1. INTRODUCTION Action

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1 Minutes of the Meeting of the Haringey Clinical Commissioning Group Clinical Cabinet Thursday 2 March 2017 at 1.15pm Hornsey Neighbourhood Health Centre Present: Dr John Rohan JR GP Governing Body Member, North East Lead, Chair of the Clinical Cabinet Dr Muhammed Akunjee MA GP Governing Body Member, South East Dr Belinda Agoe BA GP, Dementia Lead Dr Gino Amato GA GP Governing Body Member, North East Dr Christiana Aride CA GP and Clinical Lead for Gynaecology, Tynemouth Medical Practice Dr Simon Caplan SC GP Governing Body Member, North East Rachel Lissauer RL Director of Commissioning, Haringey CCG Dr David Masters DM GP Governing Body Member, West Rosie Peregrine-Jones RPJ Head of Quality, Haringey CCG Dr Kate Rees KR GP, Clinical Lead for Cancer and End of Life Care Sharon Seber SS Primary Care Health Professional Governing Body Member South East Dr Lionel Sherman LS GP, Bounds Green Group Practice Dr Daijun Tan DT GP Governing Body Member and Clinical Lead for Diabetes Sarah Timms ST Governing Body Member, Nursing In attendance: Lyndsey Abercromby LA Assistant Director of Commissioning, Haringey CCG Dr Naz Akunjee NA GP,West Green Surgery Mohammed Al-Mahfuz MA- Practice Manager, Charlton House Medical Centre M Manuel Anthony MA Operations Manager, Morum House Medical Centre Claire Davidson CD Lead for Self-Management Support and Behaviour Change, Whittington Health Sonia Hall SH Practice Manager, Tynemouth Medical Practice Efa Mortty EM Deputy Head of Medicines Management, Haringey CCG Pauline Taylor PT Head of Medicines Management, Haringey CCG Linda Roast LR Minutes 1. INTRODUCTION Action 1.1 Chair s Introduction Dr John Rohan welcomed all present and it was agreed that the presentation on Supported Self-Management for People with Long Term Conditions would be taken at the beginning of the meeting. 1.2 Apologies for Absence No apologies were received. 1.3 Declarations of Interest There were no declarations of interest pertaining to items on the agenda. 1

2 1.4 Minutes of the Previous Meeting The Cabinet agreed the minutes of the meeting held on 5 January 2017 as an accurate record. 1.5 Matters Arising and Action Log Action 05/01/17-01: Completed Action 05/01/17 02: Included on the agenda for discussion at today s meeting. 2. CLINICAL UPDATES 2.1 Supported Self-Management for People with Long Term Conditions (LTC) Claire Davidson outlined that the Haringey population included 19,000 people over 65 with LTC and an associated 16,000 unpaid carers. This presented a significant challenge to local health services, particularly with conditions such as diabetes where prescribing costs represented 10% of the CCG budget and prevalence was expected to rise 10% by From the perspective of a patient with LTC an average of three hours per annum was spent with an NHS professional, relying on self-management for the rest of the time and it was therefore essential to optimise individuals ability and confidence to do so. The slide pack included an illustration of the House of Care with commissioning as the foundation and health care professionals committed to working in partnership with engaged and informed patients. Good communication was essential and organisational processes needed to support the patient taking a pro-active role. Claire Davidson gave an example of a patient having access to test results prior to their review and being able to prepare for issues to raise. If any aspects of this House of Care were missing it was then difficult to support self-management effectively The background to progress locally had included Islington and Haringey PCT Expert Patient Programmes (EPP) and then the Co-Creating Health Programme which had aimed to embed self-management support within mainstream health services. Due to good outcomes both Islington and Haringey CCGs had subsequently continued funding for self-management services which although Haringey had stopped at one point had been picked up again with BCF funding. The programmes available for patients now included EPP and the Diabetes Self- Management Programme (DSMP) for Type 2 diabetes. Details of the format and content of these models, plus the skills to be achieved were summarised in the slide pack and a Patient Activation Measure was used as a tool to assess escalation in the levels of self-management. The process applied aimed to help patients develop the skills and behaviour change that would assist them to take more control and a positive approach on how best to live with their LTC. Strategies used to improve confidence included action planning; feedback and problem solving; modelling; re-interpreting symptoms; and persuasion. Patients were also better informed as to access to services when needed. Training for healthcare professionals included an Advanced Development Programme (ADP) and an ADP Masterclass Dr Simon Caplan queried whether the courses were available in languages other than English and Claire Davidson advised that Turkish was currently included. 2

