Agenda and Papers. NHS West Kent Clinical Commissioning Group Governing Body. Tuesday 24 th February 2015 At 1.30 pm

Transcription

1 Agenda and Papers for the NHS West Kent Clinical Commissioning Group Governing Body To be held on Tuesday 24 th February 2015 At 1.30 pm at The Village Hotel, Castle View, Forstal Road, Sandling, Maidstone ME14 3AQ Page 1 of 83

2 Notice is hereby given of the meeting of the NHS West Kent CCG Governing Body meeting to be held on Tuesday 24 th February 2015, at 1.30 pm 3.00 pm, at The Village Hotel, Castle View, Forstal Road, Sandling, Maidstone, ME14 3AQ This meeting will be held in public. Questions from the public The Chairman will take questions from the public relating to items on the agenda or other aspects of the CCG business. A G E N D A Part 1 Chairman is Dr David Chesover *Papers for approval Time Agenda no. Agenda Item Lead Required Action 1.30 pm 22/15 Questions from the public Chair TO DISCUSS 1.40 pm 23/15 Welcomes and Introductions Chair TO NOTE 24/15 Apologies for Absence Chair TO NOTE 25/15 Quorum Chair TO NOTE 26/15 Declaration of Members Interests 27/15* Minutes from the previous meeting held on /15 Actions arising from the previous meeting held on /15 Matters Arising from the meeting held on not covered elsewhere on the agenda. Chair Chair Chair Chair TO NOTE FOR APPROVAL Pages 5-14 TO DISCUSS AND NOTE Page 15 TO DISCUSS AND NOTE Page 2 of 83

3 Chief Member Reports and Strategy Papers 1.50pm 30/15 Chairman s Report Chair ORAL REPORT 31/15* Chief Officer s Report Ian Ayres TO NOTE Pages pm 32/15 Microsystems Coaching Progress Report Gail Arnold TO NOTE Pages pm 33/15* Medicines Optimisation Scheme Gail Arnold APPROVAL Pages Performance and Assurance Reports 2.20pm 34/15 Quality Report Dr Meriel Wynter TO NOTE Pages pm 35/15 Integrated Performance Report Reg Middleton TO NOTE Separate attachment 35.1/15 NHS 111 Performance Report Dr Mark Whistler Pages pm 36/15 Corporate Risk Register Francesca Guy TO NOTE Pages & separate attachment 2.55pm 37/15 Chief GP Commissioner and Clinical Strategy Group (CSG) Report and minutes Gail Arnold TO NOTE Pages /15 Practice Engagement Committee (PEC) Report Dr Garry Singh TO NOTE Pages Resolution: Finish 3.00 pm That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest. Page 3 of 83

4 Date of the next meeting: Tuesday 24 March 2015, 1.30 pm 3.30 pm, The Village Hotel, Maidstone Dates of Future Meetings Tuesday 28 th April 2015, 1.30 pm 3.00pm, The River Centre, Tonbridge Page 4 of 83

5 DRAFT MINUTES of the Governing Body meeting Held in Public Meeting held on Tuesday 27 th January 2015 at at The River Centre, Medway Wharf Road, Tonbridge, Kent TN9 1RE Date of Approval: Present: Dr Bob Bowes Ian Ayres Dr Nick Cheales Dr David Chesover Dr Nic Goodger James Hedges Dr Mark Ironmonger Dr Tony Jones Reg Middleton Daniel Monie Dr Andrew Roxburgh Dr Garry Singh Dr Sanjay Singh Sue Southon Malti Varshney Dr Mark Whistler Dr Meriel Wynter In attendance: Mr Tony Broadrick Francesca Guy Richard Segall Jones Louise Matthews Observing: Alistair Smith Steve Golding Apologies: Gail Arnold Alison Brett Dr Bruno Capone Dr Tim Palmer Chair of the Governing Body Chief Officer/Accountable Officer GP Governing Body Member GP Governing Body Member Secondary Care Clinician Lay Member for Governance GP Governing Body Member GP Governing Body Member Chief Finance Officer Deputy Chief Nurse (on behalf of Alison Brett) GP Governing Body Member Chair of PEC and Finance and Performance Committee and GP Governing Body Member Chief GP Commissioner and GP Governing Body Member Lay Member for Patient and Public Engagement Public Health Consultant and Governing Body Member Chair of the UCB and GP Governing Body Member GP Governing Body Member Patient Participation Group Chair (Observer) Deputy Company Secretary Company Secretary Deputy Chief Operating Officer Lay Member, Finance and Performance Committee Lay Member, Audit Chief Operating Officer/Deputy Chief Officer Acting Chief Nurse Governing Body Member GP Governing Body Member Page 1 of 10 Page 5 of 83

6 1/15 Questions from the public Ms Sian Burr, from Marden Patient Reference Group, asked the following questions: 1. The proposals are that out of hours care will be covered by: GPs out of hours service; GPs at A&E, A&E and enhanced response services. How do patients access the correct service? Do they Ring 111? Is this service the filter that directs to the appropriate service? Will social services, which are proposed to be part of the integrated services, have an out of hours duty? Ian Ayres responded that the proposals would not change how patients accessed out of hours services, which would remain via NHS 111. Mr Ayres confirmed that there would be no change to social services. 2. The Mapping the Future plan was put forward some time ago, and the summary event took place in June and September How much further has the plan been implemented, particularly the integration of services? The Chair responded that Mapping the Future set the strategic vision for the healthcare system in West Kent and this had been given further impetus by Simon Stevens Five Year Forward View. Further developmental work was now required to work through the detail of the plan and in particular what the future provider landscape would look like in West Kent. 3. The aims for Kent s Emotional Wellbeing Services have initial cost implications. Are the funds available and are some funds available from the education budget? The Chair responded that funds were available from Kent County Council (KCC) and the Health and Wellbeing Board would be responsible for agreeing the delivery of the services. Cllr Richard Davison commented that a planning application had been submitted to build up to 300 houses in Edenbridge. Cllr Davison commented that this would have an impact on the local infrastructure and asked whether there was sufficient GP capacity to take on these additional patients. The Chair responded that the GP workforce fell under the remit of NHS England and advised Cllr Davison to raise the matter with them. Malti Varshney commented that she would also raise the issue with KCC and feedback to Cllr Davison. Action: Malti Varshney Cllr Davison reported that the kitchens at Edenbridge Hospital had been out of action since September Mr Ayres agreed to follow this up. Action: Ian Ayres 2/15 Welcomes and Introductions The Chair welcomed Daniel Monie, Deputy Chief Nurse, to the meeting who was attending on behalf of Alison Brett. Page 2 of 10 Page 6 of 83

7 3/15 Apologies for absence Apologies had been received from Dr Bruno Capone, Dr Tim Palmer, Gail Arnold and Alison Brett. 4/15 Quorum The Chair confirmed that the meeting was quorate. 5/15 Declaration of Members Interests Dr Nic Goodger reported that he was now the Divisional Medical Director for East Kent Hospitals. The Chair declared that he had written a piece on public engagement for the South West Kent Health Federation's application for the Prime Minister's challenge fund, for which he neither offered nor received payment. 6/15 Minutes from the previous meeting held on 16 th December 2014 The minutes from the meeting held on 16 th December 2014 were approved. 7/15 Actions arising from the previous meeting held on 16 th December 2014 The following actions were discussed: 193/14: Dr Garry Singh reported that he planned to establish a sub-committee of the Patient Engagement Committee (PEC) to review education /14: The Chair questioned whether the PEC terms of reference needed to come back to Governing Body for approval. Action: Richard Segall Jones 8/15 Matters Arising from the meeting held on 16 th December 2014 not covered elsewhere on the agenda There were no matters arising from the previous meeting. 9/15 Chairman s Report The Chair reported that he had taken part in Dry January, together with Dr Tony Jones and Dr David Chesover. The West Kent Health and Wellbeing board had discussed the possibility of arranging other health promotion initiatives, such as a cyclathon. 10/15 Chief Officer s Report Mr Ayres reported that the Federations had submitted bids to the Prime Minister s Challenge Fund for four primary care hubs across the patch. WK CCG supported this Page 3 of 10 Page 7 of 83

8 application. Mr Ayres reported that KCC and Kent Community Health NHS Trust (KCHT) currently operated an integrated store for some of the equipment for patients living at home or in care homes. CCGs and KCC had agreed to procure a single stores arrangement, providing health and local authority funded equipment, which would require a section 75 agreement. The Governing Body agreed to give delegated authority to the Accountable Officer to approve the section 75 agreement. Mr Ayres gave an update on the progress of the clinical microsystems coaching pilot and noted that so far feedback had been positive and other practices were keen to join the pilot. A further update would be provided by the Chief Operating Officer at the Governing Body meeting in March /15 Care Plan Management System Update Keith Price joined the meeting to give an update on the Care Plan Management System project and noted that the contract with Orion was due to be signed shortly. Reg Middleton added that, in signing the contract, officers would be mindful of the parameters mandated by the Governing Body. The Chair asked what progress the Governing Body could expect to see and by when. Mr Price responded that the first phase of the project would involve 10 to 15 GP practices and would focus on the care plans for top the 2% of patients who were at greatest risk of unplanned admission to hospital. It was anticipated that the system would be up and running by April Sue Southon noted that additional CAPEX was due to be released from NHS England and asked whether Mr Price was confident that this funding would be spent by the end of the 2014/15 financial year. Mr Middleton responded that the additional 200k funding from NHS England had not yet been confirmed, however plans had been based on the basis that the funding would be secured and spent by the end of the financial year. Ms Southon asked whether the CCG was working with the CSU to develop the communications plan. Mr Price responded that the communications plan had been developed a while ago in discussion with the CSU. 11/15 Operational Planning Mr Ayres opened the discussion by stating that the purpose of this agenda item was to provide the Governing Body with a briefing on the instructions that had been given to CCGs on the creation and submission of their plans. Mr Ayres commented that the CCG was only able to plan for one year due to the upcoming general election, however planning would need to be seen as part of a longer term strategy. Mr Middleton gave an update on NHS funding in 2015/16, proposed allocation by commissioning stream and the impact on WK CCG. CCGs would need to understand the Page 4 of 10 Page 8 of 83

9 deliverability and phasing of the cost savings that they were required to achieve. Louise Matthews gave an update on the key headline areas for commissioning and the priorities for operational delivery in 2015/16. Ms Matthews drew attention to the key dates in the planning timetable. Ms Varshney noted that this linked to the report on potential years of life lost and asked what the CCG s strategic direction was in relation to stroke and cancer services. Mr Ayres responded that the CCG was in discussion with Maidstone and Tunbridge Wells NHS Trust (MTW) about how to improve performance in relation to stroke care, however it was unlikely that any changes to the service would be introduced before the general election. Mr Ayres added that it was not yet clear what the strategy would be in relation to cancer services and further work would need to be done to understand what factors were driving performance. Dr Sanjay Singh welcomed the earlier receipt of resilience funding which would allow the CCG to plan resilience earlier in the year. Mr Middleton endorsed these comments but noted that there would be a reduction in allocation compared with previous years and therefore the resources would need to be prioritised. Mr Middleton added that, although the CCG would receive an increased allocation, the underlying deficit position would consume a level of resource from the cash increase that the CCG would receive next year. The financial position would therefore continue to be challenging in 2015/16. 12/15 Learning Disabilities Integrated Commissioning Mr Ayres introduced the paper and reported that learning disabilities services had undergone a process of integration. There was a good arrangement between the CSU and KCC in Kent, however the governance was not in place to make this arrangement legitimate. This would require a section 75 agreement and the paper outlined the process of developing the section 75. The Governing Body was therefore asked for approval of the direction of travel, noting that this would not change the services on the ground for learning disabilities. Dr David Chesover added that the CCG mental health team had been very actively involved in the development of the section 75. Ms Varshney asked whether there was any opportunity to work more closely with NHS England given that the front end of services for learning disabilities sat within primary care. Mr Ayres responded that this would be commissioned through the core GMS contract. The CCG would work with NHS England on the whole of the learning disability pathway, however the section 75 agreement would not touch on primary care. The Governing Body unanimously approved the direction of travel as set out in the paper to work towards an integrated commissioning arrangement for learning disability, with KCC as the lead agency with a pooled health and social care budget under a section 75 agreement. Page 5 of 10 Page 9 of 83

10 13/15 Care Homes Business Case James Hedges introduced the paper and noted that the paper was for approval, rather than ratification as stated in the paper. Richard Segall Jones reported that the proposal was presented to Governing Body by officers and had been agreed by the Clinical Strategy Group (CSG). The GP members of the Governing Body were asked to abstain from voting on the proposal due to the conflict of interest presented by the proposal to pay GPs 80 per advanced care plan (ACP). Approval would therefore be by the non-gp members of the Governing Body. Louise Matthews reported that the business case had been discussed by CSG and 6 options had been considered. The CSG had recommended option 6: to invest in both ACPs for high intensity care home residents and the one year Intensive Support Team (IST) pilot for a targeted 20 care homes. 144k was required for 1800 ACPs to be undertaken by GPs plus 168k for the IST. This equated to a total cost of 312k, however 200k would be from reinvested VMO LES monies with an additional investment required of 112k. Mr Ayres reported that he and Mr Middleton had discussed the proposed rate for the ACP and had agreed that it was fair and proportionate to the work required. The proposal had also been discussed with the Lay and Independent members of the Governing Body and would be subject to retrospective scrutiny by the Audit Committee. It had been agreed that going forward any conflict of interest would be reviewed by the Audit Committee prior the proposal being presented to the Governing Body. Ms Southon added that the Lay and Independent members had received assurance that the ACPs did not duplicate anything in the GP contract. Mr Hedges asked whether the milestones for the pilot had yet been established. Dr Whistler responded that these were in the process of being developed. Mr Hedges commented that it would be helpful if these were available for the discussion at the Audit Committee in March. Ms Varshney commented that for ACPs to work effectively, buy-in would be needed from other parts of the system, such as the ambulance service and hospitals. Ms Matthews commented that this would be discussed as part of the contracting round. Mr Whistler added that the care plans were more likely to be used if they were high quality. Ms Southon commented that she supported the discontinuation of the VMO LES scheme and that this was an attractive proposal, however she would like to have seen more engagement with care home residents and suggested that this should be done for any future proposals. Ms Southon commented that consideration should be given to the following: Whether there was sufficient capacity to meet the level of consultant input required in IST; How the CCG could demonstrate that this proposal would be an integrated care service, given the significant emphasis on integration and collaboration; Whether the care manager be seconded from KCC; Page 6 of 10 Page 10 of 83

