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TRANSITION
Summary Case for Change FOR CLINICAL COMMISSIONING IN Hambleton, Richmondshire and Whitby Harrogate and Rural District and Scarborough and Ryedale
This document outlines the case for change for the future working arrangements of NHS Hambleton, Richmondshire and Whitby Clinical Commissioning Group (HRW CCG), NHS Harrogate and Rural District Clinical Commissioning Group (HaRD CCG) and NHS Scarborough and Ryedale Clinical Commissioning Group (SR CCG). It describes the context and identifies the engagement and overall narrative for the process of considering the case for change. Jane Baxter Programme Manager Julie Warren Programme Director Director of Corporate Services, Governance and Performance North Yorkshire Clinical Commissioning Groups September 2019
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Table of Contents
1. Introduction .................................................................................................... 3 2. Background .................................................................................................... 3
3. The CCGs ........................................................................................................ 4 4. Map of proposed CCG boundary and location of GP practices ................. 5 5. Contracts and Services ................................................................................. 5 6. Primary Care Delegated Commissioning ..................................................... 6 7. Local Population ............................................................................................ 6
8. A New Strategy for the Future ....................................................................... 8 9. Aims .............................................................................................................. 11 10. Population Health Management .................................................................. 11 11. Primary Care Networks ................................................................................ 12 12. Sustainability and Transformation Partnership (STP)/Integrated Care
Partnerships (ICS) ........................................................................................ 13 13. Benefits realisation ...................................................................................... 14
14. Programme Management Office ................................................................. 15 15. Financial Position ........................................................................................ 15 16. Governing Body/ Members decision .......................................................... 19 17. Issues and Risks .......................................................................................... 21
18. Communications and Engagement ............................................................ 21 19. Signatures ..................................................................................................... 24
20. Appendix 1. Map of proposed CCG boundary and location of Primary Care Networks and GP practices ................................................................ 25
21. Appendix 2. The 3 CCG Financial Long Term Plans ................................. 26
22. Abbreviations used in this document ........................................................ 27
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1. Introduction
The CCGs now wish to apply to establish a single clinical commissioning group by
dissolving NHS Hambleton, Richmondshire and Whitby Clinical Commissioning Group
(HRW CCG), NHS Harrogate and Rural District Clinical Commissioning Group (HaRD
CCG) and NHS Scarborough and Ryedale Clinical Commissioning Group (SR CCG) and
establishing NHS North Yorkshire Clinical Commissioning Group (NY CCG).
2. Background
In summer 2018, each of the three North Yorkshire CCGs completed a Capacity and
Capability Review, following guidance from NHS England (NHSE), and developed an
action plan in response. Each of the reviews highlighted the challenges now facing the
CCGs. All three CCGs had significant capacity constraints and it was clear that different
ways of working would be necessary to address these. As a result a key recommendation
was as follows:
‘The CCGs’ leadership must urgently meet with NHS England to agree the
optimum approach to ensure the right capacity across the three organisations,
and how these should be led.
It was agreed with the three Clinical Chairs and three Accountable Officers that there were
benefits of coming together to enact some of the business of the CCGs given:
Three Strategic Transformation Partnerships / Integrated Care System (STP/ICS)
(North East and North Cumbria / West Yorkshire and Harrogate / Humber Coast and
Vale);
Five members of Parliament;
North Yorkshire County Council a single conversation/one Health & Wellbeing Board
(HWBB) Better Care Fund (BCF);
Five Borough/ District Councils;
Underlying financial deficit in all three CCGs;
NHS England ‘special measures’ applied in some areas;
Geographical challenges;
Three financially challenged providers; single approach consistent planning parameters
Small rural hospitals with long travel times and fragile infrastructure between them;
Capacity and capability issues within three small CCGs to drive strategic change;
A 20% management cost saving required by CCGs and NHS England over 2018/19 and
2019/20;
The necessity to make single strategic decisions to reduce duplication and bureaucracy,
and enable priority to be given to local decision making as appropriate.
NYCCG will pay the levy for national apprenticeships to invest in future workforce.
The three North Yorkshire CCG Governing Bodies have worked closely together to
determine the operating model. From these discussions, the following actions were
supported:
To obtain legal advice from Capsticks;
Approved arrangements for risk sharing across CCGs for a single management
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structure;
Principles to determine the joint operational governance arrangements;
Building on strong local engagement with clinicians, partners and patients;
Develop new clinical operational model.
Throughout 2019/20 the CCGs remain distinct and separate bodies constitutionally, with
separate Clinical Chairs and lay members. The CCGs will be holding Committees-in-
Common (CsiC) for all statutory committees and Joint Committees for all non-statutory
committees. When appropriate, Governing Bodies will meet as Committees-in-Common.
3. The CCGs
The three CCGs were formed in April 2013 taking over responsibility for planning, paying
for, and monitoring, local health services from Primary Care Trusts (PCTs). These were
new organisations combining the expertise of local family doctors and NHS managers
putting local doctors and nurses at the heart of deciding which health services to provide,
and where and how they would be provided.
