Item 8.1 South Gloucestershire Clinical Commissioning Group Clinical Operational Executive Meeting Date: Wednesday, 14 th January 2015 Time: 1.30-5.00pm Location: Cleve Rugby Club Minutes Attendees: Dr Jon Hayes (JH) [Chair], Clinical Chair Jane Gibbs (JG), Chief Officer (from 2.15pm) Melanie Green (MGr), Head of Medicines Management Kate Lavington (KL), Head of Community Commissioning Dr Kate Mansfield (KM), Children and Maternity Lead Dr Jon Evans (JE), Long-Term Conditions Lead Dr Peter Bagshaw (PB), Mental Health, Dementia, Learning Difficulties and Adult Safeguarding Lead Dr Ann Sephton (AS), Deputy Clinical Chair / Urgent Care Lead Dr Stephen Illingworth (SI), Clinical Lead for Primary Care and Rehabilitation Sharon Kingscott (SK), Chief Finance Officer Dr Kathryn Hudson (KH), Director of Partnerships and Joint Commissioning Thom Manning (TM), Head of Performance and Information Dr Andrew Appleton (AA), CCG Board Member Dr Rupa Parmar (RP), Avon Local Medical Committee Louise Rickitt (LR), Head of Strategy and Service Redesign Anne Morris (AM),Director of Nursing and Head of Quality and Safeguarding, Designate David Jarrett, (DJ), Director of Operations Steve Rea (SR), Commissioning Delivery Manager Jon Shaw, (JS), Head of Commissioning Partnership and Performance, South Gloucestershire Council Dr Joanne Hartland (JoH), Research and Development Manager, Avon Primary Care Research Collaborative Janet Biard (JB), CCG Board Member (from 2pm) Dr Mark Pietroni (MP), Director of Public Health, South Gloucestershire Council (from 2.05pm) Rachel Clarke (RC), Public Health Specialist Registrar, South Gloucestershire Council Dominic Moody (DM), Communications Manager, South West Commissioning Support Unit Helen Wilkinson (HW), Medicines Optimisation Lead Martin Gregg (MG), CCG Board Member Lesley Johnson (LJ), Acute Contract Manager, South West Commissioning Support Unit (for first part of the meeting) 1
In Attendance: Eszter Kormendi (EK) [note taker], PA, South Gloucestershire CCG Ben Bennett (BB), Programme Director Strategy & Development, South West Commissioning Unit (for item 10.1 only) Babs Williams (BW), Head of Service Redesign, South West Commissioning Support Unit (for items 8.1 and 8.2 only) Kim Smith (KS), Person Centred Commissioning Manager (for items 8.1 and 8.2 only) Abi Evans (AE), Programme Manager, South West Commissioning Support Unit (for items 8.1 and 8.2 only) Karen Michael-Cox (KMC), Senior Project Manager, South West Commissioning Support Unit (for items 8.1 and 8.2 only) Apologies: Dr Tharsha Sivayokan (TS), Planned Care Lead Lindsay Gee (LG), Head of Commissioning Children, Young People and Maternity Sara Blackmore (SaB), Consultant in Public Health, South Glos Council Susan Hamilton (SH), Consultant in Public Health, South Gloucestershire Council Dr Alison Wint, (AW) Clinical Lead for Cancer Dr Nick Kennedy, (NK), CCG Board Member Felicity Taylor-Drewe (FTD), Delivery Director, South West Commissioning Support Unit Dr Charlie Record (CR), CCG Board Member Kirsteen Akhurst (KA), Operational Delivery Manager 1. Welcome JH welcomed everyone to the meeting and apologies were received. 2. Declarations of interest None. 3. Minutes of Previous Meeting/Matters Arising 3.1 The minutes of the previous meeting were approved. 3.2 Matters Arising not on the agenda Please see Appendix 1. 4. Chair s update verbal 4.1 NBT s performance The challenges faced by NBT continue to be significant. To follow up on the first meeting, NHS England called the representatives of the NBT health system to a second meeting on 10 th December. JH and JG attended from the CCG. The focus on the system and the monitoring of its performance would remain significant. 4.2 CQC inspection of NBT The CQC s feedback report following NBT s inspection in November is due to be published to partners in February. 2
5. Update on financial position The CCG is still expected to achieve its forecast deficit of 6.7m but it is proving increasingly difficult and mitigating circumstances are being sought. NHS England has published the 2015/16 financial allocations. There is good news for South Gloucestershire: the CCG will receive an increase of 7% ( 17.3m). However, this includes resilience (winter pressures) funding of 1.4m, which gives us a net growth figure for 2015/16 of 6.48% ( 16m). Our original planned assumption was for growth of 3.33% ( 8.3m). The uplift will increase funding from 968 per head of population to 997. South Gloucestershire CCG was at 6.94% below our target funding (as defined by the national allocation formula) which is a shortfall of - 19m. The increase in 2015/16 will improve our position to 5.71% below our target funding level, with a shortfall of - 16m. The additional funding is already committed and has been built into our position, mainly on expected investment on Mental Health as mandated by NHS England (via its business rules for CCGs), changes to growth assumptions, progress to clear the backlog of patients waiting for elective care in order to achieve NHS Constitution access standards, and changes to technical guidance. We are therefore still expecting to increase our cumulative deficit in 2015/16, but it will be at a lower run rate than the last 2 years (i.e. our in-year overspend will be less than that in previous years). 