11 How this proposal would relate to patients who were not in a care home, but were receiving care at home; How patients and relatives were supported in the decisions about ACPs; Whether the regular review of ACPs would be the responsibility of the GPs. Dr Sanjay Singh commented that this was a short-term strategy that allowed a number of concepts to be tested, which would inform the long term strategy. Dr Singh agreed that patient engagement would be key to the success of the pilot. The proposal also sought to bring equity to the resources available without significant additional expenditure. Dr Singh agreed that the suggestion to second a KCC manager was a good one. He also added that responsibility for reviewing the plan would rest with the GP. Dr Tony Jones commented that this proposal provided an opportunity for collaboration with the ambulance service. The care plan would support them to make the decision to leave a patient at home. The Care Homes business plan was approved by the Lay and Independent Members of the Governing Body, subject to the following caveats: The development of the milestones for the IST pilot; Review by the Audit Committee. 14/15 Transforming Outpatients Department Dr Nick Cheales introduced this item and noted that Governing Body approval was required regarding the 2015/16 commissioning intention for the following: The continuation of the Transforming Outpatients programme with further specialties onto KinesisGP and more practices included; To invest in Transforming Outpatients Department as an invest to save initiative; To realise total net savings of 938, 300 by reducing outpatient attendances, follow up appointments and reducing the number of steps in a patients pathway. Dr Cheales commented that behaviour change was fundamental to the success of the project and it would therefore take time to embed. Dr Cheales added that, although KinesisGP was easy to use, the functionality was currently limited and there were plans to further develop the system in the future. Mr Ayres commented that the system-wide IT strategies needed to be more closely aligned. Dr Chesover congratulated Dr Cheales on taking the programme forward and maintaining colleagues enthusiasm to use the system. Dr Chesover supported the proposal to add mental health and suggested that this was an opportunity to use primary healthcare specialists. Ms Southon commented that this was a very good business case. Ms Southon asked whether there was any feedback from those GPs who had not used KinesisGP. Ms Southon Page 7 of 10 Page 11 of 83

12 suggested that written information could be provided to patients to highlight that this service could be used. Ms Southon also suggested that the criteria for success should include patient satisfaction. Dr Cheales responded that most practices had used KinesisGP at least once. There were always early adopters and late adopters and it took time to change behaviours, however no strongly negative feedback had been received. Dr Ironmonger commented that he was finding it easier to speak with consultants and he would not want to see this programme overshadow this. The Governing Body approved the business case. 15/15 Quality Report Dr Wynter noted that the Quality Report was presented in a new format and she sought Governing Body feedback on the new format. Dr Wynter highlighted the key elements of the Quality Report. Dr Wynter also noted that the Quality Team was undergoing a self-assessment, the results of which would be fed back to Governing Body in the next 2 months. Mr Monie reported that the data for c.difficile only included the first two weeks of the month. A couple of the cases related to West Kent residents who had attended out of area hospitals. Mr Monie noted that increased resource in the Quality Team meant that the team was able to work more closely with providers. Ms Southon added that the Quality Report was discussed in detail by the Quality Committee. Ms Southon asked for assurance on the public engagement process for the development of the model of care for stroke services. Mr Ayres responded that this was a joint piece of work undertaken by WK CCG and MTW and that it would need to go out to formal consultation. The KCC Health Overview and Scrutiny Committee had confirmed that it was content with the proposed approach. 16/15 Health Outcomes for the Population of West Kent Ms Varshney commented that this report was a follow up to the report presented to the Governing Body in November and examined West Kent s position relative to the other six CCGs in Kent. Ms Varshney noted that West Kent s ranking had declined for stroke and certain cancers, which suggested that a greater emphasis was needed on prevention initiatives such as smoking cessation and healthy weight. Dr Garry Singh suggested the CCG would benefit from having a GP lead for cancer. Dr Singh also commented that it would be useful to have more data on localities and practices to understand where further work needed to be done. Ms Varshney supported the proposal to have a GP lead for cancer and commented that the health equity audit would help to identify those areas which required greater focus. Page 8 of 10 Page 12 of 83

13 Mr Ayres commented that the deep dive needed to cover all cancers, including those which did not have a screening programme. Dr Sanjay Singh commented that this would help to inform the development of the cancer strategy. The Chair asked whether there was any way of measuring the benefit from prevention schemes. Ms Varshney responded that return on investment tools were being developed. The Governing Body noted this report. 17/15 Integrated Performance Report Mr Middleton reported that the financial and performance position reflected the recent pressures the local system had been under. Mr Middleton reported the following for the month of December 2014: There had been a deterioration against the A&E standard and performance levels had yet to be restored to the levels that they had been before winter. This has been a national problem and local performance has been in line with national performance ; Ambulance response times had shown a deterioration; There had been 22 mixed sex accommodation breaches; Planned care continued to hold up; There had been no occurrences of 52 week breaches; The planned surplus position had improved due to the return of funds from NHS England relating to Continuing Healthcare national risk pool monies. However, NHS England expected the CCG to deliver a higher surplus as a result of the return of this funding. 18/15 Equality and Diversity Annual Report 2014 Ms Southon introduced this item and noted that the CCG was required to publish an annual Equality and Diversity Report. The Governing Body approved the Equality and Diversity Annual Report for /15 Chief GP Commissioner and Clinical Strategy Group Report Dr Sanjay Singh gave an update on the key items of discussion at the CSG meeting on 10 th February 2015: The CSG had discussed and approved the Care Homes Business Case; The CSG had received an update on Romney Ward and had noted that clinical objectives were being met. A discussion followed about the funding options for the ward; The CSG had agreed that clinical leads should be identified as champions for particular projects going forward; The CSG had approved the Medicines Optimisation Scheme for 2015/16, subject to Page 9 of 10 Page 13 of 83

14 one amendment, which would be presented to a future Governing Body meeting for approval. 20/15 Practice Engagement Committee Report Dr Garry Singh reported that the Practice Engagement Committee had discussed the following at its last meeting on 6 th January 2015: Current A&E performance; An update on the Pharmacy First scheme. An evaluation of the scheme was currently underway; Kent and Medway Mental Health Crisis Care Concordat; Co-commissioning and had agreed that a decision about co-commissioning should be deferred until after the general election; until such time, the approach should be one of closer involvement. 21/15 Audit Committee Report Mr Hedges gave an update on the items of discussion at the last Audit Committee meeting on 13 th January 2015: The GP members of the Governing Body had been invited to attend Audit Committee meetings as observers. The Chair of the Governing Body had been invited to attend the meeting at which the draft annual report and accounts would be discussed; The Audit Committee discussed the status of the flood protection at Wharf House. The Committee had been assured that in the event of a flood, staff would be able to work at the Station Road site in Maidstone. The server was now located off site and therefore the CCG would be able to continue to operate in the short term; The audit report from TIAA on asset disposal had now been completed. Date of next meeting The next meeting of the Governing Body is on Tuesday 24 th February at the Village Hotel, Maidstone at 1.30pm. Page 10 of 10 Page 14 of 83

15 Actions of West Kent CCG Governing Body Meeting Action No (in Action Date of Responsibility Progress and outcome date accordance completion with agenda no) 25/11/ /14 Dr Tim Palmer (via the Medicines Optimisation Group) to review the content of the Pharmacy First leaflet to ensure that it was clear what service the pharmacist would provide. February 2015 TP Underway. The evaluation of the Pharmacy First Scheme is due to be completed in February The content of the leaflet will be reviewed on the back of this evaluation. 27/01/2015 1/15 Malti Varshney to contact the planning team at Sevenoaks Council and provide them with the relevant NHS contact details. 27/01/2015 1/15 Ian Ayres to find out from Edenbridge Hospital when the kitchens were likely to be up and running again. 24/02/2015 MV Action complete. 24/02/2015 IA Page 15 of 83

16 Chief Officer s Report This paper is for: Information For further information or for any enquiries relating to this report please contact: Ian Ayres (Chief Officer / Accountable Officer) Date: 13/02/15 Reporting Officer: Ian Ayres (Chief Officer / Accountable Officer) Agenda Item: Lead Director: Ian Ayres (Chief Officer / Accountable Officer) Version: final Report Summary: this report lists number of documents of reports issued by NHS England or other bodies which Governing Body Members need to be aware of. FOI status: This paper is disclosable under the FOI Act Strategic objectives links: Board Assurance Framework links: Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment Various Various Not applicable None Failure to comply with requirements set out in these documents may put the CCGs Authorization or reputation at risk Report history: Appendices Next steps: None None None Page 16 of 83

17 Chief Officer s Report The following reports/papers have been received from NHS England and other organisations which the governing Body need to be aware of. Integrated Equipment Stores The Governing Body meeting in January 2015 authorised the Accountable Officer to sign a S75 Agreement to cover existing arrangements and the re-procurement of a new single provider for the Local Authority and Health. The agreement has now been finalised and signed. Procurement of a new provider for an integrated equipment store has now commenced, led by Kent County Council. Lead Officer: Reg Middleton / Ian Ayres Better Care Fund S75 The establishment of the Better Care Fund for 2015/16 requires a Section 75 agreement between Health and the Local Authority. Locally this has been agreed as a single S75 signed by all CCGs and KCC. There will be CCG specific schedules setting out local governance, performance management arrangements, and spending plans for each CCG and aligned KCC spending. Development of the S75 has been led by CCG CFOs (with external legal advice) and the final document will be ready by 27 th February. The Kent wide Health and Wellbeing Board on 18 March will agree the final BCF plan and partners will need to sign the BCF S75 agreement after that meeting. Initial KCC and West Kent expenditure in 2015/16 as set out in the BCF is a continuation of 2014/15 expenditure on a range of services. This will be reviewed during 2015/16 to consider how the money might be more effectively spent in a joined up manner. Any proposed changes will be brought back to the Governing Body for approval. The Governing Body is asked to delegate Authority to the Accountable Officer to sign the S75 after the 18 March Health and Wellbeing Board. Freedom to Speak Up: Report by Sir Robert Francis On 11 February Sir Robert Francis published his report on the Freedom to Speak Up review. In his report Sir Robert sets out 20 Principles and Actions which aim to create the right conditions for NHS staff to speak up, share what works right across the NHS and get all organisations up to the standard of the best and provide redress when things go wrong in future. Page 17 of 83

18 Sir Robert s proposals include: action at every level of the NHS to make raising concerns part of every member of staff s normal working life a Freedom to Speak Up Guardian in every NHS trust a named person in every hospital to give independent support and advice to staff who want to speak up and hold the board to account it fails to focus on the patient safety issue. a National Independent Officer who can support local Guardians, to intervene when cases are going wrong and identify any failing to address dangers to patient safety, the integrity of the NHS or injustice to staff a new support scheme to help good NHS staff who have found themselves out of a job as a result of raising concerns get back into work. The full report can be found at: Lead officer: Ian Ayres / Alison Brett NHS England 2015/16 National Tariff Proposals On the 29 January 2015 Monitor announced the results of the consultation on the 2015/16 National Tariff. Around 13% of clinical commissioning groups (CCGs), 37% of relevant providers by number, and 75% of relevant providers by share of supply, objected to the proposed method for determining national prices for NHS services. Under the legislation governing the NHS payment system, the proposals cannot be introduced if the proportion of CCGs, or the proportion of relevant providers (by number or weighted by share of supply), who object to the method equals or exceeds 51%, unless there is a reference to the Competition and Markets Authority. As the share of total tariff income received by the objecting providers exceeds 51%, the National Tariff cannot be introduced in its current form at this stage and its implementation will be delayed. Monitor and NHS England are now considering the feedback received from the consultation and possible next steps, in the context of what the legislation permits in the event that an objection threshold is breached. Page 18 of 83

19 Further details can be found at: Lead Officer: Reg Middleton Commissioning Support Lead Provider Framework The Lead Provider Framework is now live and ready for use by CCGs and other commissioners to buy any combination of support services from. The range of organisations that have met the demanding quality and value for money thresholds include a combination of CSUs, their partners and independent sector consortia. South East Commissioning Support Unit (SECSU) have been appointed to the framework Further details available from: Lead Officer: Ian Ayres 360 CCG Stakeholder Survey The 360 CCG stakeholder survey will be conducted by Ipsos Mori on behalf of NHS England in March 2015, with an expectation that all CCGs will take part. The survey is an integral part of the CCG annual assessment and provides an opportunity for CCGs and their stakeholders to critique and further develop working relationships. Lead Officer: Richard Segall-Jones Report on transforming services for people with learning disabilities NHS England, along with other national partners, has published a report that sets out the next steps to transform services for people with learning disabilities and/or autism. Transforming Care Next Steps outlines work to be delivered by NHS England, the Local Government Association, the Association of Adult Social Services, the Care Quality Commission, Health Education England and the Department of Health, to improve how we care for people with learning disabilities by providing care in community settings, closer to home, and significantly reducing the number of people in hospital settings. Further details available from: Lead Officer: Dave Holman Page 19 of 83

