Minutes. 1 Welcome: JG welcomed everyone to the meeting, including LD and informed them that she will be Chairing the meeting on behalf of MB.

Transcription

1 Clinical Commissioning Leadership Group (CCLG) Held on 23 rd November 2017, Room 1.08, Castlewood, Clevedon. Minutes Present: Jeanette George (JG) (Chief Operating Officer, NS CCG) Kevin Haggerty (KH) (Clinical Lead - Urgent Care) Mike Jenkins (MJ) (Clinical Lead Mental Health) Jeremy Maynard (JM) (Clinical Lead Quality) Jackie Green (JGr) (Deputy CFO-North Somerset) Miriam Ainsworth (MA) (Clinical Lead Community services) Tony Ryan (TR) (Clinical Lead Children s and Maternity) Debbie Campbell (DC) (Head of Medicines Management, NS CCG) Colin Bradbury (CB) (Area Director) In attendance: Sonia Galley (SG) (Minute Taker) By invitation: Rorie Jefferies (RJ) (Senior Contract Manager-North Somerset) attending for Jo Underwood Marie Davies (MD) (Head of Commissioning for Quality for Bristol, North Somerset and South Gloucestershire) attending for Susan Masters Angela Stinchcombe (AS) (Deputy Head of Medicines Management) Mark Hemmings (MH) (Transformation Programme Lead for Maternity, Children & Young People s Services) Colin Bradbury (CB) (Sustainability Board Programme Director) Lodee Dudley (LD) (Public Health Consultant) representing Natalie Field and Sheila Smith Apologies: Mary Backhouse, Chair (MB) (Clinical Chair, NS CCG) Julie Kell (JK) (Associate Director of Transformation) Georgie Bigg (GB) (Chair of Healthwatch North Somerset) Joanna Underwood (JU) (Delivery Director) Rachael Kenyon (RK) (Clinical Lead Planned Care) Item No 1 Welcome: JG welcomed everyone to the meeting, including LD and informed them that she will be Chairing the meeting on behalf of MB. Action 2 Apologies: Apologies as noted above. 3 Declarations of Interest: MJ asked if there was a declaration of interest for GPs reference item 14. Page 1 of 11

2 KH confirmed that there would not be any financial gain from this item. None were received. 4 Good News Stories: MJ informed the meeting that the BNSSG Executives have signed up to the Time to Change Programme which is a staff mental health programme. Carleigh Nuttall is leading on this. 5 Chair s Reflections: JG reported that it is currently a very stressful time for the Senior Management Team and the Executive PAs who are at the start of their 30 day consultation meetings for phase 2 of restructuring. JG asked for everyone to be mindful of their interactions with affected colleagues. Support mechanisms for staff have been rolled out across BNSSG. JG confirmed that she is in discussion with Kate Rush about the Clinical Leader s process and this will become clearer. KH said that the job descriptions had not yet been distributed. Action 81: JG to ask MB about the Clinical Leader s job descriptions and application process. JG 6 Minutes of meeting held on 26 th October 2017: The minutes were agreed as a true record. 7 Action Log: Action 54: Closed. Action 74: Closed. New Action 82: To put this item on the CCLG January agenda. Action 77: Closed. This issue is being looked at in the STP Musculoskeletal Group headed by David Jarrett. Scoping work is being reported on and this item will return to CCLG. New Action 83: Fractured neck of femur reporting. Action 78: Closed. Action 79: Closed. Action 80. Closed. MD MD 8 Finance Report: JGr delivered the Finance Report. There has not been very much change since the last CCLG meeting in October. Two major risks highlighted were: NCSO Drugs cost has increased each month to 600K per month across BNSSG. Although to note that NSCCG forecasting Page 2 of 11

3 is to break even. Savings - 83m target of which North Somerset (NS) is only 3m off control total. The 4.9m deficit should be hit which is better than last year. KH asked about ambulatory care concerns. JGr replied that this was picked up in Weston Area Health Trust (WAHT). There is a big increase in short stay admissions in WAHT and NBT, both of which are being investigated. NHS England (NHSE) have informed the CCG that it needs to report on what is being paid for ambulatory care. RJ informed the meeting that the Quarter 1 letter the CCG has sent to the Trust summarising all outstanding contractual issues noted that an initial audit into zero length of stay had raised sufficient concerns for a wider and more robust audit to be required. The timing of the audit has yet to be fixed and this was noted in the Quarter 2 letter, which would be sent shortly. Action 84: Ambulatory Care to be put on the CCLG agenda for next year. SG MA asked if the WAHT emergency department night time closure affected ambulatory care. JG replied that admissions to WAHT had reduced but repatriation back is not happening as patients are being discharged directly back to their homes, which has an impact on WHAT activity and thus funding. 9 Performance Report: RJ delivered the Performance Report on behalf of JU. He noted that access and performance trends had broadly continued in September, drawing attention to the following: A&E NBT and WAHT waits had improved slightly on their year to date position, with UHB remaining static High occupancy at NBT was leading to delays for beds and impacting significantly on performance UHB were conducting a six week improvement programme WAHT were launching primary care streaming and had recruited additional middle grades Elective Care Performance across BNSSG providers had remained consistent, with very little movement on previous months Diagnostics UHB, NBT and WHAT are not meeting the diagnostic standard. Page 3 of 11

