Overview 31st October 2018

This report provides an update on the financial performance of NHS Leeds Clinical Commissioning Group for the seven months to 31st October 2018 and the expected outturn position for the 2018-19

financial year.

The CCG is on target to achieve its financial control total. Althouhg the CCG is still significantly some way from achieving its £34.3m QIPP target with a forecast of just over £20m, risks identified during

the planning stage have now been mitigated or reduced enabling the CCG to achieve its overall in year financial target. Resources are being directed into the Commissioning for Value programme to

ensure that there is a robust process in place to review all commissioning expenditure and monitor QIPP plans. QIPP is reported and monitored through the Commissioning for Value Board.

An underspend on running costs of £633k has been released in Month 7. The CCG financial plan reflected the part year effect of 20% infrastructure reductions and realignment of staff to system transformation, this was a

requirement of the three Leeds CCGs merger plans. This part year effect equated to an expected £2,847k underspend in year on running cost allocation (running costs budgets being set lower than allocation). The CCG

plan was on a trajectory in year to the full year effect of 20% £3,480k from 2019/20. In year staff turnover and other earlier than expected reductions in non pay costs have resulted in the CCG being able to achieve the full

year effect trajectory earlier than expected and therefore running costs are forecast to underspend against allocation by a further c£600k in year thereby achieving the full 20% reduction earlier.

Page 2

Financial Position Summary 31st October 2018


Revenue Expenditure 2018-19 Budget Actual Variance Budget Forecast Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000Programme ServicesAcute Services 343,897 344,376 479 585,765 586,585 820 486

Mental Health Services 79,732 79,283 -449 136,684 136,678 -5 -14

Community Health Services including Childrens Services 81,639 81,456 -183 136,623 136,609 -14 -40

Continuing Care Services 32,600 32,269 -331 55,886 54,696 -1,190 1

Prescribing and Primary Care Services 90,462 89,347 -1,114 155,043 153,642 -1,401 -626

Other 3,457 2,858 -599 5,750 5,011 -740 -162

Primary Care Co-Commissioning 65,839 65,839 0 111,589 111,589 0 0

Total Programme Services 697,626 695,428 -2,198 1,187,340 1,184,811 -2,529 -355

RUNNING COSTS 8,674 8,287 -387 14,671 14,038 -633 -633

RESERVES 4,592 7,177 2,586 17,433 20,595 3,162 988

CCG Net Expenditure 710,892 710,892 0 1,219,444 1,219,444 0 0

Allocations 31st October 2018

NHS Leeds Clinical Commissioning Group Allocations

Allocations 2018-19

£'000 £'000 £'000 £'000Opening Baseline Allocation 1,088,029 17,402 112,484 1,217,915

Subtotal Month 1 Adjustments 475 44 0 519Subtotal Month 2 Adjustments 0 0 0 0

Subtotal Month 3 Adjustments 4,362 0 -895 3,467

Subtotal Month 4 Adjustments 957 0 0 957Subtotal Month 5 Adjustments 89 116 0 205Subtotal Month 6 Adjustments 1,264 0 0 1,264

Subtotal Month 7 Adjustments 117 0 0 117

Closing Allocation 1,095,293 17,562 111,589 1,224,444

M07 allocations:

Non recurrent allocation of £125k received for Q3 wave 1 liaision for mental health transformation funding.

Annual Variance

movement from

previous month

Year To Date Annual

Recurrent allocation of £15k received in respect of growth on the Identification Rule changes for specialised commissioning allocation received in the previous month.

Running CostsCo-

commissioning

IN YEAR

ALLOCATIONProgramme

Defund of £23k re part year effect transfer of funding for research excess treatment costs to Bradford District CCG as delegated representative of National Health Research Clinical Research Network.

Page 3

Risks and Mitigations 31st October 2018

NHS Leeds Clinical Commissioning Group Allocations

Risks and Mitigations 2018-19 Full Risk Value

Description of Risk £'000Acute overperformance, 52 week waits, QIPP underachievement Acute Services 6,450

Transforming care partnership, out of area, elective funding Mental Health 3,400

New community beds service, Equipment service Community Health 1,050

Care home fees Continuing Care 350

Prescribing, including for new community beds and no cheaper obtainable stock Primary Care 1,000

CSU Stranded costs Running Costs 0

Total Risks 12,250

Description of Mitigation £'000Contingency held 6,096Reserves held 6,154

Total Mitigation 12,250

Net Risk 0

Reserves are sufficient to cover all identified and quantified risks at this stage.

Risk Area

Full Mitigation

Page 4

Acute Services 31st October 2018

Budget Actual Variance Budget Forecast Variance

£'000 £'000 £'000 £'000 £'000 £'000Leeds Teaching Hospitals NHS Trust 246,211 246,211 0 418,302 418,302 0

Mid Yorkshire NHS Trust 15,894 15,748 -146 27,246 26,996 -250

Harrogate Foundations Trust 15,822 16,331 510 27,123 27,997 874

Bradford Foundation Trust 3,053 2,937 -117 5,234 5,034 -200

York Foundation Trust 1,603 1,585 -18 2,748 2,718 -30

Other NHS Trusts 5,217 5,283 67 8,943 9,057 114

Non contract Activity 3,992 3,992 0 6,844 6,844 0

Non NHS Acute 24,730 24,853 123 42,395 42,606 211

Urgent Care 27,375 27,434 59 46,929 47,030 101

Total Acute Services 343,897 344,376 479 585,765 586,585 820

Leeds Teaching Hospitals (LTHT) - An Aligned Incentives Contract (AIC) benefits tracker document has been produced and reviewed at Contract Management Board (CMB) listing a number of schemes

which have been realised due to the AIC. The next phase is to identify some simple measures to quantify the kinds of qualitative benefits that have been pulled together on the benefits tracker.

The CCG and LTHT have started negotiations around the 2019-20 contract.

The Harrogate contract is now forecasting an overtrade position which has increased by a further £749K. An element of this relates to prior period reconciliation. The balance of the overtrade is due to

seeing higher costs within day case, elective and non-elective points of delivery. The day case and elective overtrade is driven by trauma and orthopaedic procedures, non-elective by geriatric medicine

procedures. The overtrade is reduced by underspends within critical care and excess bed days.

We are continuing to forecast minor undertrades across our Mid Yorkshire and Bradford contracts; this is due to day case and non-elective procedures at Mid Yorkshire and outpatient procedures at

Bradford. The Hull and East Yorkshire Hospital contract is forecasting an £80K overtrade due to non-elective procedures within the General Medicine specialty and critical care days.

After reviewing Month 6 a number of independent sector contracts such as Spa Medicare and Spire Methley Park are forecast to overspend based on a phased profile where activity increases during

winter. These overspends are mitigated by a significant under spend at Spire Leeds. All variances are due to trauma and orthopaedic and general surgery procedures.

The any qualified provider (AQP) position has remained the same as Month 6, over all the AQP contracts in total the forecast is in line with the budget.

The urgent care overspend relates to the Shakespeare walk in centre, based at Burmantofts Health Centre, which is currently forecasting to overtrade by £150K; the drivers of the increased activity are

continuing to be assessed to see if it is possible to mitigate the trend.

AnnualYear To DateNHS Leeds Clinical Commissioning Group

Page 5

Mental Health Services 31st October 2018


£'000 £'000 £'000 £'000 £'000 £'000Leeds and York Partnership Foundation Trust 56,556 56,580 24 96,953 96,956 2

Tees Esk and Wear Valley NHS Foundation Trust 641 611 -30 1,099 1,099 0

Bradford District Care NHS Foundation Trust 94 93 0 160 160 0

Independent/Voluntary Sector/LCC 3,002 2,806 -196 5,147 5,147 0

Learning Disabilities 15,416 15,495 78 26,428 26,562 134

IAPT 676 676 0 1,158 1,158 0

Mental Health Specialist Services 2,553 2,249 -304 4,376 4,222 -154

Mental Health NCAs 298 295 -3 511 505 -6

Mental Health Other 496 478 -18 850 869 18

Total Mental Health Services 79,732 79,283 -449 136,684 136,678 -5


At month 7, there are no material changes to the financial position reported for Month 6. Mental health and Learning Disabilities is forecasting an underspend of -£5K, this is an improvement of -£14K

from month 6.

A new S117 protocol has been jointly approved between NHS Leeds CCG and Leeds City Council and will be implemented for November 2018 via the Continuing Care team. This will negate the risks and

the financial impact associated with any funding agreement.

For TCP, the funding apportionment for the cohort that have stepped down into community services are currently in discussion with Commissioners between NHS Leeds CCG and Leeds City Council.

Finance will be informed of the outcome by the working group.

The financial risk regarding the Transforming Care trajectory, Elective funding approvals continues for month 7. The risks and processes surrounding these services are under continuous review.

Year To Date Annual

Page 6

Community Health Services 31st October 2018


£'000 £'000 £'000 £'000 £'000 £'000Leeds Community Healthcare NHS Trust 56,260 56,260 0 96,406 96,406 0

Voluntary Sector/Local Authority 10,969 11,059 90 18,804 18,960 157

Community Beds 6,776 6,709 -67 11,616 11,501 -115

Hospices 4,535 4,505 -30 4,653 4,622 -31

Reablement 1,637 1,637 0 2,807 2,807 0

Safeguarding 424 415 -9 726 711 -16

Sub Total Community Health Services 80,601 80,585 -16 135,013 135,007 -5Children's Services excluding Continuing Care 1,037 870 -167 1,610 1,602 -9

Total Community Health Services including Childrens 81,639 81,456 -183 136,623 136,609 -14

The Community Beds Service forecast underspend has increased by £32k to £115k this month. This relates to patients in Camellia homes receiving 1:1 care which is funded by Leeds City council.

There is minimal change in Childrens Services forecast, an underspend increase of £5k which is due to the activity based LAC service.

NHS Leeds Clinical Commissioning Group Year To Date Annual

Page 7

Continuing Care Services 31st October 2018


£'000 £'000 £'000 £'000 £'000 £'000Continuing Healthcare (CHC) 20,427 19,923 -504 35,017 33,855 -1,162

Continuing Healthcare Personal Health Budgets (PHBs) 3,501 3,900 399 6,001 6,686 685

Funded Nursing Care (FNC) 5,141 5,152 11 8,813 8,808 -4

Children Continuing Care including PHBs 834 644 -190 1,429 1,179 -251

Continuing Healthcare - operational 1,423 1,331 -92 2,439 2,282 -156

Neuro-rehab 1,276 1,319 43 2,187 1,886 -301

Total Continuing Care Services 32,600 32,269 -331 55,886 54,696 -1,190

Continuing care services are demand led services, and so forecasts will fluctuate throughout the year. Personal Health Budgets are to become the default delivery mode for CHC homecare from April

2019, and this is reflected in the current trend.

The Continuing Care forecast is currently showing a £1,190k overall under spend, a similar level to last month. FNC has increased by £148k and PHB’s have decreased by £171k. This is due to a review

of all packages by the service during the month

AnnualNHS Leeds Clinical Commissioning Group

Year To Date

Page 8

Prescribing and Primary Care Services 31st October 2018


£'000 £'000 £'000 £'000 £'000 £'000Prescribing 73,404 72,821 -583 125,836 124,836 -1,000

Ex centrally funded drugs 1,992 1,992 0 3,414 3,414 0

Oxygen contract 681 681 0 1,168 1,168 0

Primary Care Schemes 10,817 10,801 -16 18,544 18,536 -8

Clinical Leads 377 355 -22 586 571 -15

Primary Care - GP IT 1,443 1,443 0 2,473 2,473 0

Medicines Optimisation in Care Homes Project 341 52 -289 438 286 -152

Sub Total Prescribing and Primary Care Services 89,055 88,145 -910 152,459 151,284 -1,176Prescribing Staff 911 771 -140 1,561 1,401 -161

Primary Care Staff 456 414 -42 782 718 -64

Confederation Staff 40 17 -23 240 240 0

Sub Total GP Confederation 1,407 1,203 -204 2,584 2,359 -225

Total Prescribing & Primary Care Services 90,462 89,347 -1,114 155,043 153,642 -1,401

AnnualNHS Leeds Clinical Commissioning Group

Year To Date

Prescribing: August data has now been received; the forecast remains at an £1M under trade position as at Month 6. The position is likely to reduce further in future months. The finance team are

working with prescribing colleagues to monitor the position going forward and will amend the forecast as more data is received.

Primary Care: The locally agreed further 1% non-recurrent pay increase in return for a full workforce data collection exercise to enable an accurate workforce picture to be understood across the City

will be paid to Practices in November. Further to this practices will provide information on their appointment systems to help understand current demand.

The Medicines Optimisation in Care Homes Project is expected to underspend by £152k as the allocation was given retrospectively part way through the year, and is not adjusted for delays in

recruitment.

There is a new section this month for the GP Confederation reflecting the staffing element of the confederation. The embedded prescribing and primary care provider staff are shown as full year

budget and spend, although the element relating to the confederation is only effective from 1st October 2018.

Page 9

Other Services 31st October 2018


£'000 £'000 £'000 £'000 £'000 £'000Non acute commissioning - LIDS 449 442 -8 770 757 -13

Proactive Care and transformational projects 2,005 1,597 -408 3,379 3,027 -352

Cancer Projects 55 56 0 45 45 0

Programme Staff - Transforming care/out of area 88 75 -13 151 139 -11

Programme Staff - Sustainability and transformation programmes 697 607 -90 1,124 939 -185

Programme Staff - Nursing and Quality 162 81 -81 282 103 -179

Total Other Services 3,457 2,858 -599 5,750 5,011 -740

Programme staffing underspend relates to vacancies which will continue to be held, and recharges of staff who have gone on secondment.

Proactive care and transformation projects underspend has increased by £54k this month to £352k. This relates to the transfer of funding in respect of research excess treatment costs and release of

associated forecasts and accruals (£12k); underspend on the Leeds Plan (£16k); reduction in forecast for carers support as the provider is unable to provide an element of the service (£15k); and

further slippage on recruitment relating to the React to Red project (£11k), this is being reviewed as to whether the funding can be utilised differently.

Year To Date

Cancer projects are funded by non recurrent allocation. £70k has been received for quarters 1 and 2 and is anticipated to spend in full, offset by defund of £25k which is spread across the year.

NHS Leeds Clinical Commissioning Group Annual

Page 10

Primary Care Co-Commissioning 31st October 2018


£'000 £'000 £'000 £'000 £'000 £'000GMS 14,524 14,530 5 24,899 24,914 14

PMS 28,100 28,102 2 48,171 48,196 25

APMS 2,510 2,516 6 4,303 4,301 -2

Premises cost reimbursements 9,626 9,512 -114 15,245 14,933 -312

Primary Care NHS Property Services Costs - GP 0 0 0 0 0 0

Other premises costs 130 131 2 222 222 0

Enhanced Services 1,675 1,629 -46 2,873 2,873 0

QOF 5,545 5,546 1 9,507 9,923 416

Other GP Services(inc PCO) 3,729 3,874 146 6,369 6,228 -141

Delegated Contingency 0 0 0 0 0 0

Reserves 0 0 0 0 0 0

Total Primary Care Co-Commissioning 65,839 65,839 0 111,589 111,589 0

As mentioned previously the nationally agreed GP pay increase was paid in October and is reflected in the year to date position. The Community Health Partnerships RPI (Retail Price Increase) increase

for 18.19 LIFT buildings has been agreed and paid at a value of £250K across the city; this is covered within the budget.

Year To Date AnnualNHS Leeds Clinical Commissioning Group

Page 11

Running Costs 31st October 2018

Budget Actual Variance Budget Forecast Variance£'000 £'000 £'000 £'000 £'000 £'000

Pay 5,357 4,809 -549 9,184 8,461 -722

Non Pay/Income 3,317 3,478 162 5,487 5,577 89

Total Running Costs 8,674 8,287 -387 14,671 14,038 -633

Running Costs are now expected to underspend by £633k at the end of the financial year. Underspend on pay has increased in month 7 reflecting current vacancies. Non pay expenditure is showing a

year to date overspend which includes provision costs, although lower than forecast in Month 6.

NHS Leeds Clinical Commissioning Group Year To Date Annual

Page 12

Consolidated Statement of Financial Position 31st October 2018

31st October 2018 31st March 2018

£'000 £'000

Current AssetsTrade & Other Receivables 8,431 3,556

Cash & Cash Equivalents 26 291

Total Current Assets 8,457 3,847

Total Assets 8,457 3,847

Current LiabilitiesTrade & Other Payables: (69,742) (63,132)

Borrowings 0 0

Provisions (2,183) (1,448)

Total Current Liabilities (71,925) (64,579)

Total Assets less Current Liabilities (63,468) (60,732)

Non-current LiabilitiesProvisions (1,483) (1,348)

Total Non-current Liabilities (1,483) (1,348)

Total Assets Employed (64,951) (62,080)

Financed by Taxpayers’ EquityGeneral Fund (64,951) (62,080)

Total Taxpayers’ Equity (64,951) (62,080)

Page 13

1


























Title: CCG Financial Control, Planning and Governance Self-Assessment Q2



appropriate

()

Report Author: Judith Williams, Head of Corporate Reporting & Strategic Financial Planning

Decision


Reviewed by Committee/Date: Audit Committee 24th October 2018

Information



2

EXECUTIVE SUMMARY: The Financial Control, Planning and Governance Self- Assessment template has been designed by NHS England in conjunction with the Financial and Resilience Working Group (FRWG). The purpose of the template is to provide assurance that there are adequately designed and effective financial controls and governance processes in place to mitigate risk. The self-assessment is designed to consider the overall control environment and covers financial control, planning and governance. The assessment is required to be submitted to NHS England Area Team on a quarterly basis, reported to the next available CCG Governing Body meeting and will be used as an indicator of risk.

NEXT STEPS: The self-assessment for quarter 2 2018/19 was submitted to NHS England Area Team on 8th October 2018 in line with the national timetable. It then went to Audit Committee for endorsement on the 24th October, 2018. The self-assessment will be reviewed by the CCG and submitted to NHS England on a quarterly basis in line with NHS England reporting requirements and will be submitted to Audit Committee for subsequent endorsement and Governing Body for information.

RECOMMENDATION: The CCG Governing Body is asked to:

(a) NOTE the CCG quarter 2 2018/19 CCG Financial Control and Governance Self–

Assessment

CCG Financial Control, Planning and Governance Self-Assessment

Domain # Assessment Criteria Frequency Y/N/P/NA Please explain key reasons where not met Actions to address issues identified

8 CCG can confirm they have a high confidence that the plan is achievable and the CCG has the capacity and capability to deliver it? QuarterlyYes

13 Is the CCG reporting FOT equal to or better than plan? Quarterly Yes

14 Is the CCG's underlying position equal to or better than plan, i.e. no emerging deficit or deterioration in-year? Quarterly Yes

15 CCG to confirm that all identified risks have been fully quantified within the reported position? If no, please specify Quarterly Yes

16Is the CCG reporting nil net risks? i.e. gross risks identified and quantified with fully identified mitigating actions that are clear and developed

and fully off-set identified risks, .Quarterly

Yes

17The CCG to positively confirm that it is not relying on any unconfirmed outstanding allocations as in-year mitigation to deliver forecast? If unable

to confirm, please specify type of allocation, amount and anticipated funding source?Quarterly

Yes

18 Is the CCG unidentified QIPP less than 15%? if no, state value and actions being taken Quarterly Yes

19 Is year to date QIPP delivery in line with planned profile? Quarterly Yes

21Can the CCG confirm that there is consistency in financial reporting and that this is signed off by the CFO? (including but not limited to; internally

and externally reported, across ledger system and related financial reporting such as agreement of balances and finance reports).Quarterly

Yes

22If the CCG is subject to a Financial Recovery Plan (FRP), the CCG can confirm that this is 'owned' by the whole CCG and not just finance?

(potential evidence - as a minimum is an update provided to the Governing Body on a monthly basis, named leads)Quarterly

Not Applicable

23 Does the expenditure run rate triangulate with the cash run rate allowing for reasonable reconciling items? If no, state material causes QuarterlyYes

24The CCG can confirm, all contracts signed for 2018-19 including; any MOUs, secondment agreements, BCF, pool agreements etc and any

contract variations required for 2018-19Quarterly

Yes With the exception of GDPR contract variations to be returned from providers

25 The CCG can confirm they have no identified / outstanding contractual disputes (formal or informal)? Quarterly Yes

26 The CCG can confirm that there are currently no Novel or contentious contract procurements planned (1-3 year pipeline)? Quarterly Yes

27The CCG can confirm that it has a positive working relationship with its key stakeholders? including main NHS providers, GPs and local

authority/ies? If no, please specifyQuarterly Yes

28 The CCG has strong engagement with it's main provider Trusts, including where the CCG is not the lead commissioner? Quarterly Yes

29

The CCG can confirm that it is operating within a system where the main providers have accepted their in-year control totals and are forecasting

to deliver control total compliant plans? i.e. no providers are reported as 'off plan' or in special measures/financial recovery? If no, please

specify?

Quarterly

Yes

30The CCG is reasonably confident in the delivery of the reported financial position of its providers or partners including main NHS providers,

independent sector, other partner organisations etc.? If no, please specify.Quarterly

Partial

All three main Providers include significant risk in their financial

planning projections for 18/19

The introduction of Aligned Incentive Contract with LTHT is already showing financial benefits in terms of risk reduction.

However, LTHT CIP plans are still high risk. Out of Area Placements and Acute Mental Health service demands are also

projecting a risky financial year for LYPFT.

36

CCG undertakes and can provide evidence of a process of internal financial management? this should include (but may not be limited to)

detailed monthly financial reporting to budget managers / owners and review, evidence of challenge with the 'owner', and a process to seek

Recover Action actual performance is adverse to plan.

Quarterly

Yes

37 The CCG can evidence that the balance sheet is reviewed every month with full reconciliations and sign off of all control accounts? QuarterlyYes

38The CCG to confirm that robust processes are in place to support the completion of Agreement of balance returns and that they are completed

on time and differences with NHS bodies are actively resolved?Quarterly

Yes

39 Accounts payable and receivable are both regularly reviewed, proactively managed and regularly reported to the Governing Body? QuarterlyYes

40 The CCG can confirm that any debtor or creditor balances (Non-NHS) over 120 days have all been fully provided for? Quarterly Yes

41 All cash forecast and drawdown requirements are agreed and signed off with appropriate governance e.g. CCG CFO Quarterly Yes

42The CCG manages cash balances effectively and has not required any supplementary cash drawdowns in the last 12 months? If no, confirm how

many instances and actions being taken to avoid reoccurrence?Quarterly

No

JW/TVM: Several supplementary drawdowns done, as individual

Leeds CCGs, in last 12 mths. Predominantly as a result of suppliers

inconsistent processing of invoices Putting suppliers on to tradeshift

44 CCG can confirm there are effective risk management processes in place? Including; the identification, quantification and mitigation of risk QuarterlyYes

45Where applicable, the CCG can confirm that risk sharing arrangements with other CCGs and trusts or other partners are fully documented and

collectively agreed and the associated financial risks are evaluated monthly to inform CCG Forecasts. Quarterly

Not Applicable

46Where applicable, the CCG can confirm that financial controls are in place to ensure the CCG is not placed at undue financial risk as a result of

CCG hosting/lead arrangements? e.g. where the CCG receives income for the provision of services commissioned by other organisationsQuarterly

Not Applicable

47 The CCG undertakes a Pro-active horizon scanning process with risks assessed in terms of likelihood and financial impact? Quarterly Yes

48The CCG Governing Body financially assesses all risks on risk register on a periodic and timely basis, a process which is supported by a robust risk

tracking and reporting system regularly reporting to the appropriate committee. Quarterly

Yes

54Audit committee ensures responsibilities for implementing recommendations are appropriately assigned with timescales agreed and major

items delivered on time.Quarterly

Yes

55Audit Committee obtains direct evidence in key areas of concern where appropriate to reduce reliance on representations from senior

managementQuarterly

Yes

56CCG can confirm it has no outstanding internal audit category 1 findings and recommendations and all lower level recommendations

implemented on time and in full?Quarterly

Yes

60 CCG can evidence through reporting that there is a clear audit trail of reporting activity performance and the financial implications? Quarterly

Yes

The Governing Body for the new CCG has mandated the Commissioning for Value Delivery Board of the CCG to oversee QIPP

delivery oversight as the single most important aspect for CCG financial control and assurance

63The CCG can evidence that; the Finance & Investment Committee has met regularly as stipulated in terms of reference with agendas and

minutes recording decisions, and robust monitoring and follow up of actions?Quarterly

Not Applicable JW

65The Committee report clearly articulates: in year and forecast position, underlying run rate, key risks and mitigations, QIPP progress, clear

actions and progress, key financial and related operational performance, procurement plan, committee work plan etcQuarterly

Not Applicable JW

66

The GB Finance report clearly articulates key financial performance information including; in year and forecast position, the budget is reconciled

to the allocation, underlying run rate, key risks and mitigations, QIPP progress, clear actions and progress, and key financial and related

operational performance is evident?

Quarterly

Yes see point 60 - Dedicated delivery board in palce at the CCG to oversee QIPP delivery and commisisoning decisions overall

67

The CCG GB fulfil a role of constructive, focussed and relevant challenges with timely and robust monitoring and follow up of actions? This will

include (but is not limited to) the reporting of the financial position of the CCG is a standing agenda item, there is sufficient time given to discuss

finance, there is effective challenge, the whole of the GB takes collective responsibility for the finances and receive appropriate training

Quarterly

Yes

De

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&

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Domain # Assessment Criteria Frequency Y/N/P/NA Please explain key reasons where not met Actions to address issues identified

69CCG to confirm finance roles are all filled by substantive appointments? If no, state % wte vacancy and proportion covered by interim staffing

arangementsQuarterly

Yes

70 Are the Executive Team all substantive appointments with no vacancies? If no, state which roles are currently vacant Quarterly Yes

72The CCG staff turnover % based on the previous 12 months is 5% or less? If no, state the turn over % and whether the CCG considers this

acceptable stating the rationaleQuarterly

No

Turnover is a reflection of the organisation still bedding down

from the merger of 3 CCGs

Would expect the in month turnover to reduce, but due to the way this is calculated year to date figure can only worsen as

more months are added in, but this is not a reflection of the true position in terms of the stability of the workforce.

73CCG can confirm where relevant, shared management team recognises the organisational boundaries and allows sufficient time to focus on the

separate issues of each constituent CCG?Quarterly

Not Applicable

74 CCG can confirm there is a robust PMO function in place for QIPP delivery? Quarterly Yes

75 CCG can confirm there is sufficient resource in place to ensure the delivery of the QIPP schemes? Quarterly Yes

78 Can the CCG evidence clear clinical leadership and engagement in the development and delivery of QIPP plans? Quarterly Yes

79Can the CCG confirm and evidence that they have extensively reviewed the “Financial Resilience Support Site” and "Difficult Decision" paper

taking necessary steps to fully implement identified opportunities?Quarterly

Yes

80 Can the CCG confirm that all QIPP schemes have associated, risk assessed business cases with key milestones identified for delivery? Quarterly

Partial

The CCG is currently establishing processes for development and sign off of all business cases. In recent years each CCG had

developed its own processes which has left gaps in process and capture of benefits, risks and asssumptions ocontained

within business cases. Whilst the new CCG is trying to retrospectively capture any benefits associated with existing schemes

we are focussing more on developing a more robust process for schemes that are currently in development

81CCG can confirm that QIPP performance is monitored at least monthly at individual initiative level with QIPP performance figures reconciling to

reported I&E performance?Quarterly

Partial Updates on progress with milestones and impacts will be proved to the CfV Board on a monthly basis.

82

CCG can confirm it has robust contracting arrangements in place with commissioning support service provider? This includes; a signed contract

detailing all services to be delivered and related standards of performance, regular meeting to review performance against the contract, CCG

acts as an intelligent customer with clear specifications, division of duties and responsibilities with effective escalation and dispute procedures.

Quarterly

Yes

83

The CCG is confident that the CSU provider is resillient and provides value add? i.e. Service provider delivers economies of scale and regularly

demonstrates value for money. Service provider able to draw on support from a wider pool of commissioning support staff across a wider

geography and not over-reliant on one or two key staff. Niche expertise available as required to address specific issues, rigorous approach,

share and continuously implement best practice.

Quarterly

Partial

The CCG has 2 CSU support services one of which is delivering VFM

and the other is not.

Mitigation is in place to counter the issue of the lack of VFM and the service provision shortfalls of the non-delivering CSU

short term. In the long term, we are working in partnership towards the termination of the non VFM services and in housing

of these services (which is already in hand as part of our interim mitigation action) – by March 2019 at the very latest.

84

CCG can confirm it has an excellent working partnership with the service provider? i.e. roles and working arrangements clearly defined, shared

purpose, mutual trust, customer service is routinely monitored, open communications with constructive challenge and joint organisational

development

Quarterly

Partial

Relationships with both CSUs are good but the one that is failing to

deliver does not have the trust of the CCG.

Mitigation is in place to in-house services and we are now working in partnership with the CSU in question to manage the

transition of service by the end of March 2019.