20 NHS Clinical Commissioners On 20 January 2015 NHSCC and NHS England hosted a joint webinar to go through the draft refresh of the 2015/16 CCG Assurance Framework. The webinar was chaired by NHSCC Director Julie Wood and Anthony Kealy from NHS England presented. The slides detailing the draft refresh can be found here: Lead Officer: Ian Ayres Page 20 of 83

21 Update on Introduction of Clinical Microsystems within West Kent CCG This paper is for: Information Recommendation: That the Governing Body notes the attached progress update. For further information or for any enquiries relating to this report please contact: Gail Arnold, Chief Operating Officer Date: February 2015 Reporting Officer: Gail Arnold Agenda Item: 32/15 Lead Director: Gail Arnold Version: FINAL Report Summary: The report provides a progress report on implementing clinical microsystems within West Kent CCG and specifically notes those practices currently working on this agenda and the focus of these microsystems. FOI status: This paper is disclosable under the FOI Act Strategic objectives links: Board Assurance Framework links: Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment Delivering high quality care to the patients of West Kent CCG Improving the performance of primary care Creating a foundation for the establishment of new primary care Included in report Use of supporting primary care monies Report history: Appendices N/A None West Kent CCG Front Sheet Page 21 of 83

22 Introduction The introduction of clinical microsystems within West Kent CCG was supported by the board and forms a key part of the utilisation of the 5 per patient funding for commissioning services to support practices in their delivery of the avoiding unplanned admissions enhanced service. The clinical microsystem approach is supported by the Dartmouth Institute; our coaches have been trained by them and they are training and supporting clinical microsystems around the world. A clinical microsystem is formed from a group of people involved in delivering front line services to patients. Its focus is on the delivery of quality improvement in the care given to this group of patients and the resulting outcomes. Each clinical microsystem is facilitated by a microsystem coach who works with the practice to support the quality improvement initiative which is the focus of the microsystem. A key part of the microsystem is the involvement of the patient within it. Within each microsystem area there should be display boards so that the whole practice understands and engages with what the microsystem is trying to achieve. Reimbursement for backfill of one GP and either the practice manager or practice nurse (as appropriate to the project) is provided by the CCG from the available funding. In West Kent CCG the level of implementation for this programme of clinical microsystem is a single general practice. West Kent CCG is the first organisation in the UK NHS to implement clinical microsystems in primary care. Progress to Date The first 5 coaches have successfully completed both their clinical microsystem training and the academic course. Each coach is working with a microsystem team within a General Practice from West Kent CCG., with a plan to work with a second practice soon. The implementation of this project started slowly in the CCG. It has been difficult to gain engagement from practices and feedback suggests this is due to the pressures currently facing general practice, the difficulties with conveying the concept and setting it contextually within the commissioning strategy of the CCG. Being able to describe the plan and its objectives in language which easily related to the business of primary care and hearing the coaches personal reflections rather than documented commentary has increased engagement and now take up of the clinical microsystems offer. The global aim set by the CCG for Clinical Microsystems in West Kent is the reduction in unplanned attendances and admissions in acute hospitals. Currently there are 5 microsystems in progress, focusing on a range of initiatives, in the following practices: West Kent CCG Front Sheet Page 22 of 83

23 Tonbridge Medical Group focus on patients who frequently use urgent care pathways and children who attend A&E Thornhills Surgery achieving BP compliance in the diabetic population Edenbridge Surgery managing the increasing volume of telephone calls to the practice Snodland Surgery The surgery is currently analysing data collected in the microsystem to identify their specific aim but likely to be around alternative solutions for patients who frequently access urgent care services Wallis Avenue managing the use of GP appointments for over the counter medications by patients in receipt of free prescriptions Those practices that have started their microsystem and are engaged with coaching are reporting a positive experience and improvement momentum is growing. A further four coaches are just embarking on the training programme and the CCG is currently identifying the four practices with which they will be working and introductory meetings with practice teams will be taking place shortly. In addition there are now a further five practices waiting to start on the programme. These five will become the second wave microsystems for each of the first five coaches who were trained. At the initiation of the clinical microsystem, each practice embarks on a brainstorming of potential areas for focus. On average each practice has three areas on which they would like to focus and it is the intention of the coaches to remain with each practice to complete the first three initiatives. Therefore within the next six months it is likely that c. 42 microsystems will have been formed. Other points of note The pace of progress in each practice varies. If insufficient progress or engagement is being seen in a clinical microsystem then a decision will need to be made whether to cease the initiative, especially given the number of initiatives identified and the waiting list of practices wishing to start. Whilst it was initially envisaged that the clinical microsystems would be related to the business of practice support teams, this is not the case in all the microsystem focus areas. Coaching Reflections Feedback received from one of West Kent CCG s coaches: This has been an exciting opportunity to learn new skills and to make a significant change to improve quality and processes in Primary Care. The pace of work in Primary Care is often such that there is no time to reflect, think and implement changes based on evidence. What we have seen demonstrated is how important protected time can be to allow a multiprofessional team to get together to reflect and change Practice resulting in quality West Kent CCG Front Sheet Page 23 of 83

24 improvements in the care and services delivered to patients. By breaking down barriers and flattening hierarchy all can be involved. Small steps can lead to significant improvements. I have been challenged by this opportunity but value the skills I have learnt and see potential for making significant changes to Primary Care. Key Risks for the Programme a. The ability of the CCG to identify and train potential coaches to keep up with the number of practices wishing to join the clinical microsystem initiative. b. The ability of the coaching team to sustain delivery in each of the microsystems being established and to balance this against the delivery of their day job. c. The availability of staff able to provide support services to the microsystem ie data analysis and graphic representation, patient engagement, communications support, production of displays. d. The ability of the practices to sustain their commitment to the microsystem. Recommendations The Governing Body is asked to note this progress report. West Kent CCG Front Sheet Page 24 of 83

25 Medicines Optimisation Scheme This paper is for: For Approval Recommendation: The Governing Body is asked to approve the Medicines Optimisation Scheme for 2015/16 For further information or for any enquiries relating to this report please contact: Dr Tim Palmer, GP, MOG Chair: Priscilla Kankam, Lead Pharmacist: Date: 24 th February 2015 Reporting Officer: Priscilla Kankam Agenda Item: 33/15 Lead Director: Version: Final Report Summary: The GP element of the prescribing budget accounts for 14% of the whole NHS West Kent CCG budget and therefore possesses a significant risk if appropriate financial stewardship measures are not adopted. The Medicines Optimisation Group (MOG) is seeking approval form the committee in order to implement the 2015/16 prescribing incentive scheme also known as the Medicines Optimisation Scheme (MOS). The aim of the scheme is to promote and increase evidence based cost effective prescribing in line with the National Institute for Health and Clinical Excellence (NICE) Medicines and Prescribing Centre (MPC) and local guidance (e.g. NHS West Kent CCG Medicines Optimisation Group (MOG), The scheme had been developed with input from a wide range of health care professionals and other primary care support workers. The scheme has proved an effective way to influence change in practices and improve Prescribing over a number of years, without such a scheme in place the areas focused on would take a number of years to change and improve practice. Funding for the scheme is set at maximum of up to 1.00 per registered patient (using list size held at the beginning of the financial year). The funds for the incentive scheme will be top-sliced from the annual prescribing budget. NHS West Kent CCG Page 25 of 83

26 The scheme will be monitored, validated and moderated by the MOG The MOS has supported the delivery of the strategic aims and objectives of the CCG in the last 2 years and has delivered significant savings on the prescribing budget. The Governing Body is asked to approve the implementation of the MOS scheme. FOI status: This paper is disclosable under the FOI Act; Strategic objectives links: Board Assurance Framework links: Strategic Goal C: Improved health outcomes and reduced health inequalities Strategic Goal E: Deliver sustainable finances Strategic Goal F: Ensure robust governance A/C: Failure to make the strategic changes needed to deliver Mapping the Future may result in a local healthcare system that - is unsustainable in the long term - is unable to ensure high quality accessible services for local people - does not deliver improved outcomes and reduced inequalities Identified risks & risk management actions: Resource implications: E: Loss of control over provider activity and system finances could result in the CCG being unable to invest in service development and ultimately breaching its statutory duties. Failure to deliver on one of the strategic goals of the CCG: Deliver sustainable financial balance on the prescribing budget. Outlined in the document Legal implications including N/A equality and diversity assessment Report history: N/A Appendices Appendix 1 Next steps: Implementation Phase March 2015 NHS West Kent CCG Page 26 of 83

27 Executive summary The GP element of the prescribing budget accounts for 14% of the whole NHS West Kent CCG budget and therefore possesses a significant risk if appropriate financial stewardship measures are not adopted. The Medicines Optimisation Group (MOG) is seeking approval form the committee in order to implement the 2015/16 prescribing incentive scheme also known as the Medicines Optimisation Scheme (MOS). The aim of the scheme is to promote and increase evidence based cost effective prescribing in line with the National Institute for Health and Clinical Excellence (NICE) Medicines and Prescribing Centre (MPC) and local guidance (e.g. NHS West Kent CCG Medicines Optimisation Group (MOG), The scheme had been developed with input from a wide range of health care professionals and other primary care support workers. The scheme has proved an effective way to influence change in practices and improve Prescribing over a number of years, without such a scheme in place the areas focused on would take a number of years to change and improve practice. Funding for the scheme is set at maximum of up to 1.00 per registered patient (using list size held at the beginning of the financial year). The funds for the incentive scheme will be top-sliced from the annual prescribing budget. The scheme will be monitored, validated and moderated by the MOG The MOS has supported the delivery of the strategic aims and objectives of the CCG in the last 2 years and has delivered significant savings on the prescribing budget. The Governing Body is asked to approve the implementation of the MOS scheme. Introduction The NHS spends over 11 billion per year on prescribing medicines; the most frequent medical intervention. It is therefore a priority to encourage cost effective evidence based prescribing both for improving health outcomes and financial management. Improving the quality of prescribing within West Kent CCG is a key priority for the Medicines Optimisation Team (MOT) and the CCG as a whole. For NHS West Kent CCG, spend on prescribed medicines was approximately 67million for with expected growth in the region of 3-4% for The purpose of this paper is to seek approval from the Governing Body to implement a Prescribing Incentive Scheme for practices within the CCG for The paper describes the aims, objectives of the scheme, the development and consultation process and how the scheme will be implemented and monitored by the Medicines Optimisation Team and Group. It goes on to describe the success of the scheme over the past two years and outlines the aspirations and challenges. Page 27 of 83

28 Background Over several years, West Kent Practices have worked hard to contain primary care prescribing costs whilst maintaining and improving quality. Incentive schemes have facilitated this work along with the support of the MOG, prescribing advisors and the practice based pharmacy technicians. For 2015/16 the MOG decided to utilise the approach employed in to ensure that the good work undertaken in the past few years continue to deliver on the desired outcomes. The aim of the scheme is to promote and increase evidence based cost effective prescribing in line with the National Institute for Health and Clinical Excellence (NICE) Medicines and Prescribing Centre (MPC) and local guidance (e.g. NHS West Kent CCG Medicines Optimisation Group (MOG)), which in turn, will improve prescribing quality and patient safety and reduce risk from medication errors whilst supporting prescribing spend within budget. Principles of the scheme The scheme is available to all GP practices in NHS WKCCG. The scheme should reward improvement in patient care and health outcomes. It is therefore important that the MOS does not simply reward low cost prescribing, but should include criteria relating to the quality of prescribing. To ensure financial stability within NHS WKCCG, it is vital that NHS WKCCG and its member practices maintain control of prescribing costs. However, a reduction of costs at the expense of patient health or healthcare is not acceptable. The scheme should encourage practices to consider both quality and cost, and hence cost-effectiveness of their prescribing, and reward practices appropriately. Finance Funding for the scheme is set at maximum of up to 1.00 per registered patient (using list size held at the beginning of the financial year). The funds for the incentive scheme will be top-sliced from the annual prescribing budget. Payments made to practices under the scheme will be held by the CCG until payment is made. The incentive payment is made in line with the rules/legislation of Department of Health. The scheme is expected to deliver a saving in the region of 1.2m on a 370,000 investment on the assumption of 80% practice participation and achievement. Page 28 of 83