4 WAHT s endoscopy suite will open 8 December after refurbishment. Lack of capacity is the main reason for diagnostic underperformance and the Trust is expected to be compliant early in the new year. 62 Day Cancer Standard WAHT performance continues to be below standard and has worsened in recent months. A new cancer manager and lead nurse have been appointed and the focus of the organisation is on clearing the longest waiters in order to improve performance in the medium and long terms. The CCG has asked for an assessment of what this means for performance and a revised Remedial Action Plan (RAP) if appropriate. 09:28 AS entered the room 10 Prescribing Participation Scheme Reports from 2016/17: Angela Stinchcombe delivered this report. Appendix 1:Antimicrobial Stewardship: This project was commenced to support the national focus to reduce inappropriate prescribing of antibiotics. NSCCG achieved the Quality Premium, but more work is needed. UTIs are an issue for most GP practices and there is varied practice across the CCG area. As part of this work a patient form detailing symptoms was introduced for submission with urine samples, along with detailed guidance and symptom checklists for care homes residents. UTIs remain a focus for 2017/18. Audit results have indicated both otitis media and cellulitis were being inappropriately treated with Co-Amoxiclav so OptimiseRx messages have been added to GP systems to flag this to prescribers at the point of prescribing. Further audits highlighted that prescribers need to ensure the correct antibiotics and correct course length for sore throats are prescribed in line with national & local antibiotic guidelines. Appendix 2: Implementation of BNSSG COPD Guidelines: The Chronic Obstructive Pulmonary Disease (COPD) project in 2015/16 highlighted potential over-prescribing of triple therapy in COPD (ICS+LABA+LAMA) in some patients. With no national guidance available for stepping these patients down, the Medicines Management Team (MMT) worked with secondary care to develop ways to identify appropriate patients for stepping down (no exacerbation in the last 18 months or pneumonia) and guidance on how to step down or stop the ICS component. During the lifetime of the project new evidence emerged that LAMA/LABA combinations increase patient s quality of life if there Page 4 of 11

5 are no exacerbations. This work led to new EMIS codes for identification of patients who had stepped down, could be considered for stepping down or not suitable for stepping down. Appendix 3: Preventing Acute Kidney Injury (AKI): AKI is a rapid deterioration of renal function and was a national focus in 2016/17. Prompt recognition of symptoms and treatment leads to improved prognosis. The results show AKI coding improved in patients at high risk of AKI; U&Es not checked in patients within 2 weeks of initiation or dose change on ACE-I/ARB fell; annual U&Es in patients taking nephrotoxic medicines and not being tested fell. Recommendations made included adding automatic Read Codes when protocols initiated for improved audit trail; educate all members of the practice team in the importance of regular bloods and adhering to practice protocols on blood testing frequency. Appendix 4:Preventing Unplanned Admissions: This was a retrospective review of 6 months medical records post unplanned admissions to see if the admission could have been prevented, and to provide future learning. National and local priorities identified 4 areas with high levels of unplanned admissions: exacerbation of asthma or COPD; AKI or diabetics with symptoms of hypoglycemia. The aim was to check all medicines, ensure there was a process in place to reconcile medicines post-discharge and if the discharge information was received in a timely manner. 62% of patients discharged had medication issues. Only 3% of admissions were due to hypoglycemia (similar to prevalence). 93% of discharge summaries were received within 7 days. 09:39 MD entered the room 11 Quality Report: MD delivered the Quality Exceptions Report. Notable Practice: BNSSG CCGs: ED Observational Visits to North Bristol NHS Trust (NBT), Weston Area Health Trust (WAHT) and University Hospitals Bristol NHS Foundation Trust (UH Bristol) the BNSSG Quality Team has completed assurance visits to the Emergency Departments (EDs) at NBT and WAHT, a visit to UH Bristol s ED is due to take place in the near future. The purpose of the visits is to monitor the quality of care in the ED and provide support to the Trust in preparing for a future CQC visit. The key themes to be monitored include managing capacity and meeting the 4 hour target, Delivering Care, Measuring Impact, Getting staffing right, Patient experience and Page 5 of 11

