City and Hackney Clinical Commissioning Forum Thursday 6

City and Hackney Clinical Commissioning Forum Thursday 6 th July 2017 St Joseph’s Hospice

Agenda Items Led by 1. Welcome Clare Highton 2. Members’ Forum: Request for approval of changes to the CCG Constitution and Scheme of Reservation and Delegation Matthew Knell 3. Integrated Commissioning, STP & ACS Update Clare Highton 4. 8 -8 Access Mark Rickets 5. Local Standards – Reporting Breaches Update Gary Marlowe/David Spells 6. Equality & Diversity Consultation Anita Coutinho 7. POLCV River Calveley/Gary Marlowe

Request for approval of changes to the CCG Constitution and Scheme of Reservation and Delegation Presentation to the Thursday 6 July 2017 Members Forum FOR DECISION

Background • • The CCGs Remuneration Committee’s Terms of Reference were updated in June 2015 but the changes were not considered for inclusion in the CCGs Constitution and Scheme of Reservation and Delegation at the time; These changes are now indicated on the following slides, with removal of text highlighted in red and addition in blue; There may be further changes to the Remuneration Committee Terms of Reference (and consequently Constitution and Scheme of Reservation and Delegation) to follow in July 2017; One further, minor change is included to confirm that the measures relating to Integrated Commissioning Committees in the Scheme of Reservation and Delegation are regarding services within pooled budgets.

For Decision • • We are seeking Members Forum approval of the changes to the Scheme of Delegation and Reservation, detailed overleaf; The Constitution is currently with NHS England for approval of changes debated and agreed at Members Forums and Governing Body through to March 2017 – we expect their decision imminently; Due to our removal of the Scheme of Delegation and Reservation from the Constitution itself, these changes will not need to be submitted to NHS England for approval (reliant on them approving the document submitted in March 2017!); As such, these changes won’t be able to be actioned until after NHSE’s approval has been granted; All changes have been produced with and consulted on with our solicitors and explanatory comments are included on the next slide; The changes made in this round of amendments build on those previously agreed by the Members Forum and Governing Body; The Governing Body approved these changes at their meeting on Friday 28 June 2017.

Changes to the CCG’s Constitution Previous text Updated text Document location Source Explanation Remuneration Committee - which is accountable to the CCGs Governing Body makes recommendations to the Governing Body on determinations about the remuneration, fees and other allowances for employees and for people who provide services to the CCG and on determinations about allowances under any pension scheme that the CCG may establish as an alternative to the NHS pension scheme. The Governing Body shall approve and keep under review the terms of reference for the Remuneration Committee, including information on the membership of the Committee ; Remuneration Committee - which is accountable to the CCGs Governing Body and: • Agrees the remuneration packages and other terms of service for members of the CCG Governing Body, Clinical Executive Committee and Clinical Leads and other GP and clinical remuneration/sessional rates. • Determines the remuneration and conditions of service of the CCG staff who are on VSM. • Considers the remuneration, terms and conditions as part of the appointment of the Chief Officer & Chief Finance Officer. • Make recommendations on any severance payments of the Chief Officer and Chief Finance Officer, seeking HM Treasury approval as appropriate in accordance with the guidance ‘Managing Public Money’ (available on the HM Treasury. gov. uk website). • Takes independent advice where appropriate in order to properly exercise its functions. • Makes recommendations to the Governing Body on any proposals for a new pay and remuneration framework for employees of the CCG, people who provide services to the CCG, and allowances under any pension scheme it might establish if not the NHS pension scheme. Constitution, section 7. 17 b, page 33 Remuneration Committee Terms of Reference Updated Constitution to reflect changes to the Remuneration Committee Terms of Reference

Changes to the CCG’s Constitution Previous text Updated text Document location Source Explanation Remuneration Committee - which is accountable to the CCGs Governing Body makes recommendations to the Governing Body on determinations about the remuneration, fees and other allowances for employees and for people who provide services to the CCG and on determinations about allowances under any pension scheme that the CCG may establish as an alternative to the NHS pension scheme. The Governing Body shall approve and keep under review the terms of reference for the Remuneration Committee, including information on the membership of the Committee ; (Continued from previous slide) Constitution, section 7. 17 b, page 33 Remuneration Committee Terms of Reference Updated Constitution to reflect changes to the Remuneration Committee Terms of Reference • • • Receives an annual report on the arrangements for Governing Body and clinical leadership - CCG governing body members, Clinical Executive Committee and Clinical Lead roles – sessional commitments, attendance records and payments made and note any changes made by the Chair/ Chief Officer/ Chief Finance Officer under their delegated responsibilities. Receives at least an annual report on the CCG management structure from the Chief Officer and note any changes made to the structure or grades by the Chair/ Chief Officer/ Chief Finance Officer under their delegated responsibilities. Holds an extraordinary meeting to consider proposals for supporting the delivery of any additional functions which the CCG takes on. Receives an annual report on the CCG expenditure against its running cost allowance. Undertakes any other function delegated to it by the CCG Governing Body in line with the CCG’s constitution.