29 Development of 2015/16 scheme Ideas for the scheme were collated after discussions were held between the Medicine Optimisation Team members. These ideas were taken to the MOG and in turn generated further discussions including practice prescribing habits. Projects in the scheme were chosen to be in line with both National Priorities and local needs. Practices, Pharmacists, and pharmacy technicians were all involved in deciding the projects for the year. The 2015/16 scheme has been designed to focus on the four guiding principles of medicines optimisation which are: 1. Aim to understand the patient`s experience 2. Evidence based choice of medicines 3. Ensure safe use of medicines 4. Make medicines optimisation part of routine practice The scheme is structured to deliver on the strategic aims of the CCG and will focus on safety, quality and value for money. Some aspects of the scheme are ongoing, building on the success of the previous year, for example, QIPP projects. Safety This is covered by the inclusion of the following projects in the scheme Eclipse Live system a clinical risk system in prescribing which identifies those at risk of medicine related emergency admissions to ensure incidents of avoidable harm from medicines will be reduced, patients will have more confidence in taking their medicines, remain well with reduced admissions and readmissions to hospitals related to medicines usage. Audit of New Oral Anticoagulants (NOACs) and Low Molecular Weight Heparin (LMWH) a high risk medication. Quality The scheme has key areas which requires practices to focus on ensuring optimal patient outcomes are obtained from choosing a medicine using best evidence (for example, following NICE guidance, local formularies and guidance etc.) and these outcomes are measured. Antibiotic prescribing Benzodiazepine prescribing Practices are also required to meet with a pharmacist during the year to discuss all medicines related issues including controlled drug prescribing. During the meeting the pharmacists have the opportunity to highlight poor prescribing practices and work with the practices on areas of concern. Page 29 of 83

30 Value for money To ensure that the most appropriate choice of clinically and cost effective medicines (informed by the best available evidence base) are made that can best meet the needs of the patient. In addition to more cost effective choices of a medicine, treatments of limited clinical value are not used and medicines no longer required are stopped. Combination of the above contributes towards the CCGs Quality, Innovation, Productivity and Prevention (QIPP) agenda. The MOG agreed to use an individualised QIPP plan approach to ensure that practices concentrate on areas which would produce greatest benefit in contributing to the outcomes of the scheme. The MOG also agreed that in order to maximise potential, the scheme should be launched earlier in the year and the monitoring period extended over 9 months and not limited to a quarter as in previous years. Monitoring of the scheme Progress of the scheme is monitored on a monthly basis throughout the year by the MOT members and practices are advised of corrective actions to undertake to mitigate any risks to achieving the. Individualised progress reports (MOS Tracker) will be sent to each practice and summarised via a similar locality report, being presented at Patch Meetings throughout the year. Validation of the scheme The MOG will oversee validation of the scheme at the end of the financial year. A moderation process will be considered for each practice if necessary. Governance is assured through the MOG which in turn feeds into the CSG and Practice Engagement Committee (PEC). Risks and mitigating actions 1. Lack of practice engagement in the scheme. A member of the medicines optimisation team will arrange to meet with the prescribing lead and practice manager of each practice to promote the scheme. 2. Failure to implement recommendations. Regular reports will be presented to the Medicines Optimisation Group (MOG) on practice progress. Regular reports will be issued to practices on progress of individual projects. Technicians aligned to practices to support and engage practices in the MOS agenda. Regular feedback from prescribers to the MOG through practice visits and patches meetings. Page 30 of 83

31 3. Staff capacity to support practices Effective workforce planning to ensure practices is well supported throughout the year. Staff training and retention is key to the delivery of the project. Success of the previous year s scheme The scheme has proved an effective way to influence changes in prescribing habits and improve efficiencies. The MOG has employed the principles and format outlined above for the past 2 years. The MOS scheme generated a saving of 2,618,000 on an investment of 412,615 and the is on track to deliver a saving of 926,000 on an investment of 368,000 (based on 80% practice achievements). Delivery o 2014/15 has been particularly challenging because of factors which are beyond the control of the MOG, the MOT and primary care prescribers in general. This includes impact of Category M drug price changes which had an adverse effect to the tune 500k to the prescribing budget in this financial year. Category M was introduced in April 2005 when the new community pharmacy contractual framework was launched. It was used to set the reimbursement prices of over 500 medicines and is a principal price adjustment mechanism to ensure delivery of the retained margin guaranteed as part of the contractual framework. It uses information gathered from manufacturers on volumes and prices of products sold plus information from the Pricing Authority on dispensing volumes to set prices each quarter. As it is set in advance on a quarterly basis, CCG s and prescribers have do not have any influential levers. Recommendations The Governing Body is asked to consider the information provided above and Approve the Medicines Optimisation Scheme Next steps Scheme launched to all practices on the 1 st of March Monthly monitoring by the MOG Interim report to the Audit Committee end of Page 31 of 83

32 Medicines Optimisation Scheme DATE: Page 32 of 83 Patient focused Providing quality improving outcomes

33 NHS West Kent CCG Medicines Optimisation Scheme Introduction The NHS spends over 11 billion per year on prescribing medicines; the most frequent medical intervention. It is therefore a priority to encourage cost effective evidence based prescribing both for improving health outcomes and financial management. This paper sets out the 2015/16 Medicines Optimisation Scheme (MOS) for NHS West Kent Clinical Commissioning Group (NHS WKCCG). Aims and Objectives The aim of the scheme is to promote and increase evidence based cost effective prescribing in line with the National Institute for Health and Clinical Excellence (NICE) Medicines and Prescribing Centre (MPC) and local guidance (e.g. NHS West Kent CCG Medicines Optimisation Group (MOG)), which in turn, will improve prescribing quality and patient safety and reduce risk from medication errors whilst supporting prescribing spend within budget. Principles Incentives should reward improvement in patient care and health outcomes. It is therefore important that the Medicines Optimisation Scheme does not simply reward low cost prescribing, but should include criteria relating to the quality of prescribing. To ensure financial stability within NHS WKCCG, it is vital that NHS WKCCG and its member practices maintain control of prescribing costs. However, a reduction of costs at the expense of patient health or healthcare is not acceptable. The scheme should encourage practices to consider both quality and cost, and hence costeffectiveness of their prescribing, and reward practices appropriately. Finance Funding for the 2015/16 MOS will be a maximum of up to 1.00 per patient (using list size held by NHS England as at 01/04/15) if all 20 points are achieved. The funds for the incentive scheme will be top-sliced from the prescribing budget before the budget is devolved to practice level. Payments made to practices under the Medicines Optimisation Scheme will be held by NHS WKCCG. The incentive payment should be in line with the rules/legislation of Dept of Health. Eligibility to participate in the scheme The scheme will be available to all GP practices in NHS WKCCG. In the event of a dispute over a practice s entitlement, it will first be discussed between the practice and NHS WKCCG Prescribing Advisors. If no decision can be reached it will be discussed between the practice and NHS West Kent CCG Medicines Optimisation Group (MOG). This will include sharing all relevant data with the MOG as required for them to be able to make an informed decision. Scheme details The scheme consists of one section. 1. All projects detailed are compulsory elements of the scheme. 2. The maximum number of points each practice can earn is 20 points. 3. In order to participate in the scheme as many of the clinical team as possible are required to meet with a member of the Medicines Optimisation Team on 2 occasions. Medicines Optimisation Scheme 2015/16 Final Draft: to be ratified by Medicines Optimisation Group Page 33 of 83

34 Target areas 1 As many of the clinical team as possible to meet with a member of the Medicines Optimisation Team on 2 occasions. Meeting 1- To agree participation in MOS Meeting 2- To meet with Prescribing Advisor Weighting for points Evaluation Completed & date Eclipse Live - Review patients with Red (all) and Amber (2 patients per 1000 patients practice population) alerts monthly from April 1 st st March points for completed reviews for Red and 2 points for completed reviews for Amber alert patients Review the prescribing of New Oral Anticoagulants (NOAC) and Low Molecular Weight Heparin to ensure adherence to local and National guidelines 3 3 point for conducting the Audit.. 4 Adherence to First Choice Dressings List Review all non-formulary prescribing of dressings and increase adherence to formulary 4 2 points for adhering to formulary dressings by 50% 4 points for adhering to formulary dressings by 75% 5 Review prescribing of erectile dysfunction drugs Phosphodiesterase type 5 Inhibitors (PDE5) Drugs 3 2 points for 50% reduction in spend and a further 1 point for maintaining reduction. 1 point for 25% reduction in spend and a further 1 point for maintaining reduction 6 Individualised QIPP plan for practices to be completed by Medicines Optimisation Team. A list of QIPP projects is available in Appendix 1. Practices will be advised of the QIPP projects that will be worked on at the initial practice visit. 6 Work will be completed by Medicines Optimisation Team. Submitted recommendations must be reviewed and approved if clinically appropriate within an agreed timescale (2 weeks) so that maximum financial savings can be achieved. Medicines Optimisation Scheme 2015/16 Final Draft: to be ratified by Medicines Optimisation Group Page 34 of 83

35 Evaluation of Scheme Baseline data for all the target areas will be based on prescribing data for Quarter 2 of the 2014/2015 financial year (July - September 2014); except for the Antibiotic element of the scheme (please refer to the detail below). Individualised QIPP plan will be completed by a member of the Medicines Optimisation Team over the course of 2015/2016. Data for validating the projects see under individual projects All documentary evidence must be submitted to the MOT by 31 st October Submissions must be made to the generic account wkccg.medman@nhs.net Medicines Optimisation Team members are only able to support practices with the Individualised QIPP Plan element. All other elements must be completed by practice staff or clinicians. Practices must start working on these projects at the earliest opportunity since the index period for payment is Q2 of 2015/16 Practices must then hold their position for the rest of the remaining financial year Medicines Optimisation Scheme 2015/16 Final Draft: to be ratified by Medicines Optimisation Group Page 35 of 83

36 NHS West Kent CCG Medicines Optimisation Scheme Compulsory Section Meet with a member of the Medicines Optimisation Team As many members of the practices clinical team are required to meet with a member of the Medicines Optimisation Team on 2 occasions: 1 To agree participation in the scheme during the first meeting. Second meeting with a Prescribing Advisor to discuss prescribing and highlight any barriers to implementation. Eclipse Live Background Eclipse Live (Electronic Care Leading to Improved Safety Empowerment) is a clinical risk assessment system in prescribing, and provides a safety net function. The system identifies those at risk of medicine related emergency admissions. It has been developed to combat the thousands of deaths each year caused by medication-related incidents more than half of which are preventable. Eclipse Live enables practices to monitor a large number of patients against set criteria. Method To achieve the points in this target area, the practice must review: All patients with a RED alert at least once a month. All patients with an AMBER alert at least once a month (2 patients per 1000 patient population). Maximum 4 points Evaluation The practice must conduct the reviews monthly during 2015/16. Completed reviews achieve a maximum of 4 points. The Medicines Optimisation Team will validate practices use of the Eclipse Live system. NOAC and LMWH Audit Background NICE clinical guidance NICE now support the use of NOACs, which include dabigatran, rivaroxaban and apixaban. Both dabigatran and apixaban are licensed for the prevention of stroke and systemic embolism in non-valvular AF if the patient has one or more of the following symptoms: Had a stroke or transient ischaemic attack Aged 75 or older Hypertension Symptomatic heart failure CHA2DS2-VASc score should be used to assess stroke risk and patients with a CHA2DS2-VASc score of 2 or above should be offered anticoagulation. The risks and benefits in comparison to warfarin should be discussed with the patient. The advantages of NOACs are that they do not require the same level of monitoring or Maximum 3 points Medicines Optimisation Scheme 2015/16 Final Draft: to be ratified by Medicines Optimisation Group Page 36 of 83

37 3 dose adjustments as warfarin. They can also both be used as an option for the prophylaxis of venous thromboembolism in adults after total hip or knee replacement. Rivaroxaban can be used in the same situations as dabigatran and apixaban but is also licensed in the treatment of DVT and prevention of recurrent PE or DVT in adults. As well being prescribed in the treatment of PE and preventing recurrent venous thromboembolism. Low molecular weight heparins or Fondaparinux are also recommended by NICE for the treatment and prophylaxis of DVT. Patients can be offered LMWH, UFH or fondaparinux, usually LMWH are preferred due to the reduced risk of heparin induced thrombocytopenia. LMWHs or fondaparinux have also in the past been offered to patients who cannot tolerate warfarin or alternative vitamin K antagonists. Therefore there is the potential for some patients on LMWHs or fondaparinux to switch to a NOAC. The aim is to review all patients prescribed NOACs and LMWHs/fondaparinux in primary care to ensure that prescribers are adhering to the guidelines as outlined in NICE and the West Kent commissioning group. Adherence to First Choice Dressings List Background The aim of the First Choice Dressings List is to promote rational prescribing by encouraging safe, effective, appropriate and economic use of dressings. This ensures patients receive the correct dressings at the correct time in the right quantities. The list has been compiled by a panel consisting of KCHT Tissue Viability Nurse Specialists, Nursing and Podiatry Representatives. It is reviewed regularly to ensure current evidence based practice is adhered to. Maximum 4 points 4 Both medical and non-medical prescribers from KCHT are expected to comply with the First Choice Dressings List. Dressings should be requested only until the next wound assessment and/or for a maximum of 4 weeks (although can be less). Split packs of wound dressings can be prescribed and prescribers should only order a quantity that is clinically required, rather than prescribing whole packs, to reduce waste and inefficiencies. Care homes are expected to request dressings from the First Choice Dressings list. Requests for dressings that do not feature on the First Choice Dressings list should be challenged and an alternative dressing suggested where possible. Method To achieve points in this target area the practice is required to review all nonformulary prescribing of dressings and increase adherence to formulary from baseline adherence. Evaluation Practices will be evaluated on Q2 2015/2016 epact data (July Sept 15) 2 points are available for adhering to formulary choice dressings by 50% of all 2 Medicines Optimisation Scheme 2015/16 Final Draft: to be ratified by Medicines Optimisation Group Page 37 of 83

