PRIMARY CARE CO-COMMISSIONING IN NORTH WEST LONDON WEST LONDON CCG. November 2014 EXECUTIVE SUMMARY

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1 PRIMARY CARE CO-COMMISSIONING IN NORTH WEST LONDON WEST LONDON CCG November 2014 EXECUTIVE SUMMARY Following the submission of the North West London (NWL) Expression of Interest (EoI) in Primary Care Co-commissioning in June, the eight NWL Clinical Commissioning Groups (CCGs) together with NHS England / London (NHSE/L) have been engaging with General Practitioner (GP) colleagues and other stakeholders to gauge the interest in further exploration of how co-commissioning could help achieve their shared commitment of supporting and securing the future of general practice to ensure that the right care is delivered for the people in NWL. The Delivering Better Outcomes of Care paper that was developed on behalf of the eight NWL CCGs and was reviewed and agreed by the NWL CCG governing bodies in September, sets out the vision for transformed care which places the patient and their carers at the centre of their care and describes how co-commissioning could be an enabler for this vision. As guidance is still emerging from NHS England (NHSE), there is still work required to determine how co-commissioning could be best used in NWL, however proceeding into shadow arrangements will allow the CCGs to start testing proposals as they emerge and come to joint agreements on the best way of moving forward into fully established arrangements in April 2015, if it is decided that this will be beneficial for NWL. The response from GP members across the NW London Collaboration of CCGs is that cocommissioning is worth exploring further in NWL as an enabler for the vision for primary care, by enabling greater local and clinical influence on how primary care commissioning decisions are made. However there are still a number of issues to be addressed, in particular relating to ensuring that conflicts of interest can be managed appropriately with CCGs jointly commissioning primary care services and identifying robust and sustainable funding routes for the delivery of enhanced services prior to any final decisions being made. The proposal to establish co-commissioning arrangements in shadow form has been considered and approved by the constituent GP memberships of the Collaboration of NWL CCGs in October this year

2 including the GP members of; Brent CCG, Central London CCG 1, Ealing CCG, Hammersmith and Fulham CCG, Harrow CCG, Hillingdon CCG, Hounslow CCG and West London CCG. This paper will be presented to each of the eight NWL CCG governing bodies in November for review and agreement. As this paper has been endorsed by West London CCG governing body it is proposed that West London CCG now enters into shadow co-commissioning arrangements with the other seven CCGs of NW London 2 and NHSE / London to test proposals to-date and to further explore the benefits cocommissioning could offer. This paper sets out the proposed next steps and recommendations to the West London CCG governing body. The governing body is asked to note GP members support of the following recommendations in October and therefore endorse them. In October GP members were asked to agree that: Primary care co-commissioning will support the achievement of local visions for whole systems integrated care with general practice at its core by allowing local clinicians to have more influence over the commissioning of primary care services The proposals to date reflect a sound approach to maximising the anticipated benefits and minimising the risks of primary care co-commissioning West London CCG will, jointly with the other seven CCGs in North West London 3, enter into a shadow joint commissioning partnership with NHS England in November 2014, in a Joint Committee. In this arrangement, all decisions will continue to be ratified by each CCG and NHS England. In October GP members were also asked to note that in March 2015 before full operating takes place, GP members will be asked to agree that, should the shadow Joint Committee demonstrate that the co-commissioning arrangements in place will support achieving the vision for local and 1 Currently only seven of the eight NWL CCGs have gained GP member endorsement of the recommendations set out above: Central London CCG will be seeking support from GP members to enter into shadow arrangements on 4 th November Therefore West London CCG governing body is asked to agree to enter into shadow joint arrangements with the other seven NWL CCGs and NHSE, dependent on the support of Central London CCG GP members. 2 Refer to footnote 1 3 Refer to footnote 1