NHS Hambleton, Richmondshire and Whitby Clinical Commissioning
Group
Accountable officer: Amanda Bloor
Address: Civic Centre Stone Cross, Northallerton DL6 2UU
Local authority: North Yorkshire County Council
2019/20 budget: £224.1 million
Number of staff: 45
Number of practices: 22 practices (4 PCNs)
Registered list size: 143,900
NHS Harrogate and Rural District Clinical Commissioning Group
Accountable officer: Amanda Bloor
Address: 1 Grimbald Crag Court, Knaresborough HG5 8QB
Local authority: North Yorkshire County Council
2019/20 budget: £233.9 million
Number of staff: 59
Number of practices: 17 practices (4 PCNs)
Registered list size: 162,800
NHS Scarborough and Ryedale Clinical Commissioning Group
Accountable officer: Amanda Bloor
Address: Scarborough Town Hall, Scarborough YO11 2HG
Local authority: North Yorkshire County Council
2019/20 budget: £192.9million
Number of staff: 87
Number of practices: 12 practices (3 PCNs)
Registered list size: 120,400
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4. Map of proposed CCG boundary and location of GP practices
The proposed boundary is aligned and coterminous with both the existing Local Authority
(LA) and CCGs. There is no requirement to adjust boundaries or change the relationship
of any GP practices. The new North Yorkshire CCG will consist of 51 GP member
practices, 11 Primary Care Networks and will serve a registered population of
427,100 (as of January 2019). See Appendix 1 - Map of proposed CCG boundary and
location of Primary Care Networks and GP practices.
5. Contracts and Services
NHS Hambleton, Richmondshire and Whitby CCG is the host commissioner for South
Tees Hospitals NHS Foundation Trust (STHFT) and leads negotiations on behalf of all
three CCGs. It carries out activity, analysis and raises challenges on behalf of all three. It
also commissions acute services with Harrogate, Leeds and York Hospitals.
NHS Harrogate and Rural District CCG is the host commissioner with Harrogate and
District NHS Foundation Trust (HDFT) and Tees, Esk and Wear Valley NHS Foundation
Trust (TEWV) and leads negotiations on behalf of all three CCGs. The CCG also
commissions acute services with Leeds, Sheffield, South Tees and York Hospitals.
NHS Scarborough and Ryedale CCG commissions acute services with York Teaching
Hospital NHS Foundation Trust, (YHFT) which includes York, Scarborough and Bridlington
Hospitals. The CCG also commissions acute services with Hull, Leeds, Sheffield and
South Tees Hospitals.
The eMBED contract provides services to all three CCGs including Information
Governance, Business Intelligence (Data Services for Commissioners Regional Office)
and other functions such as information technology. The CCGs vary in their utilisation of
these services. North of England Commissioning Support (NECS) will be taking over
these contracts from April 2020 due to eMBED withdrawing from all health contracts. An
internal project team across the NY CCGs is overseeing the smooth transition. NECS
have developed a project plan which includes a phased approach and provides assurance
that capacity is in place to fulfil the contract requirements. Monitoring potential risks
through the corporate risk register. NY CCGs will become a customer owner with NECS
with a share of any profits being reinvested in local services from April 2020.
Yorkshire Ambulance Service; (YAS) 999, NHS 111 and Patient Transport, are contracted
by all three North Yorkshire CCGs.
The CCGs have collaborated since their inception on joint ‘at scale’ projects,
namely: Mental Health Transformation, Better Care Fund, Primary Care Networks,
children’s, vulnerable people, continuing healthcare commissioning and
transforming care partnership (TCP).
Other lead contract arrangements include, British Pregnancy Advisory Service (BPAS),
Marie Curie and end of life care.
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6. Primary Care Delegated Commissioning
The three North Yorkshire CCGs currently have fully delegated co-commissioning
responsibility for the GP core contract. HaRD CCG and SR CCG took on this responsibility
from 1 April 2015 with HRW CCG becoming fully delegated from 1 April 2018. A new
delegation would be sought for the new single CCG.
The development of primary care and management of the contracts is managed through
dedicated primary care commissioning leads across the three CCGs and through Primary
Care Steering Groups. Formally, the North Yorkshire CCGs Primary Care Commissioning
Committees meet as Committees in Common. The meeting is chaired by a Governing
Body lay member and attended by NHSE. In addition, each CCG is meeting at least
monthly with their respective Primary Care Network (PCNs), Clinical Directors (CDs) to
provide support and development of PCNs. A North Yorkshire meeting of the 11 CDs is
taking place quarterly as a workshop; this is run jointly with the Local Medical Committee
(YORLMC).
7. Local Population
The area of Hambleton, Richmondshire and Whitby, Harrogate and Rural District and
Scarborough and Ryedale is home to a population with wide and diverse needs together
with areas of rurality and urban conurbations. Despite the focus of population within the
main towns of the county, a significant part of Harrogate and Hambleton and
Richmondshire is rural in nature.
Outside of urban centres and market towns, North Yorkshire is sparsely populated with
54.5% of the population living in rural areas and 16.9% of the population living in areas
which are defined as super sparse.
The total registered population of the new North Yorkshire CCG will be 425,700. Across
the three CCGs, there is a high proportion of people aged over 65, ranging between 21-
26% compared with England (17.3%). The proportion of people aged 5-14 years old
ranges between 10-11% and is slightly lower than England (11.6%).
The total population will increase only slightly over the next 20 years. This is in contrast to
the England population which will increase by 11.3% over the same period.
Population projections Total Population (1000’s) % change from 2018
CCG 2018 2029 2039 2029 2039
NHS Hambleton, Richmondshire
and Whitby CCG 153.1 152.7 151.6 -0.26% -1.0%
NHS Harrogate and Rural
District CCG 160.6 161.9 162.8 0.81% 1.37%
NHS Scarborough and Ryedale
CCG 112.0 113.6 114.2 1.43% 1.96%
North Yorkshire CCG’s
Combined 425.7 428.2 428.6 0.59% 0.68%
However, the proportion of age groups that make up the North Yorkshire CCG population
will change dramatically over the next 20 years.