3 2.1.4 In response to Dr Kate Rees, Claire Davidson confirmed that patients with chronic pain were accepted on the course and also patients living with unexplained long term symptoms (in excess of three months). Referrals could be made to WH and patients could also self-refer. Despite the very positive patient feedback Dr Kate Rees queried measurement of outcomes. She noted past experience of programmes, particularly for chronic pain, which appeared not to have resulted in any change. Claire Davidson reported that WH evaluation showed average increases in patient activation from level 2 to level 3 and reduced use of care services. The CCG was working on further tracking of the reductions in GP, OPD and A&E attendances and Rachel Lissauer confirmed this as a QIPP scheme. Patients at level 1 experienced poorer health and were subject to more medical errors, so the improvement in levels was linked to improved outcomes. Evidence demonstrated that those with less confidence and coping poorly benefitted most from EPP. Action planning represented a large part of the programme and modelling provided examples of others living with LTC Dr Gino Amato acknowledged that there were significant issues with patients at level 1. Patients with diabetes accounted for a huge percentage of GP appointments but a recently published article had suggested that such attendance was the only factor that made a difference. Claire Davidson referred to the WH DSMP evaluation which demonstrated clinically significant improvement in diabetes control and impact on reducing the risk of diabetic complications. Patients knowledge of HbA1C testing and their latest results was also greatly increased. Dr Simon Caplan noted the information presented in relation to glycaemic control and reduced complications and queried whether a direct extrapolation was possible. Claire Davidson advised that the data had been collated by a specialist Consultant who could provide further explanation The positive comments of patients were noted and Dr Kate Rees asked whether benefits were sustained. She noted that just having regular contact was often a positive factor for patients. She emphasised the need to measure effectiveness of the programme in real terms. Claire Davidson advised that work was currently underway on further evaluation of benefits post intervention, with a validated evaluation tool and work based on NICE guidance. Rachel Lissauer noted that increasing the number of patients referred to the programmes would allow fuller assessment of impact. Claire Davidson advised that the service was on target to achieve the number of completers commissioned by Haringey but, given the high numbers of patients with LTC, more referrals were encouraged and particularly from GP Practices. Practice referral rates and top referring Practices for Haringey were included in the slide pack plus other key referral sources. It was discussed that Practice referral rates for the DSMP were higher than for the EPP and Dr John Rohan suggested this could be due to the patient alert on EMIS regarding structured education. Sonia Hall also observed that for some LTCs other alternatives were available, such as cardiac rehabilitation programmes, whereas the DSMP would probably be the only option for patients with diabetes. In response to Sharon Seber, Claire Davidson agreed the need to increase referrals from secondary care. Course locations were noted and Claire Davidson advised that outreach could be arranged Feedback on the ADP training for clinicians was positive. Summary details were noted in the slide pack and further information on future dates could be accessed via the website. Dr David Masters asked whether one hour training sessions might be possible as a part of Practice meetings. Claire Davidson suggested that it could be possible to arrange joint training sessions for a group of Practices but would require a longer time slot to be of any real value. 3

4 2.1.8 Dr John Rohan expressed the Cabinet s thanks to Claire Davidson for her attendance and informative presentation. 3. Commissioning Items 3.1 Alignment of Sustainability and Transformation Plan and Haringey CCG Local Priorities Rachel Lissauer explained that the Governing Body had previously identified local priorities for the CCG and the Plan on a Page had been refreshed in The paper presented today set out how these local priorities aligned with the initiatives identified in the STP for NCL. It could be demonstrated that there was a great deal of alignment to the STP in many areas with close association to work underway locally, including work of the Haringey and Islington Partnership. However, it was recognised that there were some aspects of this that were not explicitly articulated in the local plan. There were also some STP interventions such as CHINs and QISTs where more work would be required locally in order to ensure delivery. The Governing Body had recommended that member Practices be advised of the current position and the paper was provided for information. 3.2 Shared Care Update Lyndsey Abercromby reported that, following Cabinet discussion at previous meetings, there had been further investigation of existing shared care arrangements. It had been acknowledged that there was a distinction between formal shared care and scope creep, with GPs increasingly expected to take on additional responsibilities. The paper presented included a list of existing, formal shared care agreements, guidelines and fact sheets. In the absence of formal agreements scope creep led not only to additional work but also inconsistencies as to the services provided by Practices and resulting inequity for patients. Anecdotal accounts were insufficient for challenging Trusts and therefore an audit was proposed in order to gather evidence of examples over a one month period. A template would be established on survey monkey and Practices would be asked to capture incidences where secondary care providers had requested them to undertake tasks which a year ago secondary care would have completed. Questions and comments were invited It was discussed that numerous and various types of follow up requests were received from secondary care and often without appropriate supporting information such as details of test results. Dr John Rohan cited examples of this relating to maternity/midwifery services. Dr Christiana Aride agreed similar experience and noted the need for clarity on responsibility for swab tests and iron prescribing. Dr Simon Caplan advised that it would be expected that responsibility rested with the obstetric/midwifery services and these incidences should be included in the audit. 4

