Agenda item

This item will consider and discuss the governance arrangements currently being considered by the North-West London Collaboration of Clinical Commissioning Groups Shadow Joint Committee, and its proposed terms of reference. 

Councillor Vaughan welcomed Janet Cree, Managing Director of Hammersmith & Fulham CCG and Dr Tim Spicer, Chair of Hammersmith & Fulham CCG Governing Body.  Janet Cree briefly explained that the eight governing bodies that formed the NW London collaboration of CCGs had approved that a joint committee be set up in January 2018 in shadow form.  The development of governance and logistical arrangements required to support this new structure would be work in progress and it was confirmed that there was no delegated authority at that the time.  The terms of reference for the shadow joint committee had been drafted and published. They would be formally considered by all the governing bodies, with a power for delegated decision making most likely to be in place by the second quarter of 2018/19.

Councillor Ben Coleman expressed concern that the report had not sought two-way dialogue between the governing bodies and interested stakeholders. The shadow joint committee would be working through the issues, and feedback any insights arising from this discussion.  Janet Cree confirmed that this would then go back to each of the governing bodies for further consideration and acknowledged that there may be further amendments made to the terms of reference before being formally approved.  Councillor Coleman pointed out that there had been little clarity on this issue and that it was legitimately open to discussion and scrutiny.  Residents were concerned that local powers would be diluted and result in significant changes to services that were much needed and valued.  He asked what those changes might be and whether they would be subject to scrutiny by eight of scrutiny committees of the NW London boroughs.

Dr Spicer confirmed that there would be changes to the draft terms of reference before formal approval.  He explained that much of the CCG’s work and activities were local, elements of which took place across North West London.  In addition to supporting the on-going work of the Joint Health and Overview Scrutiny Committees (JHOSC), local scrutiny would also continue. There would be no change in terms of accountability and Dr Spicer assured Councillor Coleman that there would be consultation, recognising the importance of strong local involvement with residents.  The local health economy was complex and there was a need for a governance structure to co-ordinate the more complex health provision across Hammersmith & Fulham. This would add to acute service provision activities such as cancer.  It was explained that not all trusts do the more complex cancer treatments and care.  This was not a matter of having more ‘clout’, it was about having access to more specialist care from acute service-providing trusts.

Co-optee, Jim Grealy sought clarification regarding the CCG’s attendance at the Committee and if they represented eight CCGs, or one (Hammersmith & Fulham).  Referring to point 17, Reporting, reference was made to local representation, engagement and public reporting, which were not the same.  He asked the CCG how they would relate to the public in the Borough and address their concerns.  Dr Spicer explained that they would be reporting differently but that local engagement would remain the same.  Local accountability and support to the Health and Wellbeing Board would not change.  The shadow joint committee would work similarly and did not replace Hammersmith & Fulham CCG. Day to day relationships would remain the same.  Dr Spicer agreed that there was different demand across the Borough and that one size did not fit all, local adjustments were required to reflect local need.

The report inferred that there would be separate decision making and Jim Grealy sought assurance that the local collaboration would not be able to retreat to its own area.  He asked how the CCG would reconcile potential differences.  Dr Spicer replied that he did not think that it was a function of the shadow joint committee to take decisions that were detrimental to local people.  The CCG wanted to take decisions that were consistent and useful across large sections of the community, for example, trying to ensure improved and consistent nursing care home standards. Dr Spicer acknowledged that any tension between the CCG and the collaborative joint committee would be resolved to the benefit of residents.

Councillor Vaughan referred to the draft terms of reference and the point that decision making would be achieved by consensus.  He understood that this was preferable to the majority vote system where there was an obligation to attend PAC.  He asked if the CCG had agreed to either a consensual, unanimity or majority voting processes, as part of that collaborative arrangement, which they may have to defend.  Dr Spicer replied that currently there was no binding decision making.  The CCG had set out the draft arrangement in the draft terms of reference and agreed to accept scrutiny of this, maintaining accountability. 

Councillor Vaughan responded that it would be different in terms of the bigger decisions.  If the CCG disagreed with the majority view, this would need to be defended at this PAC.  Dr Spicer acknowledged this as a legitimate concern.  The CCG had worked collaboratively for six years, and that while each CCG was not always happy with whole approach, the benefits outweighed this.  He clarified that the PAC would be scrutinising Hammersmith & Fulham CCG. 

Councillor Coleman observed that if the CCG was outvoted, then the other CCG members would not come to this PAC.  He asked if the minutes of the meeting would demonstrate the CCG’s disagreement at the joint committee.  Dr Spicer confirmed that the minutes would record both the discussion and the vote. 

Co-optee Bryan Naylor commented that there were some areas of uncertainty, and that his interpretation of the terms of reference was not the same.  The shadow joint committee would make local decisions.  He suggested that the terms of reference should be brought back to the PAC for consideration and amendment.  Dr Spicer said that the agreed terms of reference would be more helpful to review, depending on the timing.  This would be a functional committee, engaged in a collaborative process, working for the benefit of local population. The PAC would have an opportunity to scrutinise the terms of reference once they were agreed, prior to implementation.

Lisa Redfern referred to point 4, Duties: Decision Making and asked about joint decisions in relation to all acute mental health services that the Local Authority was not involved in and suggested that greater clarity was required on this section.  Dr Spicer agreed and explained that most of the work undertaken on acute services was joint but it was acknowledged that some further redrafting of the terms of reference was required.