38 prescribing of dressings 4 points are available for adhering to formulary choice dressings by 75% of all prescribing of dressings or 4 Total estimated spend on dressing for 2014/15 = 1,782,897 ( 863,338 of this was for non-formulary dressings) Assuming a 50% reduction over a 12month period there is the potential to save 430K. 5 Erectile dysfunction Background Three selective PDE5 inhibitors are licensed for the treatment of erectile dysfunction sildenafil, tadalafil and vardenafil. They are all included in the Interface Formulary. Sildenafil is first line treatment; tadalafil and vardenafil are second line treatments. These medications have proven efficacy and safety; the major difference between them is that sildenafil and vardenafil are relatively shortacting drugs, with a half-life of approximately 4 hours, whereas tadalafil has a longer half-life of 17.5 hours. The Viagra patent has expired and therefore the generic price has dropped significantly. Cialis remains in patent until the end of 2017, and Levitra until the end of Method To achieve the points in this target area, the practice is required to; Ensure new patients with a diagnosis of erectile dysfunction should be prescribed generic sildenafil as first line treatment. Ensure all patients on the other PDE5 inhibitors should be prescribed according to the SLS indications. Ensure all patients on the other PDE5 inhibitors are switched to generic sildenafil if clinically appropriately. Follow the recommendation that one treatment per week at NHS expense is allowed, based on research evidence in the age groups. Prescribers should bear in mind that these medications have a street value. Review all patients on ONCE DAILY treatment of PDE5 and if appropriate switch to on demand sildenafil (generic). Review and switch all patients who have been on ONCE DAILY Tadalafil/Cialis for more than 24 months to on demand Sildenfil (generic), as part of erectile or penile rehabilitation strategies in men who have undergone radical prostatectomy as treatment should not exceed 24 months. Maximum 3 points Evaluation Practices will be evaluated on Q2 2015/16 e-pact data. Practices will need to maintain position for the remainder of 2015/16. 2 points for 50% reduction in spend and a further 1 point for maintaining reduction for the remainder of 2015/16. 1 point for 25% reduction in spend and a further 1 point for maintaining 2/3 Medicines Optimisation Scheme 2015/16 Final Draft: to be ratified by Medicines Optimisation Group Page 38 of 83

39 reduction for the remainder of 2015/16. Total estimated spend for 2014/15 = 407,334 Assuming a 50% reduction over a 12month period there is the potential to save 203,667 and a 25% reduction would save = 101,833 6 Individualised QIPP Plan Maximum 6 points 6 points will be available to all practices by allowing a member of the Medicines Optimisation Team to complete all projects identified as part of their individualised QIPP plan. Team members will work to ratified protocols and will only change patient s medication(s) once authorised by the prescriber. The Practice must cooperate with the MOT to achieve the maximum savings from the projects identified. The MOT will agree on targets and the level of engagement and support required from the practice to undertake the projects. A list of QIPP projects is available in Appendix 1. Practices will be advised of the QIPP projects that will be worked on at the initial practice visit. Payment Schedule Points 100p/patient Medicines Optimisation Scheme 2015/16 Final Draft: to be ratified by Medicines Optimisation Group Page 39 of 83

40 Appendix 1 List of QIPP projects Practices will be advised at the initial visit which projects are to be worked on as part of their individualised QIPP plan. Medicines Optimisation Scheme 2015/16 Final Draft: to be ratified by Medicines Optimisation Group Page 40 of 83

41 Chief Nurse s Quality and Safety Update This paper is for: Information Recommendation: For the Governing Body to Note For further information or for any enquiries relating to this report please contact: Dr Meriel Wynter/Alison Brett Date: 24 th February 2015 Reporting Officer: Dr Meriel Wynter Agenda Item: 34/15 Lead Director: Alison Brett Version: Final Report Summary: This report gives an update on quality and safety of West Kent CCG and Provider agencies commissioned for the Governing Body. FOI status: This paper is disclosable under the FOI Act Strategic objectives links: Board Assurance Framework links: Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment D. Service quality and patient safety Service providers commissioned, and performance managed, to promote and support the highest standards of care, patient safety and patient experience N/A N/A N/A This document has taken into account Equality and Diversity best practice. West Kent CCG Front Sheet Page 41 of 83

42 Report history: Appendices This has been written by the Acting Chief Nurse and shared for comment with the Chair of the Quality Committee. N/A Next steps: N/A West Kent CCG Front Sheet Page 42 of 83

43 Chief Nurse s Quality and Safety Update February 2015 Page 43 of 83 Patient focused Providing quality, improving outcomes

44 Introduction This report will provide an interim Quality and Safety update for Governing Body. A full Quality report will be provided bimonthly, following each Quality Committee. Data is reported to the end of December Complaints NHS West Kent CCG - Complaints Status No. Complaints Received December Complaints Closed December Total Open Complaints at end of December The themes of the complaints vary, 2 relate to continuing health care applications this month. Healthcare Associated Infections Clostridium difficile Performance West Kent (WK) CCG have a performance trajectory of 98 cases for 2014/15 which includes Acute Trust post 72 hr cases and out of area cases and pre 72 hr cases. The graph below illustrates the West Kent cumulative cases for 2014/15 against the annual trajectory for 2014/15 and is validated data to the end of December There have been 77 cases of C. difficile between April and December against an expected trajectory of 74 to the end of December. This places the CCG above trajectory. MTW (Maidstone and Tunbridge Wells NHS Trust) have had 23 cases of C. difficile infection since April, of these 19 were attributable to WK CCG they are currently under their target. There have been 50 cases of pre-72hr C. difficile along with the post 72 hr cases in other acute trusts this puts the CCG over target. Page 44 of 83

45 Axis Title West Kent CCG, Clostridium difficile performance against Trajectory WK CCG Total Cumulative Cumulative Trajectory 0 Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar WK CCG WK CCG Attributable Cases Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Total Target Non-Acute Trust (Pre 72 hrs) Acute Trust (Post 72 hrs) MTW (KCH, Acute Trust (Post 72 hrs) Other 0 Medway) 0 1 (UCLH) (Harefield (London, PRUH) Chest) 1 QEH 1 Rbromp 8 WK CCG Total WK CCG Total Cumulative Cumulative Trajectory December cases In December 7 cases have been reported 3 of these are pre 72 hr cases, 2 on admission to Maidstone Hospital, 1 from a GP specimen 4 post 72 hr case, 3 from Maidstone hospital, and 1 from the Royal Brompton MRSA Bacteraemia Performance Nationally there is a zero tolerance trajectory for MRSA bacteraemias. There has been 1 MRSA bacteraemia attributable to the Acute Trust (MTW) in May C. Difficile Root Cause Analysis (RCA) summary for April December 2014 There were 50 cases of C. difficile attributed to West Kent CCG during April- December 2015, RCA analysis requests from GP started prior to this date and historically returns have been poor, they have improved since October Notification information Of the 50 cases 5 were patients living in residential or nursing homes Of the 50 cases 17 had had admissions to hospital within the last 2 months and 2 within in the last 4 months (31 had no recent admission to local hospitals) 27/50 were GP Specimens Page 45 of 83

46 20/50 were Acute Trust Specimens 2/50 were sent by Sevenoaks cottage hospital (patients had been in longer than 72 hrs but were unrelated by typing) 1 unknown Root Cause Analysis information 11 RCA returns received (5 between April and October, and 6 received between October and December). Of these 11 RCA s 7 patients received antibiotics within 1 month, 1 patient within 2 months and 1 patient within 3 months (2 cases were unknown or data not provided). 7/11 patients received cephalosporin s or quinolones (or both), of which 5 of those were not prescribed according to West Kent antibiotic prescribing guidelines. (Details available). Predisposing factors (10/11 completed in RCA) Malignancies 0/10 Renal failure (not defined) 1/10 Inflammatory bowel disease 2/10 Multiple issues 9/10 Proton Pump Inhibitors (PPIs) 8/10 Previous CDT +ve result 2/10 (3/50) Summary Early indications from the limited information we have show that antibiotics do seem to have an impact on the acquisition or development of C.difficile (Cephalosporin s and Quinolones in particular). Although this doesn t link with GP practices who are high prescribers of those antibiotics the individual cases of C.difficile does link with Cephalosporin s and Quinolone use. There is also significant number of patients (from those with RCA returns) who developed C.difficile who were not prescribed antibiotics in accordance with the CCG prescribing guidance. Almost all of the patients with returned RCAs had been on proton pump inhibitors (PPIs), so there may be an indication for some future work on reviewing the patients need for PPIs or to see if the need for PPI s has been reviewed in the last year. Returns of RCAs are increasing but needs to improve if we are to gain better or more reliable information. A review of the Infection Prevention Control RCA template is being undertaken. There are no strong areas to address, mainly because there isn t enough RCA information to be robust, but early indications provide ideas to target future work which include, improving RCA returns, targeted work around prescribing updates and PPI indications, and joint working with the Acute Trust. Page 46 of 83

47 Serious Incidents (SI) 12 new SIs were reported for West Kent CCG patients in January (16 x SIs reported in December 2014). 1 x Grade 2 SI was reported during January, this was a child death. STEIS Ref Date Logged Time to Report Breakdown of incidents for West Kent CCG Patients logged in January 2015 Hospital Name/State if Incident Ward Specialty/Name of Provider Care Home/Independent Date Care Home etc Provider/Patient's Home Category 2015/497 06/01/ /12/14 MTW Tunbridge Wells Hospital Ward 20 Slips/Trips/Falls 0 10/03/ / /01/ /10/14 MTW maidstone medical Venous Thromboembolis 1 13/03/15 m (VTE) 2015/ /01/ /12/14 MTW tunbridge ward 12 Slips/Trips/Falls 1 13/03/ / /01/ /01/15 KMPT patients home n/a Unexpected Death of Community 1 19/03/15 Patient (in receipt) 2015/ /01/ /01/15 MTW Tunbridge Wells ward 11 Delayed diagnosis 1 19/03/ / /01/ /01/15 MTW Tunbridge Wells A/E Delayed diagnosis 1 23/03/ / /01/ /01/15 MTW maidstone N/A Slips/Trips/Falls 1 27/03/ / /01/ /01/15 MTW tunbridge wells ward 30 Venous Thromboembolis 1 27/03/15 m (VTE) 2015/ /01/ /01/15 MTW tunbridge wells A/E Delayed diagnosis 1 27/03/ / /01/ /01/15 MTW Tunbridge Wells Hospital A/E Child Death 2 01/04/ / /01/ /01/15 MTW tunbridge a/e Delayed diagnosis 1 07/04/ / /01/ /10/14 MTW maidstone mercer Venous Thromboembolis m (VTE) 1 02/04/15 Never Event Grade Due Date Category reported In the past twelve month period Slips/Trips and Falls is the highest category of SI accounting for 48% of SIs reported for West Kent patients. Delayed diagnosis is the second highest category accounting for 18% of incidents, followed by Pressure Ulcers Grade 3 at 11% of the total incidents reported. Timeliness to report There are currently 86 ongoing SIs relating to West Kent CCG patients. 43 x SIs are in the initial investigation stage with the provider; 16 x SIs have been submitted for the February Closure Group Meetings and 2 x SIs for the March meeting. 6 x have been returned to the provider requesting more information and 19 (grade 2 s) are with the Area Team awaiting closure. Closure The Quality team and their Clinical Lead GP meet fortnightly to review all the Root Cause Analyses undertaken for each SI by the providers. An SI lead from the provider is invited to attend the closure meetings to enable CCG challenge against action plans, and question demonstration of change in practice. Page 47 of 83

48 Safeguarding Mental Capacity Act funding from Area Team has allowed Designated Nurses to plan a conference for health providers focusing on the Supreme Court ruling on Deprivation of Liberty Safeguards, and how it impacts on primary and secondary health. Also under consideration is Best Interest Assessor training for Providers. A Domestic Homicide Review is being undertaken in respect of a West Kent resident. The Panel have met and independent chair has been appointed. All agencies from whom a management review is required have been identified and reviews requested. It will take approximately 10 weeks to receive and collate the data with the next panel meeting in May. Vista Independent Hospital Hampshire. The CQC have highlighted concerns of breeches in care, following an unannounced visit in November. West Kent fund one patient in this hospital, a review has been undertaken and no immediate risk to the patient has been identified, a discharge plan is in place. Provider Quality exception update Kent Community Health Trust Safeguarding training- the Quality Team have been concerned by the low level of achievement of compliance with safeguarding training, and considered this inadequate. Under the terms of the contract a Remedial Action plan was initiated in November 2014 and meetings held monthly between KCHT and CCG to monitor progress. Currently the target of 85% compliance has been achieved by adult services, and they are on trajectory to ensure children and specialist services meet the target within the agreed timescale of There have been a number of outbreaks of confirmed influenza since December in Tonbridge Cottage Hospital and Sevenoaks Hospital, the CCG have been kept informed of the situation and outbreaks managed according to Public Health England advice. Maidstone and Tunbridge Wells NHS Trust A Care Quality Commission Quality summit was held on following the CQC inspection of October The overall rating for the Trust is Requires improvement. Underlying ratings are as follows- Good for services being caring, Requires improvement for safe, effective and responsive and Inadequate for well-led. The site reports demonstrate a key area for improvement is Critical care across Maidstone and Tunbridge wells sites. The summit addressed key actions to be undertaken by the Trust, such as intensivist ward rounds at weekends on critical care units, and enhancing leadership Page 48 of 83