3 North West London, maximise the potential benefits of co-commissioning and will not lead to unmanageable risks or conflicts; Their CCG will, jointly with other CCGs in North West London 4, progress into a formal joint commissioning partnership with NHS England in April 2015; and Their CCG will amend its constitution accordingly in April 2015 to take into account these arrangements Based on GP members endorsement of the above recommendations, it is recommended that West London CCG governing body: Agrees that continuing to explore options for co-commissioning will enable NWL to shape the process to meet specific local priorities Notes that the Establishment Agreement sets out how a shadow Joint Committee will function but recognises that no formal changes to decision making are possible without a constitutional change that will require a mandate from CCG GP members Agrees that West London CCG will, jointly with the other seven CCGs in North West London 5, enter into a shadow joint commissioning partnership with NHS England in November 2014, in a Joint Committee. In this arrangement, all decisions will continue to be ratified by each CCG and NHS England Notes that go-live for fully established arrangements is anticipated to be in April 2015, and agrees to support in the resulting requirement to engage further with GP members over the coming months BACKGROUND The EoI in Primary Care Co-commissioning submitted to NHSE in June committed the NWL CCGs and NHSE to jointly exploring the development of primary care co-commissioning arrangements. The EoI was developed and submitted on the basis that by working together, both the NWL CCGs and NHSE could achieve more in primary care than either could alone. The key messages and principles underpinning the interest in co-commissioning, jointly developed by the eight NWL CCGs, Londonwide LMCs, local NWL LMC Chairs and NHSE, have been agreed as: 4 Refer to footnote 1 5 Refer to footnote 1

4 Co-commissioning should enable us to consider new ways of investing, paying and working in the primary care setting and therefore act as an enabler to the vision we have of keeping people out of hospital and delivering better, more integrated services in NW London Co-commissioning should enable us to deliver the right funding to General Practice to meet the needs of local people Co-commissioning must allow local decision-making in line with NW London priorities Co-commissioning should allow us to more easily shift funding to where it is needed in the system Co-commissioning can only be a success with strong support from all local stakeholders Currently there are no fixed plans of how co-commissioning will be taken forward. Plans will be developed with local stakeholders, including GPs, patients and the public to reflect local priorities The Expression of Interest submitted to NHSE in June and then the Delivering Better Outcomes of Care paper that was developed on behalf of the NWL CCGs and was reviewed and agreed by the eight NWL CCG governing bodies in September, both set out the vision for transformed care which places the patient and their carers at the centre of their care; with general practice at the heart of coordinating care for practice populations, and with other services increasingly organising their offer around populations formed across networks of practices and consolidated practice populations. The papers describe how co-commissioning could be an enabler for building robust general practice services which will be central to achieving this vision. Over the last few months each NWL CCG has undertaken a process of engagement with key stakeholders (including the Londonwide LMCs, local NWL LMC Chairs and NHSE regional and local area teams), NWL CCG governing bodies and GP colleagues to develop initial proposals of how cocommissioning could be used to achieve these principles by delivering the highest quality and most accessible and coordinated care for patients that will promote choice and independence. The NWL CCGs have been looking at how co-commissioning could be used in NWL to lead to the benefits required and the process by which to comprehensively explore the options open, overcome challenges that have been come up against and reach a collaborative understanding of the nature of fully established arrangements in the future.