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The over 90’s population across the area is set to rise 144% in the next 20 years. There is
a projected drop in the 0-14 year age band and working age band, which is offset by an
increase in the over 65 years population. The pattern is repeated across the three CCGs.
The data highlights the challenges with regards to the provision of health and social care in
the face of an ageing population. These challenges are best met through a strategic
joined-up approach across the three CCGs with local pathways at place dealing with
particular local issues.
7.1 Health Inequalities
There is a wide variation in deprivation levels across the three CCGs. In 2015 in HRW,
there were 10.8% of children aged 0-15 years living in low income families. HaRD, 8%
and in SR there were 19.8% compared with 19.9% in England. SR CCG has the highest
concentration of deprived neighbourhoods in North Yorkshire, predominantly located in
Scarborough town, but also in Eastfield and Filey.
The map below demonstrates that there can be as much as 11 year difference in life
expectancy for males and 13 years for women between the ward with the lowest overall
life expectancy (Castle ward in Scarborough) and that of the highest overall life
expectancy (Ripon Minster ward in Harrogate). The inequality in life expectancy is
demonstrated by the map below.
7.2 Equality Impact Assessment (EIA) (Public Sector Equality Duty)
The North Yorkshire CCG EIA is a living document which will be regularly updated to
summarise discussions and actions taken throughout the process of developing the case
to form one CCG across North Yorkshire. The EIA will be regularly updated and focuses
on; patient experience, patient safety, effectiveness, equality and workforce. The
assessment demonstrates an overall positive position supporting the case for change to a
single merged CCG.
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The limited negative impacts relate to:
Area of Focus Negative Impacts Mitigation
Patient
Experience
Patients may notice a change in
service delivery as thresholds are
aligned.
EIAs completed for
commissioning services of all
new services and any service
changes.
Any risks will be managed
through a combined risk register.
Risks are aligned to Committees
and an Executive Director lead.
Potential loss of local patient voice for influencing service design and raising concerns.
Following statutory guidance
around engagement throughout
the commissioning cycle utilising
methods to ensure strong
engagement with local people
Equality Focussing on areas of need may
deprive affluent areas of focus
EIAs completed for
commissioning services of all
new services and any service
changes
Workforce Structure/travel/change Engagement and consultation
with structures.
Staff reference group.
Sustainable methods to address
travel issues, such as skype and
car sharing to meetings
8. A New Strategy for the Future
We are creating a new organisation that will become the system leader for health services
in North Yorkshire and we will form a single commissioning voice. The System Leadership
Board (SLB) across NY/York is supportive of the merger proposal. The SLB comprises of
Chief Executives across local authorities, acute, community & mental providers helping to
shape the NY strategic plan linked to the Health and Well Being Boards (HWBBs) plans.
By creating a high-performing single commissioner for North Yorkshire the CCG will be
better able to deliver large-scale service and clinical transformation projects across acute,
community and primary care, which benefit the whole system rather than individual care
settings. Partners, providers and other key stakeholders will engage with one
commissioner.
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In line with the NHS long-term plan and the implementation framework the CCG is
developing a new commissioning strategy built around three strategic priorities: integrated
care, in-hospital care, and care for vulnerable people.
The proposed operational structure and clinical governance arrangements for North
Yorkshire CCG will support the delivery of the strategy. With a new staffing and clinical
leadership in place the strategy will be delivered through several strategic enablers.
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By streamlining commissioning and working at scale duplicated functions can be removed
and resources and assets used more effectively, aligned with our strategic priorities.
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9. Aims
A single CCG will ensure consistency and help make our resources go further, delivering
fair outcomes for patients no matter where they live. Our aims for the single CCG are:
10. Population Health Management
Across the three existing CCGs, we already recognise the importance of Population Health
Management (PHM) to improve the population’s health, prioritise investment, reduce
variation and improve health inequalities. We have been working on various population
health management initiatives across our places. Examples include: a focus on frailty in
SR CCG; identification of Atrial Fibrillation in HRW CCG; and identifying patients who are
sub-optimally treated for hypertension in HaRD CCG. However, we recognise that there is
much more to do and merging the CCGs gives an opportunity to align our resources
better. We have used the PHM maturity matrix to assess our readiness – and included our
key partners in North Yorkshire County Council (NYCC). PHM has been identified as one
of the clinical lead areas.
Our main development areas are around ensuring a common understanding of what we
mean by PHM, linking data better across systems to create a better understanding of
population segments and which cohorts have greatest impact, and use of risk stratification
across systems to identify individuals with whom to work. We are part of a PHM network
linked into West Yorkshire and Harrogate ICS and are using the learning from the Leeds
demonstrator site. We are trialling a PHM approach within a neighbourhood within the
HaRD CCG integrated care alliance (Harrogate and Rural Alliance) with the aim to focus
interventions on cohorts of patients with frailty that we will identify as being most able to
benefit, using linked system data. This is being supported through Academic Health
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Science Network (AHSN) and Imperial College. We will learn fast and share what works
across the other PCNs and neighbourhoods.
We are also working with PCN Clinical Directors across the North Yorkshire CCGs,
utilising National Association of Primary Care support, to enable emerging PCNs to
understand their populations better and prepare the ground for more sophisticated
segmentation and shift up the PCN maturity matrix. We are commissioning a Business
Intelligence tool which will have Population Health Management functionality and are
talking with our partners about how the data includes social care.
