1. Primary care co-commissioning in North West London Securing Healthwatch’s long-term input into the process February 2015

2. Content 1.Why co-commissioning? 2.Why co-commissioning in North West London? 3.Co-commissioning in North West London – what it is and isn’t 4.Resources and conflicts of interests 5.What happened last year 6.Why delegated co-commissioning is the right way forward 7.What’s happened so far this year 8.The current position – and immediate steps 9.Next steps 10.→ The role of Healthwatch in co-commissioning 11. Any questions? Appendices (listed on p.13)

3. Nationally, primary care co-commissioning should help to address a number of the key concerns and result in real benefits for patients and local communities: o Services that are joined up, coordinated and easy for users to navigate around with more services available closer to people’s home; o High quality out-of-hospitals care; o Improved health outcomes, equity of access, reduced inequalities and better patient experience; and o Enhanced local patient and public involvement in developing services, with a greater focus on prevention, staying healthy and patient empowerment. 1. Why co-commissioning? 3

4. 4 2. Why co-commissioning in North West London? o Sustainable general practice is at the core of the local vision for whole-system integrated care – and primary care co-commissioning will enable the commissioning of a new contractual offer for general practice that responds to local needs. o We are planning on developing a new wrap- around contractual offer for general practice that will align with our overall system vision. o This would be a contract to provide a range of services beyond the core GMS and so avoiding the bureaucracy of enhanced services whilst leaving the core contract unchanged.

5. 5 3. Co-commissioning in North West London – what it is and isn’t Primary care co-commissioning could enable us to achieve benefits through: o The ability for local GPs and people to influence decision-making in primary care to align with local priorities and initiatives to support achievement of the vision of NW London; o The ability to make sustainable investment into primary care and to commission a new and enhanced offer for general practice; o The ability to influence the necessary investment in estates; and o Streamlined and efficient governance arrangements that allow for local, effective, and consistent decision-making. Co-commissioning in NW London is not about: o CCGs taking on the role of performance or contract managing practices or GPs; or o Taking away the core contract from NW London practices.

6. 6 4. Resources and conflicts of interests Ensuring sufficient capacity and capability will be difficult and all CCGs that undertake co-commissioning will find the transition period challenging. This is why move to joint co-commissioning is an advantage, because it means that NHS England will retain most of its existing functional responsibilities. This gives time for local capabilities to be strengthened and the capacity questions surrounding delegated arrangements to be worked out. o Resources Local GPs are well experienced in handling conflicts of interest – this is therefore not a significant stumbling block to effective co-commissioning. National guidelines include an addendum to CCGs’ existing conflict of interest policy, which covers membership of the Joint Committee and record keeping for conflicts of interests and procurement decisions. o Conflicts of interests

7. 7 5. What happened last year Greater CCG involvement in influencing commissioning decisions made by the NHS England area teams Joint commissioning arrangements, whereby CCGs and area teams make decisions together, potentially supported by pooled funding arrangements Delegated commissioning arrangements, whereby CCGs carry out defined functions on behalf of NHS England and area teams hold CCGs to account for how effectively they carry out these functions In October 2014, the NW London CCGs’ constituent practices agreed that members would be asked in March 2015 to progress into a formal joint commissioning partnership with the other seven NWL CCGs and NHS England from April. In November 2014, following the publication of additional NHS England guidance, the NW London CCGs chairs decided that delegated arrangements (with appropriate amendments) could be the right way to meet local objectives. This was one of three co-commissioning models proposed by NHS England:

8. 8 6. Why delegated arrangements could be the right way forward The functions for both joint and delegated arrangements are the same – it is the decision-making ability that defines delegated arrangements. Delegated arrangements would mean: The ability to make local decisions on primary care investment (including the wrap- around contractual offer and local incentive schemes) No loss of local influence over current CCG out-of-hospital functions Simpler and more succinct governance arrangements More management resource from NHS England to support with functions

9. 9 7. What’s happened so far this year o 9 January 2015: the NWL CCGs submitted a draft application to NHS England for delegated primary care co-commissioning arrangements. (The application was made in draft form because membership approval and further due diligence were still required.) o 19 January 2015: the regional moderation panel delivered its feedback on the application, plus the actions required. o 21 January 2015: this is the date by which the necessary actions would have had to have been completed in order to progress the application for delegated co-commissioning. o Further feedback has also been received from the national moderation panel and from the LMC.

10. 10 8. The current position – and immediate steps o We believe that delegated co-commissioning – without contract and performance management – should be our ultimate goal, in order to release the full benefits of co-commissioning. o However, meeting NHS England’s timescales for a revised application for delegation would not have allowed the required agreements to be reached in line with NWL’s firmly-rooted approach of engagement and transparency with all stakeholders. o As a result, we are pursuing joint arrangements for 2015/16. o NO DECISIONS CAN BE MADE WITHOUT THE APPROVAL OF MEMBER PRACTICES. o Member practices will be voting on joint arrangements throughout March 2015.

11. 11 9. Next steps o We are now carrying out a rigorous due diligence process to define how delegated arrangements could meet NW London’s requirements in the future, including: Understanding the full roles of NHS England and the NW London CCGs in delegated arrangements; Ensuring we have the resources to undertake the additional workload of delegation; Putting ourselves in a robust position to deliver these additional responsibilities, including the equitable commissioning of new services; Remaining accountable to members and ensuring that decision-making remains within the influence of member practices; and Managing conflicts of interest appropriately. o This will be supported by a process of stakeholder engagement and consultation. o AGAIN, NO DECISIONS CAN BE MADE WITHOUT THE APPROVAL OF MEMBER PRACTICES. o Later in the year, members will be asked to vote on whether to progress to delegated arrangements.

