CCG GOVERNING BODY. Minutes

Transcription

1 CCG GOVERNING BODY 9 November 2017 Southwark CCG, 160 Tooley Street, SE1 2QH Minutes GOVERNING BODY MEMBERS PRESENT: Dr Penny Ackland (PA) Dr Noel Baxter (NB) Andrew Bland (AB) Gillian Branford (GB) Christine Caton (CC) Professor Ami David (AD) Dr Robert Davidson (RD) Linda Drake (LD) Joy Ellery (JE) Professor Kevin Fenton (KF) Dr Emily Gibbs (EG) Mark Kewley (MK) Wendy McDermott (WM) Ross Graves (RG) Dr Jonty Heaversedge (JH) Dr Michael Khan (MKh) Dr Nancy Kuchemann (NK) Kate Moriarty-Baker (KMB) Robert Park (RP) Dr Yvonneke Roe (YR) Stephen Whittle (SW) IN ATTENDANCE: Richard Whitfield (RW) Kieron Boyle (KB) Rowena Estwick (RE) Clair Goodey (CG) APOLOGIES: Andrew Nebel (AN) Dr Richard Gibbs (RG) Caroline Gilmartin (CG) Malcolm Hines (MH) Chair of Southwark LMC Clinical Lead Chief Officer Assistant Director, Partnership Commissioning Team Interim Chief Financial Officer Governing Body Nurse Member Clinical Lead Practice Nurse Member Lay member Director of Health and Wellbeing (Southwark Council) Clinical Lead Director of Transformation Service Development Manager, Adults Social Care (Southwark Council) representing Jay Stickland Interim Managing Director CCG Chair (Meeting Chair) Secondary Care Doctor Member Clinical Lead Interim Director of Quality & Chief Nurse Lay Member Clinical Lead Healthwatch Southwark Assurance Manager (minutes) Chief Executive, Guy s & St. Thomas Charity Partnership Manager, Guy s & St Thomas Charity SEL 111 and Service Redesign Manager Lay Member Lay Member, (Deputy Chair) Director of Integrated Commissioning Chief Financial Officer 1

2 1 Chair s Welcome JH welcomed attendees to the meeting. Public Open Space JH welcomed questions from the members of public in attendance. He stated that there would be an opportunity for greater discussion with GB members after the meeting. Elizabeth Rylance Watson (Southwark Resident) said that the minutes of the last meeting did not accurately reflect the questions she had submitted on 14 September 2017 by . She said that she would repeat these questions. She also highlighted that the extended public open space, which follows the Governing Body, is not included on the Governing Body agenda, the meeting in September was not minuted and that people left before the end of discussions. JH said that he understood that meetings had taken place between Elizabeth and members of the mental health commissioning team to discuss the issues she had highlighted by . He apologised that this information had not been provided and said he would ensure that answers are provided. 2 Elizabeth Rylance Watson referenced the draft Southwark Mental Health Strategy, and said that the number of 3800 residents is drawn by limiting the definition of Serious Mental Illness (SMI) to bipolar and psychosis whilst not referencing NICE Guidance of November 2016 which does include serious cyclical depression with or without psychosis to its SMI populations. She asked that a caveat be included with this figure which outlines the above discrepancy. KF thanked Elizabeth for this feedback which she had provided previously. He said that this had been shared with the analytics team who generated the above estimate of SMI population. He said that that draft strategy has been updated so that it takes into account the full breadth of SMI described in NICE guidance. JH highlighted that the Strategy is much wider than SMI and encompasses the entire population in relation to mental health and wellbeing. Elizabeth Rylance Watson asked for a comprehensive breakdown of Southwark s mental health spend, in particular identifying the difference in spend on the SLaM contract between Lambeth and Southwark. She would like to know how this difference is explained. JH stated that the CCG has provided previously a very detailed breakdown of MH spend and said that CC was in a unique position of being able to provide this comparative data across Lambeth and Southwark. Action CC to provide the comparative financial information for spend on mental health and SLaM between Lambeth and Southwark 2