5 3.2.3 Dr Muhammed Akunjee emphasised that hospitals should adhere to the requirements of the NHS Contract regarding minimising the burden on primary care in relation to follow up requests. He also noted that secondary care received funding for follow up work they were redirecting. Lyndsey Abercrombie advised that the wording of the contract was not specific but would be referenced. Dr Simon Caplan noted that if agreements were in place then relevant protocols should be available to inform all involved what was required of them. The problems arose when this was not the case. He cited examples of telephone calls from patients told to contact their GP for follow up blood tests etc following treatment in secondary care but with no supporting documentation available. Dr John Rohan suggested writing to Trust in relation to blood and urine test requests and Dr Muhammad Akunjee noted that serial tests were a particular issue. In response to Rachel Lissauer, Rosie Peregrine-Jones confirmed that this had been raised as a Quality Alert. Rachel Lissauer emphasised that the purpose of the audit was to collate further evidence and information of specific instances to support discussion with Trusts. Clinical Directors would then be able to ensure the issues were monitored via Collaboratives, GP networks and the Cabinet Dr David Masters suggested that developing pathways to reduce unnecessary follow ups should be part of the STP and also ensuring that resources followed where work was undertaken. Dr Naz Akunjee noted that GP waiting times would be shortened by reducing unnecessary follow ups. Dr Muhammed Akunjee noted methotrexate prescribing as an example of where current practice was inconsistent and that there needed to be a dedicated service for this. Dr Naz Akunjee advised that there were examples of this having been done in other CCGs and with the services funded outside of secondary care. Follow up issues were raised relating to children s services, out-patient attendances, prescribing of anti-psychotic drugs and associated monitoring. Dr Simon Caplan cautioned that responsibility for prescribing and testing also implied responsibility for care and treatment. Dr Kate Rees and Dr Gino Amato agreed there was significant variability of approach between Practices and consistent guidance was needed. Dr John Rohan cautioned that pressure on costs associated to new acute contractual arrangements could exacerbate the issue and this emphasised the need for clarity and prompt action to stop scope creep. Quality concerns could be an associated issue of scope creep but Sarah Timms suggested that the key issues were variability of practice rather than clinical competency. Rachel Lissauer noted that variation applied across hospitals and Practices and QIPP could be a means to streamline and allow more consistent management. She suggested that, with evidence and examples from the audit, a proposal could be developed to demonstrate management in primary care where appropriate Sharon Seber queried whether the issues of scope creep related mainly to NMUH but Dr Naz Akunjee and Dr Christiana Aride noted similar issues with other Trusts such as WH The time period for the audit was discussed and Dr Muhammed Akunjee suggested more than one month could be required. Lyndsey Abercromby advised that time for set up would be needed and it was proposed to present a summary report to the Cabinet in two months time. The Cabinet would then be able to consider any themes to be raised through the contract management process. If necessary an extension of the audit could also be reviewed at that point. 5