12. 12 10. The role of Healthwatch in joint co-commissioning o Statutory guidance recognises the valuable role that local Healthwatch committees can play in co-commissioning, thanks to their members’ deep local knowledge and understanding of the strategic context for the commissioning of health and social care. o The Establishment Agreement (EA) for co-commissioning in NW London proposes that representatives from each Healthwatch form a sub-committee, together with HWBB representatives, to guide the Joint Committee’s work. o The EA also proposes that the sub-committee nominate a representative to attend the Joint Committee as a non-voting advisor. o Proposed governance: NHS England (London) CCG Joint Committee Healthwatch and HWBB sub-committee

13. 13 11. Any questions? ?

14. | 14 Appendices A.The primary care co-commissioning timeline B.The scope of each co-commissioning model C.Key points in national guidance on functions and governance for joint and delegated arrangements D.Risks, advantages, agreements, and negotiations for each option E.Further information and guidance 14

15. o June 2014: NWL submitted an Expression of Interest for ‘joint arrangements’ with NHSE NWL local area team. This submission was facilitated by the Londonwide LMCs o October and November 2014: Constituent practices and CCG GBs in NWL agreed to support the eight CCGs entering into shadow co-commissioning arrangements o November–December 2014: Final guidance on the models of co-commissioning and managing conflicts of interest was released o 9 January 2015: NWL submitted a proforma of draft proposals for delegated arrangements o 1 April 2015: formal co-commissioning arrangements come into effect, if agreed by CCG members o Mid-year (TBC): Members will be asked to vote on whether to progress to delegated arrangements APPENDIX A: The primary care co-commissioning timeline 15 Ongoing CCG engagement and governance processes

16. APPENDIX B: The scope of each co-commissioning model 16 Out of scope for all co-commissioning options Reference: www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc- cocomms.pdfwww.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc- cocomms.pdf, p.16 (Publications Gateway Reference 02501)

17. Functions to either be jointly commissioned with NHSE or delegated to CGCs: Governance: Statutory requirements on governance including: Any co-commissioning committee must have a lay and executive majority, Chair and deputy Chair Any parties that could be conflicted in decision-making will declare their conflict and will abstain from voting The local Health and Wellbeing Boards and Healthwatch will have a right to nominate a representative to attend committee meetings as an observer APPENDIX C: Key points in national guidance on functions and governance for joint and delegated arrangements 17 Reference: www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdfwww.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf, p.18 (Publications Gateway Reference 02501)

18. A. More influenceB. Joint arrangementsC. Delegated arrangements Advantages No risk of inheriting financial / resource shortage from NHSE More flexibility in functions There is an option to continue into delegated arrangements in 2016/17 Full decision-making ability delegated, enabling full local decision-making in primary care investment and the commissioning of a new ‘wrap around’ contractual offer for general practice Succinct and simpler governance arrangements More management resource inherited from NHSE Risks Would not be able to influence primary care investment decisions and specifically would not be able to commission for a new ‘wrap around’ contractual offer for general practice Would not have any influence in how co-commissioning will be designed and implemented in the future To protect CCGs from real and perceived conflicts of interest, decision-making would have to be done with a lay majority (this is still more influence than in current or arrangements) Distraction from CCGs primary role Complex governance arrangements in which all decisions will be reliant on NHSE approval Little or no management resource inherited To protect CCGs from real and perceived conflicts of interest, decision-making would have to be done with a lay majority (this is still more influence than in current or joint arrangements) Distraction from CCGs primary role Termination of arrangements if required may be more complicated NWL agreements Governance must not result in loss of local CCG influence Comprehensive due diligence is required to validate financial allocations and resources NWL CCGs are not willing to perform contract management functions Governance must not result in loss if local CCG influence Comprehensive due diligence is required to validate financial allocations and resources Local negotia- tions How contract management functions would be managed in formal arrangements APPENDIX D: Risks, advantages, agreements, and negotiations for each option 18

19. The following documentation provides in greater detail the scope for each of the co-commissioning options set out by NHS England and further supporting guidance: Next steps towards primary care co-commissioning. NHS England and NHS Clinical Commissioners. 10 November 2014. Publications Gateway Reference 02501 Managing conflicts of interest: statutory guidance for CCGs. NHS England. 18 December 2014. Publications Gateway Reference 02726 Primary care co-commissioning: regional roadshows questions and answers. NHS England. 18 December 2014. Publications Gateway Reference 02761 GPC update on co-commissioning of primary care: Important Guidance for CCG member practices and LMCs. GMC. December 2014. For further information or to submit a comment, please contact your CCG Chair, Londonwide LMCs representative, or the NW London Primary Care Transformation team: Londonwide LMCs, North West London MD – Tony Grewal, Tony.Grewal@lmc.org.uk Londonwide LMCs, North West London MD – Eleanor Scott, Eleanor.Scott@lmc.org.uk Collaboration of NW London CCGs, Primary Care Transformation Programme, Deputy Director - Matthew Walker, matthew.walker@nw.london.nhs.uk APPENDIX E: Further information and guidance 19