5 NATIONAL GUIDANCE Over the last weeks, NHSE has released guidance on the governance for co-commissioning, the signoff process and expected timescales. At this stage there is still a lack of clarity as to the functions that will be in scope of each of the three options for co-commissioning set out by NHSE, namely: Greater CCG involvement in influencing commissioning decisions made by NHSE area teams; Joint commissioning arrangements, whereby CCGs and area teams make decisions together, potentially supported by pooled funding arrangements; and Delegated commissioning arrangements, whereby CCGs carry out defined functions on behalf of NHSE and area teams hold CCGs to account for how effectively they carry out these functions. In the absence of any further guidance from NHSE at this stage, it is necessary to explore all of the co-commissioning functions that could be of interest for NWL based on the principles and benefits agreed in our engagement so far. This will enable the development of sound proposals for NHSE, ensuring that NWL stakeholders can influence and shape the process to meet the requirements of local people. The key points of the guidance show that: Functions relating to contract and performance management are out of scope for all cocommissioning arrangements including in fully delegated arrangements. NHSE guidance states that: We have not detected an appetite in CCGs to take on revalidation and performer s lists, and many CCGs also believe that individual and practice performance management aspects of contract management should not be open for delegation. Based on this feedback, our emerging thinking is to exclude these functions from being delegated 6. There is likely to be a need to deliver efficiency savings in primary care, year on year. The assumption is that this will be achieved through alignment with secondary care commissioning or through developing more cost effective out-of hospital services. 6 Dr Amanda Doyle, Ian Dodge, Ivan Ellul and Julia Simon. Sept Proposed next steps towards primary care co-commissioning: an overview.

6 Area teams will provide CCGs with area team plans which set out, at a granular level, the financial plans, allocations, assumptions, forecast QIPP/efficiency savings and investment proposals for primary care. Area teams will also advise on in-year financial performance in 2014/15. (This information will not be available at an individual practice level). National guidance also suggests that the GMS Minimum Practice Income Guarantee (MPIG) will be phased out by April 2020, and a review of local PMS agreements is currently underway. Further NHSE guidance is anticipated over the following weeks that will provide further clarity on the above. TAKING PLANS FORWARD IN NORTH WEST LONDON How national guidance will influence the decision in North West London The NWL CCGs are committed to ensuring that co- commissioning responsibilities are only assumed if it is believed that doing so will lead to real tangible benefits for the CCG and NWL as a whole. It is believed that local clinical and public influence on the prioritisation of primary care investment would indeed enable the development of the right mechanisms to deliver local benefits however it must be noted that the NWL CCGs cannot and will not enter into any arrangement that could jeopardise the services provided in NWL. To ensure that patients and clinical colleagues are protected, prior to entering any binding decisions there must be assurance of robust funding routes and management resources available to enable co-commissioning arrangements without relying solely on already stretched CCG resources. Further information and guidance from NHSE will provide an indication of whether entering into cocommissioning arrangements will be the right choice for NWL. The NWL primary care co-commissioning Establishment Agreement for shadow arrangements Establishing co-commissioning arrangements will require the establishment of a primary care cocommissioning Joint Committee between the commissioners; NHSE and the NWL CCGs 7. As national guidance is still emerging on what could be in scope for such a committee, a period of shadow functioning provides an ideal opportunity to trial proposals to-date and establish how these could be supported by the right organisational structure and funding while continuing to be flexible enough to adapt to meet emerging local and national requirements. 7 Refer to footnote 1

7 Although a Legislative Reform Order (LRO) has been passed to enable the creation of joint committees between CCGs and NHSE from 1 October , no constitutional changes are required to establish the shadow committee in October as the body will not be making any independent decisions. In shadow arrangements all decisions will need to be ratified by each of the eight NWL CCGs and NHSE. 9 Through feedback generated from engagement with a wide stakeholder population since September, an Establishment Agreement has been developed to support the creation of the committee which underpins how co-commissioning could be taken forward in shadow form. The Establishment Agreement has been developed through joint working sessions between the eight NWL CCGs, Londonwide LMCs, local NWL LMC Chairs and NHSE as well as testing ideas and proposals with GP colleagues and patient, public and lay representatives, capturing a broad range of discussions that have been happening at a local level. This document specifies membership for the committee, functions, voting arrangements for when they are necessary and appropriate processes for managing conflicts of interest, and will act as an extended terms of reference for shadow working arrangements. This document must be robust enough to withstand scrutiny and enable clarity in shadow working arrangements, however needs to be flexible and not overly-prescriptive so that options can be tried and tested prior to national guidance emerging and any binding decisions being made. Although the Establishment Agreement for shadow co-commissioning arrangements by its nature must be flexible, there are a number of components that stakeholders in NWL, including local GP members, agree cannot be compromised on both for shadow and fully established working. The NWL CCGs will not be applying to NHSE to assume any functions relating to the management of core contracts or performance management responsibilities of either individual GPs or practices. Furthermore, draft national guidance recognises that these functions are beyond the responsibilities sought by NWL CCGs and assures that these will not be in scope for any form of co-commissioning, including fully delegated arrangements, as detailed previously. 8 This Order is made under section 1 of the Legislative and Regulatory Reform Act 2006 (c.51). It amends sections 14Z3 and 14Z9 of the National Health Service Act 2006 (c.41) 9 Refer to footnote 1