49 and learning across the Trust. A detailed action plan is to be submitted by the Trust to CQC by A&E performance- Maidstone and Tunbridge Wells NHS Trust (MTW) was under considerable pressure over the Christmas period. During the middle part of January there was some recovery, although the position deteriorated once again in the first part of February. Key issues; all escalation areas are open, only limited elective care is taking place, performance against the 4 hour access standard for A & E is regularly below the 95% target, and mixed sex breeches were due to use of an escalation area in Tunbridge Wells Hospital. Page 49 of 83

50 NHS 111 Performance Report Quarter 3 This paper is for: information Recommendation: The Board is asked to note the report on the performance of the NHS 111 service. For further information or for any enquiries relating to this report please contact: Michele.Armstrong@nhs.net Reporting Officer: Dr Mark Whistler Lead Director: Gail Arnold, Chief Operating Officer Report Summary: 13 th February 2015 Agenda Item: 35.1/15 Version:1 The NHS 111 service has now been operational for just under two years. Initial performance was poor and rectification plans were implemented. There has been considerable improvement in performance after the initial difficulties, although in quarter 3 there has been a worsening of performance against agreed indicators. The enclosed report provides an update on: Performance against agreed performance indicators; West Kent data; Number of complaints; Serious incidents; Patient satisfaction; and Identified risks/issues. FOI status: This paper is disclosable under the FOI Act; Strategic objectives links: NHS 111 contributes to the following of the CCG s strategic goals: C: Improved health outcomes and reduced health inequalities; D: Service quality and patient safety West Kent CCG Front Sheet Page 50 of 83

51 Board Assurance Framework links: Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment The Strategic Urgent Care Board has oversight of how the NHS 111 fits within the wider urgent care system. Service risks are addressed in the attached report N/A N/A Report history: Appendices N/A None. Next steps: Regular performance reports are submitted to the Governing Body. West Kent CCG Front Sheet Page 51 of 83

52 NHS 111 Performance Report Quarter 3 Date Prepared: February 2015 Date: February 2015 Author: Michele Armstrong Page 52 of 83 Patient focused, providing quality, improving outcomes

53 NHS 111 Performance Report Background The NHS 111 service for the West Kent area is provided by SECAMB operating from two call centres at Ashford and Dorking and has been operational for nearly 2 years. The service is commissioned currently on a regional basis and covers Kent, Medway, Sussex and Surrey, includes 22 CCGs and services a total population of 4.7 million. Swale CCG is the Coordinating Commissioner for the service. The service commenced in March 2013 and operates out of two call centres, at Ashford (Kent) and Dorking (Surrey). Call volumes have increased since the commencement of the service, with current demand over 100,000 calls per month: 4,000 5,000 on a weekend day. National Key Performance Indicators (KPIs) The table below shows the performance of the Kent, Medway, Sussex and Surrey service (KMSS 111) against agreed performance indicators. Summary Report - NHS 111 Kent, Surrey and Sussex for the month of Dec 2014 Band A Band B Band C KPI Id Indicator Name Indicator description Monthly Trend Actual Target Met Target Met Target Met KPI 2 (NQR 8) KPI 3 (NQR 8) KPI 7 (LQR 4) KPI 8 (LQR 5) KPI 9 (LQR 6) KPI 10 (LQR 7) KPI 12 (LQR 10) Abandoned Calls Call Waiting Time Triage Rate Transfer to 999 Attend Accident and Emergency Department Warm Transfers Call Back Time Percentage of calls abandoned Percentage of calls answered within 60 seconds of the introductory message Percentage of answered calls triaged Percentage of answered calls transferred to 999 Percentage of patients advised to attend Accident and Emergency Department Percentage of Warm transfers to NHS 111 service Clinician where required Percentage of Call backs in <10 minutes 6.00% <=5.00% <=6.00% <=7.00% 77.58% 86.98% 11.03% 5.18% >=95.00% >=92.00% >=60.00% <=10.00% <=5.00% >=55.00% <=12.00% <=6.00% 61.69% >=98.00% >=96.00% >=90.00% >=50.00% <=15.00% <=7.00% >=94.00% 66.53% % <100.00% Rectification KPI Warm transfers & Call backs <10 mins 87.18% >=90.00% >=85.00% >=80.00% Michele Armstrong 12 th February 2015 Draft 1.0 Page 53 of 83

54 Overview During quarter 3, the service received 314,870 calls, approximately 25% more calls than quarter 2 (256,208). Call volumes were 5% above forecast for the month of December, but there were particular spikes in activity on specific days over the Christmas period. For example, on 27 th December the service received just under 14,000 calls, around 3 times normal call volumes on a weekend. Based on activity for Christmas 2014, KMSS 111 had planned for 9,000 calls. In addition to higher than forecast call volumes, significant telephony and technical issues affected performance levels in the weekends before Christmas. The telephony issues are believed to be a continuation of a national incident on 20 th November, during which time the telephony system stopped routing callers to the correct NHS 111 call centre for the area from which which the call was being generated. Over the 9 key days of the Christmas bank holiday and New Years the 111 service was again impacted by telephony issues. These issues have been escalated to the national NHS 111 team at NHS England who are responsible for the NHS 111 telephony contract. The service noted that a significant proportion of their calls were generated from some OOH providers struggling to meet their own call-back targets. This resulted in a number of patients calling NHS 111 because they hadn t received their expected call from the OOH service, a number of whom required further triage because of a change in their condition. These issues had a significant impact on KMSS 111 s performance against KPIs. The service failed to meet the KPIs relating to calls answered within 60 seconds and abandoned calls. The 999 referral rate for December decreased compared to November, but is still above the 10% KPI. NHS 111, 999 and Out of Hours providers are being invited to attend a multi- organisation meeting on 26 February to review the Christmas and New Year period. 999 Referral Rates 999 referral rates have risen, compared to quarter 2 with an average referral rate of 11.03% in December (compared to 10.71% in September), although it was higher than this on some specific days (16.08% on 31 st December). This continues the trend of rising referrals rates for the year as a whole; up from a low of 8.69% in April A significant factor is thought to be the large cohort of new health advisors who are needed to manage the significant increase in call volumes over the winter period. There is an ongoing project ongoing to identify any other contributing factors and to implement further measures to reduce this. Following discussion with SECAmb, a pilot to re-triage 111 ambulance referrals is continuing to until March Michele Armstrong 12 th February 2015 Draft 1.0 Page 54 of 83

55 Advised to attend A&E During 2014 there has been an increase in referrals to A&E with 5.18% of callers advised to attend A& E in December (compared to 4.54% in December 2013). This is a slight improvement from quarter 2; 6.54% of callers were advised to attend A& E in September Investigation into the underlying reasons for the increase has indicated that there is no single factor driving it, but rather general demand in the urgent and emergency care system. Warm Transfers/Call Back Time This KPI (referred to as the rectification KPI) is that 90% of callers who need clinical advice will either speak to a clinician during the initial call, or will be called back within 10 minutes. Since July there had been sustained improvement in performance against this KPI so that it was consistently above the target of 90%. Performance against this KPI fell below the 90% target in December, predominantly because of winter call volumes. West Kent Data The tables below show the number of calls received by KMSS 111 by CCG area and also the number of calls per 1000 of the population Number of Calls by CCG CCG Populatio n May, 2014 Jun, 2014 Jul, 2014 Aug, 2014 Sep, 2014 Oct, 2014 Kent 1,525,285 26,751 22,858 22,933 23,151 21,546 23,799 25,981 32,347 West Kent 473,905 7,713 6,741 6,668 6,859 6,299 6,632 7,413 9,437 Dartford, Gravesha m and 253,904 3,856 3,319 3,429 3,388 3,076 3,654 3,993 5,286 Swanley South Kent Coast 202,450 3,675 3,157 3,215 3,288 3,148 3,433 3,826 4,587 Thanet 142,891 3,435 2,953 3,260 2,955 2,861 3,119 3,289 4,038 Canterbury and 216,020 3,788 2,920 2,748 3,002 2,638 3,014 3,320 3,837 Coastal Ashford 127,427 2,290 2,098 1,950 1,991 1,939 2,143 2,270 2,787 Swale 108,688 1,994 1,670 1,663 1,668 1,585 1,804 1,870 2,375 The figures show that there are more calls to KMSS 111 from West Kent residents than any other of the Kent CCGs. However, this is a reflection of the larger population size of West Kent. The data for number of calls per 1000 of the population indicates that the population of West Kent is a lower user of NHS 111, per head of the population, than most areas of Kent, although as for all areas this increased during December. Nov, 2014 Dec, 2014 Michele Armstrong 12 th February 2015 Draft 1.0 Page 55 of 83

56 Number of calls per 1000 of the population by CCG May, 2014 Jun, 2014 Jul, 2014 Aug, 2014 Sep, 2014 Oct, 2014 Nov, 2014 Dec, 2014 Kent Thanet South Kent Coast Ashford Swale West Kent Dartford, Gravesham and Swanley Canterbury and Coastal The table below provides a breakdown of the dispositions for calls received from West Kent callers during quarter 2 (ie. shows the service identified from the Directory of Service as having staff with the necessary skills to meet the healthcare needs of the caller) Call Dispositions for Quarter 2 Healthcare Needs Registered in West Kent GP / Local Service 14,278 Ambulance Dispatch 3,007 Emergency Department 1,692 Self-Care 1,399 Call Closed Within Pathways 1,155 Dental Service 703 Repeat Prescription 546 Health Information 228 Community Nurse 174 Pharmacy 70 Report of Results / Tests 113 Page 56 of 83

57 The data shows that the proportion of calls referred to 999 and advised to attend A & E is higher for West Kent than across the KMSS 111 region (see table above showing performance against national KPIs). However, rates of referral to 999 compare favourably with the most of the other Kent CCGs (eg. 15.5% of South Kent Coast callers, and 15.6% of Swale callers were referred to 999). However, along with Ashford CCG, West Kent has the highest level of referrals to the Emergency Department (7.2%) Quality Report to the Clinical Governance Group Complaints The chart below shows that there has been a marked increase in the level of complaints received by the service in quarter 3 (up from 66 in quarter 2, to 106 in quarter 3) This increase may in part be due to measures KMSS 111 has taken simplify the reporting process for healthcare professionals wishing to provide feedback, but is likely to also be influenced by KMSS 111 s worsening performance against their KPIs in quarter 3. The themes identified with the highest percentages for complaints closed October December were; Patient Care - 38% (40 Complaints) NHS 111 Timeliness - 11% (12 Complaints) Michele Armstrong 12 th February 2015 Draft 1.0 Page 57 of 83

58 System and Operating Procedures 8% (9 Complaints) Lessons learned and follow-up actions are identified for all complaints investigated. Patient Satisfaction Every month a sample of patients / users of the 111 service who have provided consent to be contacted assist with telephone interviews to provide feedback on their experience. During the period August to December callers were interviewed. The chart below shows that the majority of those interviewed would recommend NHS 111 to family and friends Potential Incidents and Serious Incidents Two new potential serious incidents were opened during December. These both relate to the weekend of 22 nd and 23 rd November when the service experienced significant IT issues. Identified Risks/Issues The report provides an update on those risks/issues that are most relevant and of greatest concern to West Kent. Michele Armstrong 12 th February 2015 Draft 1.0 Page 58 of 83

59 Delays in GP speak to dispositions Issue: Since March 2013, KMSS 111 has been unique in having the Speak to GP disposition delivered within the service by NHS 111 in-house GPs. However Harmoni/Care UK have had difficulties in delivering this service to the agreed specification. Update: An options paper, looking at how the service could be delivered, was submitted to West Kent CSG in October. It was agreed that the service should move from KMSS 111 to the Out of Hours provider from 1 April The CCG is negotiating arrangements for this transfer with IC24. Failure to meet the clinical call-back target. Issue: The national standard for clinical call-back is for 100% of callers requiring a call-back to be called-back within ten minutes. Since its inception, KMSS has failed to meet this target. To assure the safety of cases that take more than 60 minutes for the call back, a sample of calls are audited and risk assessed against an agreed audit tool. (The audit tool was approved through a peer review validation meeting with commissioner clinical governance leads and provider clinical and medical leads to provide assurance on the efficacy of the risk assessment process) Update: It has been decided to monitor the clinical call-back target and the warm transfer target as a combined percentage. The new target is that 90% of callers who need clinical advice will either speak to a clinician during the initial call, or will be called back within 10 minutes. During quarter 2 there was a sustained improvement performance against this KPI, with attainment consistently above 90%. During November and December 2014 this declined to 89.32% and 87.18% respectively. Procurement of the NHS 111 Service Issue: The KMSS NHS 111 contract is due to expire on the 31st March 2016 and CCGs are required to considering what service they would like to commission. This has possible implications for the West Kent Out-of-Hours and Hospital at Home Service as the timescales for these two procurements are not currently aligned, although there may be some scope to extend the existing NHS 111 contract which would address this issue. Update: A commissioner event aimed at CCGs and clinical leads took place on 4th December to provide commissioners with sufficient information on procurement options and risks, lessons learnt over the last 18 months, future innovations and key commissioning implications/ issues in the current and downstream services to aid them in making Michele Armstrong 12 th February 2015 Draft 1.0 Page 59 of 83

60 decisions. We have indicated that West Kent will be looking for an extension to enable the work to link with timescales for our Out of Hours procurement and ongoing urgent care redesign work. Repeat Prescription Service Issue: NHS 111 is continuing to see large numbers of patients ringing to request routine repeat prescriptions during the Out of Hours period. Non-urgent repeat prescriptions comprised of around 4 percent of all calls to NHS 111 and over the Xmas and New Year period; there was an increase of 66% compared with an average week-end. These requests are then passed to and managed by Out of Hours service, where the volumes involved can reduce their capacity to respond to more urgent cases Update: KMSS have asked CCGs to consider repeat prescriptions a priority since at times of peak-demand these requests are impacting adversely upon the urgent care system. Michele Armstrong 12 th February 2015 Draft 1.0 Page 60 of 83