3 Elizabeth Rylance Watson stated that this will help members of the public to understand the decision making on mental health spend within the STP delivery plan. AB clarified that the STP does not make decisions on mental health spend. The STP is a partnership and the overall spend would be the aggregate across the 6 CCGs. Action AB to confirm the wording of the STP delivery plan regarding commitment to mental health spend. Elizabeth Rylance Watson asked for greater explanation of the BCF mental health spend and how this will feed into the providers. GB stated that SLaM was the main provider and that she would provide a fuller more detailed breakdown of spend on different providers and SLaM. Action: GB to provide ERW with the more detailed breakdown of BCF mental health spend. Cllr David Noakes (opposition spokesperson for health) stated that he wanted to bring to the attention of the Governing Body that the draft Southwark Mental Health Strategy has a target of reducing suicide by at least 10% over the five years of the strategy. He said that he was surprised that this is not more ambitious. KF said that he was part of a community consultation on the strategy recently and that this included discussion regarding this target. He said that it is important to find a balance between a zero suicide ambition and a minimum target. He said that the wording had been tested with the community and there was agreement that stating that the ambition is to reduce suicide as much as possible with a minimum target of 10% was appropriate. Elizabeth Rylance Watson stated that feedback she had provided previously regarding version 0.6 of the strategy was that a suitable target would be for the lowest suicide rate in London. Bob Skelly (Southwark Resident) said that he had counted there had been approximately 211 SIs during 2016/17, including five in one month at Denmark Hill. He said that previously he had been told that this information could not easily be used to make comparisons between trusts. He asked whether the number of SIs and Never Events was normal and asked why comparisons could not be made between trusts. NB stated that he would be worried if they came from the same ward and related to the same event. He said that they tend to happen at different sites and relate to different events. NB cited the example of nasogastric tube placement which had been identified as a theme from previous SIs and led to specific work at each trust to communicate the policy. NB said that far more SIs are reported now than used to be and that this relates to the development of very clear processes for reporting and informing all staff when these occur. He said that there is a lot of confidence in the processes which are in 3

4 place. He stated that one of the issues for making comparisons between trusts is not having an accurate denominator which encompasses volume and complexity of all activity. He said that there can be more value in tracking the number of near misses. KMB said that there has been discussion across South London Quality Surveillance group to widen the examination of themes to a larger scale. Provider presentation and questions: Guy s and St Thomas Charity JH welcomed Rowena Estwick and Kieron Boyle from Guy s and St Thomas Charity. KB provided an overview of the charity, how it works within Southwark and Lambeth communities in partnership with other organisations and its role as a hospital charity for Guy s and St Thomas Foundation Trust. A short video describing the charity s programme based approach, the communities it supports and examples of the projects it has supported was shown to the Governing Body. JE asked how the charity decides its programmes and whether they are open to suggestions from partners and members of the public. 3 KB stated that programmes are chosen by the board and represent a 5-10 year focus. The intention is that this process occurs approximately every 2 years so that there are 4-6 programmes at any one time. RP said that the charity had been enormously helpful on a number of projects, including SLIC. He asked if the money had been spent wisely and whether this could have been spent better KB said that money had been spent wisely. He said that it is important to use significant resources to get to a sustainable change tipping point. This is an area for improvement. SW said there appears to be a tension between funding projects where the impact is measurable and those which may help people which can t be quantified. He asked what the riskiest project which has been invested in. KB said that there are risks with the projects they fund but that the charity can take risks. He said that they will not take risks and back projects where it is not clear there is an understanding of impact on the wider system. JH thanked both Kieron and Rowena for attending. 4

5 Southwark Showcase: MK spoke about the Extended Primary Care Service. He framed this in the wider developments in primary care, or primary care leaders, federations and the move towards LCNs. MK highlighted the positive experience of patients experiencing the service and the fundamental transformative impact of the service in widening the perspective in primary care towards working at scale. He identified Hayley Sloan, Harprit Lally, Louise Flynn and Aarti Gandesha for particular praise. 4 SW said that he was very grateful that the service exists. He said that Healthwatch has also undertaken practice visits. This highlighted an inconsistency in information provided by practices and understanding of practice staff. This will be incorporated into a Healthwatch evaluation with recommendations, which he urged be considered side by side with the Deloitte evaluation. JH agreed that this should be the case. AB said that the CCG, LMC and federations need to utilise their shared GP membership to ensure that there is consistent messaging and understanding of the service across primary care. He said that Southwark was scoring in the mid 80%s in terms of practices understanding how to use the service. This compares very favourably with other parts of London and is an improvement compared to previous quarters. AB said that there needs to be a focussing on public communication across London when all areas go live. A public facing campaign will help to do this. 5 Introduction and apologies for absence Introductions were made and apologies received. Minutes and action log from the last meeting on 14 September The minutes were agreed to be an accurate record of the meeting on 14 September The action log was reviewed. It was noted that there were no outstanding actions All members were asked to declare any change in conflicts of interests and raise any conflicts relating to items on the agenda. No conflict relating to agenda items were declared. The register was circulated for update and signing. 5