6. Summary of performance QIPP reporting and programme updates contract performance 6.1 A) Operating Plan and QIPP Programme Delivery Update & Monthly QIPP Report SR reported the year-to-date actual QIPP savings are at 1,494k as opposed to the year-to-date planned saving of 3,804k. The pressure on contracts means it has been difficult to see savings on QIPP schemes. Some schemes started later in the year than others, this has had an effect on the variance year-to-date figure. SR will present a delivery overview of the 2015/16 QIPP scheme at the February meeting of the COE. Clinical Leads update on QIPP delivery The Clinical Operational Executive Committee noted the circulated Operational Plan and QIPP Programme Delivery Update under item 6.1. Clinical Leads added the following points to their areas: Dr Kate Mansfield Children and Maternity Lead The CAMHS service is having difficulties with recruiting staff. As a result they are currently not taking any referrals. Work is underway to find alternative solutions. Dr Ann Sephton Urgent Care Lead The System Flow Partnership Group agreed to hold a perfect week around the NBT system. This will include primary care. Jez Tozer and Kate Hannam 3
will be co-ordinating the work. Many other hospitals have successfully used the Ideal Week to make long-lasting improvements to their services. This initiative aims to generate energy for change by doing things differently to support patient flow and consequently improve patient experience, safety and staff morale. The 4 main working groups of the NBT System Flow Partnership carry on meeting regularly. The new NHS 111 Intervention Managers are now in post and they have already prevented some admissions. Dr Andrew Appleton Clinical Lead for IT The weekend working pilot is now available within the One Care Consortium Programme. Enhanced work is underway to enable community services to access EMIS Web, with training starting in February. The roll-out of practice Intranet is starting at the end of February. Work with BNSSG is ongoing. Web-based consultation facilities are expected to go live at the end of January in ten One Care Consortium practices. Dr Stephen Illingworth Clinical Lead for Primary Care and Rehabilitation It has now been agreed that one of the Elgar Wards will be managed by Sirona Care and Health as part of the Rehabilitation, Reablement and Recovery Strategy. This is expected to be implemented in the Spring. Steve Rea on behalf of Dr Alison Wint Clinical Lead for Cancer Discussions with NBT regarding the piloting of the new colorectal pathway are coming to an end. A final agreement is hoped to be reached soon. 2- week-wait referrals to upper and lower GI can now be requested on ICE. 7. Presentation 7.1 Approach to 2015/16 NBT contract negotiations LJ attended the meeting on FTD s behalf to give an overview to the Clinical Operational Executive Committee on the forthcoming contract negotiations with NBT. The approach takes into account the National Guidance. The Quality themes within the contract aim for commissioners to ensure providers operate according to the quality requirements of the NHS Constitution. 7-day working will have to include discharges, not only medical cover. Next year s CQUINs are going to include: improving urgent and emergency care, identification and treatment of Sepsis and Acute Kidney injury (national CQUINS); as well as falls, prevention of pressure ulcers and staff wellbeing (local CQUINS). National tariff rules are to be applied in determining the financial envelope. Some of the service themes are national recommendations but some are related to issues discussed by the System Flow Partnership. The themes include improving urgent and emergency care; planned care; cancer services especially survivorship and colorectal pathway; implementation of the rehabilitation model and benchmarking outpatients. Members of the COE suggested the following themes for inclusion: 4
It would be helpful if outpatient letters highlighted actions required of GPs Influence NBT to provide improved access to outpatient facilities in the community, especially in Yate and at Cossham Hospital NBT s communication with patients needs to be addressed. Patients are often unclear about the outcome of their appointments and they go back to primary care because of lack of contact from NBT. Reiterate that a Care Plan is different from a Discharge Summary. ACTION: LJ/FTD to incorporate these comments into the contract negotiations. The COE also agrees that the continuity of CQUINs is essential. LJ reassured the COE that the CQUINs are monitored regularly and there is some continuity within the themes. ACTION: Emma Savage s CQUINs report to be sent to the COE on a quarterly basis. LJ/FTD LJ/FTD The contract sign off deadline is 11 th March and the CSU is working towards this. 8. Business Cases 2015/16 8.1 Overview presentation outlining all cases expected and decision making process 40 business cases were received this year. SR outlined the decision-making process for investment: 14 th January COE meeting 7 business cases will be reviewed. These propose either the largest service transformation or ask for the largest amount of investment. 20 th and 27 th January Internal business case review group meets to evaluate all the business cases 12 th February COE meeting Review of remaining cases and final decision making on investment The business cases fit into 4 categories: Category 1: required investment Category 2: QIPP return Category 3: Investing for the future Category 4: Funding above outturn where the 2014/15 spending is expected to be above the 2014/15 outturn The business cases cover the following areas: Planned Care Urgent and Emergency care End of Life and Long-Term Conditions Cancer Continuing Healthcare Medicines Management Children's and Maternity Mental Health, Learning Difficulties and Dementia 5