85

Commissioning support provider has the required Business Intelligence capability and capacity? i.e. capacity and expertise to handle and process

large volumes of data and provide accurate, clean, relevant and timely information and intelligence. All data is stored and handled in accordance

with required governance with full audit and tracking. Appropriate data and information held to support commissioning decisions

Quarterly

Yes

CSU

Su

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ort

Cap

abili

ty a

nd

Cap

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MO

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(Q

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)

1


























Title: Chief Executive Officer’s Report

Lead Governing Body Member: Phil Corrigan, Chief Executive


appropriate

()

Report Author: Phil Corrigan, Chief Executive

Decision

Reviewed by EMT/Date: n/a

Discussion

Reviewed by Committee/Date: n/a

Information


Approved by Lead Governing Body member (Y/N): N

2

EXECUTIVE SUMMARY: CQC Review of Leeds Health & Care System CQC have recently undertaken a system review of our Leeds health and care system with a particular focus on people aged over-65 including those living with dementia. This is in response to pressures the system locally and nationally is currently facing, in-particular around patient flow. The review focused on how well we are: maintaining people’s health and wellbeing at home; providing care and support when people experience a crisis; and supporting people when they leave hospital. For each aspect the CQC tested whether the support and services offered are safe, effective, caring and responsive. The review was carried out under section 48 of the Health and Social Care Act 2008. CQC have already carried out similar reviews in other local authority areas across the country. Information on learning to date and other reviews is available on the CQC website including in the report Beyond Barriers: https://www.cqc.org.uk/publications/themed-work/beyond-barriers-how-older-people-move-between-healthcare-england https://www.cqc.org.uk/local-systems-review In September, the Review Team visited Leeds for two-days, so they could meet with service-users. They returned for five days in October, when they had the opportunity to visit our health and care sites (including hospitals, care homes and nursing homes) and meet patients, community groups, our workforce, and strategic leaders and decision-makers. During their visits, the CQC recognised that as a health and care system we work well together for the benefit of our communities and residents. They were also able to see that we are taking steps to improve areas of concern that exist within our complex system, particularly improving issues with patient flow. The CQC did look to identify aspects across the system that we can further improve to ensure that we continue to make positive steps to reducing lengths of stay in hospital, and improving delayed transfer of care rates. The CQC are currently writing up their findings, with a report expected to be published in late December. This will coincide with a summit to be held in Leeds in mid-December where the draft findings will be presented and the system will come together to develop an action plan to address the findings outlined by the CQC. Relocation of Harrogate and Rural Districts Mental Health Services Tees Esk and Wear Valleys (TEWV) NHS Foundation Trust have undertaken significant work over a 4 year period to review and address significant issues with mental health inpatient facilities for adults and older people on the Briary Wing in Harrogate. It has been widely accepted for many years that the inpatient mental health facilities provided on the Harrogate District Hospital site do not meet modern standards for inpatient mental health care, a view which was supported during a visit by the Care Quality Commission (CQC).

https://www.cqc.org.uk/publications/themed-work/beyond-barriers-how-older-people-move-between-healthcare-england

https://www.cqc.org.uk/publications/themed-work/beyond-barriers-how-older-people-move-between-healthcare-england

https://www.cqc.org.uk/local-systems-review

3

After this review and a listening and engagement project with the local population, it has been decided that inpatient services will move from Harrogate to York, which will allow for an upgrade in in-patient facilities with individual en-suite accommodation. There will also be an increase in community based resources to minimise the need for admission and to promote earlier discharge to accessible and responsive specialist community teams. Specifically the Trust will be looking to invest in expanding the crisis and home treatment team for adults and the rapid response and Intermediate care team for older people (RRICE). Operating hours of the wider community teams would also increase to cover 7 day working. The consultation process will continue and will incorporate the views of Wetherby GPs and residents. This will impact a very small cohort of people within Wetherby who need an acute mental health hospital admission, who will have to travel to York instead of Harrogate. However, they will benefit from better facilities and a wider pool of clinical staff due to the ward being located within a wider hospital site in York. Overall, the community offer will be strengthened and more people will be supported in their home or in the community. Key Messages from the West Yorkshire & Harrogate Joint Committee of Clinical Commissioning Groups The key messages from the recent meeting of the West Yorkshire & Harrogate Joint Committee of CCGs held on 6 November 2018 are attached at Appendix 1. Contribution from Director of Operational Delivery iBCF/Spring Budget scheme funding – Second Bidding Round As per the announcement at the Leeds Plan Delivery Group meeting on 27 September 2018, this is an invitation to bid against £1.8m of available monies from within the iBCF/Spring Budget scheme funding. This is made up of monies allocated to the Leeds Plan in the first bidding round and underspends from existing first round schemes. This process has been signed off and approved by the Partnership Executive Group. This second bidding round will take a similar approach to that used for the original iBCF/Spring Budget scheme approval process taken in 2017. This will ensure that the schemes, which will add to those already within the iBCF, are robust enough to receive funds. Criteria for funding: In terms of the criteria that the iBCF/Spring Budget schemes should meet, these remain as before with an added focus on the priorities of the Leeds Plan and the Leeds Health and Care system:-

Nationally Mandated:- o Reduce pressure on health and social care services and contribute to the

sustainability of those services for the future; o Protect the vulnerable and reduce inequalities, improve quality and reduce

inconsistency and build a sustainable system within the reduced resources available;

o Directly relate to or as a minimum support the overall aims and intentions of the actions outlined within the Leeds Health and Wellbeing Strategy and the Leeds Health and Care Plan;

4

Benefits including their impact (if any) upon the key national metrics (Non-Elective Admissions, Admissions to Residential Care, Effectiveness of Reablement and Delayed Transfers of Care) are evidenced;

Place focused

Additionally for this round two, it is proposed that any scheme should be aligned with either:-

an existing project or workstream within the Leeds Plan which will enhance or accelerate the outcomes of that project or

an enabler workstream that will deliver benefits across the programmes and projects within the Leeds Plan

Schemes should also be supportive of the outcomes of the Newton Europe work where appropriate.

Contribution from Head of Communications and Engagement

Big Leeds Chat In October through the People’s Voices Group, a sub group of the Leeds Health and Wellbeing Board, we organised the Big Leeds Chat. The Big Leeds Chat is the first time that all organisations in Leeds have come together under one roof to listen to local people. The aim of the event was hear what people think about living in our city and to show Leeds citizens that we are working together as one health and care system. The Big Leeds Chat is a ‘conversation’ about what matters to local people. The conversation focussed on, but was not limited to, health and wellbeing. We asked people three simple questions:

• What do you love about living in Leeds? • What do you do to stay healthy? • What would you like to see change to make Leeds an even better city to live in?

An engagement report is being produced to summarise the key themes emerging from the first event. The Big Leeds Chat will become a regular event with the aim of holding it on a quarterly basis. Deliberative event – changing face of primary care In September, we held a deliberative event attended by 64 people closely representing the wider Leeds population to discuss how primary care is changing and how we can work with patients and the public to encourage appropriate use of services. During the event people looked at four key areas of the 10 high impact actions to free up GP time that have been developed by NHS England. People were supportive of ensuring that the time of GPs was used in the most effective way. This is to ensure the wider health and care workforce can take on some of the duties that GPs currently undertake where they are better suited for other skilled professionals. People discussed how something called active signposting has resulted in GP practice staff receiving additional training so they can help ensure patients are directed to the right healthcare professional at the right time and in the right place.

5

This included a new approach that will see people with musculoskeletal (MSK) conditions being asked to see a physio first rather than a GP – an approach with a working title of ‘first contact practitioner’. The day also covered ideas from people to reduce did not attends (DNAs) as well as how people can develop the confidence to self-care or self-manage existing conditions. World mental health day Lots of activities took place on World Mental Health Day to challenge any stigma associated with mental ill health as well as signposting to local services. In particular we promoted two co-produced websites – Mindwell (www.mindwell-leeds.org.uk) aimed primarily at over 18s and Mindmate (www.mindmate.org.uk) aimed at children and young people. The Mindwell site was promoted at a series of roadshow type events within the cities further and higher education college and university campuses. We teamed up with the British Transport Police to undertake activities at Leeds train station to promote Mindmate. Over-the-counter medicines campaign In 2017-2018 we spent £3.2 million on prescribing over-the-counter medicines in Leeds. To help ensure we make the best use of our budget we have now implemented national guidance (issued by NHS England) and are asking GPs not to routinely prescribe over-the-counter medicines for a range of minor health concerns. Instead we are asking local people to buy over-the-counter medicines from their local pharmacy or supermarket. To support this we’ve been running a public facing campaign that includes sharing national leaflets, local materials and two videos featuring a Leeds GP and a Leeds pharmacist. The videos outline why we are asking people to buy their own medicines as well making greater use of pharmacies. The resources are all available on our website: www.leedsccg.nhs.uk/otc Pre-engagement work for urgent treatment centre proposals We have started pre-engagement work ahead of a formal engagement exercise planned for the new year. We want to understand the views of local people around our proposals to develop urgent treatment centres in the city to meet a national mandate set out by NHS England. The pre-engagement is specifically looking to get feedback from people who have used the Shakespeare Walk-in Centre to find out more about their experience of using the service as well as their thoughts on it being part of a potentially more comprehensive urgent treatment centre based up the road at St James’s Hospital. The survey runs until 16 November and we will take into account people’s views ahead of the formal 12 week engagement at the beginning of 2019. Primary Care Mental Health Engagement Between June and Sept 2018 we asked people in Leeds what they think about primary care mental health services in Leeds. The engagement ended on 30 Sept 2018 and over 1100 people shared their views.

http://www.mindwell-leeds.org.uk/

http://www.mindmate.org.uk/

http://www.leedsccg.nhs.uk/otc

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Many people were satisfied with the service they received but told us that the criteria for accessing the service were confusing and that the waiting times were too long. People also told us that a patient centred service was important to them and that they want to be able access the service in different ways and be able to choose an intervention that would work for them. We will use the feedback we receive to inform and shape a new single service which meets the needs and preferences of local people. For more information please visit: https://www.leedsccg.nhs.uk/get-involved/your-views/primarycaremhservices/

Contribution from the Chief Financial Officer Building the Leeds Way LTHT are currently preparing their planning application to Leeds City Council in preparation for their Outline Business Case (OBC) Submission to NHS England later this financial year. An approved planning application will lend the business case more weight in terms of viability and deliverability. The scheme centres on major redevelopment on the Leeds General Infirmary site with some minor enabling and upgrade works at other sites. A number of options are being considered including the one originally proposed as the preferred option in LTHT’s Strategic Outline Case (SOC). Greater emphasis is now being placed on the centralisation of maternity and children’s services in the additional options being considered in the OBC. LTHT are currently exploring a range of financing options including traditional Public Sector Financing as well as alternatives to PFI and PFI2. The choice of the final financing model with have a material bearing on the recurrent revenue costs of the final selected option(s) as well as the assumptions which will then be made to support how revenue costs will be covered. We are anticipating clarity on all of these issues towards the end of the current financial year.

RECOMMENDATION: The Governing Body is asked to: (a) RECEIVE the Chief Executive’s report

https://www.leedsccg.nhs.uk/get-involved/your-views/primarycaremhservices/

Note The Joint Committee has delegated powers from the WY&H CCGs to make collective decisions on specific, agreed WY&H work programmes, including mental health, urgent care, cancer and stroke. It can also make recommendations to the CCGs. The Committee supports the wider HCP, but does not represent all of the partners. Agenda papers and further information are available from the Joint Committee web pages: https://wyh-jointcommitteeccgs.co.uk/ or contact Stephen Gregg, Governance Lead [email protected].

West Yorkshire & Harrogate (WY&H) Joint Committee of Clinical Commissioning Groups Summary of key decisions

Meeting held in public on Tuesday 6 November 2018

Improving Stroke Outcomes The Committee considered the latest in a series of updates from the Stroke Task and Finish Group. The report brought the programme to a conclusion and summarised progress in three areas – commissioning and delivering high quality, sustainable stroke care, reducing variation and plans for the whole care pathway. The Joint Committee: 1. Approved four hyper acute stroke units as the ‘optimal’ service delivery model for sustainable and

‘fit for the future’ hyper acute stroke care – Bradford, Calderdale and Huddersfield, Leeds and Mid Yorkshire.

2. Approved the recommendation that all commissioners utilise the agreed hyper acute stroke service specification when commissioning hyper acute care services.

3. Acknowledged that local plans to take people with suspected stroke in Harrogate to a specialist hyper acute stroke service in either Leeds or York will be led by Harrogate. Plans will maintain a rehabilitation service for stroke patients at Harrogate District Hospital, to which they can be transferred after receiving hyper acute stroke care.

4. Supported there is no requirement to further engage or consult across the whole of WY (taking into account the views of local people and the Joint Health Overview and Scrutiny Committee).

5. Noted the views of stakeholders, in line with the NHS England service change assurance process.

6. Approved the recommendation to re-establish a sustainable WY&H stroke clinical network. 7. Noted work underway to further improve quality and outcomes across the whole of the stroke

pathway and support the aspiration to adopt a standardised ‘whole pathway’ stroke service specification across WY&H as soon as possible.

8. Noted that a paper will be presented to the System Leadership Executive Group in December 2018 to ensure there is a continued focus on further improving stroke outcomes across WY&H.

West Yorkshire and Harrogate Healthy Hearts project

The Committee reviewed progress on the project, which aimed to reduce cardio-vascular disease, and built on the stroke prevention work. A number of places across WY&H were already doing similar work, and the project provided the opportunity to improve outcomes by standardising the approach across WY&H. A successful formal launch had taken place in September.

The Joint Committee: Noted the update on the project.

Joint Committee governance

The Committee reviewed the draft terms of reference of the Patient and Public Involvement (PPI) Assurance Group, made up of CCG PPI lay members. The Committee also reviewed the significant risks to the delivery of the Committee’s work plan and arrangements for managing system-wide risks.

The Joint Committee: 1. Agreed the terms of reference of the PPI Assurance Group.

https://wyh-jointcommitteeccgs.co.uk/

https://wyh-jointcommitteeccgs.co.uk/

mailto:[email protected]

1

Agenda Item: GB 18/100i FOI Exempt: N



Title: Operational Scheme of Delegation

Lead Governing Body Member: Sabrina Armstrong, Director of Corporate Services / Visseh Pejhan-Sykes, Chief Finance Officer


appropriate

()

Report Author: Laura Parsons, Head of Corporate Governance & Risk

Decision

Reviewed by EMT/SMT/Date: n/a Discussion

Reviewed by Committee/Date: Audit Committee – 24 October 2018

Information

























2

EXECUTIVE SUMMARY: The Clinical Commissioning Group’s (CCG) operational scheme of delegation was approved by the Governing Body on 11 April 2018. Following six months of operation, it has been reviewed to ensure that it remains up to date and that all relevant items are incorporated. The Internal Contracting Team have reviewed the CCG’s Procurement Policy and it is proposed that thresholds for tendering are increased to be in line with the EU thresholds (see pages 2-3 of the scheme of delegation). The changes proposed are as follows:

Procurement route Current Proposed

Minimum of 2 quotations Below £10,000 Below £10,000

Minimum of 3 quotations £10,000 - £50,000 £10,000 - £100,000

Minimum of 5 quotations £50,001 - £160,000 £100,001 - £615,277 (Healthcare contracts) £100,001 - £181,301 (Non-healthcare contracts)

Competitive tendering Over £160,000 £615,278 and over (Healthcare contracts) £181,302 and over (Non-healthcare contracts)

Under the legislation (Public Contracts Regulations 2015) there are different thresholds for healthcare contracts and non-healthcare contracts and these are reflected in the proposed thresholds. These higher tender thresholds for healthcare procurement will allow the CCG to concentrate resources on the higher value/higher risk procurements whilst still assuring value for money for lower value contracts by the use of Requests for Quotations. Please note that the procurement thresholds are reviewed by the EU every 2 years (the next review is due in January 2020). These are not expected to change before the UK leaves the EU but the thresholds in the Scheme of Delegation will be reviewed again if new guidance is received from Central Government following “Brexit”. A further minor amendment is proposed to include authority for signing a Memorandum of Understanding (MOU), and it is proposed that this is delegated to the Chief Officer and/or relevant Executive Director, depending on the subject of the MOU. The Audit Committee has reviewed the proposed changes and supports the principle of aligning the thresholds with the EU limits, but agreed that it was for the Governing Body to decide the appropriate delegation.

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NEXT STEPS: All staff will be advised of the changes made to the Scheme of Delegation and it will be uploaded onto the CCG website.


(a) APPROVE the proposed amendments to the Operational Scheme of Delegation.

Leeds CCG Scheme of Delegation V2.0 DRAFT

OPERATIONAL SCHEME OF DELEGATION

FINANCE

Issue Authority Delegated To Reference Documents

Budgets

Responsibility for keeping expenditure within budget: At individual budget level (pay, non pay and income)

Budget Holder/Budget Manager Budgetary Control Framework

Responsibility for keeping expenditure within budget: Totality of the service area / department

Budget Holder

Responsibility for keeping expenditure within budget: Financial reserves and provisions

Chief Finance Officer (CFO)

Approval of new Budget Holders or of change to existing budget holders

CFO or Deputy CFO

Any transfer (virement) from non-pay budgets to pay budgets CFO or Deputy CFO

Transfers (budget virement) within pay and non pay budgets Up to £300k (if affordable within overall budget) – Budget Holder (where transfers between budget holders both sets of budget holders must agree)

>£300k up to £1500k - Deputy CFO

Over £1500k – CFO

Transfers from reserves – CFO

Transfers between pay and non-pay budgets are by exception and must be agreed by CFO

https://www.leedsccg.nhs.uk/content/uploads/2018/04/NHS-Leeds-CCG-Budgetary-Control-Framework-v1.0-April-2018.pdf


Maintenance/operation of bank accounts

Day to day operation of organisational bank accounts Senior finance manager in conjunction with Shared Business Services representative

Authorisation for cash limit drawdown Deputy CFO or Senior Finance Manager Corporate finance

Authorisation for cheque requests (excluding retrospective continuing healthcare claims)

up to £15,000 - Authorised Budget Holder Representative

over £15,000 by exception only – Deputy CFO

Non Pay Expenditure

Before orders are placed for goods and services the following conditions must be complied with:

Procurement Policy

Confirmation that budgetary provision is available

Budget Holder/Budget Manager

Healthcare Contracts (as defined by Schedule 3 of the Public Contracts Regulations 2015) Where formal competitive tendering is not required e.g. below £615,278 , then quotations must be obtained and documentary evidence kept of the following

under £10,000 a minimum of 2 written quotations;

between £10,000 and £100,000 a minimum of 3 written quotations;

between £100,001 and £615,277 a minimum of 5 written quotations.

For Requisitions that exceed a 12 Month Period The total value of requisitions that cover more than a 12 month period or that are open ended need to be considered as a total value, not just

Budget Holder/Budget Manager Commitment of any expenditure must be in line with delegated limits stated herein

https://www.leedsccg.nhs.uk/content/uploads/2018/04/Procurement-Policy-April-2018.pdf


the cost for the 12 month period. Non Healthcare contracts

Where formal competitive tendering is not required e.g. below £181,302 , then quotations must be obtained and documentary evidence kept of the following

under £10,000 a minimum of 2 written quotations;

between £10,000 and £100,000 a minimum of 3 written quotations;

between £100,001 and £181,301 a minimum of 5 written quotations.

For Requisitions that exceed a 12 Month Period The total value of requisitions that cover more than a 12 month period or that are open ended need to be considered as a total value, not just the cost for the 12 month period.

Budget Holder/Budget Manager Commitment of any expenditure must be in line with delegated limits stated herein

For orders in excess of £615,278 (healthcare contracts) or £181,302 (non healthcare contracts) including VAT competitive tendering will apply, the form of which is dependent on the precise goods or services involved. Therefore for all competitive tenders the advice of the Chief Finance Officer must be sought. Note: OJEU existing limits are £615,278 including VAT for healthcare services and £181,302 including VAT for non healthcare services

Budget Holder/Budget Manager All tenders awarded should be reported to the Audit Committee for information Commitment of any expenditure must be in line with delegated limits stated herein

Waiving of requirement to obtain quotations and tenders Chief Officer (CO) and CFO and report to Audit Committee

Approving expenditure greater than a tender price by Up to £45k and within budget - Relevant Executive Officer

Up to a maximum of £90,000 – CFO

£90,000 and above – CO and CFO


Decision to tender for new/existing service (within agreed budget) Up to £150k – Authorised Budget Manager

>£150k up to £300k – Budget Holder

>£300k up to £1500k – CO or CFO

>£1500k – CCG Governing Body

Authorisation of new contracts for non pay and subsequent variations

Up to £300k – Budget Holder

Over £300k to £1500k– CO or CFO

Over £1500k – CCG Governing Body

Annual Renewal of existing healthcare contracts Up to £1500k – Budget Holder and CFO

Over £1500k– CO and CFO

Agreement of new GP local enhanced services / GP incentive schemes Up to £750k for total scheme (up to £25k for an individual practice) – CO and CFO

>£750k for total scheme (>£25k for an individual practice) – PCCC

Running costs: Approval of supplier contracts Up to £300k – CFO

>£300k up to £1500k – CO and CFO

>£1500k – CCG Governing Body

Lease Cars Budget Holder in line with operational process

Salary sacrifice schemes CFO or Deputy CFO

Payments in line with approved healthcare contracts Budget holder or budget manager (within delegated limits) or authorised senior finance lead on behalf of budget holder

Other contractual payments (e.g. CQUIN, reconciliation adjustments) Budget Holder or budget holder representative within delegated limits


Payments of invoices for non-contractual activity Budget holder or budget holder representative or senior finance lead in line with delegated limits

Approval of Continuing Healthcare packages and other individual care packages

Packages costing<£1.5k/week – Clinical Leads or Care Coordinators

Packages costing>£1.5k up to £2.5k/week – Clinical Service Manager or Business Manager

Packages costing>£2.5k up to £10k/week – Commissioning Lead

Packages costing >£10k/week – CO

Payment in respect of Continuing Healthcare Packages and other individual care packages

Payments for invoices by individual homes / packages up to £25k – CHC Finance Administrator

Payments for invoices by individual homes / packages up to £75k – CHC Finance Lead

Payments for invoices by individual homes / packages up to £130k – Clinical Services Manager / Business Manager

Payments for invoices by individual homes / packages >£130k up to £250k – Commissioning Lead

Payments for invoices by individual homes / packages > £250k – CO

Consultancy Expenditure (amounts refer to the cost over the duration of the contract / project)

Prior to expenditure being committed all business cases: 1. to be submitted to NHS England via pro-forma

(to be approved internally first by CFO) [email protected];

2. and authorised by CFO and CO in line with organisational establishment/engagement control framework



Approval of invoices/payments/raising of requisitions – running costs or where a payment is not within a signed approved healthcare contract

up to £300,000 – Authorised Budget Holder Representative (when formally delegated – by exception by Budget Holder)

up to £750,000 – Budget Holder

up to £1500,000 – CFO or CO

over £1500,000 – CFO and CO

Request for sales orders • Up to £50k - Budget Holder/ Authorised Budget Holder Representative/Finance Lead

• >£50k to £250k – Deputy CFO • Over £250k – CFO


Capital Schemes / Estates

Responsibility for NHS Estate and associated capital schemes has passed to NHS Property Services

N/A

Purchase of internal fixtures and fittings – approval of requisitions By exception to be agreed by deputy CFO

Setting of Fees and Charges CFO

Engagement of bank/agency staff

Booking of Bank or Agency Staff

Budget Holder in line with organisational establishment/engagement control framework

Agreements / Licences

Preparation and signature of all tenancy agreements / licences for all staff subject to CCG Policy on accommodation for staff/operating leases/indemnity agreements/joint venture documents and service level agreements

CFO or CO

Extensions to existing leases

CFO

Letting of premises to outside organisations

CFO

Approval of rent based on professional assessment

CFO

Condemning & Disposal

Items obsolete, obsolescent, redundant, irreparable or cannot be repaired cost effectively; (including IT equipment)


with current / estimated purchase price of less than £50 per item

disposal of equipment (subject to estimated income of less than £1,000 per sale)

disposal of equipment (subject to estimated income exceeding £1,000 per sale)

Budget Holder Deputy CFO CFO

Losses, Write-offs & Compensation

Ex Gratia Payments

CFO to be reported to Audit Committee

Losses and cash due to theft, fraud, corruption, overpayment, compensation and others except for CHC retrospective claims

Up to £150k – CO or CFO

>£150k – CCG Governing Body (all losses & payments to be reported to the Audit Committee)

Retrospective Continuing Healthcare Claims Up to £5k – Budget Holder

>50k up to £250k – CFO

>£250k – CO

Write off of debts Write off of NHS and Non NHS Debtors – CO or CFO. To be reported to Audit Committee

Petty Cash Disbursements

a) Expenditure up to £75 per item

Budget Holder/Authorised budget holder representative in line with delegated limits Petty Cash disbursements over £75 per item are only allowed in exceptional circumstances with the prior agreement of the Chief Finance Officer, designated Deputy or Senior Finance Manager


Maintenance & Update of CCG Financial Procedures CFO

HUMAN RESOURCE ISSUES


Personnel and Pay

Job Description Review All requests for Job Description Review shall be dealt with in accordance with Organisational Procedure.

Agenda for Change Matching Process

Establishments Changes in workforce establishment

Executive Officer subject to finance approval and in line with Establishment Control Policy

Pay i) Authority to approve business cases for counting previous

equivalent service outside the NHS for incremental credit on commencement

ii) Authority to complete standing data form effecting pay, new starters, variations and leavers

iii) Authority to authorise overtime iv) Authority to authorise travel & subsistence expenses

Executive Officer (recommendation to be made by expert advisory panel) Budget Holder Budget Holder Senior Manager reporting to budget holder

Salary amendment forms Budget Holder

Salary agreement/change - not covered by AfC/National T&Cs Remuneration Committee

Wage advances and unpaid leave Budget Holder in consultation with finance



Salary pay overs etc. (e.g. salary advances, tax, NI, pensions, salary sacrifice scheme invoice)

Deputy CFO / Financial Accountant / Ledger Accountant

Leave i) Approval of annual leave

ii) Annual Leave – In exceptional circumstances approval of carry forward up to maximum of 1 working week. iii) Annual Leave – In extreme cases approval of carry over in excess of 1 working week. iv) Special leave arrangements (up to a maximum of 10 days per year per employee (pro rata for part time staff))

Bereavement leave – up to 3 days (and additional days at the discretion of the Line Manager)

Compassionate leave – up to 3 days

Emergency Domestic Leave – up to 1 day

Emergency Carers/Dependant/Parental Leave – up to 1 day v) Leave without pay vi) Time off in lieu vii) Maternity Leave, Adoption Leave, Maternity Support/Paternity Leave, Shared Parental Leave, Parental Leave - paid and unpaid

Line Manager Line Manager Executive Officer

Line Manager

Line Manager

Line Manager

Line Manager Line Manager Line Manager

Line Manager

Automatic in consultation with HR

Annual and Special Leave Policy

Sick Leave i) Extension of sick leave on half pay up to three months

Line Manager in conjunction with HR

Managing Sickness Absence Policy

https://www.leedsccg.nhs.uk/content/uploads/2018/07/Leeds-CCG-Annual-and-Special-Leave-Policy-V1.7-FINAL-23.07.18.pdf

https://www.leedsccg.nhs.uk/content/uploads/2018/03/LHR04-Managing-Sickness-Absence-Policy-2018.pdf

https://www.leedsccg.nhs.uk/content/uploads/2018/03/LHR04-Managing-Sickness-Absence-Policy-2018.pdf



ii) Return to work part-time on full pay to assist recovery iii) Extension of sick leave on full pay

On advice from Occupational Health in conjunction with HR Line Manager in conjunction with HR

Study Leave i) Study leave outside the UK ii) All other study leave (UK)

Executive Officer and Chief Officer Line Manager

Removal Expenses, Excess Rent and House Purchases Authorisation of payment of removal expenses incurred by officers taking up new appointments (providing consideration was promised at interview) i) up to £7,000 ii) over £7,000

Budget Holder and CFO Budget Holder and Chief Officer

Grievance Procedure All grievance cases must be dealt with strictly in accordance with the Grievance Procedure and the advice of HR.


Grievance Policy

Authorised Car and Mobile Phone Users Requests for new posts to be authorised as car users Requests for new posts to be authorised as mobile telephone users

Chief Finance Officer Budget Holder

Renewal of Fixed Term Contract

Budget Holder

https://www.leedsccg.nhs.uk/content/uploads/2018/03/Grievance-Policy-2018.pdf



Staff Retirement Policy Authorisation of extensions of contract beyond normal retirement age


Retirement Policy

Redundancy

Line Manager, HR and Remuneration Committee

Ill Health Retirement Decision to pursue retirement on the grounds of ill-health


Dismissal Executive Officer or Chief Officer as per CCG’s policies

Facilities for staff not employed by the CCG to gain practical experience Professional Recognition, Honorary Contracts & Insurance of Medical Staff Work experience students

Executive officer in conjunction with HR Budget holder in conjunction with HR

https://www.leedsccg.nhs.uk/content/uploads/2018/03/LWHR19-Retirement-Policy-2017.pdf


OTHER


Approval of Memorandum of Understanding (MOU)

Chief Officer or relevant Executive Officer

Authorisation of Sponsorship Deals Chair and CO

Standards of Business Conduct Policy

Authorisation of Research Projects

Medical Director or Nursing Director

Insurance Policies CO or CFO

Patients & Relatives Complaints

a) Overall responsibility for ensuring that all complaints are dealt with effectively

b) Responsibility for ensuring complaints relating to a Executive

Officer are investigated thoroughly

Executive Officers in conjunction with HR CO in conjunction with CCG Chair

Concerns, Complaints, Comments and Compliments Policy

Infectious Diseases and Notifiable Outbreaks On Call Manager or Executive Officer in conjunction with Public Health England

Extended Role Activities Approval of Nurses to undertake duties / procedures which can properly be described as beyond the normal scope of Nursing Practice

Director of Nursing

Patient Services

Temporary Change

Permanent Change

Executive Officer Chief Officer

https://www.leedsccg.nhs.uk/content/uploads/2018/03/Standards-of-Business-Conduct-Policy-19July2017.pdf


https://www.leedsccg.nhs.uk/content/uploads/2018/03/2016-CCG-complaints-policy-Final-1-1.pdf

https://www.leedsccg.nhs.uk/content/uploads/2018/03/2016-CCG-complaints-policy-Final-1-1.pdf


Reporting Incidents to the Police a) Where a criminal offence is suspected b) Where a fraud is involved

On Call Manager or Executive Officer Chief Finance Officer or Local Counter Fraud Specialist (LCFS)

Review of Fire Precautions

Chief Officer

Receiving Hospitality Applies to both individual and collective hospitality receipt items.