6 Managing Director s Report RG presented the Managing Director s report which provides the Governing Body with an update on major developments in local health system and within the commissioning portfolio. Each area of the report has been overseen by the relevant committee of the Governing Body including the Senior Management Team of the CCG. Clinical lead portfolio holders have been involved in each area. He highlighted the following sections for particular focus: 7 1. All six south east London CCG Governing Bodies have signed off the Stage 1 proposals for collaborative working and executive arrangements across the CCGs SEL CCG review. 2. During Quarter 4 of this financial year the CCG will confirm our Operating Plan and our Quality Innovation Productivity and Prevention (QIPP) plans for 2018/ In September the CCG held a very well attended Protected Learning Time (PLT) session to support local federations to launch the new Care Coordination Pathway for people with 3+ long term conditions. 4. The CCG has successfully recruited a team of highly capable and energetic clinicians to lead the CEA and has been successful in its application to be part of the Health Foundation s Scaling Up initiative 5. The Integration and Better Care Fund (BCF) Plan agreed by the Health and Wellbeing Board in September was approved through the NHSE assurance process without the requirement for changes or the application of additional conditions 6. Lambeth CCG, Bromley CCG and Southwark CCG are piloting a new telephone advice and guidance service called Consultant Connect. The service allows GPs to speak with local speciality consultants at GSTT and KCH in real time anytime Monday to Friday 9am-5pm. 7. The Dulwich programme is close to completing the development of the Stage 2 Business Case. 8. The return of Malcolm Hines to the CCG following a short period of recuperation after major surgery. Malcolm will resume his role as Chief Finance Officer, undertaking a phased return to work during November and December. 9. Thanks and best wishes to Aarti Gandesha who will be leaving her role at Healthwatch. SW echoed the praise for Aarti Gandesha but highlighted that funding at current levels had not yet been secured and this will impact on recruitment. YR asked whether longer term patient outcomes will be used in the evaluation of consultant connect. JH said that he was not sure if it is possible to categorically monitor outcomes but that this was an interesting challenge which needs to be considered. A lot of 6

7 evaluation is built into the pilot PA said that she was very much in favour of advice and guidance but that there needs to be consideration of the potential workload this could put back on practices. She also asked if there were implications for liability if decisions are made when acting on the advice from consultants. RD said that all calls are recorded and can be recalled. The Governing Body noted the contents of the report Report of the CCG s prime committees: August, September, October 2017 JH introduced the report, explaining the format for reporting the work of the CCG s prime committees. JH reminded members that the papers being referred to the Governing Body for decision had been thoroughly reviewed and discussed at committee stage. JH welcomed questions on the report or decisions made by delegated committees. 9 JH highlighted the item recommended to the Governing Body to be formally signed off: 1. Annual Audit Committee Report to CCG Governing Body 2. EPRR self-assessment assurance rating The Governing Body reviewed and approved the items. The Governing Body noted the content of the prime committee report and the decisions that have been made by the delegated committees. Integrated Urgent Care Service Specification JH welcomed Clair Goodey to the Governing Body to present the Integrated Urgent Care Service Specification. CG summarised the previous attempt to procure a model, the lessons learnt and the NHS England national service specification which fed into the current approach and procurement process. She said that the approach is now supported by providers. She highlighted the substantial engagement which has taken place. CG described the service model, which would be one specification and one contract for all of South East London (Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark CCGs) and incorporate call handling and clinical assessment service. RD described patient journeys for a person with a urinary tract infection and a child with diarrhoea with the current 111 service and how it would look with the new IUC 7