RC will be helping SR with reviewing the scoring matrix and the decision making process. 8.2 Review of a number of these cases including: a) Medicines Management Business Cases Care Homes pharmacist and Clinical Pharmacists community services CCG Care Home pharmacist This business case proposal is for a specialist care home pharmacist, employed to undertake medicines reconciliation and medication review for residents in care homes and improve medicines management, working in partnership with the patient s GP, Sirona community teams, other healthcare professionals and stakeholders. The Care Home Pharmacist will be part of the existing Medicines Management team. They will contribute to delivering the QIPP initiatives to improving prescribing quality and safety for care home residents and support management of the prescribing budget. They will also support training of care home staff. The proposal is supported by the recent Medicines management reconciliation on discharge pilot and national data which suggest there is often miscommunication of medication as patients move between care home settings. Moreover, 70% of care home residents have experienced poor medication in the past. The benefits of the proposal are multifaceted and it fits in with many areas of work, e.g. falls, dementia. National evidence suggests that length of stay in care homes is reduced where there are Care Home pharmacists in place. The estimated savings are expected to amount to 200,000 per annum with one Band 7 WTE Pharmacist employed at 43,305. The savings are based on national figures localised to South Gloucestershire. Clinical Pharmacists Community Services The proposal is to employ 2 WTE Band 7 Clinical Pharmacists based within the Sirona localities, to support medicines management of vulnerable patients via Clinical Medication Review & Medicines Reconciliation. These pharmacists will work in conjunction with the proposed CCG Care Home Pharmacist role. Their overarching remit will be to reduce the number of hospital admissions due to medication issues. The estimated savings are at least 160 per patient per year based on prescribing cost reductions. Assuming each pharmacist reviews 20 patients per week on average, 1880 patients could be reviewed over 12 months, giving a total savings of 300,800. Although a practice-based rather than Sirona-based approach might be preferred, the current team size does not allow for this. The approach could result in a change of working practices within primary care whereby medication review will be done as a matter of course. b) End of Life Care Coordination 6
The proposal is to implement a Single Point of Access for community end of life care services for health professionals, health and social care staff, patients and their families and carers. The service, provided by Sirona, will coordinate the patient s care and services through existing providers. There will also be 24-hours, 7-day a week advice line accessible to healthcare professionals, patients and carers. Palliative care specialist advice and service will be provided by St Peter s Hospice. The service will also incorporate the Continuing Health Care Funding fast track service. The aim of the service is to reduce A&E admissions by 5% and hospital deaths by 5% while keeping patients safe and supported. Such a service has been part of the national End of Life Care Strategy since 2009. Bristol CCG implemented a similar service in November 2014. A service based on the same principles has been in place in North Somerset for 3 years. ACTION: BW to provide feedback on the service in Bristol and North Somerset including details as to whether GP workload has been affected, reduction in hospital deaths and A&E admissions. BW/SR The annual recurrent cost of 171,000 is expected to be outweighed by the yearly savings of 247,000. c) Diabetes Specialist Nurse Service The prevalence of diabetes and its associated health care costs are growing rapidly. The proposal is to commission a diabetes specialist nurse service in South Gloucestershire. This service will significantly contribute to both improving outcomes for patients and containing spend related to diabetes in coming years. There are 3 proposed options: Option 1: do nothing (not acceptable) Option 2: commission a diabetes specialist nurse (DSN) service similar to the 2014/15 pilot but employ 5 WTE staff members plus invest 26,000 into Evidence in Practice (EiP) software to baseline current practice, identify DSN workload and measure improvement. Total cost is 218,000 per year. Option 3: similar to option 2 but instead of EiP the 26,000 investment would go into trialling an advice and guidance telephony service to help identify diabetes specialist nurse workload and provide a more formal mechanism of instant advice and guidance for GPs. This system is based on the Consultant Link model of telephone cascade and recording of calls to allow these files to be attached to patient records. Total cost in year 1 is 218,000, which could rise if the Consultant Link model would become an ongoing part of the service. Diabetes can be treated in primary care with specialist advice and guidance. Option 3 would support this. 7