Changes to the CCG’s Scheme of Reservation and Delegation Previous text Updated text Document location Source Explanation The Integrated Commissioning Committees have the following role for services and budgets delivered in either the London Borough of Hackney or City of London: In respect of pooled funds: Advice from DAC Beachcroft, the CCGs solicitors • • • Appendix D, Scheme of Reservation & Delegation (June 2017 version pending NHS E approval), page 10, reference 27 These changes involve no change in substance to the reserved or delegated authorities. The main change makes specific that BCF plans are to be approved by HWBB and NHSE in addition to the stat commissioning organisations. • • Approve the Integrated Commissioning Strategy (ICS); Approve a commissioning strategy or plan for each service or pathway identified in the ICS; Approve the design of services identified in the ICS, including pathways, specifications and models of care; Approve expenditure, including Better Care Fund budgets; . Approve the procurement process to select providers to deliver services identified in the ICS; Approve the appointment of providers to deliver services identified in the ICS; Approve action to address any variance from targets in respect of the performance of providers; Approve the arrangements for the CCG and LBH to work together, including the role of the Transformation Board any supporting committees or work programmes; Approve strategies and plans to secure the engagement of patients, the public and other stakeholders. • • Approve the Integrated Commissioning Strategy (ICS ) for services within the pooled budget; Approve a commissioning strategy or plan for each service or pathway identified in the ICS and included in the pooled budget (acknowledging that the BCF Plan must also be approved by the Health and Wellbeing Board, and NHS England); Approve the design of services identified in the ICS, including pathways, specifications and models of care; Approve expenditure, including Better Care Fund budgets; Approve the procurement process to select providers to deliver services identified in the ICS and within the pooled budget; Approve the appointment of providers to deliver services identified in the ICS and within the pooled budget; Approve action to address any variance from targets in respect of the performance of providers; Approve the arrangements for the CCG and LBH Local Authorities to work together, including the role of the Transformation Board any supporting committees or work programmes; Approve strategies and plans to secure the engagement of patients, the public and other stakeholders. We’ve taken legal advice on the tweak and while Beachcroft initially said ‘…it would be odd to include reference to a separate legal entity (such as NHSE) as having a delegated responsibility in a scheme of delegation for integrated commissioning functions between two organisations’. They however agreed that we could add simple reference to say that HWBB and NHSE will need to approve the BCF Plan, for completeness.

Changes to the CCG’s Scheme of Reservation and Delegation Previous text Updated text Document location Source Explanation The Committee has the function of making recommendations to the Governing Body as to the discharge of its functions under s. 14 L(3)(a) and (b) of the 2006 Act and in addition has other functions connected with the Governing Body’s function under s. 14 L(2) of the 2006 Act as follows: • Agree the remuneration packages and other terms of service for members of the CCG Governing Body, Clinical Executive Committee and Clinical Leads and other GP and clinical remuneration/sessional rates. • Determine the remuneration and conditions of service of the CCG staff who are on VSM. • Consider the remuneration, terms and conditions as part of the appointment of the Chief Officer & Chief Finance Officer. • Make recommendations on any severance payments of the Chief Officer and Chief Finance Officer, seeking HM Treasury approval as appropriate in accordance with the guidance ‘Managing Public Money’ (available on the HM Treasury. gov. uk website). • Take independent advice where appropriate in order to properly exercise its functions. • Make recommendations to the Governing Body on any proposals for a new pay and remuneration framework for employees of the CCG, people who provide services to the CCG, and allowances under any pension scheme it might establish if not the NHS pension scheme. Appendix D, Scheme of Reservation & Delegation (June 2017 version pending NHS E approval), page 9, reference 20 Remuneration Committee Terms of Reference Updated Constitution to reflect changes to the Remuneration Committee Terms of Reference • • Advise the Governing Body about appropriate remuneration, fees, allowances and terms of service for employees of the CCG and to other persons providing services to it, including: • all aspects of salary (including any performancerelated elements/bonuses); • provisions for other benefits, including pensions and cars; • arrangements for termination of employment and other contractual terms; • ensuring that employees are fairly rewarded for their individual contribution to the CCG - having proper regard to the CCG’s circumstances and performance and to the provisions of any national arrangements for such staff. Making decisions and advising the Governing Body on any changes to remuneration, allowances and other payments for individual Governing Body Members. Proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate advising on and overseeing appropriate contractual arrangements for such staff; Reporting in writing to the Governing Body the basis for its decisions. Determining the appointments process for all members to the Governing Body. Determining the removal process for all non-employed members of the Governing Body Taking external HR specialist advise to support remuneration decisions The Committee’s detailed Terms of Reference are on the CCG’s website.