61 CORPORATE RISK REGISTER This paper is for: Information Recommendation: The Governing Body is asked to note and review the Corporate Risk Register and advise on any points of clarification or improvement it may wish to see. For further information or for any enquiries relating to this report please contact: Richard Segall Jones, Company Secretary and head of Corporate Services Date: 24/02/2015 Reporting Officer: Richard Segall Jones, Company Secretary Agenda Item: 36/15 Lead Director: Richard Segall Jones, Company Secretary Version: 1 Report Summary: In line with the Integrated Risk Management Framework, the Corporate Risk Register is submitted to Governing Body every quarter, with exception reporting taking place in the intervening months as necessary. By considering the Corporate Risk Register, Governing Body is able to review and scrutinise actions being taken on currently identified operational risks in the context of its view of potential strategic risk, as articulated in the Board Assurance Framework. The Corporate Risk Register contains all risks rated 12 or above from each of the Operational Risk Registers maintained by the CCG s leadership and programme areas, and committees. The Corporate Risk Register has been reviewed and moderated by the Accountable Officer/Chief Officer in order to assure Governing Body that it has been presented with the key risks facing the CCG. (The Accountable Officer/Chief Officer also discusses the Operational Risk Registers with members of the senior executive team at his regular one-toone meetings with them.) Since the Governing Body last reviewed the Corporate Risk Register in November, the Company Secretary and Deputy Company Secretary have met with the officers who maintain the Operational Risk Registers to work through the CCG risk management guidance and to ensure consistency in risk scoring. The attached narrative report demonstrates that a lot of activity has taken place since November and that Operational Risk Registers are reviewed on a regular basis. The Company Secretary and Deputy Company Secretary will continue to meet with the risk register co-ordinators to further refine the risk descriptions, controls and assurances. West Kent CCG Front Sheet Page 61 of 83

62 Governing Body is asked to note the Corporate Risk Register. Any suggestions for improving its accessibility will be welcomed. FOI status: This paper is disclosable under the FOI Act. Strategic objectives links: Board Assurance Framework links: Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment Report history: Appendices The Corporate Risk Register details the top-rated risks against each of the CCG s strategic objectives. The Corporate Risk Register forms part of the CCG s overall board assurance and integrated risk management arrangements. The new Board Assurance Framework was approved by Governing Body at its meeting in September The Corporate Risk Register is a key component of the CCG s internal control arrangements, against which the CCG is assessed by its internal auditors when they consider their Audit Opinion for the year. The Audit Committee undertakes periodic review of the Operational Risk Registers maintained by leadership and programme team and committees. This is done to gain assurance (on behalf of Governing Body) that risks not being escalated to the Corporate Risk Register are, nonetheless, being appropriately managed. It is critical, however, that Governing Body is satisfied that the key risks escalated to the Corporate Risk Register are being managed appropriately and effectively. None No adverse legal or equality and diversity impact is anticipated as a result of this report. The Corporate Risk Register was presented to the Audit Committee in January Corporate Risk Register Commentary Corporate Risk Register as at 16 th February 2015 Next steps: Suggestions or recommendations made by the Governing Body will be actioned by the officers and relevant committees responsible for maintaining the ORRs in question. West Kent CCG Front Sheet Page 62 of 83

63 Corporate Risk Register February 2015 New Risks The following new risks have been assessed as scoring 12 or above and now appear on the Corporate Risk Register: Strategic Goal D Risk Ref Qual 21 Risk Description Rating Reason for new risk being assessed Potential risk of breakdown in communication and sharing of information which may impact on actions to safeguard children or adults at risk of harm following disaggregation of hosted safeguarding arrangements for designated nurses across Kent and Medway. (4x3) 12 The Kent and Medway hosted model for designated nurses for adult and child safeguarding was disaggregated on 31 December This new model has benefited West Kent CCG by having the dedicated resource of a designated nurse each for adult and child safeguarding solely for the CCG. There are risks remaining that the new service does not: have access to a wider learning network from the team of safeguarding nurses; have the ability to cover national events and study days; have adequate cover for annual leave and sickness; does not access wider administrative support. There is a Memorandum of Understanding in place across the Kent CCGs to mitigate these risks but it remains to be evaluated by the Chief Nurses as regards the impact of these changes on the level and quality of service provided. D Qual 22 No named GP for Safeguarding children cover in Kent from (4x3) 12 The designated doctor has recently emigrated prompting the need to raise this as a new risk. This has now been escalated to NHSE and the CCG Chief Nurse is taking this forward as this is a statutory requirement. The post has now gone out to advertisement and it is expected that this risk will be removed in the next few months. Page 63 of 83

64 Strategic Risk Risk Description Rating Reason for new risk being assessed Goal Ref F IG 15 There is a risk of non-compliance with Records Management Code of Practice and potential breach of personal confidential data where paper records created by the CSU (acting as Data Processor) are being stored on site. The CCG has not yet defined its infrastructure for management of paper archives. 12 The Department of Health will no longer allow submission of new archive material into the old PCT accounts and so there is a need for the CCGs to identify their own accounts for submission of IFR and CHC records. G MH09 Dementia Diagnosis Rates - Failure to reach projected 60% diagnosis rate by Dementia diagnosis has been prioritised by DOH and there is a national drive to achieve a target of 67% by WKCCG will be subject to NHSE/DOH scrutiny for failure to meet targets. (3x4) 12 WKCCG is currently under close scrutiny from NHSE due to its ambition rate of 60% dementia diagnosis by against a national ambition of 67%. Current diagnosis rate is 50.8% Risks Upgraded Strategic Risk Risk Description Rating Reason for risk being upgraded goal Ref E PEC009 Failure to embed commissioning intentions/failure to deliver QIPP 16 (previously 10) The Practice Engagement Committee agreed that this risk needs upgrading to red due to higher A&E attendances in some areas and engagement with practices is required to tackle this. The re-launch of the Enhanced Rapid Response Service and Transforming Outpatients Department are mitigations. Page 64 of 83

65 Risks downgraded The following risks have been downgraded since November and no longer appear on the Corporate Risk Register. The risks will continue to be managed through the operational risk register process. Strategic Risk Risk Description Rating Reason for risk being downgraded goal Ref F F02 Risk of the CCG failing to undertake effective Board Assurance assessments or to manage operational risk effectively, risking unexpected impediments to the achievement of its strategy 8 (previously 12) Board Assurance Framework in place that has been approved by the Governing Body. Progress has been made with the management of operational risk registers and the corporate risk register. The Audit Committee reviews the operational risk registers and corporate risk register. B MH03 IAPT Services - Failure to provide treatment that meets 15% national performance expectations leading to financial penalties in 2015/16 allocation. Financial risk of over performance as a result of the current AQP contract arrangement C MH05 ChYPS - Failure to ensure provision of adequate and timely mental health services for children and young people across Kent and Medway leading to poor patient service experience and internal and external scrutiny of contract performance D MH06 Eating Disorder Service - Failure to provide a robust and holistic Eating Disorder Service following NHS England s decision to 9 (previously 12) 9 (previously 12) 9 (previously 12) Reported quarterly access rate has improved from 13.8% to over 15%. Following compliance of a contract performance regime SPFT Tier 2/3 are now offering assessments and treatments within the contract wait standard. Wider children s emotional and wellbeing system transformation has commenced through the Health and Wellbeing board. A project plan is currently on track to redesign services across Kent and Medway Page 65 of 83

66 Strategic goal Risk Ref Risk Description Rating Reason for risk being downgraded withdraw funding for this service. This could lead to a poor service response to need and CCG criticism and complaints from patients, carers and GP's. A UC001/ 13 SECAmb performance for R1 & R2. Historically SECAmb have failed to consistently achieve R2 performance. R2 is defined as; from June 2012 category A 8 minute ambulance/paramedic response times were split into Red 1 (most urgent) and Red 2 (serious but less time critical). This is likely to impact on the delivery of urgent care in a timely and safe manner 8 (previously 12) Risk downgraded on the advice of the urgent care clinical lead. SECAMB s failure to meet this relates to the R2 target, which applies to the less serious category of patients. The clinical view is that that failure to meet the R2 target is not a significant risk to patient safety. This is consistent with proposals being considered by the Department of Health for an extension in the response time for these cases which will enable better information gathering before ambulances are dispatched. These proposals are being piloted elsewhere in the country but it is highly likely they will be rolled out everywhere in the future. We will of course continue to hold SECAMB to account for performance against this target. C MOG 007 Failure to implement MO strategy and commissioning intentions. 9 (previously 12) This risk has been downgraded as team members are developing project initiation documents for all commissioning intentions and MO strategies. This allows for consideration of risks involved with all projects before a project begins, resulting in successful projects being launched. All commissioning intentions and MO strategies have aligned clinical support resulting in them being received positively by member practices. The team restructure has also allowed for focused leadership and Page 66 of 83

67 Strategic goal Risk Ref Risk Description Rating Reason for risk being downgraded dedicated time spent on projects, making them more successful. C MOG 009 Failure to adequately test projects through pilots and audits before implementation. 9 (previously 12) Effective and more focused stakeholder engagement has been established which has been paramount through the project development stage. Full project planning is now completed which involves testing projects. E MOG 013 Failure to successfully implement Eclipse Live software. This will have an impact on the QIPP and MOS as it forms a significant element of the scheme. 8 (previously 12) Significant progress has been made with Eclipse Live. Communication with the Eclipse team has improved significantly. An increasing number of practices have gained full and automatic status enabling use of the system. A dedicated project lead is managing this project on behalf of the team. Feedback from users is positive and having a meaningful impact on patients. E MOG 014 Failure to deliver on the Medicines Optimisation QIPP agenda. 9 (previously 12) Recruitment of Technicians and team restructure has resulted in more QIPP work being rolled out across practices. Practice visits have been targeted with support from GP MOG members, resulting in effective peer-to-peer discussions. Financial recovery plan has focused efforts and highlighted projects that are quick wins. Practices with little or no engagement are highlighted to prescribing advisors for further discussions. E MOG 015 Failure to deliver on the Medicines Optimisation Scheme. 9 (previously 12) Recruitment of Technicians and team restructure has helped downgrade this risk. Effective tracking of progress has been important, as well as continual discussion with Page 67 of 83

68 Strategic goal Risk Ref Risk Description Rating Reason for risk being downgraded practices. Workforce planning has already begun for 2015/16 MOS. E MOG 016 Failure to engage external stakeholders in workstreams 9 (previously 12) Effective engagement with acute trust established. Practices have a mechanism to feed-up concerns to MO which are discussed in appropriate forums. Pharmacy Interface Group and Drugs & Therapeutic Committee attended by both parties and both meetings effective. Monthly newsletter used as a means of communication with practices. Attendance at POGs to link with other providers and workstreams. Closed Risks The following risks have been closed. Strategic Risk Risk Description Rating Reason for closure goal Ref C IC017 Expert Patient Programme 4 - There is a risk that the marketing of the service has not been effective or sufficiently directed at primary and secondary care. This will lead to inequitable access to the service, resulting in a failure to have whole population coverage. CLOSED The original grading of this service was felt to be too high compared to larger impact risks across the team and organisation. Whilst the likelihood was high, the consequence was not as great as initially thought. It should be noted that this service has been decommissioned and has now ceased. A IC011 Proactive Care 4 - Project capacity and capability to deliver the care management CLOSED This no longer presents as a risk as appropriate resources (Project lead, project support and commissioner support) Page 68 of 83

69 Strategic goal Risk Ref Risk Description Rating Reason for closure plan system and the Kent equipment review resulting in delays in delivery of outcomes. This may result in reputational risk.74 B IC013 Equipment - The equipment review across Kent does not have the capacity and expertise to undertake a detailed review including the business case for change, service spec and eligibility criteria. Current timelines are for a new service to be competitively procured and in place Oct 15. This project does not have WK CCG QIPP savings attached although requires CCG resource. This is a potential financial and reputational risk. CLOSED have been identified. The contract has been awarded to the preferred bidder and roll out is now underway. This no longer presents a risk as resources have been allocated to the project. It should be noted that KCC is the lead commissioner with East Kent being the Health leads for Kent and Medway. The timeline has been extended from October 15 to December 15 to enable sufficient time to develop the service spec and procure the new model. A PPC35 Dermatology 6 - If the current service provider serves their notice during the period of the service redesign, there would be disruption to service provision to the local population leading to the deterioration of service provision with impact on quality of provision, staff retention issues and service continuity issues. CLOSED This no longer presents a risk as termination of contract requires 12 months notice and would be subject to public consultation. The time period for serving notice has passed and the new service will go live in October Page 69 of 83

70 Strategic Goals A: Implementation of Mapping the Future Blueprint B: Further integration of health and social care where appropriate C: Deliver improved health outcomes and reduced health inequalities D: Improve service quality and patient safety E: Deliver sustainable finances F: Ensure robust governance G: Organisational competence Page 70 of 83