8 The Establishment Agreement as it currently stands will form the foundation of a more detailed document that will be developed prior to a decision being made to go live with co-commissioning in April next year. The Establishment Agreement will be updated and revised throughout the shadow period to reflect lessons learned and further decisions and align with national guidance as it emerges leading up to the establishment of formal governance arrangements. The exact nature of the arrangements for fully established arrangements will be based on what local people and clinicians want to see achieved through co-commissioning, however through engagement over the last months, it is likely that this will include the tailoring of a local enhanced primary care offer and thinking about ways to invest in estates and services that will promote equality across NWL. Gaining support from GP members and CCG governing bodies in November 2014 From September through to November, the NWL CCGs and their local LMC representatives have been working together to engage with GPs throughout NWL and to provide the opportunity for GPs to input into the emerging proposals. In October, GP members were asked to support their CCG in entering into a shadow joint commissioning partnership with NHSE in November 2014, in a Joint Committee with the other seven CCGs in NWL and NHSE. 10 Following the appetite from GP members to continue to investigate how co-commissioning could support the future of general practice and improved patient care in NWL 11, CCG governing bodies are now asked to offer their support to their CCG to continue to explore how co-commissioning arrangements could be developed to enable to greatest benefits while introducing the least risks. The NWL CCG governing bodies are also asked to support the establishment of a Joint Committee functioning in shadow form to allow proposals to date to be explored, tested and built on to enable the development of tried and tested robust plans for fully established arrangements if it is decided that this is the right way to proceed in NWL after April next year. Establishing full arrangements for primary care co-commissioning in NWL NHSE have requested the submission of proposals for fully established co-commissioning arrangements by January 2015, therefore it will be vital to have a clearer picture by then of how 10 Refer to footnote 1 11 Refer to footnote 1

9 NWL stakeholders would like to proceed. The key areas that need serious consideration over the coming months are defining exactly which components of primary care the NWL CCGs are interested in jointly commissioning to lead to the greatest benefits for NWL and therefore the organisational arrangements, management resources and funding that will be required to enable this to happen. Dependent on the outcomes of shadow working arrangements and decisions made during this period, in March 2015, all NWL GP members will be asked to review the ways of shadow working, emerging proposals based on collaborative agreements during the shadow period and confirm the formal establishment of the Joint Committee. Subject to a decision to establish formal cocommissioning arrangements, CCG constitutional arrangements will be changed to enable the Joint Committee to enact its full decision-making responsibilities. Support for this decision will be determined through seeking a formal mandate from GP members in March The full process of developing fully established arrangements will be: November 2014: The NW London CCG Governing Bodies are asked to agree to enter into shadow Primary Care Co-commissioning governance arrangements (this meeting) From the end of November 2014: Primary Care Co-Commissioning Joint Committee is established in shadow form (first meeting date TBC) January 2015: NHSE requests that CCGs submit proposals of how co-commissioning could function in fully operational form. We will need to ensure that our proposals are consistent with agreed principles March 2015: Constituent practices are asked to provide their CCG with the mandate to go ahead with full operating of the Joint Committee Primary Care Co-commissioning April 2015: In the absence of objection from key stakeholders, live co-commissioning governance will commence Engagement with patients and the public The principle of co-design underpins all of the transformational work underway in NWL and is key to the success of the Shaping a healthier future work. The NWL Patient and Public Representative Group (PPRG) and Lay Partners Advisory Group (LPAG) have been engaged on a number of occasions leading up to the decision on whether to proceed with exploring co-commissioning for NWL, both before and after the development of the EoI, to ensure that initial proposals reflected the priorities of people using NWL services.