10.1 Integrated Commissioning
The three CCGs have worked closely with North Yorkshire County Council (NYCC) and
the HWBB to develop principles and ways of working to develop integrated care. A
significant example of this is in September 2019 HaRD CCG has signed a Section 75
agreement establishing the Harrogate and Rural Alliance with its partner organisation
NYCC, HDFT, TEWV and YHN. The purpose of this is to transform the way community
health and social care services are provided for adults in HaRD CCG. It is hoped to learn
from this and develop across NY.
See separate documents Alliance Agreement and Section 75 Agreement (section 18 and
schedule 3 outlines the pooled fund).
11. Primary Care Networks
Primary care networks (PCNs) will build on the work already carried out by groups of
practices to work more closely together in the provision of ‘back office’ and patient facing
services. PCNs will enable greater provision of proactive, personalised and more
integrated health and social care.
Nominated GP leaders have worked closely with individual GP Practices, the Local
Medical Committee (LMC) and GP Federations, to develop PCNs across North Yorkshire.
This development provides one aspect of the foundation for PCN Clinical Directors to play
their crucial role in shaping and influencing the ICS and in ensuring that general practice
feels fully engaged.
PCNs were introduced in June 2019. Member practices have formed geographically
aligned Primary Care Networks typically serving natural communities of around 30,000 to
50,000, though some may be smaller, reflecting local conditions and rurality. They will now
progress through the NHSE maturity matrix for PCNs and identify population health
priorities, including focused action to reduce variation, and extend the range of services
available in out of hospital settings.
The developing Primary Care Strategy will aim to ensure that the PCNs in each of the
places can:
Lead and deliver local responsive and integrated services
Co-ordinate out of hospital care
Facilitate and promote peer review and sharing of good practice
Provide additional resilience
Develop arrangements to join up extended hours
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Improve outcomes for patients by delivering the seven mandated national service
specifications contributing to NHS Long Term Plan
Innovate and collaborate to deliver system benefits
Utilise investment in new roles to expand general practice workforce
Support PCN Accountable Directors.
12. Sustainability and Transformation Partnership (STP)/Integrated Care Partnerships (ICS)
Each of the three North Yorkshire CCGs are part of separate STPs/ICS and these are
identified below.
12.1 HRW CCG is a member of The North East & North Cumbria Integrated Care System (ICS)
Across County Durham and the Tees Valley, around 35,000 NHS staff serve a population
of 1.2 million people in specialist and local hospitals, in GP practices and community
settings, and at home.
The North East & North Cumbria and ICS is split into a number of smaller Integrated Care
Partnerships (ICPs) and HRW sits in the South ICP along with 3 other CCGs, namely
Darlington CCG, Hartlepool & Stockton-On-Tees CCG and South Tees CCG.
Across the ICS, historical performance in relation to constitutional standards has been
good. Individual variances were recognised and addressed through local plans and
performance recovery measures. The ICS has been addressing particular challenges in
relation to: cancer waiting times, A&E 4 hour standard and ambulance response times.
12.2 HaRD CCG is a member of West Yorkshire and Harrogate Integrated Care System (ICS) (WYH ICS)
The NHS and social care system in West Yorkshire and Harrogate provides care and
treatment to 2.6 million people. Across the partnership 113,000 staff are entrusted with a
budget approaching £5bn.
The West Yorkshire and Harrogate ICS is built from six local area plans. HaRD CCG is
one of them. This is based around the established relationships of the six Health and
Wellbeing Boards (HWB) and builds on their local health and wellbeing strategies. These
six local plans are where the majority of the work happens. The North Yorkshire CCG
Accountable Officer is the Senior Responsible Officer for cancer within the WYH ICS.
The ICS has then supplemented the plans with work done that can only take place at a
West Yorkshire and Harrogate level.
12.3 SR CCG is a member of Humber Coast and Vale STP
The Humber, Coast and Vale Health and Care Partnership (HCV) is a collaboration of 28
health and social care organisations who are working together to improve health and care
across its area and a population of 1.4 million.
The HCV established six place-based programmes of work in each of its six places; the
areas covered by the six CCGs within the partnership. These place-based programmes
are primarily working on achieving the first two priorities: healthier people and better out of
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hospital care.
In addition, there are three cross-cutting programmes of work across the whole of the HCV
area to plan services for the local populations. These programmes will help to achieve the
STP’s priorities: to improve hospital-based care, mental health care and cancer care.
Finally, HCV has established enabler programmes of work. This includes groups working
on communications and engagement, workforce and staffing issues, buildings and estates,
digital technology and finance.
12.4 STP/ICS current and planned handling strategy
The 3 CCGs have considered how the governance across the 3 STP/ICS currently
operates and have developed a proposed model (that is still emerging) for the operating
framework as we merge from April 2020 into one NY CCG. This is attached as a separate
document 1.4 STP/ICS Handling Statement.
13. Benefits realisation
As part of the transformation programme to become one CCG views and input from
stakeholders have been sought through strategic forums and meetings. In addition we
have been running a series of workshops with staff and with Governing Body members to
identify potential benefits of the merger. Workshops have taken place across North
Yorkshire and open invitations have been sent to all staff. The output from this work is
being built into a benefits realisation plan which will be owned by the Governing Body and
reviewed on a regular basis.