6 Staff experience. Following each visit a report of the findings and any recommendations arising from the visit will be shared with the Trust. VTE - NBT applied for exemplar status and held a VTE exemplar event attended by the interim Associate Director of Nursing and Quality on 26 October 2017 to present their application information to Executives from Kings College London. NBT received positive feedback from Professor Arya for their presentation processes, outcome and innovation and he was able to inform them that they would be awarded exemplar status. Hot Off the Press Issues: Never Events UH Bristol have now reported 7 Never Events since April (1 has subsequently been stood down.) This includes 2 Never Events reported in October, 1 wrong tooth extraction and one retained foreign object. It has been agreed following discussion at the October Quality Sub Group meeting that a Contract Performance Notice (CPN) will be issued to the Trust. As a result of issuing the CPN the Trust will be required to produce a remedial action plan. Acute Services: WAHT: Areas of Concern: SHMI - for January 2017 to March 2017 this is at , a reduction from the January December 2016 figure of which removed WAHT from the reported 10 outlying Trusts with higher than expected mortality. Data is reported on the Dr Foster website on a quarterly basis. Action being taken: the Mortality Review Group Meetings is now held on a Thursday so the new Medical Director and the GP Clinical Quality Lead can both attend. An action plan is in place detailing progression of work being undertaken along with provision of minutes from each meeting held. The CCG s GP Clinical Quality lead will work with the Medical Director to improve on the medical concerns in the areas flagged up on the Dr Foster National website and will continue to review any new areas highlighted as data evolves. Other crude mortality data produced by the Trust is showing an improved position. KH asked what the time intervals were. JM replied that it was reported on 12 months retrospectively, every 3 months. Page 6 of 11

7 VTE - reporting compliance data has shown a slight increase from 78.55% in August to 81.04% in September However this remains below the target of 95%. Action being taken: Two CPNs have been issued to the Trust (December 2016 and March 2017) in relation to the poor compliance for VTE. A remedial action plan has been formulated by the Trust. The CCG has suggested that WAHT links with NBT to share best practice and learning to facilitate the required improvements to compliance. Discharge letters - the CCG have raised concern regarding the Trust being unable to meet the contractual requirement to issue a discharge letter for every patient within 48 hours. Incidents continue to be reported from GP s pertaining to discharge letters (via the CCG DATIX system) and remain one of the leading themes. Action being taken: The Trust has a Quality Improvement Plan in place that is taking forward actions to improve discharge communication with GPs including reducing duplicate copies of letters, implementing E- discharge and Junior Doctor training. An update on progress was presented by the Trust to the October 2017 Quality and Performance group. The Trust has highlighted that financial input is needed to improve the system compatibility with providers. The Trust is planning a further update to the monthly GP forum on the progression being made. A second Contract Performance Notice (CPN) was issued in March 2017 and the CCG requested a Remedial Action Plan (RAP) with an improvement trajectory. Monthly monitoring of progress against the RAP continues via the Quality Sub Group. JM commented that there must be a focus on the quality of the discharge letter. However I.T. is a problem for WAHT and there would be a significant charge for this to be rectified. MD showed a safety thermometer slide to the members which demonstrated an increase in urinary tract infections in Weston. MD outlined the approach being taken to examine this issue which includes the development of a joint WAHT and North Somerset Community Services group. MD also reported on the Quality Dashboard as shown in the BNSSG Performance, Quality and Activity Report Month /18. Page 7 of 11

8 This report goes to Governing Body in December 2017 and then will be sent out to the GP practices for feedback across BNSSG. Performance is measured against the NHS Constitution. Only the dashboards are shown in this report. Mixed Sex Accommodation Breaches were reported as 1, which was one of the NSCCG patients in Lincolnshire. Datix trying to unify the approach across BNSSG however an options appraisal to look at potential systems will need to be undertaken. MJ asked if there would be a Primary Care section when this is taken over. MD confirmed there would be and that a dashboard is being developed. MA asked what would be reported on. MD replied potential areas could include incidents (Serious Event Audit (SEAs), CQC Outcomes, and patient experience measures. These are currently under discussion. CB asked if VTE will be going into the Performance and Quality report. JM confirmed that there is a trajectory for Weston VTE. Action 85: report to CCLG results of a deep dive on the position of VTE in WAHT and Rorie Jefferies CPN data. MD/JM 10:10 MD left the room. 12 Draft BNSSG CCG Constitution: JG distributed hard copies to the group. JG informed members that this report had just come out. The notes in the report are there for information. Louise Rickitt has been the lead on this. This has been sent to all member practices for consideration with immediate feedback required. It will then be considered in GP Forum in December and it will be then voted on for approval. The deadline for return to NHSE is the end of December An extension to the deadline is being requesting, to extend to 14 th January 2018, but NHSE may not agree to this. South Gloucestershire members will also vote on this but Bristol will not as their constitution delegates approval to their Governing Body. It has been future proofed as much as possible and has been minimised with what is included. Even minor future changes would mean that approval would need to be sought from members and from NHSE, so the proposed constitution has been kept as simple as possible. This has also been discussed and commented upon at a Governing Body Page 8 of 11