Changes to the CCG’s Scheme of Reservation and Delegation Previous text Updated text Document location Source Explanation The Committee has the function of making recommendations to the Governing Body as to the discharge of its functions under s. 14 L(3)(a) and (b) of the 2006 Act and in addition has other functions connected with the Governing Body’s function under s. 14 L(2) of the 2006 Act as follows: (Continued from previous slide) Appendix D, Scheme of Reservation & Delegation (June 2017 version pending NHS E approval), page 9, reference 20 Remuneration Committee Terms of Reference Updated Constitution to reflect changes to the Remuneration Committee Terms of Reference • • Advise the Governing Body about appropriate remuneration, fees, allowances and terms of service for employees of the CCG and to other persons providing services to it, including: • all aspects of salary (including any performancerelated elements/bonuses); • provisions for other benefits, including pensions and cars; • arrangements for termination of employment and other contractual terms; • ensuring that employees are fairly rewarded for their individual contribution to the CCG - having proper regard to the CCG’s circumstances and performance and to the provisions of any national arrangements for such staff. Making decisions and advising the Governing Body on any changes to remuneration, allowances and other payments for individual Governing Body Members. Proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate advising on and overseeing appropriate contractual arrangements for such staff; Reporting in writing to the Governing Body the basis for its decisions. Determining the appointments process for all members to the Governing Body. Determining the removal process for all non-employed members of the Governing Body Taking external HR specialist advise to support remuneration decisions The Committee’s detailed Terms of Reference are on the CCG’s website. • • • Make recommendations to the Governing Body on any proposals for a new pay and remuneration framework for employees of the CCG, people who provide services to the CCG, and allowances under any pension scheme it might establish if not the NHS pension scheme. Receive an annual report on the arrangements for Governing Body and clinical leadership - CCG governing body members, Clinical Executive Committee and Clinical Lead roles – sessional commitments, attendance records and payments made and note any changes made by the Chair/ Chief Officer/ Chief Finance Officer under their delegated responsibilities. Receive at least an annual report on the CCG management structure from the Chief Officer and note any changes made to the structure or grades by the Chair/ Chief Officer/ Chief Finance Officer under their delegated responsibilities. Hold an extraordinary meeting to consider proposals for supporting the delivery of any additional functions which the CCG takes on. Receive an annual report on the CCG expenditure against its running cost allowance. The Committee’s detailed Terms of Reference are on the CCG’s website.

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Integrated Commissioning, STP & ACS Update Verbal Update

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Clinical Commissioning Forum 6 Jul 2017 8 -8 Extended Access

NHS England Core Requirement for City and Hackney from 1 st November 2017 The London specification for Primary Care is: • Appointments available at least 18. 30 – 20. 00 Mon – Fri and 08. 00 – 20. 00 Sat and Sunday • Available to all registered patients in area (initially only half) • Pre-bookable and same day appointments available • Bookable via the practices and online by patients • Bookable via 111 (in the future) • Must have read/write access to patient records • Has to be additional capacity (not just re badged) • Consideration travel time/transport links for hubs • Evidence, based on utilisation rates of capacity throughout the week

What NHS England/CHCCG have agreed to date • • CCG commissioned Confed to develop and implement plan - programme lead deborah. parkin 1@nhs. net Initial plan submitted to NHSE/HLP on 30/6 outlining local City & Hackney intentions Extended access appointments can be delivered via the LES, DES and KPIs (as is) at practice level until 31/3/18 when LES ends Practices to deliver on their core GMS contract hours by 1/11/17 (or no longer eligible for DES) A “top up” hub must be operational by 1/11/17 expanding to 2 hubs for 1/4/18 The top up hub to run from 1/11 will be in the North – likely to be on 2 sites to accommodate for Saturday and Sunday opening – locations TBC A Primary Care Extended Access/OOH/111 working group has been set up to oversee delivery (welcome to join – first meeting 12/7, 4. 005. 30 at the CCG) 17/18 funding £ 232 k; 18/19 funding TBC