Executive Officer. Declaration required in CCG's Hospitality Register


Individual Funding Requests Approve triage process and act as the decision maker at IFR Panel meetings in relation to Leeds patients

Medical Director or Associate Medical Director or other clinician nominated by the Medical Director or Chief Officer

Individual Funding Requests Policy

Implementation of Internal and External Audit Recommendations

Lead Manager as defined in Audit report



https://www.leedsccg.nhs.uk/content/uploads/2017/11/Overarching-IFR-policy-2017.pdf

https://www.leedsccg.nhs.uk/content/uploads/2017/11/Overarching-IFR-policy-2017.pdf


Primary Care Co-Commissioning (as per NHSE delegation agreement)

Decision Person/Individual NHS England Approval Required from

General

Taking any step or action in relation to the

settlement of a Claim, where the value of the

settlement exceeds £100,000

CCG Chief Officer or Chief Finance Officer NHS England Head of Legal Services

and

Local NHS England Team Director or Director of

Finance

Any matter in relation to the Delegated Functions

which is novel, contentious or repercussive

CCG Chief Officer or Chief Finance Officer Local NHS England Team Director or Director of

Finance or

NHS England Region Director or Director of

Finance or

NHS England Chief Executive or Chief Financial

Officer

Revenue Contracts

The entering into of any Primary Medical Services

Contract which has or is capable of having a term

which exceeds five (5) years

CCG Chief Officer or Chief Finance Officer Local NHS England Team Director or Director of

Finance

1























Agenda Item: GB 18/100ii FOI Exempt: No



Title: Procurement Policy Review



appropriate

()

Report Author: Michelle van Toop, Associate Director of Procurement & Contracting

Decision

Reviewed by EMT/Date: N/A

Discussion


Information

Checked by Finance (Y/N/N/A - Date): 10 October 2018


2

EXECUTIVE SUMMARY: The NHS Leeds CCG Procurement Policy was approved by Governing Body in April 2018 and was scheduled for review in September 2018. The policy has been recirculated to various relevant internal stakeholders for comment and has been amended accordingly, especially in light of the decision to in-house procurement prior to the expiry of the eMBED contract on 31 March 2019. The draft policy was reviewed by the Audit Committee on 24 October 2018 and members agreed to recommend that it be approved by the Governing Body.

NEXT STEPS: The revised Procurement Policy will be published on the NHS Leeds CCG website when approved by Governing Body.


a) Approve the revised version (V2.0) of the Procurement Policy

3

1. SUMMARY 1.1 The NHS Leeds CCG Procurement Policy was approved by Governing Body in April 2018

and was scheduled for review in September 2018.

1.2 The policy has been recirculated to various relevant internal stakeholders for comment and has been amended accordingly, especially in light of the decision to in-house procurement prior to the expiry of the eMBED contract on 31 March 2019.

1.3 The draft policy was reviewed by the Audit Committee on 24 October and members agreed to recommend that it be approved by the Governing Body.

2. BACKGROUND 2.1 The aims and objectives of the procurement policy are:

2.1.1 To set out how the NHS LCCG will meet its statutory procurement requirements to

secure high-quality, efficient health care services that meet the needs of people who use those services; and

protect the rights of patients to choose who provides their health care in certain circumstances.

2.1.2 To set out the approach for facilitating fair, robust and enforceable contracts that provide value for money and deliver required quality standards and outcomes, with effective performance measures and contractual levers. (This document is not intended to be a detailed procedure manual. A separate Procurement Procedure Manual will be produced by March 2019 following consultation with relevant stakeholders.)

2.1.3 To enable early determination of whether, and how, services are to be opened to competition, to facilitate transparent and fair discussion with existing and potential providers and thereby to facilitate good working relationships.

2.1.4 To enable NHS LCCG to demonstrate compliance with the principles of good procurement practice in accordance with the EU Treaty Principles of:

equal treatment;

non-discrimination;

proportionality;

transparency; and

mutual recognition.

3. PROPOSAL

3.1 Following the comments provided by various internal stakeholders the following amendments are proposed:

4

Paragraph 5.3: Procurement Support Changed to reflect the in-housing of procurement support services to the Finance & Contracting Team Paragraphs 9.2 and 9.3: Thresholds Thresholds changed in line with Public Contracts Regulations as detailed requested amendment to CCG Operational Scheme of Delegation Paragraph 14.1 Third Sector Providers Sentence added to explain the Commissioning Code of Practice Paragraph 19: Primary Care Appendix 1 form removed as not used by the new organization. Paragraphs removed that related to the completion of the forms as these relate to an obsolete procedure not a matter of policy.

4. NEXT STEPS 4.1 The revised Procurement Policy will be published on the NHS Leeds CCG website when

approved by Governing Body. 5. STATUTORY/LEGAL/REGULATORY/CONTRACTUAL

5.1 This policy complies with EU and UK legislation as detailed in section 8 of the policy.

6. FINANCIAL IMPLICATIONS AND RISK 6.1 This policy complies with and NHS LCCG’s Detailed Financial Policies, Budgetary Control

framework and Scheme of Delegation for the procurement of all goods and services,

including healthcare services.

7. COMMUNICATIONS AND INVOLVEMENT 7.1 Not applicable 8. WORKFORCE

8.1 Not applicable 9. EQUALITY IMPACT ASSESSMENT 9.1 Not applicable

5

10. ENVIRONMENTAL

10.1 Not applicable

11. RECOMMENDATION


b) Approve the revised version (V2.0) of the Procurement Policy

Version: Version 2.0 draft

Ratified by:

Date ratified:

Name & Title of Originator/Author(s) Michelle van Toop, Associate Director of Procurement & Contracting (interim)

Name of Responsible Committee/Individual:

Visseh Pejhan-Sykes, Chief Finance Officer

Date issued:

Review Date: October 2022

File location: S:\Contracting (shared)\1. Contracting and guidance documents\Procurement Policy and Templates

Target Audience: All NHS Leeds CCG Employees and Members

PROCUREMENT

POLICY

Version: 2.0 Draft Effective Date: November 2018 Page 2

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CONTENTS Page

1. Introduction 3

2. Associated Policies and Procedures 4

3. Aims and Objectives 4

4. Scope of this Policy 5

5. Accountabilities and Responsibilities 5

6. Guiding Principles 7

7. Conflicts of Interest 8

8. Compliance with Regulations 8

9. Procurement approach for sub-threshold contracts 9

10. Circumstances where competitive tenders or quotations may not be required.

10

11. Contract extensions & variations to contracts during the contract term 11

12. Partnership Agreements with Local Authorities 12

13. Other contracting models 13

14. Third Sector Providers 14

15. Contract Form 15

16. Pilot Projects 15

17. Sustainable Procurement 15

18. Consultancy Expenditure/Interim Labour 15

19. Primary care contracts 16

20. Record Keeping and Register of Procurement Decisions 16

21. Use of Information Technology 17

22. Decommissioning Services 17

23. Transfer of Undertakings and Protection of Employment Regulations (TUPE)

17

24. Complaints and Dispute Procedure 17

25. Training 18

26. Monitoring Compliance with this Policy 18

Appendix 1: Template to be used when commissioning services that may potentially

be provided by GP practices

19


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1. Introduction

1.1. Procurement is a cyclical process in which goods, services and works are secured or

purchased. The process spans the whole life cycle from identification of needs, through to the end of a service’s contract or the end of the useful life of an asset. Procurement can encompass everything from repeat low-value orders, through to complex healthcare service solutions developed and delivered through partnership arrangements.

1.2. Effective procurement is an essential component of commissioning improved services and outcomes for local patients and communities and for ensuring value for money.

1.2. Procurement in the public sector is regulated by primary legislation and there are a range of procurement approaches available depending on the value of the procurement and the number of participants in the market. However The NHS Five Year Forward View and the Next Steps update published in March 2017 described a movement towards integrated care, delivered through collaboration across health and care systems. These new ways of working will require NHS Leeds CCG (LCCG) to develop new procurement and contracting models in line with guidance from NHS England.

1.3. The Public Contracts Regulations (PCR 2015) came into force on 18 April 2016 for CCGs when procuring health and care services (non-healthcare services have always been subject to PCR). These rules apply to public bodies, including CCGs, NHS England and local authorities, and have implications for the procurement of all contracts commenced after that date.

1.4. The PCR 2015 form part of the procurement landscape alongside the NHS (Procurement, Patient Choice and Competition) (No.2) Regulations 2013 (PPCCR). Made under Section 75 of the Health and Social Care Act 2012, the PPCCR apply to NHS England and CCGs and are enforced by NHS Improvement. Whilst the two regimes overlap in terms of some of their requirements, they are not the same – compliance with one regime does not automatically mean compliance with the other. NHS LCCG will ensure that it complies with

both regimes when procuring healthcare services.

1.5. The PPCCR follow a principles based approach leaving commissioners flexibility as to how best to procure and secure services in the best interests of service users. Commissioners need to comply with a number of requirements under the PPCCR to help them achieve the overall objective of securing the needs of patients and improving the quality and efficiency of services, including:

a) acting transparently and proportionately, and treating potential providers equally and in a non-discriminatory way;

b) procuring services from the providers that are most capable of delivering commissioners’ overall objective and that provide the best value for money;

c) considering ways of improving services; and

d) having arrangements in place that allow providers to express an interest in a contract.

1.4. NHS LCCG’s approach to procurement is to operate within legal and policy frameworks and where appropriate to use procurement as one of the system management tools available to achieve commissioning outcomes and increase value for money.

.


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2. Associated Policies and Procedures 2.1. This policy and any procedures derived from it should be read in accordance with the

following local policies, procedures and guidance:

NHS Leeds Clinical Commissioning Group Constitution

NHS LCCG Detailed Financial Policies

NHS LCCG Scheme of Delegation

NHS LCCG Budgetary Control Framework

NHS LCCG Declaration of Interests and Potential Conflicts of Interests Policy NHS LCCG Data Protection Impact Assessment (DPIA) Policy

3. Aims and Objectives

3.1. To set out how the NHS LCCG will meet its statutory procurement requirements to

secure high-quality, efficient health care services that meet the needs of people who use those services; and

protect the rights of patients to choose who provides their health care in certain circumstances.

3.2 To set out the approach for facilitating fair, robust and enforceable contracts that provide value for money and deliver required quality standards and outcomes, with effective performance measures and contractual levers. (This document is not intended to be a detailed procedure manual. A separate Procurement Procedure Manual will be produced by March 2019 following consultation with relevant stakeholders.)

3.4. To enable early determination of whether, and how, services are to be opened to

competition, to facilitate transparent and fair discussion with existing and potential providers and thereby to facilitate good working relationships.

3.5. To enable NHS LCCG to demonstrate compliance with the principles of good procurement

practice in accordance with the EU Treaty Principles of:

equal treatment;

non-discrimination;

proportionality;

transparency; and

mutual recognition.


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4. Scope of the Policy 4.1. As far as it is relevant, this policy applies to all NHS LCCG procurements (clinical and

non-clinical). 4.2. This policy must be followed by all NHS LCCG employees including staff on temporary or

honorary contracts, representatives acting on behalf of NHS LCCG including staff from member practices, and any external organisations acting on behalf of NHS LCCG including other CCGs, EMBED, NECS and NHS Shared Business Services.

5. Accountabilities & Responsibilities

5.1. Governing Body responsibility The Governing Body has the ultimate responsibility for ensuring that NHS LCCG meets its statutory requirements when procuring goods and services, including healthcare services. The governing body must be transparent when making decisions to procure and be the authorising body for awarding a contract once an appropriate process has been completed. When considering options for procurement the Governing body will follow the guidelines set out by NHS England and Crown Commercial Services

https://www.gov.uk/guidance/transposing-eu-procurement-directives.

5.2 Lead Responsibility

Overall responsibility for procurement within NHS LCCG rests with the CFO however individual managers will be responsible for recognising when a commissioning decision may have potential procurement implications and for seeking appropriate procurement support. Commissioning Managers are responsible for ensuring that they plan their commissioning decisions in sufficient time to carry out the required procurement process.

5.3. Procurement support

From September 2018 procurement support will be provided in-house by appropriately qualified and experienced staff in the Finance and Contracting Team. Where it is required and considered appropriate procurement support may also be provided by either: NHS Shared Business Services; or } (or their successor contractors Kier Business Services Ltd (EMBED). } subject to contract) North East Commissioning Support (NECS)} Procurement support from external organisations may incur additional costs and therefore commissioning managers must consult the Finance and Contracting Team first before contacting any of the above organisations.

In the case of collaborative or partnership projects where NHS LCCG is not the sole or

lead commissioner, procurement support arrangements will be agreed in consultation with the Lead Commissioner or Commissioning Partners on a case by case basis. This may involve support being provided by another CCG, Leeds City Council, or an independent procurement support service. Whenever external procurement support is provided by any

https://www.gov.uk/guidance/transposing-eu-procurement-directives


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organisation, NHS LCCG will have systems in place to assure itself that the supporting organisation’s business processes are robust and enable the organisation to meet its duties in relation to procurement.

5.4. Authority

If an external organisation is used to provide procurement support NHS LCCG will remain directly responsible for:

Approving the procurement route;

Signing off specifications and evaluation criteria;

Signing off decisions on which providers are taken through to the Invitation to Tender (ITT) stage following a pre-qualification process (where appropriate)

Making final decisions on the selection of the preferred provider.

Arrangements for delegation of authority to officers are set out in the Operational Scheme of Delegation, in the event of any discrepancy between this Procurement Policy and the Scheme of Delegation, the latter document will take precedence.

5.5 Engagement

NHS LCCG is committed to engaging relevant stakeholders in all aspects of procurement

and encourages their engagement in the design and co-production of services.

The CCG recognises that the engagement of clinicians, patients and public in designing

and procuring services results in better services. Business processes will therefore require

evidence of engagement for business cases to be approved. This will ensure that

procurement of services is informed by authentic and meaningful engagement.

In accordance with the NHS Constitution pledge, all staff will be engaged in changes that

affect them.

5.6 Collaboration

NHS LCCG is committed to operating in a sustainable environment where all opportunities

for efficiencies and economies of scale are considered and, were applicable applied. This

includes the sharing of operational resources or commitment to specific joint

projects/contracts across Leeds and the wider West Yorkshire footprint where this serves

the best interest of the Leeds population. The move towards further integration will

necessitate the development of new types of contracts for accountable care models and the

CCG will follow guidance from NHS England on their application.

5.7 ISAP

As NHS LCCG moves towards commissioning integrated care systems, some of these

complex contracts may include such a significant scope of services that the CCG’s

ongoing role will change. For example, the commissioner may take a more strategic

role, establishing different relationships with neighbouring CCGs, the local authority and

providers, and enable these bodies to carry out commissioning activities on its behalf.

NHS LCCG will apply the NHS England Integrated Support and Assurance Process


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(ISAP) where applicable to ensure that future arrangements are robust and viable and

that the NHSLCCG continues to deliver its statutory functions effectively.

5.8 Equality Impact Assessment:

All public bodies have statutory duties under the Equality Act 2010. The NHS LCCG aims to

design and implement services, policies and measures that meet the diverse needs of our

service, population and workforce, ensuring that none are placed at a disadvantage against

others. NHS LCCG will ensure, when applying this policy that it complies with its duties

under the Equality Act 2010 and does not discriminate on grounds of race, colour, age,

nationality, ethnicity, gender, sexual orientation, marital status, religious belief or disability.

5.9 Risk Management

When carrying out procurement activity, NHS LCCG will ensure that it plans adequate

measures to identify and manage risk.

6. Guiding Principles

6.1. In accordance with the NHS LCCG’s Constitution, when procuring health care services, NHS LCCG is required to act with a view to:

Securing the needs of health care service users

Improving the quality of the services, and

Improving the efficiency with which services are provided

6.2. NHS LCCG is required and committed to:

acting in a transparent way, including maintaining suitable records of key decisions

relating to procurement, sharing information on future procurement strategies, and

the use of sufficient and appropriate advertising of tenders.

ensuring that procurement processes are proportionate to the value, complexity and

risk of the services to be procured.

treating providers equally and in a non-discriminatory way by not treating a single

provider, or type of provider, more favourably than any other provider in particular

on the basis of ownership.

6.3. NHS LCCG is required and committed to commissioning services from the providers that:

are most capable of delivering to the quality and efficiency required

provide the optimum value for money

6.4. NHS LCCG is required and committed to act with a view to improving quality and efficiency in the provision of services. The means of doing so will include:

Providing the services in an integrated way (including with other healthcare services, health related services, or social care services as part of an accountable care system)

enabling providers to compete to provide the services


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allowing patients a choice of provider of the services

7. Conflicts of Interest.

7.1 For all procurement projects and decision making events, all members present must

declare any interest or perceived conflict of interest in relation to the topic being discussed.

7.2 Potential conflicts of interest will be managed appropriately to protect the integrity of NHS LCCG’s contract award decision making processes and the wider NHS commissioning system. This is to ensure public confidence and to protect the CCG and GP practices from any perceptions of wrong-doing.

7.2. General arrangements for managing conflicts of interest are set out in NHS LCCG’s Constitution. This section describes additional safeguards that NHS LCCG will put in place when commissioning services that could potentially be provided by GP practices and/or other system partners.

7.4. Where any practice or system partner representative on a decision-making body has a

material interest in a procurement decision, those practice representatives will be excluded from the decision-making process. See Section 19 of this policy for further details relating to GP Practices and GP Federation.

7.5 When contracting for integrated care models and/or accountable care systems NHS LCCG will take reasonable steps to ensure that competition is not distorted by allowing system partners who may tender for contracts access to information not available to other potential bidders and/or providers.

8. Compliance with Regulations

8.1 NHS LCCG and/or its agents will comply with EU and UK legislation and NHS LCCG’s

Detailed Financial Policies, Budgetary Control framework and Scheme of Delegation for

the procurement of all goods and services, including healthcare services.

8.2 BREXIT: There is no official government statement yet regarding to the impact of BREXIT

on EU and UK Public Procurement policy. Unless PCR 2015 is repealed this legislation

will remain in force even after the UK leaves the European Union. NHS LCCG will update

this section of the policy once information is available.

8.3 National Health Service Act 2006 Section 242 (Public Involvement and Consultation)

requires commissioners of healthcare services to consult patients and the public- directly

or through representatives. - in relation to service planning, development and

consideration of service changes and decisions that affect service operation.

8.4 The Health and Social Care Act 2012 empowers CCGs to commission healthcare

services for local populations. The duties of CCGs are set out in section 3 of the National

Health Services Act 2006 with updated amendments and regulations in section 13 of the

Health and Social Care act 2012.

8.5 Commissioners must comply with the NHS (Procurement, Patient Choice and

Competition) (No.2) Regulations 2013. (Section 75) (PPCCR) where objectives include

patient experience, outcomes and improved efficiency. These regulations (implemented


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under Section 75 of the Health and Social Care Act 2012) place requirements on

commissioners to ensure that they adhere to good practice in relation to procurement, do

not engage in anti-competitive behaviour and protect the right of patients to make choices

about their healthcare.

8.6 The Public Contracts Regulations 2015 (PCR 2015) Regulations 74-76 require healthcare

services with a lifetime value of £615,278 or above to be advertised Europe-wide via

OJEU (the Official Journal of the European Union) and in the UK via Contracts Finder.

Under these regulations, healthcare services (classified as health, social or other

services) may be procured using the “Light-Touch-Regime.” (LTR)

8.7 PCR 2015 also stipulates specific procurement processes that must be followed for other

goods and non-healthcare services over a lifetime value of £181,302 including VAT (for

sub-central authorities)

8.8 The OJEU Thresholds stated in paragraph 8.6 and 8.7 are current as at January 2018.

They are generally recalculated every 2 years and are communicated via a Procurement

Policy Note (PPN) on the www.gov.uk website

8.9 Other legislation relevant to this procurement policy includes:

Local Government Act 1999. If a CCG is co-commissioning with the Local Authority,

Section 3(1) of this Act sets out a duty of consultation.

Competition Act 1998

Public Services (Social Value) Act 2012. Commissioners are required to consider

how the services they commission and procure might improve the economic, social

and environmental well-being of the area.

Equality Act 2010- Section 149.

Freedom of Information Act (2000)

NHS LCCG will comply with the requirements set out in the Freedom of Information

Act 2000 (Legislation .gov.uk, 2000) whilst conducting procurements. As part of this,

information regarding individuals and organisations involved within the procurement

process will be protected during all stages of the process. On commencement of

the procurement process, NHS LCCG will make potential bidders aware of the

requirement for the CCGP to comply with the Act.

9. Procurement approach for sub-threshold contracts.

9.1. For goods and services with an aggregate value below the thresholds stated in

paragraphs 8.6 and 8.7 the following rules will apply in accordance with the organisational scheme of Delegation:

9.2 Healthcare Services

Under £10,000 a minimum of 2 written quotations must be obtained

Between £10,000 and £100,000 a minimum of 3 written quotations must be obtained

http://www.gov.uk/


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Between £100,001 and £615,227 a minimum of 5 written quotations must be obtainedunless it can be evidenced that there are less than 5 capable providers

For procurements in excess of £615,278 competitive tenders must be sought, the form of which is dependent on the precise goods and services involved. Therefore, for all tenders of healthcare services above £615,278 the advice of the Associate Director of Contracting and Procurement must be sought and commissioning managers must ensure that they allow sufficient time to conduct an appropriate process.

For procurements of healthcare services under £615,278 PPCCR Section 75 Regulations still apply.

9.3 Non Healthcare Goods and Services

Under £10,000 a minimum of 2 written quotations must be obtained

Between £10,000 and £100,000 a minimum of 3 written quotations must be obtained

Between £100,001 and £181,302 a minimum of 5 written quotations must be obtained unless it can be evidenced that there are less than 5 capable providers

For procurements in excess of £181,302 competitive tenders must be sought, the form of which is dependent on the precise goods and services involved. Therefore, for all tenders of non-healthcare services above £181,302 the advice of the Associate Director of Contracting and Procurement must be sought and commissioning managers must ensure that they allow sufficient time to conduct an appropriate process.

9.3 Where open quotations are sought below the OJEU thresholds then the opportunity should be published on Contracts Finder instead of, or in addition to, other portals or sites for contracts over the value of £25,000. This does not apply where RFQs have been sent to specific providers in accordance with paragraph 9.1

9.4 All contracts must be subject to NHS Standard Terms and Conditions which must be

stated with the specification and, although the quotations do not need to be in a specific format, a Request For Quotation (RFQ) template is available from the Finance & Contracting Department to ensure consistency. The only exception is where a framework agreement has been used in which case the terms and conditions pertaining to that framework will apply (See Section 13.2)

10. Circumstances where competitive tenders or quotations may not be required

10.1 NHS LCCG is committed to ensuring that services are procured in accordance with legislation. In limited circumstances the need to request quotations or competitive tenders may be waived. Regulation 32 of the PCR 2015 and the NHS LCCG scheme of delegation outline the following circumstances where contracts may be awarded without a full tender exercise:

10.1.1 in very exceptional circumstances where the Chief Officer and Chief Financial Officer decide that formal tendering procedures would not be practicable or the estimated expenditure or income would not warrant formal tendering procedures, and the circumstances are detailed in tender waiver and reported to the Audit Committee;

10.1.2 where the requirement is covered by an existing contract;


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10.1.3 where national or local framework agreements are in place and have been approved by the Governing Body, NHS England or Crown Commercial Services;

10.1.4 where a consortium arrangement is in place and a lead organisation has been appointed to carry out tendering activity on behalf of the consortium members;

10.1.5 where the timescale genuinely precludes competitive tendering. NB failure to plan the work properly would not be regarded as a justification for a tender waiver;

10.1.6 where competition is absent for technical reasons (in accordance with PCR2015) or specialist expertise or technology is required and is available from only one source and this has been evidenced by market consultation that no reasonable alternative or substitute exists and is not the result of the artificial narrowing down of the parameters of the procurement ;

10.1.7 when the task is essential to complete the project, and arises as a consequence of a recently completed assignment and engaging different consultants for the new task would be inappropriate; or

10.1.8 there is a clear benefit to be gained from maintaining continuity with an earlier project. However in such cases the benefits of such continuity must outweigh any potential financial advantage to be gained by competitive tendering.

10.2 The waiving of competitive tendering procedures should not be used to avoid competition or for administrative convenience or to award further work to a provider originally appointed through a competitive procedure (unless in the case of 10.1.8 above.) In any event the tender waiver must comply with Regulations 32 and 75 of the Public Contracts Regulations 2015.

10.3 In any of the circumstances detailed in paragraph 10.1.1 to 10.1.8 a Tender waiver Form must be completed by the Commissioning Manager and approved by both the CFO and CO. Signed forms should then be sent to the Head of Governance. The same process will be used to waive the request for quotations.

10.4 Tender waiver forms over a value of £181,302 will be sent to the Audit Committee for noting. In addition tender waivers over the EU Threshold may require the publication of a Voluntary Ex-Ante Transparency (VEAT) notice in the OJEU prior to the award. The advice of the Associate Director of Contracting and Procurement must be sought in these circumstances.

11. Contract Extensions and Variations to contracts during the contract term

11.1 In accordance with regulation 72 of the PCR 2015, contracts over the EU Threshold may only be varied in the following circumstances:

11.1.1 where modifications have been provided for in the original procurement documents and/or would not alter the nature of the contract.

11.1.2 where the modification is both less than 10% of the value of the contract and less than £615,278 and does not change the nature of the contract.

11.1.3 for additional services or supplies by the original contractor that have become necessary and were not included in the initial procurement and where a change of


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contractor:

cannot be made for economic or technical reasons such as requirements of

interchangeability or interoperability with existing equipment, services or installation

procured under the initial procurement, or

would cause significant inconvenience or substantial duplication of costs for the

NHS LCCG,

In the above circumstances any increase in price must not exceed 50% of the value

of the original contract

11.1.4 where all of the following conditions are fulfilled:

the need for modification has been brought about by circumstances which a diligent contracting authority could not have foreseen;

the modification does not alter the overall nature of the contract;

any increase in price does not exceed 50% of the value of the original contract

11.1.5 Where a new contractor replaces the original contractor e.g. in the case of a merger or takeover.

11.2 Modifications to contracts over the EU Threshold may also require completion of the

tender waiver process and/or the publication of a Voluntary Ex-Ante Transparency (VEAT)

notice in the OJEU prior to the award. The advice of the Associate Director of Contracting

& Procurement must be sought in these circumstances.

11.3 Contracts cannot be extended unless there is provision in the original procurement

documents to do so or one of the provisions of Regulation 72 applies. A new procurement

procedure is required for any contract variations or extensions except in the

circumstances outlined in paragraph 11.1 above.

12. Partnership Agreements with Local Authorities

12.1 National Policy and local strategies both promote the increased integration of health and social care services however new models of contracting for care, including Accountable Care organisations (ACOs), Multispecialty Community Providers (MCPs) and Primary & Acute Care Systems (PACS), still need to be procured in the same way as lead provider contracts. Alternatively several other mechanisms exist to support joint commissioning of services across health and social care such as:

12.2 Section 75 (S75) Partnership Agreements

Section 75 of the NHS Act 2006 sets out a number of powers that support partnership and

joint commissioning across health and social care. Key provisions of the act allow NHS

Bodies and Local authorities to establish pooled budgets, and also allow for the delegation

of certain statutory functions from one partner to the other through a lead commissioning

arrangement.


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Section 75 powers are intended to be used where partnership arrangements are likely to

lead to improvements in the delivery of NHS and Local Authority functions.

Although functions can be delegated, each partner remains liable for their own statutory duties.

12.3 Section 256 (S256) Agreements

S256 Agreements were established through the NHS Act 2006 and allow NHS

commissioners to make payments to Local authorities towards any Local Authority

expenditure which in the opinion of NHS LCCG would have an effect on the health of

individuals, or which would have an impact on, or be affected by, NHS commissioned

services, or are otherwise connected with other NHS functions.

They are payments to a local authority to support specific services, projects, capital costs,

or other local authority activities which have a benefit for the NHS. However these

agreements do not involve the transfer of any statutory health functions to the local

authority.

S256 Agreements are not subject to formal procurement processes, as NHS LCCG is not

directly commissioning or contracting for goods or services in this instance. However

S256 agreements must comply with any relevant Directions published by the Secretary of

State.

Section 256 specifies two prescribed documents to be completed when making the agreement:

(i) A Certificate of Expenditure (annual voucher) (ii) Memorandum of Agreement

12.4 Better Care Fund

In addition to the two types of partnership agreements described above, the Better Care Fund (BCF) is a nationally mandated pooled budget across health and social care. The BCF is intended to promote further integration and support delivery of improved outcomes across health and social care to achieve the National Conditions and Local Objectives. It is a requirement of the BCF that NHS LCCG and the Council establish a pooled fund for this purpose. The BCF is not ‘new money’ and represents the summation of existing pooled and aligned budgets along with all existing local and national transfers from health to social care. The Leeds City Council and the NHS LCCG currently use a Framework Partnership Agreement relating to the commissioning of health and social care funding. The Partners have entered into the Agreement in exercise of the powers referred to in Section 75 of the NHS Act 2006 (2006a) and/or Section 13(2) and 14(3) of the NHS Act 2006 as applicable.