The reason why the proposal asks for 5 WTE nurse specialists is because national guidance and Diabetes UK suggest that for a population of 250,000 and above, 5 nurse specialists are required. The banding of the jobs (1 Band 8b; 2 Band 7s; 2 Band 6s) is also based on national guidance. The Band 8b and Band 7 team members would be recruited in year 1 and the 2 Band 6s in year 2. ACTION: KMC to send the job descriptions to AM for review. KMC The estimated cost of the DSN service is 218,000 per year. The estimated savings for ambulance and secondary care admissions activity are between 146,000 and 620,000. Therefore the net effect of savings is between - 72,000 and + 402,000 although it is difficult to get an accurate figure given the expected rise in prevalence. Although the Clinical Operational Executive Committee is not required to make a decision at this meeting as to whether they support a business case or not, the Committee expressed a preference towards option 3, if the business case is successful. d) Tier 3 Weight Management This business case was not discussed in TS s absence. e) Community Respiratory Services The proposal is to commission a community based respiratory service for COPD patients across South Gloucestershire and a home oxygen service for all respiratory patients. The main elements of the service will be: Early supported discharge for COPD patients COPD maintenance / Prevention of Admission service Community based pulmonary rehabilitation programmes for patients with a confirmed diagnosis of COPD Oxygen assessment and review service for all adults requiring oxygen in the South Gloucestershire community Oxygen administration appropriate invoice management and use of equipment Education providing support, advice and education across the health community, in particular to primary care clinicians There is real enthusiasm among secondary care colleagues to establish such a service which could potentially be provided out of the hot clinic. Oxygen review is currently scarce so there is a need for improving this part of the service. The education element of the proposal will also lead to improvements in service provision: 4 million are spent on inhalers per year and they often are used incorrectly, if at all. The proposal will result in potential savings in the medicines management budget as well. The aim is to provide the service in primary care and in the community rather than secondary care. f) Personal Health Budgets for Long-Term Conditions and Mental Health Personal Health Budgets (PHB) are a national policy and people eligible for NHS Continuing Healthcare have had a right to request PHB since 8
April 2014, and to have a PHB from October 2014. Personal Health Budgets will also have to be made available to people with Long-Term Conditions and Mental Health from April 2015. Funding for services to people with these conditions is tied up in existing contracts. The business case requests to start the process of giving PHB to patients identified as likely to benefit. The business case asks for a one-off investment of 50,000. This amount is based on spending in other pilot sites. It is not clear how much savings are attached to the proposal. Personal Health Budgets form part of the Assurance Framework. Currently, if a patient approaches the CCG for PHB, their case is considered through a rigorous governance process with clinicians involved in the decision-making. By way of summary, SR outlined that 7 business cases had been reviewed at today s meeting. They equate to 734,000 worth of investment and would result in a gross savings of 1,944,000. SR also reminded business case writers of the importance of evidence-based commissioning and that they can speak to the evaluation team at the Avon Primary Care Research Collaborative, via JHa. 9. Papers for Decision 9.1 Approval for extension to Patient Transport Service development There are two contracts in place for the provision of non-emergency patient transport services across BNSSG, including one specifically for renal patients. Both contracts are due to expire at the end of September 2015. This end date includes the maximum permissible extensions under the contracts. This extension will have to be agreed with current providers but it will allow for meaningful Patient and Public Involvement to take place. Once the extension is negotiated, it is proposed that the formal tender process would start. As the Clinical Operational Executive Committee has delegated responsibility from the Board, it made a decision to support that the South West CSU enters into negotiations with current providers of patient transport services to extend current arrangements whilst a tender exercise is completed. A paper outlining the proposed procurement process will be presented to the Board later in January. 9.2 Re-procurement of services currently carried out through Independent Sector Treatment Centres The contract with the Independent Sector Treatment Centres expires at the end of October 2015. The re-procurement process is about to start, via an Any Qualified Provider (AQP) process, which will continue to provide services currently undertaken through the ISTCs. The Clinical Operational Executive Committee is asked to agree the suggested approach to Patient and Public Involvement (PPI) for the 9