Key benefits identified include:
Proposed Changes Expected Benefits
Creation of single, large budget
As a larger organisation covering a wider area the CCG will have more bargaining power with larger contracts leading to savings in costs of licenses, contracts and other services
Increased influence on regional and national debate
Increase in North Yorkshire wide QIPP/efficiency schemes to deliver larger savings.
Introduction of single statutory committees
Reduction of number of attendees (in total) leading to time and cost savings.
Less time spent by staff preparing for and supporting meetings.
Introduction of single executive team
Less complex and more efficient working for partners
Stronger strategic relationships with partners
Restructure with single teams aligned with priorities
More staff time dedicated to priorities
Removal of duplication of effort
Less staff time spent researching and writing reports
Increased use of technology by staff and committee members
Reduction in travel costs
Carbon footprint reduction
Less time spent travelling
Increase in productive working time
Less time producing standard reports
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Introduce single set of working processes, procedures and policies
A Reduction in processes and procedures as three CCG systems become one (i.e. FOI, NHS Returns, Policy and SOP development) will lead to an increase in staff capacity
Reduce cost of systems
Reduce cost of support services
Shared view of demographic need
Increase in resource allocation across the county based on need
Improved patient outcomes
Joint commissioning with partners
Reduced complexity when jointly commissioning saving time for the CCG and for partners.
Stronger negotiating position leading to better value commissioning
Single commissioning voices and negotiation
Better value contracts
Reduction in unit costs for services
Staff time saved
Standardise best practice across the County
Reduction in bed days in hospital
Reduction in medication costs
Improvement in clinical outcomes
Reduction of waste within pathways
Improve patient satisfaction
North Yorkshire-wide training and development programmes
Better value training costs
Standardised service provision
14. Programme Management Office
A dedicated transition Operational Project team led by the Director of Corporate Services,
Governance and Performance, has been convened since April 2019 to manage the
transition to a future state and develop and implement a detailed plan e.g. finance,
governance, quality, human resources, communications, risk and issues. The project
team has been supported by NHS England throughout. This work will continue to develop
through the merger process, in particular taking into account feedback from member
practices and other stakeholders.
The Governing Bodies have committed the resources/capacity to support the merger
application and have commissioned additional support from NECS where required.
15. Financial Position
15.1 Financial context
All CCGs are expected to comply with NHS business rules. In recent years the three
CCGs have found it increasingly difficult to meet this requirement. The 2018/19 outturn for
the CCGs is set out in the table on page 16.
T
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2018/19
Financial Performance HaRD HRW SR Total £m £m £m £m
Expenditure 236.0 219.2 198.0 653.2 Allocation 226.0 216.3 186.1 628.4 In Year deficit 10.0 2.9 11.9 24.8 CSF -10.0 -3.0 -0.4 13.4 Deficit b/f 18.6 5.9 9.1 33.5 Deficit c/f 18.6 5.8 20.6 44.9
QIPP £ 4.4 7.5 5.5 17.4 % 1.9% 3.5% 3.0% 2.8%
The merging of the three CCGs will enable the creation of a more robust finance function,
better able to meet the demands of the future.
15.2 Financial Plans
The CCGs are developing financial plans in partnership with the other organisations in
their respective health systems. HaRD CCG (as part of the West Yorkshire & Harrogate
ICS), SR CCG with York (as part of the Humber, Coast & Vale STP) and HRW CCG (as
part of North East & North Cumbria and North East ICS). These plans are in the process of
being produced in line with the timescales, processes and assumptions of the three
STP/ICSs.
The CCG financial plan is based on the resources available to the CCGs. Revenue
allocations have been issued up to 2021/22 with indicative values for 2022/23 and
2023/24. The CCG will commence with an allocation of £673.1m being the aggregation of
the allocations of the three former CCGs.
These allocations reflect a varied ‘distance from target’ position. It is not known how the
allocation or distance from target for the merged CCG will be calculated. It is assumed that
the allocation will be an aggregation of the allocations of the existing CCGs.
On this basis the CCG will have an allocation of 2020/21 of £673.1m and opening
distances from target of:
Distance from target HaRD HRW SR
2019/20 2% 3.8% -1.4%
The CCGs plans show planned expenditure against resource allocations. These are
combined into a whole North Yorkshire CCG position. See Appendix 2 for the summary.
These plans are at a draft stage and will see the merged CCG with a year on year deficit
of £6.8m, a significant reduction from the year on year deficit of £18m in 2020/21.
Central to delivering these plans is the need to meet QIPP cost reduction targets. To
deliver the plan will require cost reductions of £72m over the five year period of the plan, at
an average of 2.1% of allocation.
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The delivery of these QIPP targets relies on the effective partnership working within the
three health systems:
York/Scarborough system: In partnership with Vale of York CCG and York Teaching
Hospitals NHS Foundation Trust;
Harrogate system: In partnership with Harrogate District Hospital NHS Foundation
Trust;
South Durham/Tees system: In partnership with the three acute providers and two
CCGs in south Durham and Teesside.
Each of these STP/ICS’s has their own project management arrangements to ensure the
delivery of expected efficiencies.
While these are predominantly acute based processes, the CCG will continue with its
historic success in delivering QIPP cost efficiencies through: effective medicines
management, looking to deliver QIPP savings in continuing healthcare by reviewing
processes and in particular working more closely with NYCC and work with primary care
though Primary Care Networks to reduce hospital based healthcare.