NHS LCCG will ensure it adheres to any current and updated National Policy and Guidance on the Better Care Fund.

13. Other Contracting Models

13.1 Spot Purchasing


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From time to time there will be the need to spot purchase contracts for particular individual patient needs or for urgency of placements requirements at various times. At these times, a competitive process may be waived using the same process described in paragraphs 10.2 to 10.4.

It will be expected that these contracts will undergo best value reviews to ensure that NHS

LCCG is getting value from the contract. Value for money should be assessed by the manager with responsibility for signing off the spot purchasing agreement or individual service agreement, and then reviewed annually.

Sign off of spot purchase agreements should follow the Detailed Scheme of Delegation. In

all cases the NHS LCCG should ensure that the provider is fit for purpose to provide the particular service. The process will follow EU and UK Public Procurement rules and NHS LCCG’s Financial Policies and Scheme of Delegation as appropriate.

13.2 Framework Agreements

Framework agreements are pre-tendered agreements which are established in compliance with the PCR2015 and which, once established, can be used by NHS LCCG to purchase certain products and/or services without the need to carry out a full procurement process.

A framework can be established:

By NHS LCCG for its own use

By another CCG, Contracting Authority or central purchasing body such as the Crown Commercial Service.

Various existing frameworks are available for NHS LCCG to use such as the Crown Commercial Service (CSS) or NHS Shared Business Services (SBS) to purchases goods or services without a full local tender. Each framework will have its own ordering process to follow but the timescales and transaction costs are usually far lower than running a full procurement. The terms and conditions applicable to any subsequent call-off contract are defined by the particular framework agreement and may not be compatible with the NHS standard contract and therefore advice must be sought from the framework owner prior to conducting a mini-competition.

13.3 Any Qualified Provider (AQP)

AQP describes an approach for contracting for services whereby

Providers qualify and register to provide services via an assurance process that tests providers’ fitness to offer NHS-funded services.

The CCG sets local pathways and referral protocols which providers must accept

Referring clinicians offer patients a choice of qualified for the service being referred to

Competition is based on quality, not price. Providers are paid a fixed price determined by a national or local tariff.

With the AQP model, for a prescribed range of services, any provider that meets criteria for entering a market can compete for business within that market. Under AQP there are no guarantees of volume or payment, and competition is encouraged within a range of services rather than for sole provision of them.

The AQP model promotes choice and contestability, and sustained competition on the basis of quality rather than cost. A service that is contracted through the AQP model may


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not need to be tendered using the full EU process although it must be advertised appropriately and potential service providers will need to be qualified/accredited. The NHS LCCG will consider PCR 2015 in relation AQP contracts and will have due regard at all times to the EU Treaty principles of non-discrimination, equal treatment, transparency, mutual recognition and proportionality when applying the AQP Procedure.

13.4 Grants

Where third sector organisations provide healthcare services, the NHS LCCG may elect to provide funding through a grant agreement. Use of grants can be considered where:

NHS LCCG is only making a partial contribution to the costs of a service (e.g. where a service is also supported by charitable donations or other funding streams)

Funding is provided for development or strategic purposes

The provider market is not well developed

The services are innovative or experimental

Where funding is non-contestable (i.e. only one provider)

Grants will not be used to avoid competition where it is appropriate for a formal procurement to be undertaken.

NHS LCCP will follow NHS England Grant Agreement Guidance on the use of the draft model Grant Funding Agreement although the model grant agreement is non-mandatory and is for local adaptation as required.

14. Third sector providers and support for campaigns

14.1 NHS LCCG will support the Governments attempts to increase activity in third sector providers and small and medium enterprises. NHS LCCG will ensure that no organisation is discriminated against. NHS LCCG will act transparently and not request disproportionate demanding information, therefore reducing the barriers to entry. Commissioning Managers should refer to the Commissioning Code of Practice. The code provides a framework and promotes best practice in Commissioning which should be shared between all commissioners and all sectors in Leeds.

14.2 NHS LCCG will work in partnership with Leeds City Council and Third Sector Leeds to strengthen relationships between the public and third sectors to deliver the best outcomes for the people of Leeds in accordance with the Compact for Leeds.

14.3 Where NHS LCCG wishes to support a local or national campaign (e.g. through the purchase of campaign media) the Scheme of Delegation will apply in the same way as for the purchase of goods and services. The authorising Budget Holder must satisfy themselves that the campaign is compatible with the NHS LCCG commissioning strategy and that it conforms to the relevant NHS policies (e.g. in terms of branding, information governance etc.)

15. Contract Form 15.1 NHS LCCG will ensure that, where appropriate, the NHS Standard Contract will be used

for all contracts. Where a framework agreement has been used the terms and conditions of contract will usually be those of the specific framework.

15.2 In exceptional circumstances, such as where a joint contracting arrangement is led by the

local authority, the NHS LCCG may agree to be party to a different form of contract.


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15.3 NHS LCCP will ensure that a standard Grant Agreement document will be used to record

the provision of grants to third parties which will contain the provisions upon which the grant is made.

16. Pilot Projects 16.1 Pilot Projects may be commenced in circumstances where clinical outcomes are not

known or when outputs cannot be predicted. Pilot projects must comply with EU and UK Procurement regulations.

17. Sustainable Procurement 17.1 NHS LCCG recognises the impact of its purchasing and procurement decisions on the

regional economy and the positive contribution it can make to economic and social regeneration.

17.2 Wherever it is possible, and does not contradict or contravene NHS LCCG’s procurement

principles or applicable legislation and guidance, NHS LCCG will work to develop and support a sustainable local economy and health economy.

18. Consultancy expenditure/Interim Labour 18.1 Approval to engage an interim manager, consultant or consultancy company for any

reason must be obtained in advance in accordance with Appendix 1 of the NHS LCCG Budgetary Control Framework.

18.2 In addition to 18.1 NHSLCCG is expected to secure advance approval from NHS England before engaging or continuing to employ off-payroll staff (including consultancy staff) who meet the following criteria:

Cost greater than £600 per day (excluding VAT and expenses)

Are engaged for a period greater than six months; or

Are in roles of significant influence (e.g. Accountable Officers and Directors).

19. Primary Care Contracts. 19.1 NHS LCCG will comply with the Primary Medical Care Policy and Guidance published by

NHS England with regard to the procurement and award of primary care contracts; in

particular in relation to whether a competitive process is required.

19.5 Where any practice representative on a decision- making body has a material interest in a

procurement decision, those practice representatives will be excluded from the decision-

making process. This includes where all practice representatives have a material interest,

for example where NHS LCCG is commissioning services on a single tender basis from all

GP Practices in the area.

20 Record Keeping and Register of Procurement Decisions 20.1 In accordance with the PPCC Regulations (2013) about record keeping the NHS LCCG

will:


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publish details of all contracts they award (Regulation 9(1) via Contracts Finder and/or OJEU as appropriate

record how any conflicts of interest have been managed (Regulation 6(2); and

maintain details of how a contract award complies with their duties relating to effectiveness, efficiency and improvement in the quality of services and the delivery of services in an integrated way in the National Health Service Act 2006 (Regulation 3(5) of the PPCC Regulations).

20.2 NHS LCCG will maintain a Register of Procurement Decisions taken, either for the

procurement of a new service, any extension or material variation of a current contract: This will include

The details of the decision;

Who was involved in making the decision

A summary of any conflicts of interest in relation to the decision and how this was managed by the NHS LCCG; and

The award decision taken 20.3 The register of procurement decisions will be held and maintained by the Head of

Corporate Governance & Risk and will include a list of all current and future procurements. Decisions will be added to the register as quickly as possible after they are made.

20.4 The Register of Procurement Decisions will be made available to the public by placing it

on the NHS LCCG external website.

20.5 A Contracts Register will be maintained centrally by the Contracting Department as well as a copy of all NHS LCCG contracts.

21. Use of Information Technology 21.1 NHS LCCG will require providers of procurement support to offer appropriate information

technology systems to administer the procurement process – such as e-tendering and e-evaluation systems. These are intended to assist in streamlining LCCG procurement processes whilst at the same time providing a robust audit trail.

22. Decommissioning Services

21.1 The need to decommission contracts can arise through termination of a contract due to

performance against the contract not delivering the expected outcomes, expiry of a contract and/or a commissioning decision that the contracted services are no longer required. Where services are decommissioned, NHS LCCG will ensure where necessary that contingency plans are developed to maintain patient care. Where decommissioning involves Human Resource issues, such as TUPE issues, then providers will be expected to cooperate and be involved in discussions to deal with such issues.

23. Transfer of Undertakings and Protection of Employment Regulations (TUPE) 23.1 These regulations apply when there are transfers of staff from one legal entity to another

as a consequence of a change in employer. This is a complex area of law which is continually evolving. NHS LCCG will follow the relevant Government guidance such as the Cabinet Office Statement of Practice (COSOP) Staff Transfers in the Public Sector January 2000 (Revised December 2013) (Cabinet Office, 2013).


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23.2 It is the position of NHS LCCG to advise potential bidders that whilst not categorically

stating TUPE will apply, it is recommended that they assume TUPE will apply when preparing their bids, and ensure that adequate time is built into procurement timelines where it is anticipated that TUPE may apply.

24. Complaints and Dispute Procedure 24.1 NHS LCCG’s approach to contestability means that it is likely to pursue a wide range of

competitive procurements to secure new and existing services. 24.2 NHS LCCG will utilise its dispute resolution processes to address and resolve any

complaint received from either bidders/contractors or a member of the public

25. Training 25.1 All NHS LCCG staff and others working with NHS LCCG will need to be aware of this

policy and its implications. It is not intended that staff generally will develop procurement expertise, but they will need to know when and how to seek further support.

25.2 All NHS LCCG Procurement & Contracting staff should be appropriately qualified. NHS

LCCG will provide appropriate training to enable Procurement & Contracting staff to undertake their duties in accordance with the Regulations and recognised best practice.

25.2 All commissioning staff throughout NHS LCCG should have sufficient knowledge about

procurement to know when to seek help when they encounter related issues; they must also be able to give clear and consistent messages to providers and potential providers about NHS LCCG’s procurement intentions in relation to individual service developments.

26. Monitoring Compliance with this Policy 26.1 This Policy will be reviewed every three years. 26.2 In addition it will be kept under informal review by the Deputy CFO, to ensure that

changes can be made and approved rapidly following any further developments or the publication of new or updated regulations and/or guidance.

26.3 Effectiveness in ensuring that all procurements comply with this Policy will primarily be

achieved through review by the CFO.

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Agenda Item: GB 18/100iii FOI Exempt: N



Title: Standards of Business Conduct Policy



appropriate

()

Report Author: Laura Parsons, Head of Corporate Governance & Risk

Decision

Reviewed by EMT/SMT/Date: n/a

Discussion


Information

























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EXECUTIVE SUMMARY: The Standards of Business Conduct Policy has been reviewed to ensure it is up to date following the merger of the three Leeds Clinical Commissioning Groups (CCGs). Minor amendments have been made to reflect the single CCG. Additional text has been added to the Gifts and Hospitality Declaration form relating to the publication of the information declared (Appendix 3), in line with a recommendation from the recent audit of conflicts of interest. No amendments are being recommended in relation to the procedure for accepting/declining gifts, hospitality and sponsorship, as these are in line with the latest national guidance from NHS England. The draft policy was reviewed by the Audit Committee on 24 October and members agreed to recommend that it be approved by the Governing Body.

NEXT STEPS: All staff will be informed that the policy has been updated and it will be uploaded onto the CCG’s website.


(a) APPROVE the Standards of Business Conduct Policy.

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Version: DRAFT

Ratified by: Governing Body

Date ratified:

Name & Title of originator/author: Head of Corporate Governance and Risk

Name of responsible committee/individual: Audit Committee

Date issued:

Review date:

Target audience: See section 3

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Contents

Page

1. Introduction

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2. Purpose

3

3. Scope

3

4. Duties

4

5. Receipt of Hospitality, Gifts and Commercial Sponsorship

5

6. Outside Employment

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7. Gifts Hospitality and Sponsorship Register

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8. Publication of registers

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9. Contracts for Goods and Services

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10. Intellectual Property

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11. Confidentiality

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12. The Bribery Act 2010

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13. Equality Impact Assessment

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14. Monitoring Compliance and Effectiveness

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15. Associated Documentation

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16. References

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APPENDIX 1 - The Seven Principles of Public Life

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APPENDIX 2 - Standards of Business Conduct - Quick Guide

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APPENDIX 3 - Declaration of Gift/Hospitality/Sponsorship Form

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APPENDIX 4 - Non Disclosure Agreement

21

APPENDIX 5 - Policy Consultation Process

22

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1 Introduction 1.1 The Code of Conduct and Code of Accountability in the NHS (second revision

July 2004) sets out the following three public service values which are central to the work of the NHS:

Accountability - everything done by those who work in the NHS must be able to stand the test of parliamentary scrutiny, public judgements on propriety and professional codes of conduct.

Probity - there should be an absolute standard of honesty in dealing with the assets of the NHS: integrity should be the hallmark of all personal conduct in decisions affecting patients, officers and members and suppliers, and in the use of information acquired in the course of NHS duties.

Openness - there should be sufficient transparency about NHS activities to promote confidence between the NHS and its staff, patients and the public.

1.2 In addition to the public service values described above, all individuals within

the CCG should follow the Seven Principles of Public Life (the Nolan Principles) - see Appendix 1.

1.3 All individuals within the CCG are responsible for ensuring that they are not

placed in a position which risks conflict between their private interests and their NHS duties. Every individual is responsible for ensuring that they comply with this policy. Some individuals may additionally be required to adhere to a code of conduct of their own professional body.

2 Purpose 2.1 This policy provides guidance on what is deemed to be acceptable in terms of

receipt of gifts, hospitality and sponsorship and provides a code of conduct that individuals within the CCG are expected to follow.

2.2 This policy reflects and builds on the following national guidance:

HSG(93)5 Standards of Business Conduct for NHS Staff

Seven Principles of Public Life

The Codes of Conduct and Accountability in the NHS 2004

The Code of Conduct for NHS Managers 2002

Professional Standards Authority ‘Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England’ 2012

2.3 This policy should be read in partnership with the CCG’s Conflicts of Interest

Policy, the Anti‐Fraud and Bribery Policy, the Working Time Regulations Policy (in relation to secondary employment) and the Procurement Policy.

3 Scope 3.1 This policy applies to:

All CCG employees, including: o All full and part time staff;

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o Any staff on sessional or short term contracts; o Any students and trainees; o Agency staff; and o Seconded staff.

In addition, any self-employed consultants or other individuals working for the CCG under a contract for services should declare gifts, hospitality and sponsorship in accordance with this policy, as if they were CCG employees.

Members of the governing body: All members of the CCG’s committees, sub-committees/sub-groups, including:

o Co-opted members; o Appointed deputies; and o Any members of committees/groups from other organisations.

All members of the CCG (i.e. each practice) This includes each provider of primary medical services which is a member of the CCG under Section 140 (1) of the 2006 Act. Declarations should be made by the following groups:

o GP partners o Any individual directly involved with the business or decision-

making of the CCG. Who are referred to collectively in this policy as ‘individuals within the CCG’.

4 Duties 4.1 The Chief Executive is the organisation’s designated ‘Accountable Officer’

and has overall responsibility for ensuring that the CCG operates efficiently, economically and with probity. The Chief Executive (alongside other members of the Governing Body) has a duty to ensure that the CCG provides a secure environment in which to work, and one in which people are confident to raise concerns which will be listened to and addressed.

4.2 The Chief Finance Officer is responsible for ensuring this policy is in place.

The Chief Finance Officer, in conjunction with the Chief Executive, monitors and ensures compliance with NHS Counter Fraud Authority Standards for Commissioners regarding fraud, bribery and corruption. In addition and in consultation with the Local Counter Fraud Specialist (LCFS), the Chief Finance Officer will decide whether there is sufficient cause to conduct an investigation in relation to bribery, and whether the Police and external audit need to be informed.

4.3 The Head of Corporate Governance and Risk is responsible for

administering this policy and ensuring reporting to the Audit Committee. 4.4 All members of the Governing Body must act in accordance with this policy

and lead by example in acting with the utmost integrity and ensuring adherence to all relevant regulations, policies and procedures. Governing Body members must abide by the Professional Standards Authority Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England.

http://www.professionalstandards.org.uk/docs/psa-library/november-2012---standards-for-board-members.pdf?sfvrsn=0



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4.5 Line Managers are responsible for assisting employees in complying with this

policy by ensuring that this policy and its requirements are brought to the attention of employees for whom they are responsible, and that those employees are aware of its implications for their work.

4.6 All individuals within the CCG are required to:

Act honestly and with integrity at all times and to safeguard the organisation’s resources for which they are responsible.

Ensure that they read, understand and comply with this policy.

Adhere to all relevant regulations, policies and procedures.

Raise concerns as soon as possible if they believe or suspect that a conflict with this policy has occurred, or may occur in the future.

Ensure that the interests of patients remain paramount at all times.

Be impartial and honest in the conduct of their official business.

Use the public funds entrusted to them to the best advantage of the service, always ensuring value for money.

Not abuse their official position for personal gain or to benefit their family or friends.

Not seek to gain advantage or further private business or other interests, in the course of their official duties.

Be aware that it is both a serious criminal offence (under the Bribery Act 2010, the Theft Act 1968 and the Fraud Act 2006) and disciplinary matter to corruptly receive or give any fee, loan, gift, reward or other advantage in return for doing (or not doing) anything or showing favour (or disfavour) to any person or organisation.

Understand that failure to follow this policy may damage the CCG and its work and so may be viewed as a disciplinary matter. The organisation’s Disciplinary Policy makes it clear that bringing the organisation into disrepute is potentially gross misconduct. As well as the possibility of civil and criminal prosecution, individuals that breach this policy will face disciplinary action, which could result in dismissal for gross misconduct.

5 Receipt of Hospitality, Gifts and Commercial Sponsorship

Hospitality

5.1 Delivery of services across the NHS relies on working with a wide range of partners (including industry and academia) in different places and, sometimes, outside of ‘traditional’ working hours. As a result, individuals within the CCG will sometimes appropriately receive hospitality. Individuals receiving hospitality should always be prepared to justify why it has been accepted, and be mindful that even hospitality of a small value may give rise to perceptions of impropriety and might influence behaviour.

5.2 For the purpose of this policy, hospitality is defined as offers of meals, refreshments, travel, accommodation, and other expenses in relation to attendance at meetings, conferences, education and training events, etc.

5.3 Overarching principles:

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Individuals within the CCG should not ask for or accept hospitality that may affect, or be seen to affect, their professional judgement;

Hospitality must only be accepted when there is a legitimate business reason and it is proportionate to the nature and purpose of the event;

Particular caution should be exercised when hospitality is offered by actual or potential suppliers or contractors, these can be accepted if modest and reasonable, but individuals should always obtain senior approval and declare these.

5.4 Meals and refreshments:

Under a value of £25.00 – may be accepted and need not be declared;

Of a value between £25.00 - £75.00 – may be accepted and must be declared;

Over a value of £75.00 – should be refused unless (in exceptional circumstances) senior approval is given. A clear reason must be recorded in the register of gifts and hospitality as to why it was permissible to accept.

A common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or an estimate that a reasonable person would make as to its value).

5.5 Travel and accommodation:

Modest offers to pay some or all of the travel and accommodation costs related to attendance at events may be accepted and must be declared.

Offers which go beyond modest or are of a type that the CCG itself might not usually offer, need senior approval, should only be accepted in exceptional circumstances, and must be declared. A clear reason must be recorded in the register of gifts and hospitality as to why it was permissible to accept travel and accommodation of this type.

A non-exhaustive list of examples includes: o Offers of business class or first class travel and accommodation

(including domestic travel); and o Offers of foreign travel and accommodation.

5.5 In cases of doubt, advice should be sought from the Head of Corporate

Governance and Risk or the hospitality should be politely declined.

Gifts 5.6 Staff in the NHS offer support during significant events in people’s lives. For

this work they may sometimes receive gifts as a legitimate expression of gratitude. We should be proud that our services are so valued. But situations where the acceptance of gifts could give rise to conflicts of interest should be avoided. Individuals within the CCG should be mindful that even gifts of a small value may give rise to perceptions of impropriety and might influence behaviour if not handled in an appropriate way.

5.7 A ‘gift’ is defined as any item of cash or goods, or any service, which is provided for personal benefit, free of change or at less than its commercial value.

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5.8 Overarching principles:

Individuals within the CCG must not accept gifts that may affect, or be seen to affect, their professional judgement. This overarching principle should apply in all circumstances;

Any personal gift of cash or cash equivalents (e.g. vouchers, tokens, offers of remuneration to attend meetings whilst in a capacity working for or representing the CCG) must always be declined, whatever their value and whatever their source, and the offer which has been declined must be declared and recorded in the register of gifts and hospitality.

5.9 Gifts from suppliers or contractors:

Gifts from suppliers or contractors doing business (or likely to do business) with the CCG must be declined, whatever their value (subject to this, low cost branded promotional aids may be accepted and not declared where they are under the value of a common industry standard of £6.00). The person to whom the gifts were offered must also declare the offer so that it can be recorded on the register of gifts and hospitality.

5.10 Gifts from other sources (e.g. patients, families, service users):

Individuals must not ask for any gifts;

Modest gifts of less than £50.00 can be accepted and do not need to be declared;

Gifts valued at over £50.00 should be treated with caution and only be accepted, with senior approval, on behalf of an organisation (i.e. to an organisation’s charitable funds), not in a personal capacity. These must be declared;

Multiple gifts from the same source over a 12 month period must be treated in the same way as a single gift in respect of the £50.00 threshold.

5.11 In cases of doubt, advice should be sought from the Head of Corporate

Governance and Risk or the gift should be politely declined.

5.12 If an individual becomes aware that they are a named beneficiary in the will of a patient they have provided care to, they must contact the Chief Executive or Chief Finance Officer to discuss the ethics of remaining a beneficiary.

Sponsored events

5.13 Sponsorship of NHS events by external providers is valued. Offers to meet some or part of the costs of running an event secures their ability to take place, benefiting NHS staff and patients. Without this funding there may be fewer opportunities for learning, development and partnership working. However, there is potential for conflicts of interest between the organiser and the sponsor, particularly regarding the ability to market commercial products or services. As a result there should be proper safeguards in place to prevent conflicts occurring.

5.14 For the purpose of this policy, sponsorship is defined as including:

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NHS funding from an external source, including funding of all or part of

the costs of a member of staff; and

NHS research, staff training, pharmaceuticals, equipment, meeting rooms, costs associated with meetings, meals, hotel and transport costs (including trips abroad), provision of free services (speakers), buildings or premises.

5.15 When sponsorships are offered, the following principles must be adhered to:

Sponsorship of CCG events by appropriate external bodies should only be approved if a reasonable person would conclude that the event will result in clear benefit for the CCG and the NHS.

Acceptance of commercial sponsorship must not in any way compromise the commissioning decisions of the CCG or be dependent on the purchase or supply of goods or services.

At the CCG’s discretion, sponsors or their representatives may attend of take part in the event but they should not have a dominant influence over the content or main purpose of an event, meeting, seminar, publication or training event.

The involvement of a sponsor in an event should always be clearly identified in the interests of transparency.

The sponsorship agreement must be in writing and must include the following statement: ‘The fact of sponsorship does not mean that the CCG endorses [company name]’s products or services.’ This should also be made visibly clear on any promotional or other materials relating to the event.

No information should be supplied to the sponsor from which they could gain a commercial advantage, and information which is not in the public domain should not normally be supplied.

Ensure there are no potential irregularities that may affect a company’s ability to satisfy the conditions of the agreement or impact upon it in any way. This would include checking the company’s financial standing and referring to the company’s accounts.

Consider the costs and benefits in relation to alternative options where appropriate. The decision making process must be transparent and defensible.

During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection rules and legislation. Any disclosure of confidential information must be legally and ethically appropriate. In research purposes, disclosure should not take place without approval of the Local Research Ethics Committee.

Monitor clinical and financial outcomes and ensure break clauses are built in to enable the CCG to terminate the agreement if it becomes apparent that it is not providing expected value for money / clinical outcomes.

5.16 Any sponsorship that is offered and/or accepted must be declared and approval must be sought from the Chief Executive and Chair prior to accepting sponsorship using the form attached at Appendix 3. Other forms of sponsorship:

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5.17 Organisations external to the CCG or NHS may also sponsor posts or research. However, there is potential for conflicts of interest to occur, particularly when research funding by external bodies does or could lead to a real or perceived commercial advantage, or if sponsored posts cause a conflict of interest between the aims of the sponsor and the aims of the organisation, particularly in relation to procurement and competition. There needs to be transparency and any conflicts of interest should be well managed. For further information, please refer to Managing Conflicts of Interest in the NHS: Guidance for staff and organisations. Speaking at a Meeting / Conference

5.18 Should an individual be asked to speak at an event and there is an offer of payment and delivering it during contracted hours, then there are two choices open to the individual in conjunction with agreement with the line manager:

The payment should be credited to the CCG and the relevant department within which the individual works, including the Governing Body as a “department” for GP members / Lay Members to be assigned to. Any such payments must also be declared using the form at Appendix 3. If there is no payment but other benefits are offered, such as accommodation, travel expenses, etc. then this must be declared using the form at Appendix 3.

The individual takes annual leave and the payment is made to them as a private matter between the organisation making the payment and the individual involved with the CCG. However, GPs in particular need to be mindful of the potential conflicts of interest that may still arise between their role within CCG and as a private contractor of services to the NHS. For further information please see the Conflicts of Interest Policy.

Inappropriate Offers of Hospitality/Gifts/Sponsorship

5.19 All staff and members must notify the Head of Corporate Governance and Risk of any inappropriate/overly generous offers of hospitality/gifts/sponsorship within 2 weeks of the offer being made. This includes any offers that would constitute a bribe, i.e. offers of a financial or other advantage as an incentive or reward to improperly perform your function or activities. For further information, please see the Anti-Fraud and Bribery Policy. The Head of Corporate Governance and Risk will ensure the Audit Committee is made aware of the inappropriate offer at the next meeting.

6. Outside Employment In accordance with the CCG’s Working Time Regulations Policy, individuals who are directly employed by the CCG must notify their line manager of their intention to undertake secondary employment by completing the Declaration of Secondary Employment form. Any existing outside employment must be declared on appointment, and any new outside employment must be declared when it arises. Amongst other things, the purpose of this is to ensure that the CCG is aware of any potential conflict with their CCG employment. For further information, please see the Conflicts of Interest Policy.

https://www.england.nhs.uk/wp-content/uploads/2017/02/guidance-managing-conflicts-of-interest-nhs.pdf

https://www.england.nhs.uk/wp-content/uploads/2017/02/guidance-managing-conflicts-of-interest-nhs.pdf

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6.1 Examples of work which might conflict with the business of the CCG include:

Employment with another NHS body;

Employment with another organisation which might be in a position to supply goods/services to the CCG including paid advisory positions and paid honorariums which relate to bodies likely to do business with the CCG;

Directorships e.g. of a GP federation or non-executive roles;

Self employment, including private practice, charitable trustee roles, political roles and consultancy work, in a capacity which might conflict with the work of the CCG or which might be in a position to supply goods/services to the CCG.

6.2 Permission to engage in secondary employment will be required and the CCG

reserves the right to refuse permission where it believes a conflict will arise.

7. Gifts, Hospitality and Sponsorship Register

7.1 The following must be declared as soon as reasonably practicable using the form at Appendix 3:

All offers of gifts from suppliers and contractors, other than low cost branded promotional items under the value of £6.00;

All offers of gifts from other sources (e.g. patients, families, service users) with a value of more than £50.00;

Hospitality with a value of more than £25.00; and

All offers and/or acceptances of sponsorship.

7.2 Where gifts and hospitality have been offered and declined, they must be declared and recorded if the amount would have been subject to such a declaration.

7.3 All completed hospitality/gift/sponsorship forms must be submitted to the Head of Corporate Governance and Risk for incorporating into the central register.

7.4 The Gifts and Hospitality Register will be published on the CCG website on a

quarterly basis.

7.5 A record of all gifts and hospitality will remain on the register for a minimum of

6 months after the date of offer. The CCG will retain a private record of

historic interests for a minimum of 6 years after the date on which it was

offered.

8. Publication of registers

8.1 In order to demonstrate openness the Gift and Hospitality register will be made available on the CCG’s website. Also, the register is reviewed by the Audit Committee on a quarterly basis.

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8.2 Although all individuals must declare gifts, hospitality and sponsorship, the CCG will only publish those declared by decision makers. Decision makers are defined as follows:

All governing body members;

Members of advisory groups which contribute to direct or delegated decision making on the commissioning or provision of taxpayer funded services such as working groups involved in service redesign or stakeholder engagement that will affect future provision of services;

Members of the Primary Care Commissioning Committee (PCCC);

Members of other committees of the CCG e.g., audit committee, remuneration committee etc.;

Members of new care models joint provider / commissioner groups / committees;

Members of procurement (sub-)committees;

Individuals on Agenda for Change band 8d and above;

Management, administrative and clinical staff who have the power to enter into contracts on behalf of the CCG;

Management, administrative and clinical staff involved in decision making concerning the commissioning of services, purchasing of good, medicines, medical devices or equipment, and formulary decisions; and

Management, administrative and clinical staff responsible for processing payments in behalf of the CCG.