9 closed session. KH asked about voting rights for merging practices, asking if a small GP practice would have the same weight as larger merged practices. JG replied that this was being clarified. LD commented on section 5.2 (e) Accountability, and advised softening engagement to participation. JG said that there was a need to make sure that the local council officers and Director of Public Health had the opportunity to comment on this. Action 86: JG to check with MB how she would like to communicate with Mike Jackson (NS Council). MA asked who they were to respond to. JG replied it would be Louise Rickitt. Action 87: SG to distribute Louise Rickitt address for responses. JG SG 13 The Future of the CCLG within the new BNSSG: Colin Bradbury delivered this item. There was a discussion about the way the North Somerset Area may set up its Commissioning Localities in order to best meet the needs of the local population. Considerations included how to manage the interface with the Weston & Worle and Woodspring Provider Localities and other key partners such as the Local Authority. This needs to happen whilst at the same time being very clear that we are operating corporately within a single BNSSG approach. It was agreed that however Commissioning Localities in North Somerset are configured (i.e. whether we have one or two) that there will need to be the flexibility to speak and act at an Area level in some cases, whilst at other times (for example when designing/ implementing Healthy Weston or Healthy Woodspring) operate at a more local level. There will also need to be the capability to coordinate work that crosses locality boundaries both within BNSSG and with Somerset. Action 88: CB to ensure the further detail on Commissioning Localities is shared with CCLG members and a process developed to confirm the number of Commissioning Localities within North Somerset. CB 14 Funding for CAHMS: MH delivered this verbal presentation. MH delivered this verbal presentation which set out the current challenges to the provision of local CAMHS services. The BNSSG Page 9 of 11

10 Commissioning Executive will consider proposals for service development and investment for 18/19 onwards. As with all proposals of this nature, the case needs to be made as to how any further investment will deliver tangible and sustainable benefits for the population, set against the context of the wider commissioning priorities of the CCG. It was established that, whilst the pattern of investment over the past few years has been different across CCGs, the spend per head on CAMHS services in North Somerset (according to RC Psych figures) is in line with national averages. CCLG members agreed that they had a clear understanding of the position. 11:10 MH left the room. 15 Turnaround Steering Group Minutes: a) 18 th October 2017 b)1 st November 2017 The CCLG received and noted the minutes. 16 Medicines Management Advisory Group (MMAG): 5 th October 2017 The CCLG received and noted the minutes. 17 GP Forum: 13 th September 2017 The CCLG received and noted the minutes. 18 Any Other Business: MJ noted the safety issues around Star Rectopexies. New procedures are being put in place. 11:21 RJ left the room. 19 Map of Medicine Exit Proposals: DC presented this paper. Map of Medicines (MOM) have withdrawn some of their functionality. From end March the auto population function of referral form functionality and side bar will cease. The pathways will still be available at this stage, but without the side bar will not be pushed to the clinicians in the same way, but it is envisaged the pathways will also stop at some point. Therefore needs to be decided what alternatives can be put in place. In terms of referral forms The preferred way forward is to have EMIS templates. Pre-population is difficult but once an EMIS template is available will have similar functionality. It was discussed that Remedy the system being built by Bristol CCG can hold the forms and potentially Page 10 of 11

11 be the alternative to hold the clinical pathways in the future All agreed with moving to EMIS templates and with Remedy being a potential BNSSG wide solution in the future. Agreed that the current localised pathways need retaining and must not be lost. There is a financial requirement to the decision including committing to Remedy immediately and will need a lot of support to make it fit for purpose. Some Bristol GPs are using it. A Commissioning Executive paper will be required for Bristol and south Gloucestershire CCGs to agree whether Remedy is the future BNSSG pathway system. To summarise: A paper to go to the Commissioning Executive meeting to ascertain the support for Remedy as a BNSSG solution Referral forms would need to be on EMIS templates. If it was approved the MOM information would need to be put onto Remedy. MOM is paid for up to May A solution needs to be in place soon. The CCLG: Noted the contents of this report and attached Project Initiation Document (PID) Confirmed acceptance of the offer from Map of Medicine (MOM) via the PID Agreed the proposal to move referral forms into EMIS web templates Decided to wait for the next Commissioning Executive meeting. A decision was agreed to be deferred until February days notice would be required. Action 89: Decision on way forward regarding MOM exit proposals. To be put on February 2018 CCLG agenda. SG Agreed the proposal that the Remedy website used in Bristol & South Gloucestershire will be used to hold pathway information going forward from March 2018 (subject to a further proposal on Remedy being the pathway system of choice and model of delivery being agreed by Commissioning Executive) The meeting closed at 11:45 Page 11 of 11