8 service. JH stated that the Governing Body is being asked to approve the SEL IUC Service Specification and Equality Analysis. JH clarified that the Governing Body is also being asked to approve a chair s action for the Director of Integrated Commissioning and a Lay member in addition to the CCG Chair, Chief Officer / Managing Director, Chief Financial Officer and clinical lead for urgent care to review and approve the final revised business case on behalf of the Governing Body once this has been finalised. Action: JH to convene the above group to review and sign off the final revised business case on behalf of the Governing Body KF asked if any thought had been given to integrating preventative messaging in to the service, potentially utilising digital resources. RD said that this has not been put at the forefront of the specification but it is a challenge for incorporation during the mobilisation phase. LD said that there has been a lot of discussion in the media about AI based services. She asked what scope there is for integrating with this. RD said that the specification incorporates the potential for this after the first two years (when the embedded pathways are more prescriptive). RP said that the SELDOC model in Southwark provides a very good service and is dependent on GPs choosing not to opt out. He asked for assurance that the new service will not lead to GPs opting out. RD agreed that this is a very important issue. He said that the challenge is integrating across all boroughs in South East London where this opt in approach is not necessarily in place. He said that the steer nationally is that changes should not destabilise the existing services. NK highlighted the pathway for mental health patients. She highlighted a concern that the pathway for all of these patients would be via the trust, even in cases where primary care could manage the patient. She also asked if this could impact on the identification of physical health issues as well. RD said that the guidance is clear that mental health patients be routed via the trust. He said that there is a legitimate challenge here for considering physical health as well and that potential responses to this are being considered. SW asked if the model would lead to additional pressures on the trust. He also stated that some disadvantaged and hard to reach groups are not using the current service. RD stated that these concerns had been considered. He said that across the 6 CCGs there had been approximately 2000 patients. He said that discussions are taking 8

9 place to ensure that there is sufficient capacity. JE said that there was a limited amount of information on equalities in the specification, in particular regarding LD and hearing impairment. She asked for assurance about ongoing evaluation to understand why these people are not using the service. CG said that the engagement completed to date highlighted that more is needed in terms of advertising. This includes ensuring that communities understand that language lines and BSL options exist. AD asked for more information regarding nurse leadership in the model. CG sad that strong clinical leadership is central to the specification. She highlighted that this stipulates a minimum of 1 GP will be present at all times and that in the majority of cases a pharmacist will be present as well. YR and JH highlighted the opportunities for greater integration with primary care in and out of hours. The Governing Body approved the SEL IUC Service Specification and Equality Analysis. The Governing Body approved a Chair s action to be taken by a group made up of the CCG Chair, Chief Officer / Managing Director, Chief Financial Officer, a Lay Member, Director of Integrated Commissioning and clinical lead for urgent care to review and approve the final revised business case on behalf of the Governing Body once this has been finalised. Update on the latest CCG position: i) Performance AB presented information on the latest key issues, highlighting by exception the following: 11 A&E - 4 hours target The 95% target is not being met by either trust. This reflects the picture across London and nationally. He highlighted that GST are maintaining a position above 90%. KCH performance has worsened. AB summarised the factors contributing to performance and outlined the approached to improving the out of hospital system. Referral to Treatment within 18 weeks AB said that the trajectory will not return Southwark to the national standard until March 2019 but highlighted the reduction in long waiters. 9

10 Diagnostics within 6 weeks The overall improvement in diagnostic waits means that Southwark is now consistently close to meeting the standard. AB highlighted the specific services which were not compliant at GST which drove the non-compliant position at the trust and the CCG. Cancer waits AB highlighted that Southwark had met all three cancer targets in August. He stated that numbers are very low which can lead to monthly fluctuations in performance. He stated that GST performance is largely driven by inter-hospital transfers London Ambulance Services response times AB stated that Southwark continue to have some of the most consistent performance across London. The updated position as set out above and in the accompanying assurance report was noted by the Governing Body. ii) Quality KMB highlighted the major quality issues and work being completed in the directorate. She highlighted the clinical effectiveness approach (CEA) which aims to translate best practice into quality improvements across general practice in order to reduce unwarranted variation in clinical outcomes across the borough. KMB stated that From August to September 2017 the CCG was alerted to 65 SIs, 12 of which affected Southwark residents. All SIs and Never Events are analysed by the CCG and its providers to understand and implement improvements and learning. In 2016 for example, there was a spate of incidents regarding misplaced nasogastric tubes. Focused work within providers has minimised this and the trend has now been reversed. KMB informed the Governing Body that att the end of October CQC published the report of their July 2017 inspection of SLaM Adult Community Services and has regraded the service from Good to Requires Improvement. Issues noted were risk assessments, care plans. SLaM were issued with 4 Must Do and 8 Should Do notices. Progress against their action plan will be tracked by CCGs at SLaM CQRG. KMB highlighted the requirement to reduce the number of NHS CHC assessment taking place in an acute setting, by March 2018, as part of the 8 High Impact Actions and the current performance against this. KMB highlighted the safeguarding quality assurance visits undertaken during June and July 2017 by the CCG s Safeguarding Team to services commissioned by the 10