In meeting its cost reduction targets the merged CCG will be able to identify and adopt
best practice across the three existing CCGs, introduce a single project management
process to ensure delivery and benefit from economies of scale in the identification of
future areas of cost efficiency.
15.3 Running Costs
All CCGs are required to reduce their running costs by 20% by the end of 2020/21. This
will see the merged CCG reducing its running costs by £1m.
As part of the merged CCG’s desire to use its resources efficiently and to give value for
money, the CCG would be looking at how it could reduce its running costs as part of the
realisation of the benefits of the merger. As such the NHSE/I requirement regarding
running costs does not place an additional task on the CCG.
The merger of the three CCGs provides the opportunity to fully review running costs with a
view to economies of scale.
This process has already begun with a review of clinical leadership with the objective of
rationalising the clinical supports to the three Governing Bodies and re- focusing clinical
time to support clinical transformation. This has resulted in an estimated reduction in
running costs of £450,000.
The development of a single Executive Team for the three former teams is estimated to
reduce running costs by £360,000.
Running Cost Reduction HaRD HRW SR NY
£'000 £'000 £'000 £'000
Current running cost budget 3,365 3,074 2,478 8,917
Target budget 2020/21 2,968 2,711 2,185 7,864
Reduction 397 363 293 1,053
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The detailed staff structure is still to be developed. It is expected that the elimination of
duplication, doing things once instead of three times, the streamlining of processes etc will
enable running costs to be further reduced. A target of £250,000 is set against this area.
The CCGs are currently holding a number of vacancies. It is expected that this target will
be met without redundancies.
The merger of the three CCGs brings opportunities to reduce non staff running costs, for
example reducing travel costs by utilising technology to support delivery. This will be
reviewed to agree a cost for a single organisation. Opportunities to reduce costs by
standardising and using the merged CCG’s stronger buying power will be sought.
At present there is not a consistent definition of running costs across the three CCGs. The
running cost definition will be reviewed to give a single NYCCG definition.
The CCGs have a running cost realisation plan. This gives an over achievement against
the target reduction of £130,000, allowing headroom to accommodate running cost
pressures not covered in current budgets. The plan shows £810,000 of the target
reduction of £1m being low risk.
15.4 Financial Management
The merger gives the opportunity to review current practices and ensure ‘best practice’.
Work is progressing well on the development of a robust financial management system for
the merged CCG:
Since 1 July 2019 there has been a single Chief Finance Officer covering the three
CCGs. The substantive CFO has now been appointed and commences on 1 November.
A draft finance strategy has been produced. This has the overriding objective to
“Deliver and then maintain, through prudent control, sustainable financial viability in
order to enable the CCG to achieve its purpose and goals with its partners and
stakeholders across the North Yorkshire system and achieve the CCG’s statutory
financial duties”
To deliver this overarching objective the financial strategy sets out how the North
Yorkshire CCG with its partners will:
o Demonstrate robust financial management and control
o Deliver a robust Financial Recovery Plan to deliver a sustainable financial
position
o Deliver buy-in to financial recovery and sustainability
o Enable well informed decision making
o Enable effective prioritisation of spend
o Support incentives and innovation
o Maximise opportunities provided by capital, estate and technology
Work has already begun on the implementation of this strategy. The senior finance
team meet regularly to manage the coming together of the CCGs. Leads working
across the three CCGs have been identified for all areas of finance. These leads have
the role of coordinating and where possible standardising practices.
A single Scheme of Delegation has been approved by the three CCGs. This enables
consistent decision making across the three.
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The three CCGs now operate with Audit Committees in Common. The first meeting on
19 September received a single audit plan for approval. There is a joint Finance,
Performance, Contracting and Commissioning Committee (JFPCCC) whose first
meeting was 22 August. This committee is driving the development of more consistent
financial reporting.
The three existing CCGs have the same internal and external auditors, Audit Yorkshire
and Mazars. This will assist in the smooth transition to a single CCG. The Audit
Committees of the existing CCGs had approved internal audit plans for the current year.
This will be brought into a single audit plan and presented to the Audit Committee in
Common on 19 September for approval.
While there is still some way to go, the process of setting up robust financial management
in the merged CCG is well established and on track.
15.5 Merger Preparation: Finance
Fully operational financial systems and processes are fundamental to there being a
functioning CCG from 1 April 2020. In preparation for this:
A senior finance lead (one of the current Deputy CFOs) has been identified and is
leading the merger process. Workstream leads will be identified at the appropriate time
A project plan and risk log has been developed.
There has been a learning visit to Leeds CCG to benefit from their merger experience
and links have been made with the Bradford & Airedale finance team.
The Joint Audit Committee in September received a report on progress in merger
preparation.
The CCG is in the process of considering the workload implications of the merger process
on the finance team, particularly in the period January to April 2020.
16. Governing Body/ Members decision
The decision to appoint a single Accountable Officer and single and closer collaboration
between the three North Yorkshire CCGs was formally supported by the Governing Bodies
in Summer 2018. The decision to apply for merger was formally agreed in April 2019 by
Council of Members/ Clinical Representatives and Governing Bodies meeting as
Committees in Common. Following which the single Accountable Officer notified NHS
England of the plan to apply for the creation of the one new CCG for North Yorkshire from
1 April 2020. The table on page 20 sets out timeline of decisions of support and
communications.