8.3 In exceptional circumstances, where the public disclosure of information could

give rise to a real risk of harm or is prohibited by law, an individual’s name and/or other information may be redacted from the publicly available register. Where an individual believes that substantial damage or distress may be caused, to him/herself or somebody else by the publication of information about them, they are entitled to request that the information is not published. Such requests must be made in writing. Decisions not to publish information must be made by the Conflicts of Interest Guardian for the CCG, who should seek appropriate legal advice where required, and the CCG will retain a confidential un-redacted version of the register.

8.4 All decision making staff will be made aware, in advance of publication, that the register(s) will be kept, how the information on the register(s) may be used or shared and that the register(s) will be published. This will be done by the provision of a fair processing notice that details the identity of the data controller, the purposes for which the registers are held and published, how the information on the register(s) may be used or shared and contact details for the data protection officer. This information will also be provided to individuals identified in the register(s) because they are in a relationship with the person making the declaration.

8.5 All individuals who are not decision makers but who are still required to make a declaration of interest(s) or a declaration of gifts or hospitality will be made aware that the register(s) will be kept and how the information on the register(s) may be used or shared. This will be done by the provision of a separate fair processing notice that details the identity of the data controller, the purposes for which the register(s) are held, how the information on the register(s) may be used or shared and contact details for the data protection

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officer. This information will also be provided to individuals identified in the register(s) because they are in a relationship with the person making the declaration.

9. Contracts for Goods and Services

9.1 All staff who are in contact with suppliers and contractors (including external

consultants), and in particular those who are authorised to sign Purchase Orders or place contracts for goods, materials or services, are expected to adhere to professional standards of the kind set out in the Code of Conduct of the Chartered Institute of Purchasing and Supply (CIPS).

9.2 Fair and open competition between prospective contractors or suppliers for

NHS contracts is a requirement of NHS Standing Orders and of EU Directives on Public Purchasing for Works and Supplies. This means that:

No private, public or voluntary organisation which may bid for NHS business should be given any advantage over its competitors, such as advance notice of NHS requirements. This applies to all potential contractors, whether or not there is a relationship between them and the

CCG, such as a long‐running series of previous contracts.

Each new contract should be awarded solely on merit, taking into account the requirements of the NHS and the ability of the contractors to fulfil them.

9.3 Individuals should ensure that no special favour is shown to current or former

employees or their close relatives or associates in awarding contracts to private or other businesses run by them or employing them in a senior or relevant managerial capacity. Contracts may be awarded to such businesses where they are won in fair competition against other tenders, but scrupulous care must be taken to ensure that the selection process is conducted impartially, and that individuals who are known to have a relevant interest play no part in the selection. Such interests must also be declared in accordance with the Conflicts of Interest Policy.

9.4 Individuals must not seek, or accept, preferential rates or benefits in kind for

private transactions carried out with companies with which they have had, or may have, official dealings on behalf of the CCG. This does not apply to officers’ and members’ benefit schemes offered by the NHS or trade unions.

9.5 Every invitation to tender to a prospective bidder for CCG business must

require each bidder to give a written undertaking not to engage in collusive tendering or other restrictive practice, and not to engage in canvassing the CCG, its employees or officers concerning the contract opportunity tendered.

10. Intellectual Property 10.1 Any patents, designs, trademarks or copyright resulting from the work (e.g.

research) of an individual, carried out as part of their work with the CCG, shall be the Intellectual Property of the CCG.

http://www.cips.org/Documents/About%20CIPS/CIPS_Code_of_conductv2_10_9_2013.pdf

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10.2 Approval should be sought from the appropriate line manager prior to entering into an obligation to undertake external work connected with the business of the CCG, e.g. writing articles for publication, speaking at conferences.

10.3 Where the undertaking of external work, gaining patent or copyright or the

involvement in innovative work, benefits or enhances the CCG’s reputation or results in financial gain for the CCG, consideration will be given to rewarding employees subject to any relevant guidance for the management of Intellectual Property in the NHS issued by the Department of Health.

11. Confidentiality 11.1 Information concerning the CCG which is not in the public domain must not at

any time be divulged to any unauthorised person. Similarly, patient data or personal data concerning staff must not be divulged, in line with the General Data Protection Regulation (GDPR) 2018. This duty of confidence remains after termination of employment and applies to all individuals within the CCG.

11.2 Care should be taken that confidentiality is not breached inadvertently by, for

instance discussing confidential matters in public places, such as whilst travelling by train, or by leaving portable IT equipment containing confidential information where it might easily be stolen, such as on full view in a parked car. Data should only be distributed using mechanisms with an appropriate level of security.

11.3 Individuals must maintain confidentiality of information at all times, both

commercial data and personal data, as defined by the GDPR. 11.4 Individuals should guard against providing information on the operations of

the CCG which might provide a commercial advantage to any organisation (private or NHS) in a position to supply goods or services to the CCG. For particularly sensitive procurements/contracts, individuals may be asked to sign a non-disclosure agreement, a copy of which can be found at Appendix 4.

11.5 Please note that nothing in this policy prevents an individual from raising a

concern in line with the CCG’s Whistleblowing Policy.

12. The Bribery Act 2010

12.1 The Bribery Act 2010 defines bribery as:

“Inducement for an action which is illegal, unethical or a breach of trust. Inducements can take the form of gifts, loans, fees, rewards or other privileges".

12.2 This can be broadly defined as the offering or acceptance of inducements,

gifts, favours, payment or benefit-in-kind which may influence the action of any person. Bribery does not always result in a loss. The corrupt person may not benefit directly from their deeds; however, they may be unreasonably using their position to give some advantage to another.

14

12.3 The Act also introduces a corporate offence of failing to prevent bribery where the organisation (which includes all NHS bodies) does not have adequate preventative procedures in place.

12.4 Should members or staff wish to report any concerns or allegations they have

a number of options available to them:

Report all suspected irregularities to the Chief Finance Officer who is also the contact point for NHS Counter Fraud Authority, the Police and External Audit.

Contact the Local Counter Fraud Specialist on 01904 725145 / 01423 554548 for any potential fraud related queries.

Contact the NHS Counter Fraud Authority Fraud and Corruption Reporting Line o 0800 028 4060 o www.reportnhsfraud.nhs.uk

Contact the Public Concern at Work line on 0207 404 6609

Follow the CCG’s own Whistleblowing Policy guidelines

12.5 Failure to disclose or providing falsified information is considered as gross misconduct and may lead to internal disciplinary action and/or include the involvement of the CCG’s Local Counter Fraud Specialist in line with the CCG’s Anti-Fraud and Bribery Policy.

13. Equality Impact Assessment (EIA)

13.1 A full Equality Impact Assessment is not considered to be necessary as this policy will not have a detrimental impact on a particular group.

14. Monitoring Compliance and Effectiveness 14.1 Effectiveness is monitored by the Audit Committee through regular reports on

declarations made in line with the policy. 14.2 Individuals should be aware that a breach of this policy could render them

liable to prosecution as well as leading to the termination of their employment or position with the CCG.

15. Associated Documentation

Managing Conflicts of Interest Policy

Anti‐Fraud and Bribery Policy

Working Time Regulations Policy

Procurement Policy

Whistleblowing Policy

16. References

HSG(93)5 Standards of Business Conduct for NHS Staff

Nolan Principles of Public Life

The Codes of Conduct and Accountability in the NHS 2004

http://www.reportnhsfraud.nhs.uk/

15

The Code of Conduct for NHS Managers 2002

Professional Standards Authority ‘Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England’ 2012

Bribery Act 2010

Chartered Institute of Purchasing and Supply (CIPS) Code of Conduct

16

Appendix 1 – The Seven Principles of Public Life (Nolan Principles)

Selflessness - Holders of public office should act solely in terms of the public

interest.

Integrity - Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships.

Objectivity - Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias.

Accountability - Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this.

Openness - Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing.

Honesty - Holders of public office should be truthful.

Leadership - Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs.

17

Appendix 2 - Standards of Business Conduct – Quick Guide

Make sure you understand the guidelines on standards of business conduct, and consult your line manager if you are not sure.

Make sure you are not in a position where your private interests and NHS duties may conflict.

Declare to any relevant interests in line with the Managing Conflicts of Interest Policy. If in doubt, ask yourself: i. Am I, or might I be, in a position where I (or my family/friends) could gain from the connection between my private interests and my employment? ii. Do I have access to information which could influence purchasing decisions? iii. Could my outside interest be in any way detrimental to the NHS or to patients' interests? iv. Do I have any other reason to think I may be risking a conflict of interest?

If still unsure - Declare it!

Declare the offer and receipt of gifts and hospitality as soon as possible.

Report any inappropriate offers of gifts/hospitality/sponsorship to the Head of Corporate Governance within 2 weeks of the offer being made.

Obtain permission from the Chief Executive and Chair (using the form at Appendix 3) before accepting any sponsorship agreement.

Adhere to the code of conduct of the Institute of Purchasing and Supply if you are involved in any way with the acquisition of goods and services.

Inform your line manager if you are intending to take on outside work, including any potential conflicts of interest this may cause.

Do not abuse your past or present official position to obtain preferential rates for private deals.

Do not unfairly advantage one competitor over another or show favouritism in awarding contracts.

Do not misuse or make available official "commercial in confidence" information.

18

Appendix 3

RECORD OF HOSPITALITY/GIFTS/SPONSORSHIP – DECLARATION FORM This form should be used to record any offers and/or acceptance of hospitality/gifts, and sponsorship agreements. Both declined and accepted offers should be declared in line with the following rules: Gifts from suppliers or contractors:

All gifts of any nature offered by suppliers or contractors linked (currently or prospectively) to the CCG’s business should be declined, whatever their value.

Subject to this, low cost branded promotional aids may be accepted where they are under the value of £6.00 in total, and need not be declared.

Gifts offered from other sources:

Gifts of cash and vouchers to individuals should always be declined.

Modest gifts of less than £50.00 can be accepted and do not need to be declared.

Gifts valued at over £50.00 should be treated with caution and only be accepted, with senior approval, on behalf of an organisation, not in a personal capacity. These must be declared.

Multiple gifts from the same source over a 12 month period should be treated in the same way as a single gift in respect of the £50.00 threshold.

Hospitality - meals and refreshments:

Under a value of £25.00 – may be accepted and need not be declared.

Of a value between £25.00 - £75.00 – may be accepted and must be declared.

Over a value of £75.00 – should be refused unless (in exceptional circumstances) senior approval is given. These must be declared.

Hospitality - travel and accommodation:

Modest offers to pay some or all of the travel and accommodation costs related to attendance at events may be accepted and must be declared.

Offers which go beyond modest (i.e. first class travel and accommodation and foreign travel and accommodation),or are of a type that the organisation itself might not usually offer, need senior approval, should only be accepted in exceptional circumstances, and must be declared.

Senior approval

If you wish to accept gifts worth more than £50.00, hospitality worth over £75.00, or offers of travel/accommodation which go beyond modest (see above), this must be approved by the following, who must sign Section 9:

Requesting Individual Approving Manager

Chief Executive Non-Executive Members of Governing Body

CCG Chair

Directors CCG Chair

Chief Executive

Other Individuals Relevant Director or Deputy Director

If you have declined gifts worth more than £50 or Hospitality worth over £25.00 respectively, this must be declared.

19

If you wish to enter into a sponsorship agreement, this must be approved by the Chief Executive and Chair, and they must complete section 9 below.

Name:

Position within the CCG:

Are you responsible for contract monitoring, ordering or approval powers? Yes / No (please delete as appropriate) If yes, please specify:

Details of Hospitality/Gifts/Sponsorship Offered and/or Accepted

1.Details of the hospitality/gift/sponsorship:

2. Approximate value:

3. Reason why the hospitality/gift/sponsorship is being offered:

4a. Name of organisation/individual offering hospitality or gift/sponsorship:

4b. Name of the organisation representative:

5. Products/services provided by the organisation/individual to NHS Leeds CCGs, where applicable:

6. Are the products or services being offered either used or ordered by the individual in the course of their duties?

Yes / No (please delete as appropriate)

7. Decision: Declined / Accepted (please delete as appropriate)

8. Declaration: I declare that the information I have given on this form is correct and complete. I

20

understand that if I knowingly provide false information this may result in disciplinary action

and I may be liable for prosecution and civil recovery proceedings. I consent to the

disclosure of this information for the purposes of prevention, detection and prosecution of

fraud.

Signed: Name: Designation: Date:

9. Approved: Yes / No (please delete as appropriate)

If yes, reason for approval / If no, reason offer declined (Continue overleaf if necessary):

Signed: Name: Designation: Date:

Please return completed forms to the Corporate Governance Team

[email protected] for inclusion on the register.

The information submitted will be held by the CCG for personnel or other reasons specified on this

form and to comply with the organisation’s policies. This information may be held in both manual and

electronic form in accordance with the Data Protection Act 2018. Information may be disclosed to third

parties in accordance with the Freedom of Information Act 2000 and in the case of ‘decision making

staff’ (as defined in the statutory guidance on managing conflicts of interest for CCGs), may be

published in registers that the CCG holds.

Decision making staff should be aware that the information provided in this form will be added to the

CCG’s registers which are held in hardcopy for inspection by the public and published on the CCG’s

website. Decision making staff must make any third party whose personal data they are providing in

this form aware that the personal data will held in hardcopy for inspection by the public and published

on the CCG’s website and must inform the third party that the CCG’s privacy policy is available on the

CCG’s website. If you are not sure whether you are a ‘decision making’ member of staff, please speak

to your line manager before completing this form.


21

Appendix 4 – Non Disclosure Agreement Template

NHS Leeds CCG - express requirement for confidentiality You have been requested to be involved in [INSERT DETAILS] (the “Project”). NHS Leeds CCG or other parties participating in the Project may provide you with, as part of your role in respect of the Project, access to certain confidential information relating the Project (whether before or after the date of this letter), in writing, by email, orally or by other means (including from or pursuant to discussions with any other party or which is obtained through attendance at meetings related to the Project) and trade secrets including, without limitation, technical data and know-how relating to the Project, including in particular (by way of illustration only and without limitation) [EXAMPLES] and including (but not limited to) information that you may create, develop, receive or obtain in connection with your engagement on the Project, whether or not such information (if in anything other than oral form) is marked confidential (the "Confidential Information"). Accordingly we draw to your attention that as part of your role for NHS Leeds CCG you are required to: 1.1. maintain the Confidential Information in the strictest confidence and not divulge

any of the Confidential Information to any third party without the prior written permission of NHS Leeds CCG; and

1.2. not make use of, reproduce, copy, discuss, disclose or distribute the

Confidential Information other than for use as part of your role in the Project. The above obligations in respect of this Confidential Information are supplemental to any prior representation, understanding and commitment (whether oral or written) between us. The terms of this Letter can only be changed by a written document, agreed upon by both of us and signed by duly authorised persons. These provisions shall be governed and construed by English law. Yours faithfully

For and on behalf of NHS Leeds CCG By signing this letter you agree to comply with these terms.

Signed:

Date:

Print Name:

22

Appendix 5 - Policy Consultation Process

Title of document Standards of Business Conduct Policy

Author Corporate Governance & Risk Team

Revised document Revised October 2018

Lists of persons involved in the revision of the policy

Laura Parsons - Head of Corporate Governance and Risk Sam Ramsey – Corporate Governance Manager

List of persons involved in the consultation process:

As Above Audit Committee

1

GOVERNING BODY FORWARD WORK PLAN 2018/19

ITEM NOV JAN MAR Lead

Officer

STANDING ITEMS

Welcome & apologies X X X Chair

Declarations of interest X X X Chair

Minutes of previous meeting X X X Chair

Matters arising X X X Chair

Action log X X X Chair

Questions from members of the public X X X Chair

Patient Experience/Patient Voice JH

COMMISSIONING

Chief Officer’s Report X X X PC

Integrated Quality & Performance Report X X X TR / JH

Commissioning Intentions List X SR

FINANCE

Finance Report X X X VPS

Approval of Annual Report & Accounts VPS

Approval of Annual Budget X VPS

CCG Financial Control, Planning and Governance Self-Assessment

X X X VPS

STRATEGY

Strategic Review:

- CCG Strategic Plan

- Leeds Health & Care Plan

- West Yorkshire & Harrogate STP

X X X

PC

Commissioning for Value Update X X X TR

CCG Operating Plan X TR/VPS

Risk Management Strategy X SA

RISK

Governing Body Assurance Framework X X X PC

Corporate Risk Register X X X PC

STATUTORY DUTIES

Assurance on delivery of Statutory Duties X Various

Quality Assurance / Quality Improvement X JH

GOVERNANCE

Approval of Procurement Plan 2018/19 VPS

Approval of Business Cases/Investments over £1.5m (as required)

Various

Agenda Item: GB 18/102

2

ITEM NOV JAN MAR Lead

Officer

Chair’s Summary of Committee Meetings X X X Committee Chairs

Committee Terms of Reference X Committee Chairs

Committee Annual Reports X Committee Chairs

Approval of Governing Body Appointments / Reappointments (as required)

Chair

Approval of amendments to Constitution (as required)

Chair

Forward Work Plan X X X Chair

Policy Approval (as required) Various

Review of Operational Scheme of Delegation X VPS

FOR INFORMATION

EPRR Self-Assessment X SR

NHS LEEDS CCG GOVERNING BODY AND COMMITTEE MEETING DATES – 2019-2020

MEETING APR 19 MAY 19 JUNE 19 JULY 19 AUG 19 SEPT 19 OCT 19 NOV 19 DEC 19 JAN 20 FEB 20 MAR 20

Governing Body Meeting

Wed 22

May 2pm–5pm

Pre-meet 1pm-2pm

Wed 24

July 1pm – 4pm

AGM 4.30 – 5.30pm

Wed 25 Sept

2pm – 5pm

Pre-meet

1pm – 2pm

Wed 27 Nov

2pm–5pm

Pre-meet 1pm-2pm

Wed 29 Jan

2pm–5pm

Pre-meet 1pm-2pm

Wed 25 Mar

2pm–5pm

Pre-meet 1pm-2pm

Deadline

Governing Body Workshop

Wed 3 April

9am – 1pm

Wed 12 June

9am – 1pm

Wed 14 Aug

9am – 1pm

Wed 09 Oct

9am – 1pm

Wed 11 Dec

9am – 1pm

Wed 12 Feb

9am – 1pm

Deadline

Quality & Performance Committee

Wed 8 May

2pm – 5pm

Wed 10 July

2pm – 5pm

Wed 11 Sept

2pm – 5pm

Wed 13 Nov

2pm – 5pm

Wed 15 Jan

2pm – 5pm

Wed 11 Mar

2pm – 5pm

Deadline

Primary Care Commissioning Committee

Wed 5 June 2pm – 5pm

Wed 7 Aug 2pm -5pm

Wed 2 Oct

2pm – 5pm

Wed 4 Dec 2pm – 5pm

Wed 5 Feb 2pm – 5pm

Wed 1 Apr

2pm – 5pm

Deadline

Audit Committee

Wed 24 April

11am – 1pm

Wed 22 May

12.00pm – 1pm

(Accounts)

Wed 17 July

11am – 1.00pm

Wed 16 Oct

11.00 – 1.00pm

Wed 22 Jan

11.00 – 1.00pm

Deadline

NHS LEEDS CCG GOVERNING BODY AND COMMITTEE MEETING DATES – 2019-2020

MEETING APR 19 MAY 19 JUNE 19 JULY 19 AUG 19 SEPT 19 OCT 19 NOV 19 DEC 19 JAN 20 FEB 20 MAR 20

Remuneration Committee

Wed 3 April

1.30pm – 3.00pm

Wed 12 June

1.30 – 3.00pm

Wed 09 Oct

1.30pm – 3.00pm

Wed 12 Feb

1.30pm – 3.00pm

Deadline

Clinical Commissioning Forum

Thurs 23 May

1.30 – 4.30pm

Wed 31

July 1.30 – 4.30pm

Wed 16 Oct

1.30pm – 4.30pm

Wed 22 Jan

1.30 – 4.30pm

Thurs 26 March 1.30 –

4.30pm

Deadline Patient Assurance Group

Wed 3 April

Wed 1 May

Wed 5 June

Wed 3 July

Wed 7 Aug

Wed 4 Sept

Wed 2 Oct

Wed 6 Nov

Wed 4 Dec

Wed 8 Jan

Wed 5 Feb

Wed 4 Mar

Deadline

Council of Members

Wed 4 Sept

Wed 4 Mar

Deadline

WY&H Joint Committee of CCGs – 04/09/2018

Page 1 of 4

West Yorkshire & Harrogate Joint Committee of Clinical Commissioning Groups Minutes of the meeting held in public on Tuesday 4th September 2018

Kirkdale Room, Junction 25 Conference Centre, Armytage Road, Brighouse, HD6 1QF

Members Initials Role and organisation

Marie Burnham MB Independent Lay Chair

Fatima Khan-Shah FKS Lay member

Richard Wilkinson RW Lay member

Dr James Thomas JT Chair, NHS Airedale, Wharfedale and Craven CCG

Dr Andy Withers AW Chair, NHS Bradford Districts CCG

Helen Hirst HH Chief Officer, NHS Bradford City, Bradford Districts and AWC CCGs

Dr Matt Walsh MW Chief Officer, NHS Calderdale CCG

Dr Steve Ollerton SO Chair, NHS Greater Huddersfield CCG

Carol McKenna CMc Chief Officer, NHS Greater Huddersfield CCG and North Kirklees CCG

Dr Alistair Ingram AI Chair, NHS Harrogate & Rural District CCG

Amanda Bloor ABl Chief Officer, NHS Harrogate & Rural District CCG

Dr Gordon Sinclair GS Chair, NHS Leeds CCG

Philomena Corrigan PC Chief Executive, NHS Leeds CCG

Dr David Kelly DK Chair, NHS North Kirklees CCG

Dr Adam Sheppard AS Assistant Clinical Chair, NHS Wakefield CCG (Deputy for Dr Phillip Earnshaw)

Jo Webster JW Chief Officer, NHS Wakefield CCG

Apologies

Dr Akram Khan AK Chair, Bradford City CCG

Dr Steven Cleasby SC Chair, NHS Calderdale CCG

Dr Phillip Earnshaw PE Chair, NHS Wakefield CCG

Karen Coleman KC Communication Lead, WY&H STP

Anthony Kealy AKe Locality Director, West Yorkshire, North Region NHS England

In attendance

Stephen Gregg SG Governance Lead, Joint Committee of CCGs (minutes)

Ian Holmes IH Director, WY&H Health and Care Partnership

Bryan Machin BM Finance Director, WY&H Health and Care Partnership

Catherine Thompson CT Programme Director, Elective Care/Standardisation of Commissioning Policies

6 members of the public were also in attendance.


Page 2 of 4

Item No. Agenda Item Action 59/18 Welcome, introductions and apologies

MB welcomed all to the meeting and reminded everyone of the role of the Joint Committee. Apologies were noted.

60/18 Open Forum

MB invited members of the public to ask questions about items on the agenda. SG advised that no written questions had been received. 1 member of the public asked a verbal question: Elective care/standardisation of commissioning policies

Q. If fewer children are fitted with grommets as a result of changed policies, this will place extra strain on council services and the provision of hearing aids. How have partners addressed this issue?

A. JT said that the focus of the programme was on ensuring that all patients, including children with hearing difficulties, received the treatment most clinically appropriate for their individual needs. If the clinical evidence indicated grommets, a child would continue to be fitted with them. MW added that there was currently variation in how evidence was used across the system. The programme aimed to improve understanding of the evidence and ensure that everyone received the right treatment. This would help free up capacity by not providing treatments which were not supported by clinical evidence.

61/18 Declarations of Interest

MB asked Committee members to declare any interests that might conflict with the business on today’s agenda. There were none.

62/18 Minutes of the meeting in public – 5th June 2018

The Committee reviewed the minutes of the last meeting.

The Joint Committee: Approved the minutes of the meeting on 5th June 2018.

63/18 Actions and matters arising – 5th June 2018

The Joint Committee reviewed the action log. There were no matters arising. The Joint Committee: Noted the action log.

64/18 Elective care/standardisation of commissioning policies

Matt Walsh presented an update on the Elective care/standardisation of commissioning policies programme. He outlined progress on the following work streams: Eye Care Pathway and Services, Musculoskeletal (MSK) Pathway, Clinical Thresholds and Value Based Commissioning (Procedures of limited clinical value), Supporting Healthier Choices (SHC) and Prescribing. He highlighted good progress in aligning provider and commissioner work-streams through closer working with the West Yorkshire Association of Acute Trusts. Some of the main challenges for the programme included:

• Using learning from behavioural change science to change the conversation with the public about services.

• Capitalising on the expertise of community pharmacy and working with them on shared priorities.

• Balancing the need for early diagnosis of cancer with the other pressures on the healthcare system, particularly around planned care.


Page 3 of 4

Item No. Agenda Item Action • Workload pressures across the healthcare system.

JT added that engagement had been good across West Yorkshire and Harrogate and with the WY Association of Acute Trusts. SO questioned whether greater use of physiotherapists in the MSK pathway might lead to increased demand for the service. MW recognised the need to channel the right people into the right service. CT added that the programme would be learning from work that was already being piloted in Leeds. FSK applauded efforts to involve patients in developing the proposals and emphasised the need to invest in cultural change and changing the conversation with the public if services were to be taken away from some people. HH noted how the work at WY&H level enabled commissioners in each place to share learning and help with the ‘day job’. She proposed an organisational development approach in which each CCG would agree common objectives for commissioning staff relating to work at WY&H level. Members supported this proposal. DK highlighted the need for the programme to acknowledge that some places needed to move at a different pace to others. For example, procurement of MSK services was already underway in North Kirklees. JW added that Wakefield were also reviewing MSK provision and it was important that this was linked to programme work. MW said that these links were already being made. The programme aimed to support a common direction of travel and alignment could only take place over time. AS said that it was about applying best practice to ensure the right approach for each patient within the available resources. JT added that conversations were underway with clinical leads in each place.

The Joint Committee: 1. Noted progress with the Elective Care and SCP programme, the

challenges faced, and the proposed approach to the ongoing development of the programme.

2. Supported a proposal to agree common objectives for CCG commissioning staff relating to work at WY&H level.

AOs

65/18 Partnership Memorandum of Understanding (MoU)

Ian Holmes presented the report. He advised the Joint Committee that during September the Boards/Governing bodies of individual partner organisations and Health and Wellbeing Boards would be asked to approve the MoU for the West Yorkshire and Harrogate Health and Care Partnership at meetings in public. IH explained that the MoU was not a legal document and entailed no changes in the statutory duties of CCGs. It was intended to formalise ways of working across the Partnership. New governance arrangements were proposed to improve transparency and democratic accountability and enable the Partnership to become more self-governing. In response to a question from HH, IH explained that general practice would be represented in the Partnership governance arrangements on both the Partnership Board and the System Leadership Executive. DK emphasised the need for primary care to be represented as providers. GS noted the need for the arrangements to reflect the changing community and primary care provider landscape and for these providers to be involved from the start. FKS asked about non-Executive oversight. IH noted that local authority


Page 4 of 4

Item No. Agenda Item Action members would we involved at place and would sit on the Partnership Board. Acute Trust Chairs would continue to sit on the West Yorkshire Association of Acute Trusts Committees in Common. IH added that the Partnership Board would have a non-Executive Chair. GS felt that greater clarity was needed about the roles of the Partnership and the Integrated Care System (ICS). IH said that they were largely interchangeable. HH noted the need to distinguish between Rob Webster’s role as the ICS executive lead and the non-executive, independent role of Chair of the Partnership Board. JW said that there was scope for the developing arrangements in West Yorkshire and Harrogate to influence national thinking.

The Joint Committee: Noted the MoU and the arrangements for seeking the approval of partner organisations.

66/18 Joint Committee governance

Stephen Gregg presented the report: Public and Patient Involvement (PPI) Assurance To strengthen arrangements for assuring patient and public involvement in the Joint Committee work plan, members had proposed that a PPI Assurance Group be established, building on the work of the Lay Member Assurance Group. The draft terms of reference were attached. HH expressed concern that the scope of the Group’s role as set out in the ToR was too broad, and felt that the limited capacity of Lay members meant that the ToR should have a more specific focus on assurance. This was supported. Risk management framework The Committee reviewed the significant risks to the delivery of the STP objectives covered by the Joint Committee’s work plan. MW questioned whether a more strategic assurance framework was needed to highlight the system level inter-dependencies which affected the Joint Committee’s work plan. The Committee agreed that this should be explored as part of the development of the Partnership’s governance arrangements.

IH/SG

The Joint Committee: 1. Noted the work to date of the Lay Member Assurance Group and agreed

that the Group be reconstituted as the Public and Patient Involvement Assurance Group. Requested that the terms of reference of the Group be amended to strengthen the focus on assurance and be submitted to the next meeting in public for approval.

2. Reviewed the risk management framework and the actions being taken to mitigate the risks identified.

SG

67/18 Any other business

FKS asked members to encourage their Lay members to attend the meeting of the Shadow PPI Assurance Group on 10th September.

Next Joint Committee in public – Tuesday 6th November 2018, Kirkdale Room, Junction 25 Conference Centre, Armytage Road, Brighouse, HD6 1QF.