Councillor Morton suggested that the wording around consensus, particularly voting, also required greater clarity.  Dr Spicer felt that the wording required further clarity but pointed out that the document was first drafted in December 2017 and was now slightly dated, as discussions had developed.  There were comparable anxieties across North West London but the CCG aspired to making decisions by consensus.  Dr Spicer recognised that it might not always possible to do this.  A consensual approach would have to be worked through on a case by case basis.  Where it was possible, the CCG would make decisions by consensus but this might later have to be by majority. 

Councillor Brown asked that if the majority agreed a decision, did there exist a veto so that the CCG could opt out but still maintain its sovereign position.  Dr Spicer confirmed that the joint committee existed with the agreement of all the CCGs.  Hammersmith & Fulham CCG was still a statutory body and this would continue.  Dr Spicer offered an assurance that if this did not work, the CCG discontinue the process and would advocate for benefit of LBHF residents. 

Councillor Coleman asked, if the CCG was out voted, was a six-month notice period required.   Janet Cree explained that this was the reason the terms of reference were in draft form.  The joint committee would need to work through the issues in practice and test it, hence, a period of shadow working.  This would be further considered by the governing bodies.  Janet Cree recognised the concerns but the CCG’s response would depend on the individual the circumstances. 

Councillor Coleman asked if the CCG could envisage a situation where they might refuse to implement at joint decision.  Dr Spicer said that there may be decisions that they would first come to a view on from within CCG, before going to the collaborative. Dr Spicer confirmed that, following lengthy discussions with the CCG collaborative, he would be prepared to disagree.  The CCG would stand down, if it was felt that the decision was wrong for the residents of Hammersmith & Fulham. It was very hard work to get this number of individuals to agree.  Seeking the agreement of five CCG’s and for 18 contracts to align had taken two years. There remained some details within the contracts that were imperfect, however, Dr Spicer asserted that he would not have agreed to them as a clinician, if they were wrong for a patient.

Focusing on point 17, Jim Grealy asked about local stakeholders and the fact that the term ‘consultation’ was missing.  Engagement had been one-way in recent years, with the CCG not engaging on large questions.  Jim Grealy asked the CCG to reinstate the word “consultation” at the formative stage of policy formulation and development.  Dr Spicer agreed to forward this point for consideration, acknowledging that the CCG retained a statutory duty to consult.

The CCG confirmed that if it were to take a collective decision, they would be willing to go to any of the health scrutiny committees to defend a particular decision.  Councillor Coleman asserted that the collective CCGs should all equally be willing to go to each of the scrutiny committees.  Dr Spicer affirmed that the CCG would do so, if necessary.  His responsibility was to Hammersmith & Fulham CCG and that Ealing CCG would operate in the same way.

Councillor Coleman suggested that accountability to each council in future should be more explicitly reflected in CCG documents.  Dr Spicer explained that some of the decision making was delegated to the joint committee.  Councillor Coleman responded that the key issue was the provision of acute services, conferring massive power to the joint committee, which would collectively make decisions for other councils and that there was a duty for the CCG to go where called to maintain accountability.

Janet Cree reiterated that the minutes of the CCG would reflect the discussion and voting but clarified that the joint committee was not currently a decision-making body.  Dr Spicer confirmed that the eight CCGs had been meeting for six years, with the intention being that the joint committee would replace the need for this.  Janet Cree explained that the details regarding Healthwatch representation had not yet been determined and was considering having a limited number of lay members. 

Lisa Redfern sought further clarification that what was not explicit within the terms of reference was information about the commissioning arrangements, given the size of the collaborative.  For example, Hammersmith & Fulham CCG led on specific areas and the other 2 CCGs had other specific lead commissioning arrangements.  Given the power to delegate decision-making, it was important to be clear about which CCG would be lead for a specific commissioning arrangement.  Janet Cree accepted that this required clarity. 

Dr Spicer noted that Hammersmith & Fulham was the lead commissioner for Imperial although Hammersmith & Fulham residents were not the majority users.  The lead commissioner arrangement was good for accountability but this was not an ideal arrangement due to the complexity of the provider arrangements in Hammersmith & Fulham.   Lisa Redfern agreed and added that it was increasingly complex for local authorities to navigate commissioning arrangements so that this was even more important, given the complexity of the new 8 CCG collaborative arrangement.

Merrill Hammer (Save Our Hospitals) commented that democratic and accountability arrangements were binding on all the CCGs but the joint committee was accountable to the individual CCG, which in turn was accountable to the local authority. She asked why the collaboration required such a complex structure, when complex arrangements already existed, for example, acute service provision for cancer treatment and care. Dr Spicer explained that the infrastructure only reflected the complexity of the local provider landscape.  NHS England encouraged the CCG to deliver increased level of co-ordination, to be considered by each of the eight CCGs. This new structure was necessary to deliver improvements in that co-ordination.  Dr Spicer referred to an earlier point regarding the improvement of co-ordinating the consistency of care standards across residential homes which had taken over two years.  The eight CCGs would remain but this is a way of bringing together collective decision making. 

Councillor Vaughan summarised the discussion, noting that there were several points to be referred to the joint committee and the confirmation that minutes from the joint committee will go to Hammersmith & Fulham CCG.  As this was the last PAC meeting of the municipal year, this would be added to the draft work programme, which would be agreed after the May elections. The key issues were:

·         Democratic accountability;

·         Different operating models;

·         Greater clarity around exercising vetoes;

·         The distinction between consensus as opposed to unanimity in decision-making and which would be better;

·         Clarity around lead commissioning arrangements; and

·         Consultation.

Councillor Vaughan thanked the CCG for all their contributions and participation throughout the meetings and for the constructive dialogue over the past year.