71 Clinical Strategy Group February 2015 This paper is for: Governing Body Recommendation: To note For further information or for any enquiries relating to this report please contact: Richard Segall Jones, Company Secretary Date: 24 th February 2015 Reporting Officer: Richard Segall Jones, Company Secretary Agenda Item: 37/15 Lead Director: Dr Sanjay Singh, Chair of the Clinical Strategy Group Report Summary: Version: Final This report provides an update to Governing Body on the items discussed at the Clinical Strategy Group (CSG) on 10 th February Also attached are the approved minutes of the meeting on 13 th January FOI status: This paper is disclosable under the FOI Act Strategic objectives links: Board Assurance Framework links: Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment Report history: Appendices Next steps: All strategic objectives are served by the work of the Clinical Strategy Group The work of the Clinical Strategy Group links to all BAF components. Not applicable. Not applicable. Not applicable. Not applicable. N/A N/A NHS West Kent CCG Page 71 of 83

72 Clinical Strategy Group (CSG) report: February 2015 Dr Sanjay Singh Chief GP Commissioner Page 72 of 83 Patient focused Providing quality, improving outcomes

73 Dr Sanjay Singh Chair of the Clinical Strategy Group and GP Chief Commissioner The Clinical Strategy Group (CSG) met on Tuesday 10 th February 2015 and the following items were discussed. Chair s Report Dr Nick Cheales provided an update on the Transforming Outpatients Department programme and noted that Maidstone and Tunbridge Wells NHS Trust was supportive of the programme. There will be a pause in the roll out of the programme to ensure that the appropriate processes are in place to support the addition of further specialties and GP practices onto KinesisGP. Diabetes Concept Paper The CSG discussed and commented on the proposals for the future service provision and strategy for diabetes prevention and management. The CSG was broadly supportive of the concept of shifting services into the community with an emphasis on quality within the framework as set out in the paper. The next steps will be to go out to public and wider consultation which should input into developing a full scale business case & options paper. Self-Care Delivery Strategy The CSG commented on the proposed self-care and self-management delivery strategy. It broadly supported the direction of travel as set out in the paper with a few suggestions and amendments that were noted. The next steps are to agree the plan with Kent County Council, Local Authority Health Action Teams and the West Kent Health and Wellbeing Board in advance of seeking Governing Body approval. Improving Access to Psychological Therapies Contract Options At the end of August 2015, contracts for three of the current Improving Access to Psychological Therapies (IAPT) providers in West Kent are due to expire. The CSG approved the recommended option of a new Any Qualified Provider (AQP) contract but recommended to reduce the length of the contract to two years to align with the expiry of the remaining IAPT provider contracts. This would allow for a review of the IAPT service in The CSG approved this option, subject to the agreement of the resource implications by the Chief Finance Officer and Chief Operating Officer. It also asked the Mental health Programme Oversight Group to review the current service specification and identify any opportunity to improve it if there was scope. A paper will be presented to a future Governing Body meeting. Clinical Strategy Group Governing Body report - July Page 73 of 83

74 NHS Funded Schemes Transition (Ophthalmology) As of 1 st April 2015, budgets for glaucoma and cataract schemes will transfer from NHS England to the CCG. The CSG agreed the recommendation to maintain current services for a further year, while the CCG develops an ophthalmology strategy for West Kent. Addressing Health Inequalities in West Kent CCG; Local Action for Improving Population Outcomes The CSG received an update on public health initiatives aimed at reducing health inequalities in West Kent. Date of the next meeting The next Clinical Strategy Group meeting is scheduled for Tuesday 10 th March Clinical Strategy Group Governing Body report - July Page 74 of 83

75 MINUTES OF THE CLINICAL STRATEGY GROUP MEETING HELD ON TUESDAY 13 TH JANUARY 2015 IN THE MEDWAY ROOMS, WHARF HOUSE, TONBRIDGE Date approved: 10 th February 2015 Present: Dr Sanjay Singh Gail Arnold Dr Bob Bowes Alison Brett Dr Bruno Capone Dr Nick Cheales Dr David Chesover Dr NicGoodger Dr Mark Ironmonger Dr Tony Jones Reg Middleton Malti Varshney Dr Mark Whistler Dr Meriel Wynter In attendance: Francesca Guy Priscilla Kankam Martine McCahon Pauline Stevenson Ben Wright Apologies: Ian Ayres Dr Tim Palmer Dr Andrew Roxburgh Dr Garry Singh Chair, Chief GP Commissioner & Governing Body Chief Operating Officer Chair of the Governing Body Acting Chief Nurse GP Governing Body Member GP Governing Body Member GP Governing Body Member Governing Body Member GP Governing Body Member GP Governing Body Member Chief Finance Officer Governing Body Member, Public Health GP Governing Body Member GP Governing Body Member Deputy Company Secretary (minutes) Prescribing Advisor Commissioning Programme Lead Integrated Commissioning, LTC and older people Senior Project Manager, Transforming Outpatients Department Head of PMO Chief Officer GP Governing Body Member GP Governing Body Member GP Governing Body Member 01/15 Welcomes and Introductions The Chair welcomed everyone to the meeting. 02/15 Apologies for Absence Apologies had been received from Dr Andrew Roxburgh, Dr Garry Singh, Dr Tim Palmer and Ian Ayres. Page 75 of 83

76 03/15 Quorum The Chair confirmed that the meeting was quorate. 04/15 Declaration of Members Interests No declarations of interest were declared. 05/15 Minutes from the previous meeting held on 9 th December 2014 The minutes of the meeting held on 9 th December 2014 were approved. 06/15 Actions arising from the previous meeting held on 9 th December 2014 The following actions were discussed: 196/14 Committee Effectiveness Review: The Chair reported that he and Gail Arnold had arranged additional meetings with the Heads of Commissioning to plan for Clinical Strategy Group (CSG) meetings. The outputs of this meeting would feed into the forward planner for the CSG. 196/14 Committee Effectiveness Review: The Chair confirmed that he had invited lay and independent members to observe CSG. 07/15 Matters arising from the meeting held on 9 th December 2014 not covered elsewhere on the agenda There were no other matters arising. 08/15 Chair s Report The Chair reported that there had been a decline in diabetes referrals from non-l2 practices as well as L2 practices, resulting in an overall decline in activity. The Chair reported that there had been an increase in the number of GP referrals to the Enhanced Rapid Response Service (ERRS) following the re-launch of the service and there was concern about whether there was sufficient capacity to meet the increase in activity. Mr Middleton commented that there had been additional burden on the service from Maidstone and Tunbridge Wells NHS Trust (MTW) which had been largely related to social rather than medical problems. Ms Arnold responded that ERRS activity was monitored regularly and as of last week, no social care patients were being managed by ERRS. The Chair asked GP members to highlight any operational concerns to Nikki Clarke, senior manager at Kent Community Health NHS Trust (KCHT). Page 76 of 83

77 09/15 Care Homes Business Case Martine McCahon introduced the item by stating that the CSG was being asked to approve two proposals: the emergency health care plan tool for care home clients with complex needs/multiple morbidities; and the criteria for identifying high intensity users. The CSG discussed the draft template Emergency Health Care Plan for care home clients with complex needs/multiple morbidities. In the discussion that followed, it was noted that the care plan was intended to supplement the existing care plan under the current Direct Enhanced Services (DES), with the aim of preventing inappropriate hospital admission. The content of the care plan was therefore written for care home and ambulance service staff. The following comments were made: There was too much free text to allow the form to be uploaded onto the Care Plan Management System (CPMS). The care plan also contained too much information, which would make it difficult for ambulance service staff to identify the key points; The mobile number of the next of kin should be made more visible on the care plan. A message could also be added to the care plan to urge people to consider other options before calling 999; The implementation of the care plans needed to be consistent and monitored carefully, otherwise there was a risk that it could create further gaps in health outcomes; These patients had complex needs, however the reasons for being admitted to hospital were often not complex. It was therefore important that GPs initiated this type of dialogue with patients; Patients could often change their mind when faced with a situation and therefore suggested that an element of the decision about their care would need to be made at the time of the illness; Compulsory common themes might need to be added under the anticipated acute illness section eg chest infections. The Chair summarised the discussion by stating that the CSG was broadly supportive of the principle of care planning and agreed that the current care plan needed further tweaking based on above discussions to ensure that it had an impact on non-elective admissions. The care plan was intended to provide guidance and was not contractually binding under General Medical Services (GMS). The Chair noted that a number of amendments would need to be made to the care plan following today s discussion. Dr Bruno Capone and Dr Mark Whistler agreed to formulate the final draft for implementation based on CSG feedback. Action: Bruno Capone/Mark Whistler. The CSG agreed the recommendation to trial the care plan for a year until the care home strategy was developed. The CSG approved the recommendation that GPs would be responsible for selecting which third of their care home residents would receive an Emergency Health Care Plan and noted that regular audits of the care plans would be undertaken, focusing on the quality of the Page 77 of 83

78 care plans and not which patients had been selected. The 80 rate payable for the emergency health care plan had been agreed by the Chief Officer and the Chief Finance Officer. GP members would be excluded from this decision at Governing Body due to the conflict of interest and the decision would be subject to retrospective scrutiny by the Audit Committee. The Chair noted that the Care Homes business case would be presented to the January Governing Body for approval. 10/15 Romney Ward Business Case Gail Arnold provided an update on Romney Ward and noted that overall the clinical objectives were being met. The majority of the patients were Maidstone residents which meant that Tonbridge Cottage Hospital now had capacity to meet its need. The overall benefit to the system was valued at 2m with a cost to WK CCG of 1.2m. The CSG noted that closure of the ward would result in greater numbers of patients waiting for nursing home spaces, which would result in acute hospital bed space being occupied. The CSG discussed the costs and benefits of the service and options for commissioning the service post April The Chair noted that this would be considered as part of the development of the community hospital strategy. 11/15 Transforming Outpatients Department Pauline Stevenson joined the meeting and noted that CSG approval was sought for the continuation of the Transforming Outpatients Department programme, with further specialities added onto KinesisGP and more practices included. The proposed total expenditure in 2015/16 was 185k with projected net savings of 938k. In the discussion that followed, these comments were made: The implications of rolling out this programme to other providers, along with any implementation challenges, needed to be discussed in greater detail with the commissioning team; The performance monitoring metrics should address the main criteria of success; The CCG should monitor the overall volume per month alongside the number of referrals into the Trust; It would be beneficial to have anecdotal feedback from people using the system; Consideration should be given to the impact on prescribing; The proposal to include mental health providers onto KinesisGP presented an opportunity to use specialist nurses. Ms Stevenson gave an update on roll out of KinesisGP and noted that two patient representatives had signed up to the project. Page 78 of 83

79 The CSG agreed the continuation of the Transforming Outpatients programme with further specialities added onto KinesisGP and more practices included. The additional funding of 185k was agreed by CSG to be recommended to the Governing Body for approval. The Chair asked for a further update on progress in 3 to 4 months time. Action: Pauline Stevenson 12/15 Policy Recommendation: Open MRI CSG approved policy recommendation PR : Open MRI. 14/15 Commissioners as managers, leaders and champions Dr Tony Jones presented his paper which outlined a proposal to improve contract management by having clinical leaders and champions for individual projects to drive forward sustained productivity and development of provision. The CSG was supportive of the proposal, but noted that commissioners would need to identify which projects required continued leadership and engagement. It was also noted thatclinical champions would need to ensure that they maintained their objectivity as there was a risk that they would become too attached to their championed projects. It was suggested that evaluation should always be undertaken by an external and neutral person as a way of mitigating this risk. Virginia Winstanley, GP trainee, suggested that a number of GP trainees would be interested in being project champions and agreed to send the Chair a list of those would like to be involved. Action: Virginia Winstanley 15/15 Medicines Optimisation Group (MOG) Ms Kankam presented the Medicines Optimisation Scheme for 2015/16 for CSG approval. CSG agreed that the prescribing of antibiotics should be removed as the root cause analysis of instances of C.difficile did not indicate a correlation with the prescribing of antibiotics. Ms Kankam agreed to make this amendment and to discuss with the Medicines Optimisation Group. Action: Priscilla Kankam CSG members were asked to forward any suggestions for target areas to Ms Kankam. Action: CSG The CSG approved the Medicines Optimisation Scheme for 2015/16, subject to this amendment. The revised scheme would be presented to Governing Body for approval, with GP members absenting from the vote due to the conflict of interest. 16/15 Summary Reports from POG Meetings The CSG noted the summary reports from the Programme Oversight Group (POG) meetings. Page 79 of 83

80 17/15 Approved Minutes from POG Meetings The CSG noted the approved minutes from the following POG meetings: Mental Health Urgent Care and the Urgent Care Board Planned Care and Integrated Commissioning 18/15 Date of next meeting The next Clinical Strategy Group meeting is scheduled for Tuesday 10 th February Page 80 of 83

81 Practice Engagement Committee February 2015 This paper is for: Governing Body Recommendation: To note For further information or for any enquiries relating to this report please contact: Richard Segall Jones, Company Secretary Date: 24 th February 2015 Reporting Officer: Richard Segall Jones, Company Secretary Agenda Item: 38/15 Lead Director: Dr Garry Singh, Chair of the Practice Engagement Committee Report Summary: Version: Final This report provides an update to Governing Body on the items discussed at the Practice Engagement Committee on 3 rd February FOI status: This paper is disclosable under the FOI Act Strategic objectives links: All strategic objectives are served by the work of the Practice Engagement Committee Board Assurance Framework links: Identified risks & risk management actions: Resource implications: Legal implications including equality and diversity assessment Report history: Appendices Next steps: The work of the Practice Engagement Committee links to all BAF components. Not applicable. Not applicable. Not applicable. Not applicable. N/A N/A NHS West Kent CCG Page 81 of 83