1























Agenda Item: IFI1ii FOI Exempt: No



Title: EPRR Self-Assessment & Business Continuity Plan

Lead Governing Body Member: Sue Robins, Director of Operational Delivery


appropriate

()

Report Author: Jenny Baines, Operational Commissioning Manager

Decision

Reviewed by EMT/Date:

Discussion

Reviewed by Committee/Date: QPC 14/11/18

Information


Approved by Lead Governing Body member (Y/N):

2

PURPOSE: EPRR Self-Assessment Submitted to the Governing Body as information the self-assessment that the CCG has robust EPRR arrangements. The assurance standard and assessment has been considered and approved by the Quality and Performance Committee on 14th November 2018. CCGs as Category 2 Responders are required to provide assurance to NHS England through the Local Health Resilience Partnership (LHRP) against the core standards for Emergency, Preparedness, Resilience and Response (EPRR). This requires all CCGs to complete the following : 1) Undertake a self-assessment against this year’s core standards confirming the level of compliance for each standard (full, partial or non) (enclosed). 2) Based on the outcome of the self-assessment develop an improvement plan (included in the self-assessment) which includes the actions required to achieve substantial or full compliance. 3) Provide an Annual EPRR Report for the CCG (enclosed). The outcome of the 2018/19 EPRR self-assessment has shown that of the 43 applicable standards, the CCG is : • Fully compliant with 36 of the standards • Partially compliant with 7 of the standards (compliance will be achieved within 12 months) • Non-compliant with 0 of the standards This means that Leeds CCG will declare an overall compliance level of Partial for 2018/19. The EPRR assurance is an annual requirement, in each year there is a different Deep Dive, this year is a spotlight on Command and Control. The enclosed CCG EPRR Annual Report for the period November 2017 – October 2018 sets out: • The CCG’s governance and resource arrangements supporting EPRR • 2018 CCG EPRR self-assessment against the NHS E Core Standards • Progress following the 2017 CCG self-assessment against the Core Standards • Incidents of note • Tests and Exercising, both internally and externally • Training to support the EPRR programme • Details of meetings attended by the CCG to support EPRR. CCG Business Continuity Plan The merger of the three Leeds CCGs into one was the appropriate milestone to redesign the organisation’s Business Continuity arrangements and plan. The previous version was completed in March 2017 when the three individual Leeds CCG business continuity plans were brought together into one document under One Voice

3

arrangements. Since that point there has clearly been a significant change to Leeds CCG estate, organisation and resource structure. The initial approach taken to build this 2018 plan was for each CCG team to complete a Business Impact Assessment (BIA) that :

Identified their team functions, with a view on how long that function could be disrupted before intolerable impact on the organisation.

This process was intended to identify the CCGs Critical Functions.

IT Requirements

Staff requirements

Building and Estates requirements and opportunities

Key dependencies including suppliers and equipment, internal and external. The BIAs informed the creation of the overarching business continuity plan. The business continuity plan comprehensively sets out the appropriate approach to :

Evacuating WIRA House

Contacting all staff in an emergency

Procedures for responding to disruption, namely o Loss of IT and network infrastructure o Loss of buildings and estates o Loss of suppliers, contractors and equipment o Loss of staff

The business continuity plan is a living document with a Work Programme (section 11). This is the responsibility of the CCG EPRR Group.

NEXT STEPS:

Declare an overall compliance level of Partial for 2018/19

RECOMMENDATION: The Governing Body/Committee is asked to:

(a) Receive the EPRR self-assessment assurance and the CCG Business Continuity Plan for information.

Emergency Preparedness Resilience and Response Annual Report

October 2018

1 | Page

Emergency Preparedness, Resilience and

Response Annual Report 2017-18

1. Introduction

1.1 All NHS organisations have a statutory responsibility to ensure they are properly prepared to

deal with an incident or emergency. To provide the NHS system with consistency concerning

the level and expectations regarding their preparedness, NHS England developed the

Emergency Preparedness, Resilience and Response (EPRR) Framework in 2014.

1.2 NHS England requires that the Board is regularly updated on its level of preparedness to deal

with and manage emergency situations or periods of significant disruption to services.

1.3 This report sets out, for the period November 2017 – October 2018:

The CCG’s governance and resource arrangements supporting EPRR

2018 CCG EPRR self-assessment against the NHS E Core Standards

Progress following the 2017 CCG self-assessment against the Core Standards

Incidents of note

Tests and Exercising, both internally and externally

Training to support the EPRR programme

Details of meetings attended by the CCG to support EPRR

2. Governance and Arrangements

Accountable Emergency Officer

2.1 NHS CCG Leeds’ Chief Officer, Phil Corrigan, is the Accountable Emergency Officer with strategic

responsibility for EPRR across the CCG and for providing assurance to the Board that the

organisation meets its statutory and legal requirements.


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EPRR Lead

The Head of the Unplanned Care Team, Debra Taylor-Tate, has responsibility for the EPRR

programme, with a dedicated resource, Jenny Baines, Operational Commissioning Manager

(0.6WTE), responsible for delivery.

EPRR Steering Group

2.2 Supporting the EPRR function for Leeds CCG an EPRR Steering Group has been established. The

remit of this group is communication and joint working across functions and departments

within the CCG to provide assurance of compliance as Category 2 responders under the Civil

Contingencies Act 2004, and delivery of the NHS service wide objective:

To ensure that the NHS is capable of responding to significant incidents or emergencies of any scale in a way

that delivers optimum care and assistance to the victims, that minimises the consequential disruption to

healthcare services and that brings about a speedy return to normal levels of functioning; it will do this by

enhancing its capability to work as part of a multi-agency response across organisational boundaries.

EPRR Framework 2013

See Section 4 below for the Work Plan.

On Call EPRR Arrangements

2.3 All NHS organisations are required to have resilient and dedicated EPRR on-call arrangements

24/7. Throughout the working day the Unplanned Care Team are responsible for participating

in the management of incidents. Out of hours this responsibility falls to the CCG On Call

Manager. There are constantly two CCG managers on call, performing a lead and buddy

arrangement.

3. NHS England Core Standards

3.1. The NHS EPRR Core Standards set out the minimum standards expected of NHS organisations

and providers of NHS funded care with respect to emergency preparedness, resilience and

response within their designated Category.

3.2. The EPRR Core Standards are reviewed and updated annually as lessons are identified following

incidents or testing, or changes to legislation or guidance.

Progress since 2017/18 EPRR Core Standards Self-Assessment


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3.3 Since last year’s assurance process the CCG is able to confirm the following progress:

Risks aligned on DATIX in accordance with the National Risk Register.

Confirmation of CCG roles and responsibilities within citywide Outbreak plans. The

CCG continues to participate in local and regional system outbreak planning.

On Call training has been reviewed and the new structure delivered to On Call

Managers by the Unplanned Care Team.

CCG EPRR Steering Group established with clear Terms of Reference.

2018/19 EPRR Core Standards Self-Assessment

3.4 The CCG was notified on 30th July 2018 of the expectations of the 2017/18 EPRR assurance

process (self assessment enclosed).

3.5 This year’s assurance framework has been split into ten domains:

Governance

Duty to risk assess

Duty to maintain plans

Command and control

Training and exercising

Response

Warning and informing

Cooperation

Business continuity

Chemical Biological Radiological Nuclear (CBRN) and Hazardous Material (HAZMAT)

3.6 As part of the assurance process for 2018/19 NHS Leeds CCG was required to self-assess

against of a total of 43 core standards.

3.7 The 2018/19 EPRR assurance process is far more detailed than previous years. There are

additional standards to address and additional details to consider.

3.8 NHS England acknowledged on a teleconference in August 2018 that the assessment this time

may see organisations either remain within the same level of declaration as 2017/18, and for

some even a lower level, even though they are continuously working to improve their

processes.


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3.9 The outcome of the self-assessment has shown that of the 43 applicable standards, the CCG

is:

Fully compliant with 36 of the standards

Partially compliant with 7 of the standards (compliance will be achieved within 12

months)

Non-compliant with 0 of the standards

3.10 The results of the 2017/18 self-assessment enable the CCG to declare ‘partial

compliance’ to NHS England with respect to its emergency preparedness, resilience and

response.

3.11 The self-assessment was completed by the CCG EPRR Lead and will be submitted to NHS

England prior to the 31st October 2018.

2018/19 EPRR Assurance Deep Dive

3.12 Each year NHS England uses the core standards assurance process to undertake a ‘deep

dive’ look at a specific topic relating to EPRR. This year’s deep dive topic is Command and

Control, the results will not be included in the overall organisational compliance rating.

3.13 As part of the deep dive for 2018/19 NHS Leeds CCG was required to self-assess against 8

core standards.

3.14 The outcome of the deep dive self-assessment has shown that of the 8 applicable standards,

the CCG is :

Fully compliant with 4 of the standards

Partially compliant with 1 of the standards (compliance will be achieved within 12

months)

Non-compliant with 3 of the standards

2018/19 EPRR Core Standards Action Plan

3.15 To accompany the EPRR core standards self-assessment the CCG has to submit an action

plan detailing how it will address the standards for which full compliance has not yet been

achieved.


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3.16 The following themes form the NHS Leeds CCG 2018/19 Action Plan:

Ability to mobilise an Incident Management Team in an Incident Co-ordination Centre

24/7. o Identified location, suitable equipment and resources for example trained loggists.

Confirming how the CCG will deliver its responsibilities at time of infection outbreak,

pandemic or mass casualty situation.

Delivering appropriate EPRR training to (non on call) CCG staff.

4 EPRR Work Programme

4.1 The existing work programme for the CCG EPRR Steering Group will be adjusted to reflect

the outcomes of the EPRR core standards self-assessment.

4.2 In addition, the CCG EPRR Steering Group work programme is currently focussed on:

Developing the CCG Business Continuity Plan response, including a workshop in

September to test three key situations: loss of access to WIRA, loss of staff, loss of IT

infrastructure.

National lessons learned, including recommendations from the Manchester Arena

attack/Kerslake report.

Evaluating and rolling out a CCG staff alert system.

Communication strategy – both internally and externally at the time of an incident, and

recovery.

Confirming the roles and responsibilities of the CCG Incident Management Team, and

the tools to support it.

Participation in a number of local and regional exercises.

Sharing and embedding lessons learned and recommendations following a number of

local incidents including the fire at Becklin Centre LYPFT, the pathology Telepath system

failure in 2016, and exercises including COMAH Exercise White Dove.

CCG EPRR training needs analysis to inform the development of a training package.

4.3 The breadth of EPRR responsibilities is illustrated at Appendix 1.


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5 Other CCG Emergency Preparedness Activities

5.1 Refresh and update the NHS Leeds CCG EPRR Framework and Policy.

5.2 Annual review of the On Call process, support pack and training.

5.3 Review, refresh and streamline CCG documents to support an incident (in or out of hours).

CCG Outbreak Planning Group

5.4 A Leeds CCG Outbreak Planning Group has been formed with the first meeting scheduled for

25th October 2018. The aim of the group will be to confirm the CCG responsibilities and its

response (by function) at a time of Outbreak.

Mutual Aid and Escalation

5.5 The Leeds Operational Pressures Escalation Level (LOPEL) and Mutual Aid Protocol was developed and implemented in 2017. This has been reviewed for 2018/19 and includes the following activities:

Organisations are reviewing their internal triggers and actions.

Development of an agreed Mutual Aid Impact matrix, with the intention of developing impactful and relevant mitigations that will aid timely System recovery, balancing risk across the System at times of pressure.

System wide Decision Management tool to inform critical decisions at times of heightened pressure.

The Operational Winter Group (OWG) has been established, this is a weekly system meeting of all partners to assist system flow over winter.

6 Business Continuity

6.1 Since the three Leeds CCGs merged into the single organisation Leeds CCG has been without a

meaningful Business Continuity Plan (BCP). The CCG EPRR Lead is responsible for developing

the first version of the plan, which will be delivered by 31st October 2018, and tested before the

end of the calendar year.

6.2 Each team has completed a Business Impact Assessment to identify the CCG critical functions,

including IT system and platforms, to be supported as a priority at times of disruption.


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6.3 An EPRR Steering Group workshop in September focussed on arrangements and options at

times of recognised disruption; ie loss of IT and IT Infrastructure, loss of staff due to infection

outbreak and loss of access to WIRA house.

6.4 As a result the CCG are developing Standard Operating Procedures for the critical functions so

that we are able to flex resources at short notice as required to cover our critical functions.

These are currently being developed.

6.5 The BCP will include a full contact list of staff issued mobile phones numbers.

6.6 A staff alert system to send notifications to phones at time of incident has been agreed. We are

now in the process pf scoping options.

7 Incidents

7.1 Over the last 12 months the Leeds CCG has supported the coordination of a range of planned

and unplanned citywide events and incidents.

7.2 These include :

Measles outbreak in Leeds, and subsequent learning

MERS case in Leeds

Fire at The Becklin Centre, LYPFT

Triathlon

Tour de Yorkshire

World Cup planning

2017 Ransomware attack on the NHS

7.3 In addition there have been occurrences of Leeds CCG Business Continuity incidents, including

loss of electricity to WIRA House and IT outages.

8. Tests and Exercises

8.1 The EPRR Core Standards requires that the CCG regularly tests its emergency arrangements

through :

a) A six monthly communications test (ie testing on call or daytime contacts)

b) Annual table top exercise


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c) Live exercise at least once every three years

d) Command post exercise every three years

c and d above were tested in 2016 by Exercise Buffy organised by the CCG.

The CCG has supported and participated in three recent citywide table top exercises.

Exercise INVIERNO – 4th September 2018

8.2 Exercise to test our Escalation and Mutual Aid processes and identify areas for improvement.

8.3 Exercise Invierno was hosted by the CCG Operational Resilience Group, a sub group of the

Leeds System Resilience Assurance Board (SRAB) (A&E Delivery Board).

8.4 The scenario was based upon escalating winter pressures to test and agree citywide

organisation escalation triggers and actions.

8.5 Organisations had been encouraged to revise and refresh their escalation trigger categories

and values, and internal actions, ahead of the exercise.

8.6 This exercise was part of the development of impactful actions across organisations (mutual

aid), whilst sharing risk across the System.

Exercise BEVAN – 13th September 2018

8.7 Whole system exercise to test and validate the processes and arrangements within the Leeds

Outbreak Plan which was signed off by the Health Protection Board in April 2018.

8.8 The exercise was arranged by Leeds City Council and was very well supported with over 40

participants from a range of organisations. The CCG had a dedicated table with representation

from quality, comms, unplanned care and primary care teams.

8.9 The tested scenario was based on diphtheria.

8.10 An Outbreak Control Team (OCT) was set up with representation from each organisation,

and was the focus of the exercise.


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8.11 The debrief document has not yet been received. It will be shared with relevant CCG

colleagues.

8.12 A number of internal actions and lessons for the CCG became apparat as the day

progressed. These actions have been captured by the CCG EPRR Lead in the EPRR Action

Log and will be a driver to the newly formed CCG Outbreak Planning Group. Actions include

:

ensuring appropriate representation at an OCT

creating detailed Action Cards/aide memoire for particular CCG teams

ensuring that Patient Guidance Directives (PDG’s) on Resilience Direct are complete

and up to date

communication with daytime and out of hours Primary Care.

Exercise WHITE DOVE – 9th October 2018

8.13 Exercise White Dove was a city wide multiagency test of the external emergency COMAH

(Control of Major Accident Hazards) plan for UNILEVER Ltd in Seacroft, LS14.

8.14 Due its storage of flammable substances used in the production of deodorants the

UNILEVER factory in Leeds is an Upper Tier site under the COMAH Regulations 2015. This

means it is required to test its external emergency COMAH at least every 3 years. The

Unilever COMAH plan is written by West Yorkshire Fire Service.

8.15 There was a live element at the Unilever site and a Tactical Strategic Group at Leeds City

Council’s Emergency Control which members of the CCG Unplanned Care Team attended

along with a colleague from CCG Comms.

8.16 Other organisations represented were police, fire, YAS, LTHT, LYPFT, Yorkshire Water,

Environment Agency, NHSE.

8.17 The scenario was a fork lift truck loading aerosols in the warehouse curtain-sider bay onto

a double decker trailer pushed a pallet of aerosols off the top deck. This caused a

warehouse fire that spreads rapidly. Employees were missing. Aerosols were exploding.

Smoke plume developed and moved over the local area which is very residential.

8.18 The debrief is scheduled for November 2018 however immediate lessons learned for the

CCG are :


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The importance of being familiar with Resilience Direct, in particular where plans

are held and how to use the mapping element, including how to plot a

radius/cordon around an incident.

The importance of understanding each other’s language (a key principle of JESIP,

Joint Emergency Service Interoperability Principles). There was some confusion

when the fire service applied a cordon around the scene due to risk of explosion.

Health and other partners incorrectly assumed this meant evacuation and started

working towards that.

A reminder that local GP practices will have lists of their vulnerable patients that

may need to be prioritised during an incident.

9. Training

9.2 The Core Standards sets out the need for all staff to be aware of their role during an

emergency.

On Call Training

9.3 The Unplanned Care Team coordinated a survey of all On Call Managers which requested their

comments on the CCG on call arrangements, on call training and content of the support pack.

Feedback from the On Call managers was that :

They were satisfied with on-call email summary sent by the Unplanned Care team

ahead of their on call duty

They were satisfied with how the Unplanned Care team manages the on-call rota

They requested details of previous call examples/scenarios as part of the next round of

training

They requested further information on escalation & incident management

They felt the on-call pack was up to date

9.4 During October 2018 all On Call Managers have been invited to the latest CCG On Call training.

For many performing this duty it will be refresher training.

9.5 The training will confirm their own and the CCG roles and responsibilities during an incident

whether it is a CCG business continuity incident, a critical incident within an organisation or a

system wide major incident, and sets out the documentation that needs to be completed.


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9.6 The training includes real life examples of calls to the On Call manager to illustrate when the

resource is accessed.

Wider CCG Training

9.7 The EPRR Lead and Education and Organisational Development Advisor are evaluating and

scoping appropriate e-learning packages for wider CCG colleagues, particularly around dealing

with security incidents, with priority for reception and other public and patient facing roles.

Loggist Training

9.8 In January 2018 Leeds hosted Public Health led Loggist Training. A number of CCG

colleagues attended this valuable day which set out the mechanics of an incident and

incident management team.

9.9 The 2018/19 EPRR Core Standards sets out the need for an organisation to access trained

loggists 24/7. Leeds CCG currently has around 7 trained loggists but none are on a stand by

or out of hour’s basis.

9.10 On 25th October 2018 the CCG EPRR lead is attending the CCG Workforce and Diversity

Meeting to present a paper that proposes a wider group of CCG colleagues are trained as

loggists in order to be able to implement a ring-round facility if a loggist is ever needed.

9.11 Of note, the CCG has not to date requested or needed a trained loggist out of normal

business hours.

10. External EPRR Meetings

Local Health Resilience Partnership

10.2 The Local Health Resilience Partnership (LHRP) is a strategic forum for organisations in the

local health sector and includes the private and voluntary sector where appropriate.

10.3 The LHRP facilitates health sector preparedness and planning for emergencies at Local

Resilience Forum (LRF) level. It supports the NHS, Public Health England and local authority

representatives on the LRF in their role to represent health sector emergency planning,

resilience and response matters. In West Yorkshire the LRF is led by the Police.


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10.4 Representation at the LHRP is by a CCG Director and was made by the CCG on 18th October

2017 and 15th June 2018.

West Yorkshire Health Resilience Sub Group

10.5 The WY Health Resilience Sub Group is the operational group of the LHRP that undertakes all

health related aspects of the LRF work programme.

10.6 Representation at the Health Resilience Sub Group was made by the CCG EPRR Lead on 14th

February 2018, 27th April 2018, and 12th July 2018.

10.7 NHS England is leading some ongoing work to align and streamline the West Yorkshire LHRP

and Sub Group structure and membership.

Leeds Health and Social Care Resilience Group

10.8 The Leeds Health and Social Care Resilience Group is Local Authority led and sits alongside

the Leeds City Council Leeds Resilience Group. The Health and Social Care Resilience Group

is a forum for communication and joint working across the local health and social care

economy to enhance the planning and resilience of health and social care services in Leeds,

particularly in relation to planned and unplanned incidents and event.

10.9 The Leeds Health and Social Care Resilience Group is co-chaired by the CCG EPRR Lead.

10.10 Representation at the Leeds Health and Social Care Resilience Group was made by the CCG

EPRR Lead on 15th June 2018 and 5th October 2018.

11. Conclusion and Recommendations

11.1 This report has provided an overview of the Leeds CCG EPRR arrangements and structure.

11.2 From April 2018 the NHS Leeds CCG has a dedicated EPRR resource within the Unplanned

Care team, which will enable greater development and improvement in the CCGs

emergency preparedness, resilience and response arrangements, to include business

continuity.


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11.3 For this 2018/19 period the CCG is able to declare ‘partial compliance’ to NHS England

with respect to its EPRR arrangements as assessed against the NHS England Core

Standards.

11.4 The CCG EPRR Steering Group’s work programme will be overseen by the CCG Quality and

Performance Committee.

11.5 The CCG Quality Performance Committee is asked to approve the attached Statement of

Compliance (Appendix 2).

24th October 2018

REPORT AUTHOR

Jenny Baines

Operational Commissioning Manager

Debra Taylor-Tate

Head of Unplanned Care


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Appendix 1 – EPRR Work Programme


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Appendix 2 - Statement of Compliance

Yorkshire and the Humber Local Health Resilience Partnership (LHRP)

Emergency Preparedness, Resilience and Response (EPRR) assurance 2018-

2019

STATEMENT OF COMPLIANCE

NHS Leeds Clinical Commissioning Group has undertaken a self-assessment against required areas of the EPRR Core standards self-assessment tool v1.0 Where areas require further action, NHS Leeds Clinical Commissioning Group will meet with the LHRP to review the attached core standards, associated improvement plan and to agree a process ensuring non-compliant standards are regularly monitored until an agreed level of compliance is reached.

Following self-assessment, the organisation has been assigned as an EPRR

assurance rating of Partial (from the four options in the table below) against the core

standards.


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I confirm that the above level of compliance with the core standards has been

agreed by the organisation’s board / governing body along with the enclosed action

plan and governance deep dive responses.

________________________________________________________________

Signed by the organisation’s Accountable Emergency Officer

____________________________

Date signed

_________________________ ____________________________ ____________________________

Date of Board/governing body meeting

Date presented at Public Board Date published in organisations Annual Report

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NHS LEEDS CCG BUSINESS CONTINUITY PLAN

Version 1.5

October 2018

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Contents 1. Background ................................................................................................................................. 3

2. Introduction .................................................................................................................................. 3

3. Policy Statement ......................................................................................................................... 4

4. Invocation Procedure .................................................................................................................. 4

5. WIRA House Arrangements ........................................................................................................ 5

6. Evacuating WIRA House ............................................................................................................. 6

7. Emergency Contact to all Staff.................................................................................................... 6

8. Procedures for Responding to and Recovery from a Disruptive Incident ................................... 7

8.1 Procedure for Loss of Information Technology (IT) ............................................................. 7

8.2 Procedure for Loss of Buildings and Estates ..................................................................... 11

8.3 Procedure for Loss of Suppliers, Contractors and Equipment .......................................... 12

8.4 Commissioned Services .................................................................................................... 14

8.5 Procedure for Loss of Staff ................................................................................................ 14

9. Business Impact Assessment ................................................................................................... 15

10. Business Critical Functions ....................................................................................................... 16

10.1 Priority A – Business Critical Functions: Same day of incident ....................................... 16

10.2 Priority A – Business Critical Functions: Next working day ............................................. 17

10.3 Priority A – Business Critical Functions: Up to 3 working days ....................................... 18

10.4 Priority B – Business Critical Functions: Up to 1 week .................................................... 19

10.5 Priority C – Business Critical Functions: Up to 2 weeks .................................................. 20

10.6 Priority D – Business Critical Functions: Up to 1 month .................................................. 21

11. CCG Business Continuity Work Programme .................................................................................. 23

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Version 1.5 Issue Date 31st October 2018

Author Jenny Baines, CCG EPRR Lead

Plan Review Date

April 2019

Approved By Approval Date

Document Location

Unplanned Care Team WIRA House

Reception WIRA House

CCG Office, Ashley Wing, LTHT

K Drive : \Leeds_CCG_North\Commissioning and Strategic Development\UNPLANNED

CARE\OPERATIONAL\10. EPRR\Business Continuity\FINAL PLAN

Plan Owner Phil Corrigan, Chief Executive

Business Continuity Executive Manager

Sue Robins, Director of Operational Delivery

Plan Manager Debra Tayor-Tate, Head of Unplanned Care

Change History

Versions 1-1.3 various structure and content updates in preparation of sign-off Version 1.4 - BIA referred to as Business Impact Assessment (not Analysis) Version 1.5 – clarity on IT flow charts and WIRA House estate and lease arrangements

1. Background

Under the Health and Social Care Act 2012 NHS England must be ‘properly prepared for dealing with

an emergency’ and must monitor and control all service providers to make sure they too are prepared.

Under the Civil Contingencies Act (2004) NHS organisations and sub-contractors must show that they

can deal with these incidents while maintaining services to patients. This work is referred to in the

health community as ‘emergency preparedness, resilience and response’ (EPRR).

NHS organisations and providers of NHS funded care must therefore be able to maintain continuous

levels in key services when faced with disruption from identified local risks such as severe weather,

fuel or supply shortages or industrial action.

2. Introduction

This business continuity plan is to be used to assist in the continuity and recovery of Leeds Clinical

Commissioning Group (CCG) in the event of an unplanned disruption. A disruption could be any event

which threatens personnel, buildings or operational capacity and requires special measures to be

taken to restore normal service.

The aim of the plan is to set out the roles, responsibilities and actions to be taken by the CCG to

maintain and/or recover critical functions, reducing adverse impacts so far as is practicable. In the

longer term it will help the CCG to recover and return to “business as usual”.

All Leeds CCG staff will be asked to familiarise themselves with the business continuity arrangements

and recovery procedures. New starters will be made aware of this plan and their potential role during

a disruption as part of the CCG induction process. Any staff with a specific role in the recovery from a

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disruption, or who may be asked to cover another suitable role, will receive appropriate guidance.

Line managers will be responsible for making all staff in their teams aware of the CCG Business

Continuity Plan.

3. Policy Statement

1. The CCG is committed to raising the profile of business continuity planning, and ensuring

robust and effective business continuity planning as a key mechanism in restoring and

delivering continuity of critical functions in the event of a disruption or emergency.

2. The CCG will determine its critical functions. A review of these will be undertaken annually

and this will determine the priority areas for business continuity planning.

3. Each team within the CCG is overseen by a respective Executive Director who will ensure

that they understand, support and implement the elements of the business continuity plan.

4. Each Executive Director will ensure their teams contribute to an annual review of the business

continuity documentation.

5. Contracts for goods and/or services deemed critical to the CCG’s business continuity will aim

to include a requirement for each nominated supplier to provide, for evaluation, a business

continuity plan covering the goods and/or services provided.

6. All CCG staff will be made aware of the plans that affect their teams and functions and their

role following any invocation of the business continuity plan.

7. The CCG will implement a programme of business continuity and incident testing exercises.

4. Invocation Procedure

1. First responder (any staff member identifying an issue) should notify the On Call Manager.

2. The On Call Manager should confirm details of the issue and consider activation of the CCG

Business Continuity Plan.

3. If activation is agreed, then the On Call Manager should notify the Executive Team and

Unplanned Care Team.

4. The On Call Manager or Unplanned Care Team should notify the CCG Incident Management

Team (EPRR Group)

5. The CCG Incident Management Team should coordinate Actions.

6. As above, the CCG Incident Management Team will mobilise contingency plans to support

CCG critical functions as identified through the Business Impact Assessment process

(Appendix 1).

Persons responsible for Activation of the BC Plan On Call Manager 08448 707937 (Option 1 Option 4)

Persons that need to be informed that the BC Plan has been activated

Plan Owners Phil Corrigan 07944 600442 Sue Robins 07825 761558

Executives Visseh Pejhan-Sykes 07956 748873 Dr Simon Stockill 07958 614861 Jo Harding 07785 573930

Head of Health and Care Hub (IT) Nichola Stephens 07786 278040

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Office Management Helen Avery or deputy 07880 480316

Unplanned Care Team Debra Taylor-Tate 07833 294896 Andrew Baines 07557 314849 Jenny Baines 07881 352616

CCG Incident Management Team (EPRR Steering Group)

[email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

5. WIRA House Arrangements

Figure One

NHS Leeds CCG

Office WIRA House

Full address Suites 2-4 WIRA House West Park Ring Road Leeds LS16 6EB

Normally open 07:00 – 19:00 Monday to Friday (excluding Bank Holidays)

Out of hours access to the building Yes – 24 hr access via fob and key pad

Emergency Equipment Labelled tambour unit situated by the Unplanned Care Team desks in Unit B7-B9 WIRA House.

Telephones Internet based telephony system throughout the building.

Building Owner Canmoor Asset Management No day to day contact by the CCG

CCG Landlord

NHS Property Services Anything to do with the lease or legal relationships 01924 351649 0300 303 8590 on call


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NHS Leeds CCG

Site Manager / Security

Savills Manager of all WIRA business park site (not just the CCG Units) 07866 778836

Cleaning contract Consultant Services Group Ltd CSG 01924 409988 07823 526487

In an emergency the quickest route is straight to the Site Manager, with follow up to NHS Property Services.

6. Evacuating WIRA House

During an evacuation, in accordance with CCG Fire Safety Procedure v2.1, leave the building by the

nearest available safe exit route, assisting with the evacuation of all visitors, staff or other relevant

persons. Do not use the lifts. Do not take risks and do not run or panic. Do not delay exit to collect

personal belongings.

Staff are to convene at Assembly Point 2 (CCG allocated parking bays).

Procedures to follow before re-entering after an evacuation are as follows. Do not re-enter the

building until instructed to do so by one of the following persons;

Emergency Service.

Fire Warden

Landlord’s agent or Site Manager

If the evacuation is due to a false alarm and no products of combustion are present (smoke, fumes,

flames etc) it will be the responsibility of the Landlords agent or Site Manager to confirm it is safe to

re-enter the building.