11 CCG. The updated position as set out above was noted by the Governing Body. iii) Finance CC stated that the financial position is discussed in detail at the monthly IGP. She said that the CCG is on course to deliver its financial targets for CC highlighted that the CCG is expecting to receive a capital allocation for IT in 2017/18, and as a result will also be bound by the financial duty relating to the capital resource. CC summarised the M6 position. The main Acute contracts are expected to achieve the planned level of spend, while there is an overspend on a number of the smaller contracts. She stated that included in the worst case scenario is the potential liability ( 1.75m) with Lewisham & Greenwich NHS Trust relating to the Trust Special Administrator Agreement (TSA) at South London Healthcare NHS Trust in CC highlighted the forecast for Delegated Primary Care includes the remainder of a 1.8m gap between funding allocated to the CCG for primary care and the budgeted cost (including primary care reserves) of primary care in Southwark. Mitigations have been found to reduce the gap to 1.19m. The CCG has also ring-fenced a 346k underspend within Community and Primary Care Health Services to help mitigate the funding gap. CC summarised the actions being taken by the CCG to manage in year risk and contribute to delivery of QIPP in 2018/19. She stated that 2018/19 would be more challenging than 2017/18. The updated position as set out above and in the accompanying finance report was noted by the Governing Body. iv) Risks JH Highlighted the extreme risks for the CCG. Progress is being made on the mitigation of these extreme risks which is captured and published in the larger BAF. JH identified that a new risk has been added: Risk of failure to achieve NHS Continuing Care Discharge to Assess trajectory. The risk is extreme due to the very challenging nature of the trajectory and has a number of mitigating actions in place. The IGP will continue to track this risk and seek assurance on actions. The IGP committee continues to review the BAF and directorate level risks on a monthly basis, provides scrutiny and challenge on behalf of the Governing Body. JH stated that the CCG s risk management system has been given Substantial 11

12 Assurance (highest rating) by the auditors. The IGP will continue on a monthly basis to review the BAF and directorate level risks and provide scrutiny and challenge on behalf of the Governing Body. Two risks were escalated. The risk that operational and financial instability of GP federation impacts on delivery of our local initiatives. The risk related to the OHSEL programme has increased due to worsened M5 financial position for one of the SEL CCGs affecting SEL-wide control total - other CCGs, including Southwark may not be in a position to contribute to recovery. Two risks were de-escalated and taken from the BAF. These were safeguarding children and adults risks and these were taken off as the committee felt there was enough assurance around the systems we have in Southwark. Governing Body noted the extremes risks and changes to the BAF described in the Risk register and BAF. Governing Body noted the that the CCG s risk management system has been given Substantial Assurance (highest rating) by the auditors Minutes of CCG committees 12 The Governing Body noted the minutes of the following meetings: Integrated Governance & Performance Committee (Aug, Sept 2017) Commissioning Strategy Committee (September 2017) Primary Care Commissioning Committee (July 2017) Engagement & Patient Experience Committee (September 2017) Audit Committee (May 2017) 13 Any other Business None Public Open Space JH invited questions from the public and welcomed them to an extended session to be held immediately after the meeting. 14 Elizabeth Rylance Watson said that she would be asking for more details regarding how the 1.8m gap between funding allocated to the CCG for primary care and the budgeted cost is being tracked at the next Primary Care Commissioning Committee. It was clarified that prime committee minutes are only included in the Governing Body papers once they have been signed off by that committee. Elizabeth Rylance Watson asked, regarding the IUC service, who would be holding patients records. 12

13 RD stated that GP practices hold the patient records and the security of these. He said that special patient notes are used in services out of hours where appropriate. He said coordinate my requires agreement from patients. RD stated that the same principles regarding consent and data sharing exist. He said that increasingly there is a move towards sharing care, but that this still requires compliance with appropriate data sharing processes. Elizabeth Rylance Watson asked who Babylon is. JH said that Babylon is one of a number of companies offering online access to health care, which may utilise algorithms to stratify patients. 15 Date of the next Governing Body Meeting: 2.00pm to 5.30 pm, 11 January 2018, 160 Tooley Street. 13