10 If the decision is made to move forward with co-commissioning in shadow arrangements, co-design with patients, the public and lay partners will be vital to ensure that the patient and public voice is reflected in all decision making and that they can act as guardians of transparency in decisionmaking, safeguarding against real and perceived conflicts of interest. Lay membership on a future co-commissioning Joint Committee will also be key aspect of co-design, both in shadow and in moving into fully established arrangements. The shadow period will be an opportunity to develop plans for how co-design with patients, public and lay partners will be best utilised to ensure the priorities of service users are captured and therefore the benefits that are important to the people of NWL are realised. RECOMMENDATIONS The governing body is asked to note GP members support of the following recommendations in October and therefore endorse them. In October GP members were asked to agree that: Primary care co-commissioning will support the achievement of local visions for whole systems integrated care with general practice at its core by allowing local clinicians to have more influence over the commissioning of primary care services The proposals to date reflect a sound approach to maximising the anticipated benefits and minimising the risks of primary care co-commissioning West London CCG will, jointly with the other seven CCGs in North West London 12, enter into a shadow joint commissioning partnership with NHS England in November 2014, in a Joint Committee. In this arrangement, all decisions will continue to be ratified by each CCG and NHS England. In October GP members were also asked to note that in March 2015 before full operating takes place, GP members will be asked to agree that, should the shadow Joint Committee demonstrate that the co-commissioning arrangements in place will support achieving the vision for local and North West London, maximise the potential benefits of co-commissioning and will not lead to unmanageable risks or conflicts; 12 Refer to footnote 1

11 Their CCG will, jointly with other CCGs in North West London 13, progress into a formal joint commissioning partnership with NHS England in April 2015; and Their CCG will amend its constitution accordingly in April 2015 to take into account these arrangements Based on GP members endorsement of the above recommendations, it is recommended that West London CCG governing body: Agrees that continuing to explore options for co-commissioning will enable NWL to shape the process to meet specific local priorities Notes that the Establishment Agreement sets out how a shadow Joint Committee will function but recognises that no formal changes to decision making are possible without a constitutional change that will require a mandate from CCG GP members Agrees that West London CCG will, jointly with the other seven CCGs in North West London 14, enter into a shadow joint commissioning partnership with NHS England in November 2014, in a Joint Committee. In this arrangement, all decisions will continue to be ratified by each CCG and NHS England Notes that go-live for fully established arrangements is anticipated to be in April 2015, and agrees to support in the resulting requirement to engage further with GP members over the coming months 13 Refer to footnote 1 14 Refer to footnote 1

12 APPENDIX A: Governance process and timeline This meeting

13 APPENDIX B: Wording used to seek NWL GP member support in October 2014 GP members are asked to agree that: Primary care co-commissioning will support the achievement of local visions for whole systems integrated care with general practice at its core by allowing local clinicians to have more influence over the commissioning of primary care services The proposals to date reflect a sound approach to maximising the anticipated benefits and minimising the risks of primary care co-commissioning Their CCG will, jointly with the other seven CCGs in North West London, enter into a shadow joint commissioning partnership with NHS England in November 2014, in a Joint Committee. In this arrangement, all decisions will continue to be ratified by each CCG and NHS England. GP members are also asked to note that in March 2015 before full operating takes place, they will be asked to agree that should the shadow Joint Committee demonstrate that the co-commissioning arrangements in place will support achieving the vision for local and North West London, maximise the potential benefits of co-commissioning and will not lead to unmanageable risks or conflicts; Their CCG will, jointly with other CCGs in North West London, progress into a formal joint commissioning partnership with NHS England in April 2015; and Their CCG will amend its constitution accordingly in April 2015 to take into account these arrangements