6 3.2.7 The Cabinet APPROVED the audit proposed as part of the quality assessment process and that this would be linked with issues raised via the Quality Alert system plus the examples raised today and in previous discussion with the Cabinet. Findings would be discussed with Clinical Leads and a summary report presented to the Cabinet in two months time. It was also AGREED that a letter would be sent to Trusts in relation to the issues raised regarding follow up blood tests ACTION 02/03/17 01 To write to Trusts in relation to issues raised by the Cabinet regarding requests to GPs for follow up blood testing. RL 3.3 MSK Update Lyndsey Abercromby presented a report on the latest position following the Contract Performance Notice (CPN) issued to WH in 2016 as a result of concerns regarding performance of the community MSK services against a number of KPIs. The CCG and Islington CCG (as lead commissioner) had held regular meetings with WH to review progress against the remedial action plan and there had been a number of key improvements. These included reduction of DNA levels, reduction of cancellations by the Trust and reduction in the percentage of referrals rejected. Referrals triaged within 3 days had increased to 100%. However, waiting times were still a challenge with more than half of all patients waiting more than six weeks for a first appointment. This was linked to continuing issues with the partial booking system which was still not achieving the threshold specified in the contract. One factor identified as contributing to longer waiting times was a mismatch between planned activity and the actual number of referrals made. Haringey referrals were approximately 20% higher than included in the contract. This indicated the need for a wider review of MSK services and a copy of the Wellbeing Partnership MSK Workstream Initiation Document, as approved by the Sponsor Board last month, was attached as an appendix to the report Lyndsey Abercromby explained that national Rightcare data demonstrated more than expected expenditure in secondary care and that more patients could be seen in community services. Reviewing the current service demonstrated that clinicians were working well with very positive feedback received from patients but there were issues with the system and structure of the service. In looking at effective service models elsewhere most applied a single point of access via community services and similarly for step down provision and it was being reviewed whether this could work locally. The new model developed by Camden CCG was being explored, potentially for adoption across NCL. Clinical and stakeholder workshops would work towards the presentation of an OBC to the Sponsor Board in June. Questions and comments were invited In response to Dr David Masters, Lyndsey Abercromby advised that paediatric patients were not included in the new design and in due course a further paper would clarify full details. 6

7 3.3.4 Dr Gino Amato noted that a referral pathway was already in place but Dr John Rohan observed that the current model was very dependent on levels of experience and many patients were directed to orthopaedic surgeons unnecessarily. Lyndsey Abercromby emphasised that the aim was to ensure a model that worked consistently well. Dr Simon Caplan cautioned that problems arose with down-skilling and the use of lower band staff. Dr John Rohan suggested that a multi-professional clinical model with the co-location of orthopaedic surgeons could be effective. Lyndsey Abercromby suggested there could be a model with access to Consultant level advice. She noted that on finalising an agreed model there would be phased implementation and chronic pain was proposed initially. Dr Kate Rees advised that there could need to be more specific definition, such as nerve impingement, in order to limit this category The Cabinet NOTED the update on MSK services. 3.4 Neighbourhoods/Care Closer to Home (CHINs) Rachel Lissauer explained the principle of networks included in the STP as creating partnerships with providers across a group of GP Practices for neighbourhood populations of approximately 50,000 to 80,000. This would include community services, mental health and acute specialist provision. There was a recognised need to reduce current variation of practice and the intention was to use resources more effectively and to improve quality and clinical capacity to deliver services more appropriately. In aiming to avoid admissions, funding would be taken out of acute provision. CCGs were responsible for developing CHINs to deliver services on this basis but there was not a single, prescribed approach across NCL. There would be discussion with Collaboratives and Practices and expressions of interest would be invited but the process would be extended beyond Primary Care and would include the involvement of voluntary and social care agencies. There would be a development phase of two to three months for networks to discuss priorities, joint working and to establish more detailed plans, followed by discussion of phased implementation in Haringey Rachel Lissauer noted current consideration of whether to proceed initially with willing Practices or the whole population within the CHIN/neighbourhood area. It was recognised as preferable for networks to take responsibility for the entire registered population of the geographical area but not all Practices would necessarily be included at the outset. There would need to be plans for working with the Practices not initially involved to ensure that services for all patients were consistent and of equal quality. Dr Kate Rees asked whether this would be the role of the GP Federation but it was confirmed that this was not the case. Resources were discussed and Rachel Lissauer advised that it was aimed to seek an allocation for General Practices to support planning and development. However, any further funding was unconfirmed at present and there would need to be re-shaping of the work of existing staff before any new posts or backfill was considered. Manuel Anthony queried responsibility for training of staff in this respect. Rachel Lissauer responded that, in relation to community services, the CCG had already held discussions with WH who recognised the different approach of networks. The CCG would need to broker such changes. 7