upcoming AQP procurement process. The outlined PPI process consists of 4 stages involving patients and local people as well as key stakeholders, such as the Local Authority and Healthwatch. After the new contract is awarded, local Healthwatch and members of the existing ISTC Patient Groups will be invited to nominate representatives to provide lay input into the performance management and evaluation of the new service. The proposed approach will be presented to the South Gloucestershire Public Health and Health Scrutiny Committee on 21 st January. MG welcomed the outlined PPI process but questioned how many people use the CCG s website. TM confirmed the website receives 3-4000 hits per month. The fact that the new contract will be based on national tariff is welcome. There has been a lot of positive feedback from patients on the ISTCs services but there also has been some disappointment in what kind of procedures they are contracted to do. Therefore, the new contract could be extended to more services, subject to negotiations. The Clinical Operational Executive Committee supported the proposed PPI approach. 10. Any other business 10.1 Update on Minor Injuries Service development BB s paper asked the Clinical Operational Executive Committee to consider the feedback received from the Public Health & Health Scrutiny Committee (PHHSC) in relation to the CCG s plans for improving urgent care services and specifically the decision in principle by the PHHSC to refer the matter to the Secretary of State for Health. Moreover, the PHHSC sent some follow-up questions to the CCG ahead of the Committee s next meeting of 21 st January. The COE are invited to agree a response to these questions. As COE members know, the CCG s Governing Body agreed plans for improving urgent care services for South Gloucestershire in September 2014. These plans included an in principle decision to pilot a minor injury service in primary care based on a network of practice-based provision, subject to a full business case. Further to this, the Governing Body also agreed a recommendation to defer a formal decision on previous plans for a minor injury unit at Cossham Hospital. The PHHSC was updated on the Governing Body s decision at its meeting in November 2014. At the 21 st January meeting of the PHHSC, the CCG will be given the opportunity to respond to the questions posed by the Chair of the Committee, Councillor Ian Scott, before a final decision is made whether to refer the matter to the Secretary of State for Health. BB reiterated that proceeding with the original 2009 plans would mean a significant additional cost to the CCG (circa 900,000 p.a.). Thinking has moved on since 2009 and it is now deemed that opening an MIU at Cossham might not be the right approach. It is acknowledged that there is still confusion among the public with regards to what constitutes a minor injury and what needs to be dealt with in an A&E department. 10
It is important to now hold a series of patient and public involvement sessions around the Urgent Care Strategy. The strategy also to help patients know where to go for what treatment, i.e. for certain injuries go to A&E but otherwise to primary care. The issue is that in its current form, there is no capacity in primary care to see more patients. The proposed minor injuries pilot seeks to create additional capacity within primary care. Yate MIU will continue to play an important part of the healthcare network. The COE unanimously supported not to change the plans agreed by the Governing Body in September 2014, presented to PHHSC in November 2014, for improving local urgent and emergency care services. The following actions were agreed in response to questions by Cllr Ian Scott: The reply should give some detail on the Urgent Care Strategy in order to reiterate the introductory remarks and important messages Demonstrate changes in the system since the original 2009 business case, e.g. Common Approach has been replaced by NHS 111 Outline the national picture and how pressurised the NHS is nationally JHa to provide a detailed response to the question referring to evaluation Explain how the pharmacy system works Accept that communication could have been better to date and outline future plans BB to progress these actions. 10.2 IAPT services MP informed the meeting that the IAPT services are going to be recommissioned and asked the Clinical Operational Executive Committee if the CCG would be interested in being a pilot site for this. PB will discuss the details with the lead of the pilot. ACTION: MP to send contact details to PB. BB MP The meeting closed at 5.10pm. Date of next meeting: Thursday, 12 th February 2015, Cleve Rugby Club. 11