Once the Fire Alarm has been re-set, if any further occurrences re-sound the Alarm, the building must

be evacuated again even if it is believed to be a false alarm.

For false alarms caused by other reasons, for instance dust caused by contractors, if it can be

confirmed that the activation was a false alarm the Fire Warden should contact the Site Management

of the building. Following a fire incident this will be reported on the CCG incident reporting system,

and a notification made to the Competent Person for review.

7. Emergency Contact to all Staff

In the event that the CCG experiences a disruption as a result of severe weather, loss of IT, loss of

building or utilities staff will be alerted by:

1. SMS text message or phone cascade instigated by the On Call Manager to the head of each

team for onward communication to all members of the respective teams. All managers are

required to hold up to date contact details for their team members

2. Workplace by Facebook notification delivered by the Communications and Engagement

Team.

3. Consider convening a CCG wide Skype call as a method of updating.

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8. Procedures for Responding to and Recovery from a

Disruptive Incident

The following sections document the procedures for responding to a disruption or incident including

how the CCG will continue to maintain and/or recover its key activities. A Business Impact

Assessment process across CCG teams has identified critical functions with further details below.

The procedures below aim to reduce the probability, shorten the duration and limit the impact of a

disruption to the CCG.

8.1 Procedure for Loss of Information Technology (IT)

eMBED provides Information Technology (IT) and telephony support to Leeds CCG.

To be notified in the event of complete or partial loss of standard desktop, IT applications and telephony

eMBED 0345 1408000 On Call IT Contact 07786 278040 Local WIRA IT Team 0113 8432923 Office Manager 07880 480316

Information and data essential to the operation of services and functions should always be protected

and recoverable.

CCG activities and functions have a reliance on information communications technology. Many

functions cannot be performed without such systems which will need to be reinstated before the

activities can be resumed. In some cases manual workarounds may have to be implemented while

systems are being reinstated.

Figures Two and Three below should be followed in the event of :

Figure Two: Loss of power to WIRA House affecting desk phones, door fobs, Wi-Fi, power to desks. Figure Three: Loss of server affecting RAS (Remote Access System), drive access, internet.

Information and data might include; clinical systems; supplier and stakeholder details; legal

documents (contracts, insurance policies, deeds etc.); contracts and service level agreements.

All information and data should have appropriate confidentiality; integrity; and availability. The input of

the Information Governance should be sought to ensure that information security requirements are

fully complied with and any queries answered.

During disruption, as a minimum, hourly updates should be provided by eMBED to the On Call

Manager to enable coordination of the CCG response.

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Figure Two Loss of power to WIRA House affecting desk phones, door fobs, Wi-Fi, power to desks.

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Figure Three Loss of server affecting RAS (Remote Access System), drive access, internet.

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Information captured by each team when completing their Business Impact Assessment identified all

of the information communication technology requirements for that team, and the Recovery Time

Objective (RTO) at a time of disruption.

These have then been prioritised in the table below by RTO (Figure Four) to provide ICT technical

support with clear priorities for the reinstatement of the most immediate and urgent requirements.

The devices and applications have been categorised into Priority A, B and C depending on the RTO.

Figure Four CCG IT Requirements

IT Device/Application Department/Team Recovery Time Objective

Alternative

Priority A

Email/NHS Net All 1 hour

Internet access All 1 hour

Laptops with docking stations

All 1 hour

Mobile phone network All 1 hour Desk phones

Priority B

Continuing Care Database Leeds Care Finder

Children’s Case Management Service

Continuing Healthcare

3 hours Staff would need to ring all providers.

K and S Drives All 3 hours Document hard copies

W Drive Continuing Healthcare 3 hours None. All patient and personnel files are stored on W drive.

SQL Server (this is where CCIM is stored and backed up to. All patients records are here)

Continuing Healthcare 3 hours

Remote Access (RAS) 3 hours

N3 Link Health and Care Hub 3 hours

Virgin media line WIRA House (provides access to file and print services, CCG telephony, CCG Door access)

Health and Care Hub 3 hours

Oracle Finance Ledger Finance 4 hours

Priority C

LCC line WIRA House (provides access to LCC Data warehouse and LCC File and Print Services)

Health and Care Hub 24 hours

Datix Clinical Governance 3 days

Microsoft Office All 3 days

ESR HR System Finance 3 days

Skype Health and Care Hub 3 days

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IT Device/Application Department/Team Recovery Time Objective

Alternative

Printing facilities All 3 days

WIRA Desk phones (CCG desk phones are supplied through the internet (VOIP)

All 1 week Mobile phones

Adobe Professional Corporate Governance 1 week

Priority D

Resilience Direct 1 month Emailing documents

IPads Comms and Engagement Team

1 month Laptops

MiFi device Comms and Engagement Team

1 month

8.2 Procedure for Loss of Buildings and Estates

A disruption or incident may cause a partial or complete loss of buildings and work environment.

To be notified in the event of complete or partial loss of access to or use of WIRA House

Office Manager 07880 480316 Site Manager (Savills) 07866 778836

NHS Leeds CCG is a sub-tenant within WIRA House. NHS Property Services rent the building from

Canmoor Asset Management.

The Site Manager/Security (Savills), with follow up to the Landlord (NHS Property Services), is the

most likely primary contact in the event of an incident at the CCG building such as a flood, break-in or

damaged roof. See Figure One in ‘WIRA House Arrangements’ above.

The CCG lease with the landlord (NHS Property Services) requires provision of certain facilities to the

CCG as tenants.

Consideration should be given to displacing staff performing less urgent duties to retain any available

accommodation for staff performing a higher priority function as defined by the CCG Critical Functions

as established in the Business Impact Assessment process.

Alternative accommodation arrangements at times of partial or complete loss of access to WIRA

House, including if it is deemed an unsafe work environment currently include:

Alternative Accommodation 1 Agile/home working

Agile/home working

Alternative Accommodation 2 Merrion House, Leeds City Centre

LCC Merrion House, Merrion Way, Leeds LS2 8BB – 6 desks plus meeting space on 5

th Floor (West).

NHS ID required for entry. Use own laptop. Remote access required and the use the council’s public WiFi to log onto the network.

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Alternative Accommodation 3 Ashley Wing, SJUH

CCG Office at LTHT SJUH Ashley Wing (accomodating approximately 15 across 3 rooms). 10 parking places supplied with the office space.

Alternative Accommodation 4 SPUR

Continuing Healthcare could temporarily relocate to SPUR (Single Point of Urgent Referral)

Alternative Accommodation 5 Rothwell Health Centre

Rothwell Health Centre, Stone Brig Lane, Rothwell, LS26 0UE 7 hot desks available Monday to Friday from 0830hrs to 1800hrs. Remote access not required as connected to network on login. Available on a first come first served basis. Require two door access codes to access on lower ground floor Could be used as an alternative space for 7 colleagues if Wira not available. Arranged via Peter Ainsworth at Leeds Community Health Care Trust by commissioning finance and adult commissioning team.

Alternative Accommodation 6 NHS Bradford Clinical Commissioning Group, Scorex House, Bradford

NHS Bradford Clinical Commissioning Group, Scorex House, 1, Bolton Road, Bradford, BD1 4AS. 01274 237290 (switchboard) 2 hot desks available from 0800hrs-1800hrs Monday –Friday access via reception. Present arrangement made by a Neighbourhood Team member of staff, Commissioning Manager Jamil Rehman.

Action for loss of access to WIRA House for more than 48 hours:

1. Inform all team members of lack of access.

2. Each team member to identify alternative emergency work base (including agile/home

working).

3. Inform key organisations and contacts of access limitations.

4. Team members to continue planned work outside of WIRA house.

5. Identify alternative building to continue planned activities.

6. Cancel activities if unable to find alternative site.

7. Remain accessible by email and mobile phone throughout.

8.3 Procedure for Loss of Suppliers, Contractors and Equipment

CCG activities and functions rely on a range of external suppliers, partners, contractors and providers

of commissioned services to be able to fulfil its obligations, as well as items of equipment, vehicles,

and consumables.

The information captured from the Business Impact Analysis has identified the key suppliers,

partners, contractors and providers of commissioned services on which the activity or function

depends and the equipment, vehicles, and consumables considered essential to service delivery.

CCG teams, through completion of the appropriate procurement procedures should assure

themselves that key suppliers have appropriate business continuity and disaster recovery processes

in place.

The focus should be the suppliers whose failure to deliver would most quickly disrupt services or the

wider health system.

tel:01274237290

tel:01274237290

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Mitigation arrangements might include; alternative and/or increasing sources of supply; arrangements

with suppliers for delivery of replacement stock or provisions at short notice; diversion of deliveries to

alternative locations; storage of additional supplies at other locations; keeping old machinery as

emergency replacement or for spare parts. When considering arrangements, managers need to be

aware that some specialist equipment may be difficult to acquire, or have a long lead time for delivery.

The On Call/Executive Manager may delegate coordination of this type of incident to another named

senior manager. In either case, the named coordinating manager will identify themselves to the

supplier as they key contact within the organisation who should receive updates on the situation from

the supplier in question.

In the event of fuel disruption the CCGs will need to prioritise clinical work areas (such as

Continuing Healthcare assessments) and partner with provider organisations as appropriate to

combine visits to reduce fuel usage. Commitments which involve ‘unnecessary’ travel should be

cancelled (unnecessary to be agreed by Head of Service). All other work should be undertaken

remotely/agile.

Through the Business Impact Analysis process CCG teams have identified key partners and (non IT)

equipment:

Team Key Dependency

Key Dependency 1 All NHS England (Yorkshire & Humber team)

Key Dependency 2 All Wide spectrum of partner health and care providers, including Third Sector and the Independent Sector.

Key Dependency 3 All eMBED

Key Dependency 4 Office Services NHS Property Services & Canmoor

Key Dependency 5 Unplanned Care Team Leeds City Council Resilience and Emergencies Team

Key Dependency 6 System Integration GP Confederation

Key Dependency 7 Finance LTHT Payroll

Key Dependency 8 Finance NHS Shared Business Service

Key Dependency 9 Health and Care Hub Egton Medical Supplies

Key Dependency 10 Health and Care Hub BT for N3 network

Key Dependency 11 Health and Care Hub Virgin Media

Key Dependency 12 Health and Care Hub MJOG for GP Text Messaging

Key Dependency 12 Health and Care Hub Vodafone for mobile telephony

Key Dependency 13 Health and Care Hub Redcentric (HSCN)

Key Dependency 14 Health and Care Hub On line access to RAIDR

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8.4 Commissioned Services

The CCG is required to ensure that the providers and services it is responsible for commissioning are

appropriately resilient; maintaining independent business continuity plans where appropriate whilst

maintaining the ability to respond to any emergency which may affect the population.

This assurance is provided through Contract Management meetings and through the Local Health

Resilience Partnership (LHRP) forum where health organisations are required to declare their

compliance level having self-assessed against the annual NHS England Emergency Preparedness

Resilience and Response (EPRR) core standards; sharing their plans as required.

8.5 Procedure for Loss of Staff

A disruption or incident may cause a temporary loss of staff. During any disruption or incident

causing a temporary loss of staff, managers should meet at regular intervals throughout each day of

the disruption to form a view on staff availability, prioritisation of workload and reacting to any issues

that might arise.

Managers should consider convening an Incident Management Team which may include colleagues

from Human Resources.

Contingency actions to mitigate loss of staff include:

multi-skill training of staff ensuring that more than one person has the skills and knowledge

required to maintain a critical function/s, and

the development of Operating Procedures or contingency plans so that resources may be

flexed at short notice to maintain critical functions.

Measures below should maintain the availability of staff, particularly those staff with core skills and

knowledge.

Continuity arrangements for Severe Weather

The following applies when the On Call Manager or Executive lead has declared invocation of the CCG Severe Weather Policy. Agile working arrangements as agreed locally. Where staff are released early because of severe weather conditions, they will be asked to make up the time or take some work home and make up the hours at some later date. Staff, because of severe weather conditions, who arrive late, but within a reasonable time-span, and who remain at work until the end of the working day will be asked to make up the hours by using flexi-time. Staff who do not attend work due to severe weather will be expected to use annual leave or flex-time to cover the absence.

Absences caused by the urgent need to care for children, elderly or other close relatives whose schools, day centres or other establishments have been closed because of severe weather will be considered under Special Leave Policy.

During severe weather conditions each function and its team needs to maintain contact and regularly update and communicate severe weather warnings/notifications to all staff members. Staff should consider the best way of travelling to and from work in such circumstances.

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Continuity arrangements for Health/Pandemic Outbreak

Contingency plans for critical functions should be developed so that the CCG can flex resources to cover and maintain its critical activities.

Continuity arrangements for Industrial Action

For industrial action, it is important to identify critical services and functions as it might be possible to apply to Trade Unions for an Exemption Notice (a request from the employer requesting Trade Unions to exempt one or more of their members from taking industrial action in order to provide or maintain a service or function considered critical).

9. Business Impact Assessment

The aim of this plan is to reduce the adverse impacts of disruption so far as is practicable. By

focusing on the impact of disruption rather than the cause the process identifies those activities on

which the organisation depends, and that in turn enables the organisation to determine what is

required to continue to meet its obligations.

To this effect, the functions of all CCG teams have been assessed and defined as critical or non-

critical using a Business Impact Assessment (BIA) process. Completed documents as illustration are

found at Appendix 1. This BIA process will be reviewed and updated on an annual basis. The impacts

considered included:

Reputational impact

Financial loss

Breach of statutory duty

Impact on safety of patients, staff, public

Impact on quality/ complaints/ audit

Staffing and culture (poor morale)

The table below outlines the process of determining Leeds CCG’s critical services and their order of

recovery priority. All departments assessed each of their activities using the following criteria.

Priority Rating

Maximum Tolerable Period of Disruption

Impact

A

Up to next working day CCG activities, which if disrupted, would have catastrophic effects on Leeds CCG’s business almost immediately.

Up to 3 days

B Up to 1 week CCG activities, which if disrupted, would have major impact on Leeds CCG’s business and may be scaled back for up to a week.

C Up to 2 weeks CCG activities, which if disrupted, would have moderate impact on Leeds CCG’s business and may be scaled back for 2 weeks.

D Up to and over 1 month CCG activities, which if disrupted, would have negligible impact on Leeds CCG’s business for longer than a month.

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10. Business Critical Functions

These are processes and activities which, if interrupted, will jeopardise the continued existence of the

organisation, or cause the business or organisation to sustain a severe economic loss, or whose loss

would cause an adverse outcome for patients.

Leeds CCG’s Business Critical Functions are derived from the BIA and are listed below in order of

Recovery Time Objectives.

Due to the nature of CCG business, the order of recovery may vary as the criticality of certain

activities differs depending on the time of the year, for instance financial cycles or winter

pressures.

Figure Five Business Critical Functions RTO = Recovery Time Objective

MTPOD = Maximum Tolerable Period of Disruption

10.1 Priority A – Business Critical Functions: Same day of incident

The outcome of the Business Impact Assessment process has been to identify the following activities

as critical:

Department/ Team

Activity RTO MTPOD

Unplanned Care

Supporting the On Call function and coordinating the Incident Management Team in the event of an EPRR (Emergency Preparedness, Resilience and

Response) or BC (Business Continuity) incident

4 hours 1 day

Unplanned Care

Responding to operational issues in providers which may impact service delivery to patients

4 hours 1 day


Fast track referrals for end of life care 4 hours 1 day

Health & Care Hub (Information Management & Technology IM&T)

Delivery of a CCG IT Service from WIRA House 4 hours 1 day

Health & Care Hub (IM&T)

Provision of a CCG IT remote working solution for CCG staff

4 hours 4 hours


Delivery of a GP IT Service to GP Practices in Leeds

4 hours 1 day

Continuing Care Receipt and authorisation of Fast Track referrals 4 hours 4 hours

Continuing Care Sourcing of care for patients meeting the eligibility criteria for Fast Track for continuing care.

4 hours 1 day

Neighbourhood Care commissioning team

Responding to operational issues in community care bed providers which may impact service delivery to patients.

4 hours 1 day

Safeguarding Team

Clear line of accountability for safeguarding and overall leadership responsibility for the organisations safeguarding arrangements

4 hours 1 day

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Department/ Team

Activity RTO MTPOD

Safeguarding Team

Ensuring effective arrangements for information sharing

4 hours 1 day

Safeguarding Team

Providing support and advice to staff in regards safeguarding as part of commissioning of services

4 hours 1 day

Primary Care Commissioning and Contracting

Communication and engagement with practices. 4 hours 1 day

Office Services Reception – first point of contact at the CCG 4 hours 1 day

10.2 Priority A – Business Critical Functions: Next working day

Department/ Team

Activity RTO MTPOD

Unplanned Care

Year round System Resilience management, to include oversight of operational delivery

1 day 1 week

Unplanned Care

Management of EPRR and Business Continuity issues, policies, guidance

1 day 1 week

Finance Payment of Suppliers 1 day 3 days

Finance Payment of Staff 1 day 3 days


Data Quality Support to GP Practices 1 day 3 days


GP Information Governance support 1 day 3 days


CCG Business Intelligence 1 day 1 month


Analytical support for a City Emergency (public health/disease outbreak)

1 day 1 day

Continuing Care Receipt and assessment of continuing care referrals that screen in for assessment

1 day 1 day

Contracting

Negotiation of contract terms, ensuring that the contents are fit for purpose and all parties agree, and that quality and performance requirements are defined clearly.

1 day

1 week MT is dependence on the position in the contracting cycle.

Contracting Lead on procurement exercises for the provision of services in line with procurement law.

1 day 1 week

Quality and Safety

Act as the coordinating team where concerns regarding quality of services are raised in providers eg. Hospital, care homes.

1 day 3 days

Safeguarding Team

Effective inter agency working with local authorities, the police and third sector organisations to ensure children and adults are safeguarded from abuse.

1 day 1 day

Safeguarding Team

Working with provider organisations and independent contractors across the health economy on behalf of the CCG to ensure safeguarding arrangements are in place.

1 day 3 days

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Department/ Team

Activity RTO MTPOD

Communications and Engagement

Maintaining and enhancing the CCG’s reputation amongst its stakeholders to include briefings for elective members/MPs, briefings for senior external and internal stakeholders, proactive and reactive media management and monitoring, proactive management and monitoring of social media.

1 day 2 days


Internal communications and engagement (CCG staff and members)

1 day 1 week


Developing and delivering health awareness and signposting campaigns.

1 day

2 weeks Dependant on any time critical campaigns


Quality assurance to include; monitoring quality indicators, monitoring and responding to patients queries/experience issues, acting on soft intelligence, acting on CQC reports, acting on complaints/significant incidents.

1 day 1 week


Contracting and Governance. Dealing with operational management of the delegated responsibilities relating to primary medical services. Issuing practice payments and approving invoices.

1 day 1 week


Service delivery and procurement. 1 day 1 week

Office Services

Reception – CCG support function, to include meeting room bookings, car parking arrangements, raising and receiving of stock orders and post, raising maintenance requests.

1 day 3 days

Proactive Care Contracting and governance. Responding to operational issues relating to commissioned services.

1 day 1 week

10.3 Priority A – Business Critical Functions: Up to 3 working days

Department/ Team

Activity RTO MTPOD

Finance Monthly Reporting to NHS England 3 days (Depending on financial deadlines)

1 week

Finance Monthly reporting to Internal Budget holders and Board

3 days 1 week


Engaging with patients, the public, healthcare professionals and other stakeholders.

3 days 1 week

Clinical Governance

Serious incident process 3 days 2 weeks

Clinical Governance

Incident management reporting and lead on overview of GP incidents reported.

3 days 2 weeks

Clinical Governance

Manage the CCG complaints process 3 days 1 week

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Department/ Team

Activity RTO MTPOD


Support patient risk stratification tool (RAIDR) 3 days 2 weeks


Citywide Analytical Service – population, public, geographical, service analysis and evaluation

3 days 2 weeks


Citywide Analytical Service – to inform GP Practice payments and support national health audits

3 days 2 weeks

Continuing Care Payment of invoices relating to care 3 days 1 week

Contracting Development and preparation of contracts for the provision of health care services and care support services.

3 days

1 week The MT is dependent on the position in

the contracting cycle.

Contracting

Work with commissioning, quality, governance, information and finance colleagues to manage providers and ensure that the contract terms and conditions are adhered to.

3 days 1 week.

Quality and Safety

Supporting the CCG in its responsibilities to ensure that commissioned services are safe, effective, and provide a positive patient experience.

3 days 1 week

Children and Maternity Commissioning Team

Responding to queries about detail regarding children and maternity services (internal and external)

3 days 1 week

Proactive Care Service delivery and procurement. Communication with strategic partners. Procurement activities. Responding to queries.

3 days 1 week

Planning and Performance Reporting

Performance reporting 3 days 1 week

10.4 Priority B – Business Critical Functions: Up to 1 week

Department/ Team

Activity RTO MTPOD


Referrals for continuing care assessment 1 week 1 week

Corporate Governance

Management of Public Governing Body & Primary Care Commissioning Committee

1 week 1 month

Continuing Care Provision of occupational therapy assessment and equipment

1 week 2 weeks

Continuing Care Investigation to response of appeals 1 week 2 weeks

Continuing Care Undertake reviews of previously assessed patients and review other area patients in our area on request.

1 week 2 weeks

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Department/ Team

Activity RTO MTPOD

Neighbourhood Care commissioning team

Strategic design, planning and delivery of high quality and accessible; specialist and general adult community services, palliative care, community care beds

1 week 1 month

Quality and Safety

Lead in specification and of quality standards for directly commissioned services and the quality monitoring of commissioned providers

1 week 1 week

Quality and Safety

Lead in the ongoing review and triangulation of information and assurance in relation to clinical quality performance in provider organisations.

1 week 1 week

Quality and Safety

Coordinate and manage provider Quality Assurance processes and mechanisms

1 week 1week


Responding to complaints, IFT, CETR and FOI requests

1 week 2 weeks

Safeguarding Team

Ensuring staff receive training in recognising and reporting safeguarding issues, appropriate supervision is in place and staff are competent to carry out their responsibilities for safeguarding

1 week 1 month

Office Services Support function to Executive Directors 1 week 2 weeks


Programme management of Commissioning for Value Programme

1 week 2 weeks


Strategic leads for the Health and Care Plan 1 week 2 weeks

Finance Annual reporting

1 week (more critical If falls on or near 20

th

working day in April)

The activities below are non-critical and consideration will be given to:

Not recovering these activities until critical activities have been resumed

Suspending these activities and diverting their resources to support the critical ones.

10.5 Priority C – Business Critical Functions: Up to 2 weeks

Department/ Team

Activity RTO MTPOD

System Integration

Role of instigator/secretariat for the Provider Partnership Board & Clinical Strategy Group and Task & Finish Groups

2 weeks Over 1 month

System Integration

Development of GP Confederation 2 weeks Over 1 month

System Integration

Development of outcomes commissioning 2 weeks Over 1 month

System Integration

Development of Local Care Partnerships 2 weeks Over 1 month

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Department/ Team

Activity RTO MTPOD


Development of Personal Health Budgets 2 weeks 2 weeks


Discharge of children with complex health needs 2 weeks 2 weeks

Planned Care & Long Term Conditions

Management of the Funding Request Processes 2 weeks 6 weeks

Unplanned Care

Strategic design, planning and delivery of high quality and accessible urgent care for the Leeds health and care economy

2 weeks 1 month

Clinical Governance.

Clinical governance. Supporting the wider quality improvement agenda, providing assurance to the governing body.

2 weeks 2 weeks

Clinical Governance

Assurance around Patient Experience framework, systems, information and action.

2 weeks 1 month

Clinical Governance

Responsibility for the Datix system (risk and incidents)

2 weeks 2 weeks

Quality and Safety

Interpretation and implementation of policies and initiatives driven by central NHS guidance, or local prioritisation

2 weeks 2 weeks

Continuing Care Assessment of referrals that screen in for Funded Nursing Care assessment.

2 weeks 2 weeks

Proactive Care Management of networks/partnership working/strategic lead.

2 weeks 1 month


Operational and Strategic Planning. Coordination of business planning processes.

2 weeks 1 month

10.6 Priority D – Business Critical Functions: Up to 1 month

The Business Impact Assessment identifies functions that are less critical and could be suspended for

a period greater than 1 month.

Department/ Team

Activity RTO MTPOD

Corporate Governance

Coordination of Subject Access Requests 1 month 1 month


Commissioning of all outpatient, elective and day care services across hospital and AQP (Any Qualified Provider) settings (Independent Sector and NHS)

1 month 6 weeks


Commissioning of pathways for patients with long term conditions

1 month 6 weeks


Commissioning of pathways for patients with stroke and neurological conditions

1 month 6 weeks

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Department/ Team

Activity RTO MTPOD


Commissioning of children’s services and maternity care

1 month 6 weeks

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11. CCG Business Continuity Work Programme

Work Area

Project Position Action Required Driver Contacts Update

EPRR

Business Continuity

The CCG has identified its CCG critical functions and now needs operating procedures in place for colleagues to be able to support those critical functions.

Development of short operating procedures to enable short notice flexing of resources at times of disruption.

Best Practice. EPRR BC Workshop.

EPRR Steering Group

EPRR Business Continuity

The CCG does not have a single organisation wide method of contacting all staff at short notice.

EPRR Leads to test internal team communications or notifications (text or WhatsApp).

Best Practice EPRR Steering Group


The CCG does not have a single organisation wide method of contacting all staff at short notice.

Small focus group to implement Everbridge as an alert system within the CCG.

NHS England EPRR Core Standards

Group within the EPRR Steering Group


Leeds CCG business continuity plan brings together information supplied by all CCG teams.

EPRR leads to quality assure the whole plan, particularly in relation to information regarding their own team.



The business continuity plan has plans on what to do with a loss of use of WIRA House, and how to evacuate.

Plan should include maps with directions and floor plans as an appendix.

Best Practice EPRR Lead Office Manager


The majority of teams within the CCG have undertaken a Business Impact Assessment to identify key activities and requirements.

Consider whether BIAs are required from Med Opt Confederation & Primary Care Development Both teams may be relocating out of WIRA.

Complete business continuity planning.

EPRR Lead Med Opt and Primary Care contacts


The majority of teams within the CCG have undertaken a Business Impact Assessment to identify key activities and requirements.

Liaise with teams below for outstanding BIAs: 1. Mental Health & Learning

Disability. 2. Med Optimisation. 3. People & Organisational

Development.


EPRR Lead and specific EPRR Steering Group contacts


The CCG On-Call number is the go-to number for reporting any incidents that

Circulate On-Call number to all staff Best Practice EPRR Steering Group

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Work Area


may impact the organisation and/or require invocation of the business continuity plan.


Leeds CCG is situated in a rented building, sharing the space with other (non health) companies.

Establish whether Savile’s (landlord) have any contingencies or responsibility to rehouse CCG in the event of a long-term facilities issue.


Office Manager


A contingency within the ‘loss of power at WIRA /IT’ element of the business continuity plan is the use of MiFi’s.

Ensure staff awareness of and how to operate a ‘MiFi’. Confirm whether ‘tethering’ to work phones is supported at times of disruption, and raise awareness if so.


IT EPRR Lead


Agile or remote working at times of loss of building access or severe weather is dependent on staff having their laptops.

Executive Management Team to consider a policy that staff must take their laptops home at the end of every day.

Best Practice

EPRR Lead Head of Commissioning


The business continuity plan provides information on how to respond in the event of disruption.

Include specific scenario action cards in the business continuity plan as aide memoires.

Best Practice

EPRR Lead (ref Stafford and St Helen’s in EPRR BC file)


The business continuity plan includes contact details for a small number of critical individuals to inform in the event of invocation. CCG is in the process of rolling out work mobile phones to all staff across the organisation.

Business continuity plan to include a ‘Key contact list’, to consist of: Name Role/Responsibility Office Number Mobile Number Email Address

Best Practice IT EPRR Lead


Awareness of the business continuity plan is limited to those that have participated in its development and/or the CCG EPRR Steering Group.

Raise the profile of the plan via Workplace by Facebook, the staff bulletin and the Extranet. Staff to be encouraged to familiarise


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Work Area


themselves with the plan. Plan to be Bc awareness training resilience direct


Business Continuity Plan is retained on Resilience Direct

Ensure all On Call managers are aware and have appropriate access to Resilience Direct.

Best Practice EPRR Lead


The CCG has not recently tested its business continuity arrangements.

The CCG should rehearse a full scale activation of its business continuity plan.


EPRR Steering Group


The CCG relies upon internet based telephony (desk phones) and mobile phones.

The CCG should consider an analogue phone within its designated incident room in case the internet telephony fails for a prolonged period.


EPRR Lead

Please select type of organisation: 12

Core Standards

Total

standards

applicable

Fully compliantPartially

compliantNon compliant Overall assessment: Partially compliant

Governance 6 6 0 0

Duty to risk assess 2 2 0 0

Duty to maintain plans 9 6 3 0

Command and control 2 2 0 0

Training and exercising 3 2 1 0

Response 5 3 2 0 Instructions:

Warning and informing 3 3 0 0 Step 1: Select the type of organisation from the drop-down at the top of this page

Cooperation 4 3 1 0 Step 2: Complete the Self-Assessment RAG in the 'EPRR Core Standards' tab

Business Continuity 9 9 0 0 Step 3: Complete the Self-Assessment RAG in the 'Deep dive' tab

CBRN 0 0 0 0 Step 4: Ambulance providers only: Complete the Self-Assessment in the 'Interoperable capabilities' tab

Total 43 36 7 0 Step 5: Click the 'Produce Action Plan' button below

Deep Dive

Total

standards

applicable


compliantNon compliant

Incident Coordination Centres 4 0 1 3

Command structures 4 4 0 0

Total 8 4 1 3

Interoperable capabilities

Total

standards

applicable


compliantNon compliant

MTFA 28 0 0 0

HART 33 0 0 0

CBRN 32 0 0 0

MassCas 11 0 0 0

C2 36 0 0 0

JESIP 23 0 0 0

Total 163 0 0 0

Clinical Commissioning Group

Interoperable capabilities: Self-assessment not started

Ref Domain Standard DetailClinical

Commissionin

g Group

Evidence - examples listed below

1 Governance Appointed AEO

The organisation has appointed an Accountable Emergency Officer (AEO)

responsible for Emergency Preparedness Resilience and Response (EPRR). This

individual should be a board level director, and have the appropriate authority,

resources and budget to direct the EPRR portfolio.