8 3.4.3 Dr David Masters noted, from prior experience, that there could be difficulties in Practices working together and he recommended starting with those that were most willing to be involved. Rachel Lissauer emphasised that the network would however have to plan how to cover the whole population in order for patients to benefit equally. Dr John Rohan suggested that outliers would subsequently follow by example. Manuel Anthony agreed that it would be realised that exclusion was not an option and he cited that both Islington and Hackney had achieved very widescale uptake. Sonia Hall suggested a focus on factors that would encourage involvement. Dr Gino Amato noted that discussion at the recent GB seminar had highlighted that having community services located with Practices would be a key incentive. The Cabinet had previously raised the example of how beneficial this would be in respect to health visiting services. It was agreed that more detail was needed but in due course the advantages of the changes would outweigh initial reservations. 4. Quality Items 4.1 Quarter 3 GP Alerts and Follow-up Action Rosie Peregrine-Jones presented a summary of key concerns identified by GP alerts and complaints reported to the CCG in quarter /2017 plus the associated action taken. She explained that the number of Quality Alerts received in quarter 3 was more than double received in the previous quarter. A significant percentage were related to the issue of additional workload passed to Primary Care by acute providers, as discussed earlier in the meeting. She advised that any such examples raised by the Quality Alert system in relation to compliance with NHS Standard Contract requirements would continue to be investigated individually with providers. There had also been a number of Alerts related to the NMUH pathology service which had been discussed at the CQRG. NMUH had investigated and responded regarding changes to be made and this would continue to be monitored by the CCG. Rosie Peregrine-Jones noted that as of 1 April CCGs would not be allowed access to patient identifiable information and this raised process issues in relation to the future handling of Quality Alerts. Questions and comments were invited In response to Manuel Anthony, Rosie Peregrine-Jones advised that she could circulate the information provided by the CSU in relation to patient identifiable information. Dr Simon Caplan emphasised that the CCG would need to be provided with anonymised information in order to maintain appropriate overview. Rosie Peregrine-Jones provided assurance that on-going processes would be subject to thorough review Rachel Lissauer reported the CCG was liaising with the CSU to include a matrix in relation to NHS Standard Contract requirements in all acute contracts. Dr Simon Caplan referred to the matrix already used by NMUH and that this should be universally applied The Cabinet NOTED the report of GP Alerts, complaints and follow-up action for quarter / Business Items 5.1 Prescribing Quality and Savings Scheme (PQSS) 2017/2018 8

9 5.1.1 Pauline Taylor presented a draft summary of the PQSS for 2017/2018. She explained that the scheme was similar to that of the previous year and aligned to NCL STP priorities. Consideration was being given to stratifying payments for patient reviews to reflect higher payment for improved outcomes. Comments were required within one week. Following further work the detailed scheme would be taken to the Medicines Optimisation Committee on 15 March and the LMC in April Efa Mortty referred to the areas of patient review listed in section A. A new inclusion had been made for adults with asthma and an audit tool similar to that for COPD would be used to identify patients requiring a care plan. A different approach for reviews in relation to atrial fibrillation was explained in that Trusts would provide Practices with a list of patients identified as suffering from AF not on the Practice QOF AF register. Reviews in relation to diabetes and COPD would continue as currently. Section B described work with prescribing advisors. Section C (applied to Practices not completing Section D) included reducing over-ordering and encouraging on-line ordering of prescriptions; promoting self-care; review of the prescribing of hypnotics to build on positive results in the previous year; and a new quality indicator to reduce acute kidney injury (AKI) with a risk assessment tool and education for patients. Section D related only to Practices supporting care homes and where a repeat prescribing audit had identified high levels of waste. Questions and comments were invited In response to Dr Christiana Aride, Efa Mortty described that attendances in secondary care recorded possible AF and a retrospective review by providers could be linked to the QOF Register. Practices would be notified of any omissions from the QOF Register to ensure these patients were reviewed. Dr Belinda Agoe cautioned regarding retrospective challenge and liability should any such patients have suffered a stroke. Dr Gino Amato emphasised that the audit provided a valuable opportunity to review the information captured from discharge reports Dr David Masters noted his view that the RCP 3 questions in relation to asthma review were outdated and insufficiently sensitive and that the focus should be on asthma care plans Dr David Masters suggested that the requirements in relation to reducing acute kidney injury could involve a very high number of patients. Efa Mortty advised that the specific drugs indicated were listed but with the inclusion of patients over 65 she acknowledged this could be onerous. Sonia Hall noted experience of a similar scheme elsewhere where the risk assessment tool had been quite concise. Dr Simon Caplan s recommendation to initially pilot the software in one Practice was agreed. 6. ANY OTHER BUSINESS 6.1 There were no other items of business. 7. DATE OF NEXT MEETING 7.1 Thursday 4 May pm 3.00pm Hornsey Central Neighbourhood Health Centre 9