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Date Meeting Detail
July 2018 Governing
Bodies
Single Accountable Officer/ single Executive structure
and closer collaboration between 3 CCGs supported by
NHSE agreed
December
2018
Single accountable officer appointed across North
Yorkshire CCGs
7 February
2019
Governing
Bodies (CsiC)
GBs agree to commence the necessary governance step
to develop joint governance arrangements across the 3
CCGs, including drafting of a model governance
structure.
14 March
2019
Joint Governing
Bodies
Workshop
The establishment of new joint committees was
discussed and agreed.
April 2019 Council of
Members /
Clinical
Representatives
And
Governing
Bodies Meeting
as CsiC (Formal
Meeting)
CoM/CR approved proposal to submit a merger request
in September 2019 to NHSE for the 3 CCGs to be
operational as one North Yorkshire CCG from April 2020.
CoM/CR made a recommendation for the Governing
Bodies to commit to work together to determine and
support the operating and governance model during
2019/20.
Noted decision made by CoM/CR that the Governing
Bodies will now commit to work together to help
determine the transitional arrangements and to support
the development of the operating and governance model
during 2019/20.
27 June
2019
Governing
Bodies CsiC
(Workshop)
Discussed Governance Structure in detail and agreed
new interim structure.
July 2019 Full Executive team appointment including interim CFO
(substantive November 2019)
July /
August
2019
Governing
Body Meetings
All Governing Bodies:
Noted that they have discussed and given feedback on
the North Yorkshire CCGs Governance Structure.
Approved the North Yorkshire CCGs Governance
Structure.
Approved to disestablish the CCG Governing Bodies
non-statutory Committees.
Agreed to make a recommendation to CoM/CR to
establish the new non-statutory joint committees.
Noted that the committees in the new structure will
convene inaugural meetings in order to discuss and
approve terms of reference.
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Date Meeting Detail
Noted the statutory committees (Audit, Primary Care
Commissioning and Remuneration) remain and meet in
Committees as Common until 31 March 2020.
Noted the update regarding Communications and
Engagement and that further work needs to be done
before a decision is made regarding the reporting and
governance arrangements of this group.
July /
August
2019
Joint
Committees
The following Committees met to discuss and agree the
terms of reference and make recommendations to
CoM/CR on 20 August 2019 to ratify terms of reference:
o Joint Business Executive Committee
o Joint Finance, Performance, Contracting and
Commissioning Committee
o Joint Quality and Clinical Governance Committee
September
2019
Statutory
Committees
The following meetings convened as Committees in
Common and each committee approved common terms
of reference:
o Audit Committees
o Primary Care Commissioning Committees
Pre- application panel with NHSE
Joint GBs workshop and CsiC ‘in public’ to approve
merger application submission
17. Issues and Risks
As part of the process of bringing together the governance arrangements of the 3 CCGs a review of the risk register took place in July 2019. An internal risk group is meeting monthly to oversee the delivery. The main risks facing the 3 CCGs are in the areas of:
Financial challenge
Being in 3 STP/ICS’s
Loss of local engagement
Loss of clinical leadership
Workforce The CCGs have mitigating actions against all these areas but the Governing Bodies and Audit Committees have asked to have regular updates.
18. Communications and Engagement
Since April 2019, we have been engaging with local people and organisations on a
proposal to create one CCG across North Yorkshire. Communications have described how
becoming one CCG is the logical next step following agreement in 2018 to appoint a single
operating team across the three CCGs, allowing us to take a more streamlined approach
to commissioning and to simplify our governance arrangements.
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The new organisation would be more efficient, enable operations at scale while retaining a
local focus, and be consistent with the NHS Long Term Plan.
18.1 Staff
Involving our staff has been central to our merger discussions. Since April 2019 we have
provided monthly updates and Q&A opportunities in sessions led by senior staff across all
three CCGs. A joint staff e-newsletter has been put in place to share information and
develop cross working. A staff working group has been operational since May to help us
ensure effective communications across the CCGs and develop our approach to the
merger. This partnership with staff will continue through the merger process as we shape
the North Yorkshire CCG.
18.2 Patients and the Community
We held sessions with the patient representative group of each CCG to understand
perceived benefits and any concerns about the proposed merger. This intelligence has
helped us articulate our approach and has informed our thinking on future engagement
with patients and their representatives across the CCGs. We have also issued general
briefings on the proposed merger to our virtual networks. In addition we used our summer
2019 Annual General Meetings (AGMs) as an opportunity to discuss the merger and
gather views from patients and the public. We have developed a survey document which
we distributed at our AGMs and which is also available electronically, to enable people to
share their views.
18.3 Local Authority Engagement
The proposed North Yorkshire CCG will sit entirely within North Yorkshire County Council
(NYCC). NYCC colleagues are supportive of the proposed merger and we have letters of
support from Cllr Carl Les, leader of the council and Cllr John Ennis, Chair of the Scrutiny
of Health Committee. We have also shared our proposals and invited feedback from
leaders of the local district councils across the existing CCGs (Harrogate Borough Council,
Hambleton District Council, Richmondshire District Council, Ryedale District Council and
Scarborough Borough Council).
18.4 Provider and Partner Engagement
We have shared our proposals and invited feedback from leadership of NHS Trust
partners which provide services across the CCGs as well as with neighbouring CCGs, and
members of the volunteer and community sector. Feedback from all partners is
summarised below.
18.5 YORLMC
We have met and worked with YoRLMC (covering NY CCGs and Vale of York CCG) in
developing the strategy, PCNs and the wider clinical leadership model and have received
a letter of support.