A non-executive board member, or suitable alternative, should be identified to

support them in this role.

Y

• Name and role of appointed individual

2 Governance EPRR Policy Statement

The organisation has an overarching EPRR policy statement.

This should take into account the organisation’s:

• Business objectives and processes

• Key suppliers and contractual arrangements

• Risk assessment(s)

• Functions and / or organisation, structural and staff changes.

The policy should:

• Have a review schedule and version control

• Use unambiguous terminology

• Identify those responsible for making sure the policies and arrangements are

updated, distributed and regularly tested

• Include references to other sources of information and supporting documentation.

Y

Evidence of an up to date EPRR policy statement that includes:

• Resourcing commitment

• Access to funds

• Commitment to Emergency Planning, Business Continuity, Training, Exercising etc.

3 Governance EPRR board reports

The Chief Executive Officer / Clinical Commissioning Group Accountable Officer

ensures that the Accountable Emergency Officer discharges their responsibilities to

provide EPRR reports to the Board / Governing Body, no less frequently than

annually.

These reports should be taken to a public board, and as a minimum, include an

overview on:

• training and exercises undertaken by the organisation

• business continuity, critical incidents and major incidents

• the organisation's position in relation to the NHS England EPRR assurance

process.

Y

• Public Board meeting minutes

• Evidence of presenting the results of the annual EPRR assurance process to the

Public Board

4 Governance EPRR work programme

The organisation has an annual EPRR work programme, informed by lessons

identified from:

• incidents and exercises

• identified risks

• outcomes from assurance processes.

Y

• Process explicitly described within the EPRR policy statement

• Annual work plan

5 Governance EPRR Resource

The Board / Governing Body is satisfied that the organisation has sufficient and

appropriate resource, proportionate to its size, to ensure it can fully discharge its

EPRR duties.Y

• EPRR Policy identifies resources required to fulfill EPRR function; policy has been

signed off by the organisation's Board

• Assessment of role / resources

• Role description of EPRR Staff

• Organisation structure chart

• Internal Governance process chart including EPRR group

6 GovernanceContinuous improvement

process

The organisation has clearly defined processes for capturing learning from incidents

and exercises to inform the development of future EPRR arrangements. Y


7 Duty to risk assess Risk assessment

The organisation has a process in place to regularly assess the risks to the

population it serves. This process should consider community and national risk

registers.

Y

• Evidence that EPRR risks are regularly considered and recorded

• Evidence that EPRR risks are represented and recorded on the organisations

corporate risk register

8 Duty to risk assess Risk Management

The organisation has a robust method of reporting, recording, monitoring and

escalating EPRR risks. Y

• EPRR risks are considered in the organisation's risk management policy

• Reference to EPRR risk management in the organisation's EPRR policy document

9 Duty to maintain plans Collaborative planning

Plans have been developed in collaboration with partners and service providers to

ensure the whole patient pathway is considered.

Y

Partners consulted with as part of the planning process are demonstrable in

planning arrangements

11 Duty to maintain plans Critical incident

In line with current guidance and legislation, the organisation has effective

arrangements in place to respond to a critical incident (as per the EPRR

Framework).

Y

Arrangements should be:

• current

• in line with current national guidance

• in line with risk assessment

• tested regularly

• signed off by the appropriate mechanism

• shared appropriately with those required to use them

• outline any equipment requirements

• outline any staff training required

12 Duty to maintain plans Major incident


arrangements in place to respond to a major incident (as per the EPRR

Framework).

Y


• current








13 Duty to maintain plans Heatwave


arrangements in place to respond to the impacts of heat wave on the population the

organisation serves and its staff.

Y


• current








14 Duty to maintain plans Cold weather


arrangements in place to respond to the impacts of snow and cold weather (not

internal business continuity) on the population the organisation serves.

Y


• current








15 Duty to maintain plans Pandemic influenza


arrangements in place to respond to pandemic influenza as described in the

National Risk Register.

Y


• current








16 Duty to maintain plans Infectious disease


arrangements in place to respond to an infectious disease outbreak within the

organisation or the community it serves, covering a range of diseases including Viral

Haemorrhagic Fever. These arrangements should be made in conjunction with

Infection Control teams; including supply of adequate FFP3. Y


• current








18 Duty to maintain plans Mass Casualty - surge


arrangements in place to respond to mass casualties. For an acute receiving

hospital this should incorporate arrangements to increase capacity by 10% in 6

hours and 20% in 12 hours.

Y


• current








20 Duty to maintain plans Shelter and evacuation


arrangements in place to place to shelter and / or evacuate patients, staff and

visitors. This should include arrangements to perform a whole site shelter and / or

evacuation.

Y


• current








24 Command and control On call mechanism

A resilient and dedicated EPRR on call mechanism in place 24 / 7 to receive

notifications relating to business continuity incidents, critical incidents and major

incidents.

This should provide the facility to respond or escalate notifications to an executive

level.

Y


• On call Standards and expectations are set out

• Include 24 hour arrangements for alerting managers and other key staff.

25 Command and control Trained on call staff

On call staff are trained and competent to perform their role, and are in a position of

delegated authority on behalf on the Chief Executive Officer / Clinical

Commissioning Group Accountable Officer.

The identified individual:

• Should be trained according to the NHS England EPRR competencies (National

Occupational Standards)

• Can determine whether a critical, major or business continuity incident has

occurred

• Has a specific process to adopt during the decision making

• Is aware who should be consulted and informed during decision making

• Should ensure appropriate records are maintained throughout.

Y


26 Training and exercising EPRR Training

The organisation carries out training in line with a training needs analysis to ensure

staff are competent in their role; training records are kept to demonstrate this.

Y


• Evidence of a training needs analysis

• Training records for all staff on call and those performing a role within the ICC

• Training materials

• Evidence of personal training and exercising portfolios for key staff

27 Training and exercisingEPRR exercising and testing

programme

The organisation has an exercising and testing programme to safely test major

incident, critical incident and business continuity response arrangements.

Organisations should meet the following exercising and testing requirements:

• a six-monthly communications test

• annual table top exercise

• live exercise at least once every three years

• command post exercise every three years.

The exercising programme must:

• identify exercises relevant to local risks

• meet the needs of the organisation type and stakeholders

• ensure warning and informing arrangements are effective.

Lessons identified must be captured, recorded and acted upon as part of continuous

improvement.

Y

• Exercising Schedule

• Evidence of post exercise reports and embedding learning

28 Training and exercisingStrategic and tactical

responder training

Strategic and tactical responders must maintain a continuous personal development

portfolio demonstrating training in accordance with the National Occupational

Standards, and / or incident / exercise participation

Y

• Training records

• Evidence of personal training and exercising portfolios for key staff

30 ResponseIncident Co-ordination Centre

(ICC)

The organisation has a preidentified an Incident Co-ordination Centre (ICC) and

alternative fall-back location.

Both locations should be tested and exercised to ensure they are fit for purpose, and

supported with documentation for its activation and operation.

Y

• Documented processes for establishing an ICC

• Maps and diagrams

• A testing schedule

• A training schedule

• Pre identified roles and responsibilities, with action cards

• Demonstration ICC location is resilient to loss of utilities, including

telecommunications, and external hazards

31 ResponseAccess to planning

arrangements

Version controlled, hard copies of all response arrangements are available to staff at

all times. Staff should be aware of where they are stored; they should be easily

accessible.

Y

Planning arrangements are easily accessible - both electronically and hard copies

32 ResponseManagement of business

continuity incidents

The organisations incident response arrangements encompass the management of

business continuity incidents. Y

• Business Continuity Response plans

33 Response Loggist

The organisation has 24 hour access to a trained loggist(s) to ensure decisions are

recorded during business continuity incidents, critical incidents and major incidents.

Y

• Documented processes for accessing and utilising loggists


34 Response Situation Reports

The organisation has processes in place for receiving, completing, authorising and

submitting situation reports (SitReps) and briefings during the response to business

continuity incidents, critical incidents and major incidents.

Y

• Documented processes for completing, signing off and submitting SitReps

• Evidence of testing and exercising

37 Warning and informingCommunication with partners

and stakeholders

The organisation has arrangements to communicate with partners and stakeholder

organisations during and after a major incident, critical incident or business

continuity incident.

Y

• Have emergency communications response arrangements in place

• Social Media Policy specifying advice to staff on appropriate use of personal social

media accounts whilst the organisation is in incident response

• Using lessons identified from previous major incidents to inform the development of

future incident response communications

• Having a systematic process for tracking information flows and logging information

requests and being able to deal with multiple requests for information as part of

normal business processes

• Being able to demonstrate that publication of plans and assessments is part of a

joined-up communications strategy and part of your organisation's warning and

informing work

38 Warning and informing Warning and informing

The organisation has processes for warning and informing the public and staff

during major incidents, critical incidents or business continuity incidents.

Y


• Be able to demonstrate consideration of target audience when publishing materials

(including staff, public and other agencies)

• Communicating with the public to encourage and empower the community to help

themselves in an emergency in a way which compliments the response of

responders



• Setting up protocols with the media for warning and informing

39 Warning and informing Media strategy

The organisation has a media strategy to enable communication with the public.

This includes identification of and access to a trained media spokespeople able to

represent the organisation to the media at all times.

Y




• Setting up protocols with the media for warning and informing

• Having an agreed media strategy which identifies and trains key staff in dealing

with the media including nominating spokespeople and 'talking heads'

40 Cooperation LRHP attendance

The Accountable Emergency Officer, or an appropriate director, attends (no less

than 75%) of Local Health Resilience Partnership (LHRP) meetings per annum. Y

• Minutes of meetings

41 Cooperation LRF / BRF attendance

The organisation participates in, contributes to or is adequately represented at Local

Resilience Forum (LRF) or Borough Resilience Forum (BRF), demonstrating

engagement and co-operation with other responders.

Y

• Minutes of meetings

• Governance agreement if the organisation is represented

42 Cooperation Mutual aid arrangements

The organisation has agreed mutual aid arrangements in place outlining the process

for requesting, co-ordinating and maintaining resource eg staff, equipment, services

and supplies.

These arrangements may be formal and should include the process for requesting

Military Aid to Civil Authorities (MACA).

Y

• Detailed documentation on the process for requesting, receiving and managing

mutual aid requests

• Signed mutual aid agreements where appropriate

46 Cooperation Information sharing

The organisation has an agreed protocol(s) for sharing appropriate information with

stakeholders.

Y

• Documented and signed information sharing protocol

• Evidence relevant guidance has been considered, e.g. Freedom of Information Act

2000, General Data Protection Regulation and the Civil Contingencies Act 2004 ‘duty

to communicate with the public’.

47 Business Continuity BC policy statementThe organisation has in place a policy statement of intent to undertake Business

Continuity Management System (BCMS).Y

Demonstrable a statement of intent outlining that they will undertake BC - Policy

Statement

48 Business Continuity BCMS scope and objectives

The organisation has established the scope and objectives of the BCMS, specifying

the risk management process and how this will be documented.

Y

BCMS should detail:

• Scope e.g. key products and services within the scope and exclusions from the

scope

• Objectives of the system

• The requirement to undertake BC e.g. Statutory, Regulatory and contractual duties

• Specific roles within the BCMS including responsibilities, competencies and

authorities.

• The risk management processes for the organisation i.e. how risk will be assessed

and documented (e.g. Risk Register), the acceptable level of risk and risk review

and monitoring process

• Resource requirements

• Communications strategy with all staff to ensure they are aware of their roles

• Stakeholders

49 Business Continuity Business Impact Assessment

The organisation annually assesses and documents the impact of disruption to its

services through Business Impact Analysis(s).

Y

Documented process on how BIA will be conducted, including:

• the method to be used

• the frequency of review

• how the information will be used to inform planning

• how RA is used to support.

50 Business ContinuityData Protection and Security

Toolkit

Organisation's IT department certify that they are compliant with the Data Protection

and Security Toolkit on an annual basis. Y

Statement of compliance

51 Business Continuity Business Continuity Plans

The organisation has established business continuity plans for the management of

incidents. Detailing how it will respond, recover and manage its services during

disruptions to:

• people

• information and data

• premises

• suppliers and contractors

• IT and infrastructure

These plans will be updated regularly (at a minimum annually), or following

organisational change.

Y

• Documented evidence that as a minimum the BCP checklist is covered by the

various plans of the organisation

52 Business ContinuityBCMS monitoring and

evaluation

The organisation's BCMS is monitored, measured and evaluated against the Key

Performance Indicators. Reports on these and the outcome of any exercises, and

status of any corrective action are annually reported to the board. Y

• EPRR policy document or stand alone Business continuity policy

• Board papers

53 Business Continuity BC audit

The organisation has a process for internal audit, and outcomes are included in the

report to the board. Y


• Board papers

• Audit reports

54 Business ContinuityBCMS continuous

improvement process

There is a process in place to assess and take corrective action to ensure continual

improvement to the BCMS.

Y


• Board papers

• Action plans

55 Business ContinuityAssurance of commissioned

providers / suppliers BCPs

The organisation has in place a system to assess the business continuity plans of

commissioned providers or suppliers; and are assured that these providers

arrangements work with their own. Y


• Provider/supplier assurance framework

• Provider/supplier business continuity arrangements

Ref Domain Standard DetailClinical

Commissionin

g Group

Evidence - examples listed below

Self assessment RAG

Red = Not compliant with core standard. In line

with the organisation’s EPRR work

programme, compliance will not be reached

within the next 12 months.

Amber = Not compliant with core standard. The

organisation’s EPRR work programme

demonstrates evidence of progress and an

action plan to achieve full compliance within

the next 12 months.

Green = Fully compliant with core standard.

Action to be taken Lead Timescale Comments

Deep Dive - Command and control

Domain: Incident Coordination Centres

1 Incident Coordination CentresCommunication and IT

equipment The organisation has equipped their ICC with suitable and resilient

communications and IT equipment in line with NHS England

Resilient Telecommunications Guidance.

Y Non compliant

ICC identified. All IT and telephony equipment

currently is VOIP. Resilience to be tested in

line with NHS E

ResilienceTelecommunications Guidance. No

landline phone via copper wiring.

Jenny Baines 30/06/2019

2 Incident Coordination Centres Resilience The organisation has the ability to establish an ICC (24/7) and

maintains a state of organisational readiness at all times.Y

Up to date training records of staff able to

resource an ICC

Non compliant

There are two managers on call at any one

time. Other critical members to a CCG ICC are

not on call and not able to be mobilised 24/7, ie

Unplanned Care, Communications, Primary

Care Team, Medicine Optimisation.


3 Incident Coordination Centres Equipment testing

ICC equipment has been tested every three months as a minimum

to ensure functionality, and corrective action taken where

necessary.

Y

Post test reports

Lessons identified

EPRR programme

Non compliant

Once appropriate equipment is identified and

agreed for installation it will be tested as

required.


4 Incident Coordination Centres FunctionsThe organisation has arrangements in place outlining how it's ICC

will coordinate it's functions as defined in the EPRR Framework.Y

Arrangements outline the following functions:

Coordination

Policy making

Operations

Information gathering

Dispersing public information.

Partially compliant

This is in the workplan of the CCG EPRR

Group and will be included in the CCG EPRR

Framework.

Current SBAR documentation will ensure that

appropriate CCG functions are represented at

an ICC.


Domain: Command structures

5 Command structures Resilience

The organisation has a documented command structure which

establishes strategic, tactical and operational roles and

responsibilities 24 / 7. Y

Training records of staff able to perform

commander roles

EPRR policy statement - command structure

Exercise reportsFully compliant

6 Command structures Stakeholder interaction

The organisation has documented how its command structure

interacts with the wider NHS and multi-agency response structures. Y

EPRR policy statement and response structure

Fully compliant

7 Command structuresDecision making

processes

The organisation has in place processes to ensure defensible

decision making; this could be aligned to the JESIP joint decision

making model. Y

EPRR policy statement inclusive of a decision

making model

Training records of those competent in the

processFully compliant

8 Command structures Recovery planning

The organisation has a documented process to formally hand over

responsibility from response to recovery.Y

Recovery planning arrangements involving a

coordinated approach from the affected

organisation(s) and multi-agency partners Fully compliant

Partially compliant

Ref Domain Standard Detail Evidence - examples listed below

Self assessment RAG

Red = Not compliant with core standard. In line

with the organisation’s EPRR work programme,

compliance will not be reached within the next

12 months.

Amber = Not compliant with core standard. The

organisation’s EPRR work programme

demonstrates an action plan to achieve full

compliance within the next 12 months.

Green = Fully compliant with core standard.

Action to be taken Lead Timescale Comments

15 Duty to maintain plansPandemic influenza


arrangements in place to respond to pandemic influenza as described in the

National Risk Register.


• current





• shared appropriately with those required to use

them



Partially compliant

A CCG Outbreak Planning group will meet for the

first time in October 2018 to define CCG roles and

responsibiliries at time of outbreak, and to coinfirm

CCG plans on how to mobolise.


16 Duty to maintain plansInfectious disease


arrangements in place to respond to an infectious disease outbreak within the

organisation or the community it serves, covering a range of diseases including

Viral Haemorrhagic Fever. These arrangements should be made in conjunction

with Infection Control teams; including supply of adequate FFP3.


• current






them



Partially compliant

A CCG Outbreak Planning group will meet for the

first time in October 2018 to define CCG roles and

responsibiliries at time of outbreak, and to confirm

CCG plans on how to mobolise.


18 Duty to maintain plansMass Casualty - surge


arrangements in place to respond to mass casualties. For an acute receiving

hospital this should incorporate arrangements to increase capacity by 10% in 6

hours and 20% in 12 hours.


• current






them



Partially compliant

Leeds CCG is participating in NHSE Yorkshire and

Humber meetings to develop and agree a regional

Mass Casualty plan. The CCG will have an Action

Card within that plan which will then be taken to the

CCG Outbreak Group to determine responsibilities

and how to mobilise.


26 Training and exercisingEPRR Training

The organisation carries out training in line with a training needs analysis to

ensure staff are competent in their role; training records are kept to demonstrate

this.

• Process explicitly described within the EPRR

policy statement

• Evidence of a training needs analysis

• Training records for all staff on call and those

performing a role within the ICC

• Training materials

• Evidence of personal training and exercising

portfolios for key staff

Partially compliant

Training needs currently being scoped in conjunction

with CCG Organisational Development team,

recognising resources available from Health & Care

Academy and NaCTSO.


30 ResponseIncident Co-ordination

Centre (ICC)

The organisation has a preidentified an Incident Co-ordination Centre (ICC) and

alternative fall-back location.

Both locations should be tested and exercised to ensure they are fit for purpose,

and supported with documentation for its activation and operation.

• Documented processes for establishing an ICC

• Maps and diagrams

• A testing schedule

• A training schedule

• Pre identified roles and responsibilities, with

action cards

• Demonstration ICC location is resilient to loss of

utilities, including telecommunications, and

external hazards

Partially compliant

CCG has a meeting room identified as an ICC

(MR1). No fall back location identified at this time,

requirement to be confirmed.

MR1 to be furnished with hard copy plans, maps.


33 Response Loggist

The organisation has 24 hour access to a trained loggist(s) to ensure decisions

are recorded during business continuity incidents, critical incidents and major

incidents.

• Documented processes for accessing and

utilising loggists


Partially compliant

Leeds CCG has two approaches :

1. to join with Yorkshire & Humber, or WY level

NHSE to resource a widely held rota of health staff

on standby.

2. train a wide group of CCG staff as a ring-round

approach should a loggist be required. This to be

considered by Workforce and Diversity group on

25/10/18.


40 Cooperation LRHP attendance

The Accountable Emergency Officer, or an appropriate director, attends (no less

than 75%) of Local Health Resilience Partnership (LHRP) meetings per annum.

• Minutes of meetingsPartially compliant

An appropriate representative has previously

attended LHRP. Going forwards this attendance will

be at Director level.


1 Incident Coordination CentresCommunication and IT

equipment

The organisation has equipped their ICC with suitable and resilient

communications and IT equipment in line with NHS England Resilient

Telecommunications Guidance.

Non compliant

ICC identified. All IT and telephony equipment

currently is VOIP. Resilience to be tested in line with

NHS E ResilienceTelecommunications Guidance.

No landline phone via copper wiring.


2 Incident Coordination CentresResilience The organisation has the ability to establish an ICC (24/7) and maintains a state of

organisational readiness at all times.

Up to date training records of staff able to

resource an ICC

Non compliant

There are two managers on call at any one time.

Other critical members to a CCG ICC are not on call

and not able to be mobilised 24/7, ie Unplanned

Care, Communications, Primary Care Team,

Medicine Optimisation.


3 Incident Coordination CentresEquipment testingICC equipment has been tested every three months as a minimum to ensure

functionality, and corrective action taken where necessary.

Post test reports

Lessons identified

EPRR programme

Non compliantOnce appropriate equipment is identified and agreed

for installation it will be tested as required.Jenny Baines 30/06/2019

4 Incident Coordination CentresFunctionsThe organisation has arrangements in place outlining how it's ICC will coordinate

it's functions as defined in the EPRR Framework.

Arrangements outline the following functions:

Coordination

Policy making

Operations

Information gathering

Dispersing public information.

Partially compliant

This is in the workplan of the CCG EPRR Group and

will be included in the CCG EPRR Framework.

Current SBAR documentation will ensure that

appropriate CCG functions are represented at an

ICC.


Overall assessment:

1























Agenda Item: IFI1iii FOI Exempt: No



Title: Commissioning for Value Update

Lead Governing Body Member: Tim Ryley, Director of Strategy, Performance and Planning


appropriate

()

Report Author: Mark Fox, Head of Operational Planning and Performance

Decision


Reviewed by Committee/Date: Audit Committee, 24th October 2018

Information



2

EXECUTIVE SUMMARY:

A paper was presented to the Audit Committee on 24 October 2018 to provide a brief history of the Commissioning for Value(CfV) programme, an overview of the delivery of the projects monitored via the programme and an outline of next steps which support the continued development of the programme. This is outlined in Appendix 1 (attached). This report is for information only.

NEXT STEPS:

RECOMMENDATION:


(a) RECEIVE the update for information only.

1























Agenda Item: AC 18/45e FOI Exempt: N

NHS Leeds CCG Audit Committee Meeting

Date of meeting: 24 October 2018

Title: Commissioning for Value – Programme Update

Lead Governing Body Member: Tim Ryley, Director of Strategy, Performance and Planning


appropriate

()

Report Author: Mark Fox, Head of Operational Planning and Performance

Decision

Reviewed by EMT/Date: n/a

Discussion

Reviewed by Committee/Date: n/a

Information

Checked by Finance (Y/N/N/A - Date): Yes

Approved by Lead Governing Body member (Y/N): Yes

Appendix 1

2

EXECUTIVE SUMMARY: This paper presents a brief history of the commissioning for value programme, an overview of the delivery of the projects monitored via the programme and an outline of next steps which support the continued development of the programme. The vast majority of projects monitored are progressing as planned or all identified milestones have been delivered. The CCG is on target to achieve its overall financial targets although the CCG is still significantly some way from achieving its £34.3m efficiency target at the mid-way point in the year with a forecast of just over £20m. Resources are being directed into the Commissioning for Value programme to ensure that there is a robust process in place to review all commissioning expenditure and monitor efficiency plans.

NEXT STEPS: Engagement with commissioning, quality, business intelligence, finance and contract colleagues is required as part of the planned review of the programme to improve upon it and to address the issues which are currently being experienced.

RECOMMENDATION: The Audit Committee is asked to:

a) REVIEW the information contained within this report; and b) SUPPORT the continued development of the Commissioning for Value Programme.

3

1. SUMMARY 1.1 This paper presents a brief history of the commissioning for value programme, an overview

of the delivery of the projects monitored via the programme and an outline of next steps which support the continued development of the programme.

2. BACKGROUND 2.1 The NHS is under significant service and financial pressure. In 2015 it was estimated that

the NHS would need to find £22 billion in efficiencies by 2021 in order to achieve financial balance. For Leeds CCG this equates to the need to find approximately £34m in efficiencies every year. The funding gap has to be addressed whilst at the same time ensuring that patients continue to receive safe, high quality accessible services and that we improve the population’s health and wellbeing.

2.2 Leeds CCG has established the Commissioning for Value Programme to ensure that its financial and commissioning resources are targeted at delivering the changes that offer the best value for money for our population. It is important to recognise that the programme focus extend to securing value in its widest sense i.e. the delivery of benefits in terms of quality of services, health outcomes and finance.

2.3 The programme has many strengths; the focus on Value (Value = Health Gain for each pound spent), the standardisation of process and tools, and the comprehensive identification of work currently underway to name but a few examples. However, the programme has been in place for just under 12 months which prompts the need for a comprehensive review to see how it can be improved and to address the issues which are currently being experienced.

3. PROGRAMME DELIVERY UPDATE 3.1 Progress against the delivery of project milestones and against financial, activity and quality

benefits are monitored on a monthly basis by the Commissioning for Value Delivery Board. Progress against these domains are ‘BRAG’ rated using the following methodology:

BRAG Status

Milestones Finance / Activity / Quality

Blue All identified project milestones have been delivered

Benefits have been delivered

Red At least 10% of milestones are notably off-track (by more than 2 weeks)

There are serious issues/risks associated with the delivery of benefits

Green More than 90% of milestones are on-track to be delivered on-time

Benefits are on-track to be delivered

Amber All other milestone scenarios There are minor issues/risks associated with the delivery of benefits

4

3.2 Projects deemed to be ‘off-track’ (ie. red or amber) are discussed with the Delivery Board with appropriate scrutiny and support provided to identify action being taken to address the current project status.

3.3 Progress against financial, activity and quality benefits is currently self-reported by the project lead. For a number of projects, we are not yet in a position to support the rationale for the BRAG status by using quantifiable evidence.

3.4 The following information has been extracted from the September-18 programme highlight report and has been reviewed by the Commissioning for Value Delivery Board.

3.5 The programme currently oversees the delivery of 43 ‘live’ projects. A live project is defined as a project which is currently reported to be in delivery, or has been in delivery during 2018/19 and has since closed yet monitoring of the project benefits continues.

3.6 A number of other projects (typically in early scoping stages) are also overseen by the delivery board but are not reported upon here.

3.7 Milestone Progress by team Team Red Amber Green Blue Total

Children’s and Maternity 1 0 4 2 7

Continuing Care 0 0 3 0 3

Medicines Optimisation – Commissioning 0 0 5 1 6

Medicines Optimisation – Provider 0 3 2 0 5

Mental Health and Learning Disabilities 1 0 0 0 1

Neighbourhood Care 0 0 0 0 0

Planned Care and Long Term Conditions 2 2 2 1 7

Primary Care 2 1 4 0 7

Proactive Care 0 0 1 0 1

Quality and Safety 0 1 0 0 1

Unplanned Care 0 0 5 0 5

Total 6 7 26 4 43

The vast majority of projects are progressing as planned or all identified milestones have been delivered (30 out of 43).

3.8 Progress against benefit realisation The table below summarises the progress against benefit realisation for live projects. Not all live projects are reported upon within this table since benefits realisation may not yet have started (for example, the current stage of a project may be focused on the implementation of a new service and monitoring of benefit realisation would commence once this service has commenced). Benefit Domain

Red Amber Green Blue Not Applicable

Total

Finance 3 12 22 0 4 41

Activity 2 14 20 0 5 41

Quality 3 21 14 0 2 40

5

3.9 Progress against efficiency requirement The CCG is on target to achieve its overall financial targets although the CCG is still significantly some way from achieving its £34.3m efficiency target at the mid-way point in the year with a forecast of just over £20m.

3.10 This value is made up of two separate elements: 1. Savings realised through contract negotiation and budget setting. These are

made up of a mixture of activity levels being lower than expected national averages, efficiencies reducing the need for demographic growth and specific case management.

Value - £15.794m

2. Delivery of projects within the Commissioning for Value Programme.

Value - £4.671m

It is important to note that this value is representative only of a subset of projects within the programme since the anticipated financial efficiency for all projects has not yet been identified.

3.11 Additionally during the initial financial planning stage risks of £24m were identified, at

month 6 these risks have been reduced or mitigated down to £12.25m so a further £11.75m benefit has been realised.

3.12 Resources are being directed into the Commissioning for Value programme to ensure that there is a robust process in place to review all commissioning expenditure and monitor efficiency plans.

4. NEXT STEPS 4.1 Engagement with commissioning, quality, business intelligence, finance and contract

colleagues is required as part of the planned review of the programme to improve upon it and to address the issues which are currently being experienced.

11. RECOMMENDATION

The Audit Committee is asked to:

a) REVIEW the information contained within this report; and b) SUPPORT the continued development of the Commissioning for Value Programme.

71633548c5390f9d8a76 …… · AGENDA NHS Leeds CCG Governing Body Meeting Date: Wednesday 28...

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