Next Steps • • NHS England formal assurance procedure Detailed project plan to be drawn up following feedback from NHSE as first stage of the above process Appoint an EMIS co-ordinator (to ensure the date sharing agreements and interoperability across practices) and a central rota and data administrator to work with the Programme Director in the operationalisation of the project Engagement piece to commence with practices and patient groups Training for reception staff Decisions to be made about the SOUTH HUB from 1/4/18 - needs to be convenient for City patients Consultation running from now over the summer

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Local Standards – Reporting Breaches Update Verbal Update

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Equality and Diversity – We need your views! Dr Anita Coutinho Clinical Lead in Equality and Diversity

Equality and Diversity City and Hackney CCG is committed to promoting equality, diversity and human rights for our residents Because this is important for our rich and varied population Also as a legal requirement! We need to integrate equality, diversity and human rights outcomes into all aspects of commissioning, service access and delivery, employment practice, engagement and involvement

We need to learn from your experience! Specifically, we need YOUR HELP and your views on the existing E&D objectives as well as your thoughts on what the future objectives should look like. . • • What are the key issues around equality and diversity that you face in your practice … has your practice done anything about this? Has this changed over the years?

Current Objectives: • • • Reduce mental health inequalities amongst communities in East London Reduce mortality from cardiovascular disease and respiratory disease Ensure equitable access to services for residents of the City of London

Questions for Thought… • • • What do you think are some of the ‘big health issues’ in City and Hackney? Who are the groups affected by these? Are there particular groups or communities whose health needs are not being met? Why do you think this is? How can health services in City and Hackney better meet the needs of those groups experiencing inequality?

Thank you! If you would like to contribute further please feel free to email at: Anita. Coutinho 1@nhs. net

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New process Procedures of Limited Clinical Value (Po. LCV) § Current policy in place since 14/15 § 2016/17 - £ 1. 3 m of procedures undertaken at HUH and Barts § Aim of new process to reduce this significantly in 17/19 § The Policy hasn’t changed merely a process ensuring it is being followed by both GPs and Trusts is being implemented

The Procedures – List 1 Bartholins cysts Blepharoplasty Bunion surgery Carpal tunnel syndrome - Surgery for Chronic sinusitis - Surgical Treatment for Dupuytrens contracture Ganglia - Surgical excision of Grommets These procedures all have a criteria that if met and documented means they can be provided with no formal approval. A specific referral form for each procedure with the relevant criteria should now be used for all referrals to secondary care. Hysterectomy for menorrhagia Keloid and other scar revisions (Injection available in community) Skin and subcutaneous lesions - Excision of Sympathectomy Tonsillectomy Trigger Finger – Surgery for Varicocoele - Surgery for Varicose veins – Interventions for Note: A few procedures are not on this list because they are generally ordered by consultants eg: Botulinum toxin, open MRI, double balloon enteroscopy and knee washout for osteoarthritis

The Procedures – List 2 These procedures are not routinely funded and all require IFR approval Acupuncture Sacral nerve stimulation for urinary incontinence Cartilage implantation Tattoo removal Cholecystectomy for asymptomatic gallstones Treatment of vascular lesions Cosmetic face lifts and brow lifts White cell apheresis D&C for heavy menstrual bleeding in women under 40 Abdominoplasty and excess skin excision Herbal medicines Continuous glucose monitoring for Type 1 diabetes Homoeopathy Ketogenic diet for epilepsy Female breast reduction/correction of breast asymmetry/breast lift Labiaplasty Hair epilation Liposuction Hair transplantation MRI guided USS for uterine fibroids Male breast reduction Non-medical circumcision Non-core gender reassignment Osteopathy Pinnaplasty/Otoplasty Repair of totally split earlobes Rhinoplasty Reversal of female sterilisation Treatment for alopecia Reversal of vasectomy Treatment for scarring and skin hyper/hypo pigmentation Breast augmentation

Po. LCV • HUH have agreed to reject any referrals for Po. LCV procedures if the form has not been completed and attached to the e. RS referral • Where consultants order the procedure they will document the criteria has been met before proceeding Full Po. LCV Policy and IFR process available at: http: //www. cityandhackneyccg. nhs. uk/gp/IFRPOLCV 2. htm Referral forms available at http: //www. cityandhackneyccg. nhs. uk/gp/referrals/test-page 2. htm

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