18.6 Healthwatch Engagement
We have met with HealthWatch North Yorkshire. They support the merger proposal and
the opportunity to be part of quality and engagement discussions within the new
governance structure. As with other stakeholders, they have encouraged us to maintain
Page 23 of 28
high standards in transparency, accountability and quality as we transition to a new
organisation.
18.7 Integrated Care Systems /Sustainability and Transformation Partnerships
The proposed North Yorkshire CCG is part of three Sustainability and Transformation
Partnerships /Integrated Care Systems (STP/ICS). We are working through the
implications of this with the three STP/ICSs and NHSE to identify the most effective way to
retain the strong links which currently exist and provide measurable benefits for the people
we serve.
18.8 Engagement Feedback
Partners and the community are encouraging about the proposal to merge and endorse
the benefits this will bring, including:
Greater efficiency, and streamlining in the decision making process.
Shared good practice and adopting the best from each of the three existing CCGs.
Consistency in approach to commissioning.
Reduce the ‘postcode lottery’.
The opportunity to address historic financial challenges, and ensure that NHS pounds
are spent in the best way possible.
The enhanced ability to engage strategically with our partners.
We have been encouraged to:
Ensure we retain our local and clinical focus as we transition to a new organisation.
Ensure transparency and accountability even though we may be operating on a larger
footprint.
Monitor patient delivery through transition to ensure there is no disruption or
deterioration in service.
Make sure we retain our local patient voice.
Address concerns that money will flow into the most deprived areas.
Contributions from partners, communities and our staff have helped us develop our plans
so far and engagement continues. Up to date information is available on all CCG websites.
Intelligence gathered from our partners and public is helping us shape our engagement
strategy for the new NYCCG. We have also been continuing regular conversations with
our patient engagement groups to discuss how we best ensure the local voice is retained
in future commissioning decisions, including making the most of this opportunity to do
things differently and better in the future.
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19. Signatures
I can confirm that the decision to apply for the merger is made in accordance with each of
the existing CCG’s governance arrangements.
Signed by: Single Accountable Officer: Amanda Bloor
Date: 30 September 2019 Clinical Chairs: Dr Charles Parker, Hambleton, Richmondshire and Whitby CCG Date: 30 September 2019 Dr Alistair Ingram, Harrogate and Rural District CCG
Date: 30 September 2019 Dr Phil Garnett, Scarborough and Ryedale CCG
Date: 30 September 2019
Page 25 of 28
20. Appendix 1. Map of proposed CCG boundary and location of Primary Care Networks and GP practices
Page 26 of 28
21. Appendix 2. The 3 CCG Financial Long Term Plans
HaRD HRW SR NY
2020/21 2021/22 2022/23 2023/24
£m £m £m £m £m £m £m £m
Expenditure 242.7 225.8 197.7 666.2 691.8 706.9 725.5 745.6
Allocation 234.7 224.2 192.9 651.8 673.8 693.4 716.5 739.6
In Year deficit 8.0 1.6 4.8 14.4 18.0 13.5 9.0 6.8
CSF -8.0 -1.6 -4.8 -14.4 0.0 0.0 -1.0 -1.0
Deficit b/f 18.6 5.8 0.0 24.4 44.9 63.0 76.5 84.5
Deficit c/f 18.6 5.8 0.0 24.4 63.0 76.5 84.5 90.3
QIPP £ 4.8 3.8 7.8 16.4 15.2 13.4 13.4 13.5
% 2.0% 1.7% 4.0% 2.5% 2.3% 1.9% 1.9% 1.8%
NY CCG
2019/20
Page 27 of 28
22. Abbreviations used in this document
A&E Accident & Emergency
AGM Annual General Meeting
AHSN Allied Health Science Network
BCF Better Care Fund
BI Business Intelligence
BPAS British Pregnancy Advisory Service
CCG Clinical Commissioning Group
CFO Chief Finance Officer
CsiC Committees-in-Common
CoM/CR Council of Members/Clinical Representatives
EIA Equality Impact Assessment
FOI Freedom of Information
GB Governing Body
GMS General Medical Services (contract)
GP GP General Practitioner
HCV Humber Coast and Vale (STP)
HDFT Harrogate and Rural District NHS FT
HRW CCG Hambleton, Richmondshire and Whitby CCG
HaRD CCG Harrogate and Rural District CCG
HWBB Health and Wellbeing Board
ICS Integrated Care System
JFPCCC Joint Finance, Performance, Contracting and Commissioning Committee
LA Local Authority
LMC Local Medical Committee
LTP NHS Long Term Plan (10 year Plan)
MOU Memorandum of Understanding
MSP Managing Successful Programmes
NECS North of England Commissioning Support
NHS National Health Service
NHSE NHS England
NY North Yorkshire
NYCC North Yorkshire County Council
PCN Primary Care Network (of GPs)
PCT Primary Care Trust
PHE Public Health England
PHM Population Health Management
PSED Public Sector Equality Duty
Q&A Questions & Answers
QIPP Quality, Innovation, Productivity, Prevention
Page 28 of 28
SLB System Leadership Board
SOP Standard Operating Procedure
SR CCG Scarborough and Ryedale CCG
STHFT South Tees Hospitals NHS FT
STP Sustainability and Transformation Partnership
TCP Transforming Care Partnership
TEWV Tees, Esk and Wear Valley NHS Foundation Trust
VoY CCG Vale of York CCG
YAS Yorkshire Ambulance Service
YHN Yorkshire Health Network
YORLMC Local Medical Council
YTHFT York Teaching Hospital NHS FT
