NHS Herts Valleys Clinical Commissioning Group Board Meeting 18 January 2018 Title West Herts Hospitals Trust CQC Report Agenda item 14 Purpose* (tick) Decision Approval Discussion Assurance Information only Author and job title Responsible director and job title Director signature Katie Fisher Chief Executive West Herts Hospitals Trust Katie Fisher Chief Executive West Herts Hospitals Trust Katie Fisher Short summary of paper The attached presentation summarises the outcomes from Wets Herts Hospital Trust s CQC inspection which took place on 31 August and 1 September 2017. Recommendation(s) The Board/Committee is being asked to: Receive presentation from Katie Fisher as assurance of recent demonstrable improvements. Engagement with Not applicable patients/public/staff and other stakeholders Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West Hertfordshire. Board Assurance Framework Refer to assurance levels table below and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\Current versions for front sheet reference N.B. The executive summary for this paper explicitly points to the evidence to support the assurance level indicated above. For example: Very high what is the evidence to support the current strong position & how will it be sustained? High what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium - what is being done to address gaps in assurance and how successful is this action proving? Low - what are the urgent actions planned to address the lack of assurance? Ref. Risk Owner Risk description Current risk score and movement since last month Target risk score Assurance Level New strategic risks identified by this report
Other significant risks related to this report (from the CRR) Resource implications Not applicable CFO Signature Potential conflicts of interest Equality and quality impact analyses (indicate the key points the analysis has identified relevant to decision required) Equality delivery system (identify which goal your proposal / paper supports) Report history Which Groups or Committees have seen this report and when? Where does the report go next? Appendices Not applicable Not applicable Better Health Outcomes Improved Patient Access and Experience A Representative and Supported Workforce Inclusive Leadership State which groups or committees have previously reviewed this report or a version of this report. State the date and any relevant recommendations from that committee. Also state what the next steps are for report does it go to another committee for example? Appendix 1: CQC presentation **Assurance levels use this guide to identify the level of assurance indicated in the risk table above. Level Very high High Medium Low Details Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. However, we have identified issues that, if not addressed, increase the likelihood of the risk materialising. Taking account of the issues identified in this report, whilst the Board can take some assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective, action needs to be taken to ensure this risk is managed. Taking account of the issues identified, the Board cannot take assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied or effective. Action needs to be taken to ensure this risk is managed. Media release Inspiring leadership, sustained improvements and the hard work of dedicated staff has resulted in West Hertfordshire Hospitals NHS Trust moving out of special measures.
Inspectors from the Care Quality Commission (CQC) made this recommendation following a full inspection of the trust s three hospitals in summer 2017. The decision to take the trust out of special measures was made by NHS Improvement, the regulator of hospital trusts. CQC inspectors also commented on the strong, supportive and visible leadership and noted a positive culture where staff are proud to work at the trust. As well as leaving the status of special measures behind, the trust which manages Watford General Hospital, Hemel Hempstead Hospital and St Albans City Hospital has seen a positive and dramatic change in the ratings for its sites and services, despite the overall rating remaining 'requires improvement'. Trust chair Professor Steve Barnett said: These results tell a story of commitment, care and high quality services. Even the quickest glance makes it clear that we have come a long, long way since being placed in special measures in 2015. Events in recent weeks only emphasise the kind of workforce we re so lucky to have; we won a national award from the Health Service Journal; our medical director was invited to present nationally about our low mortality rates; and staff struggled through snow and ice to keep our services going and our patients safe. I am immensely proud of our staff. They never stop wanting to improve, to learn and to deliver the very best care for every patient, every day. Our leadership teams, from the Board to the wards, have been growing in strength over the last few years and this has played a big part in our move out of special measures. To find out more, please see our media release, presentation and the CQC reports. The CQC's reports CQC overall inspection report CQC inspection report for Hemel Hempstead CQC inspection report St Albans City Hospital CQC inspection report for Watford General Hospital
Item 14 Appendix 1 the very best care for every patient, every day Results of our Care Quality Commission inspection Published January 2018
the very best care for every patient, every day Our vision Our aims are: To deliver the best quality care for our patients To be a great place to work and learn To improve our financial sustainability To develop a strategy for the future Our values: Commitment, Care, Quality
the very best care for every patient, every day Watford General Hospital Inpatient emergency and intensive care Elective care for higher risk patients Outpatient and diagnostic services 600 beds and 9 theatres Women's and children's services Hemel Hempstead Hospital UTC open seven days a week, 8am-10pm Diagnostic services, incl. MRI and pathology Outpatient services Endoscopy and bowel cancer screening services Herts Community Trust operates intermediate care beds on site St Albans City Hospital Elective care (inpatient low risk and day case) Outpatient and diagnostic services 40 beds and 6 theatres Minor Injuries Unit open 7 days a week, 9am-8pm,
the very best care for every patient, every day About us Our local hospitals at Watford, Hemel Hempstead and St Albans cover a catchment area of over 500,000 people 140,000 emergency patients treated 460,000 outpatient attendances 47,000 planned operations 5,000 babies delivered with 4,800 staff and 340 volunteers
the very best care for every patient, every day The inspection The Care Quality Commission (CQC) assesses five aspects of a site or service safe, caring, responsive, effective and well led and awards them ratings: inadequate, requires improvement, good or outstanding Each hospital is given an overall rating and the trust is given an overall rating In 2015 we were rated inadequate overall and went into special measures In 2016 we were rated requires improvement overall and remained in special measures. Our latest inspection took place 31 August to 1 September 2017. The CQC inspectors visited all three West Herts hospitals and also made unannounced visits to all three sites on 12 September They interviewed frontline staff and the leadership team, spoke to patients and relatives and took soundings from key stakeholders. They reviewed nearly 1,000 documents: policies, data and additional information in relation to specific questions
the very best care for every patient, every day The headlines West Hertfordshire Hospitals NHS Trust is out of special measures! We have demonstrated sustained improvements across the board We were rated as requires improvement for safe, effective, responsive and well led and we were rated good for caring Our overall rating remains requires improvement but we have achieved a significant increase in the number of services rated as good Eight services were rated good (compared to five in 2016) Four services were rated as requires improvement (five in 2016); one was rated as inadequate (two in 2016, although one is no longer run by us) 45 individual quality ratings of good compared to 32 in 2015 Only three individual ratings of inadequate compared to eight in 2016
the very best care for every patient, every day What the inspectors observed All staff treat patients in a respectful and considerate manner A positive culture, focused on improving patient outcomes and experience Patients and relatives are included decisions about their treatment and care Staff are proud to work at the trust Leadership is strong, supportive and visible Women are positive about the care they receive on maternity and gynaecology wards. One woman and her partner said their experience was amazing, really impressed Parents and children said the service was wonderful. Staff treat children with kindness, dignity and respect and always go the extra mile Family members are happy with the end of life care their relatives receive
the very best care for every patient, every day Where did we do well? Three services achieved GOOD across ALL FIVE ELEMENTS: maternity; children and young people; surgery at St Albans Outpatients and diagnostic imaging at Watford significantly improved their ratings Hemel Hempstead Hospital overall has moved from inadequate to requires improvement. There is a NOT A SINGLE ASPECT of any service at Hemel Hempstead that has an inadequate rating a massive change from nine red ratings last year to none this year St Albans City Hospital also now has NO inadequate ratings Nationally, 55% of hospitals core services are rated good we achieved 61.5% so we are ABOVE THE NATIONAL AVERAGE
the very best care for every patient, every day Good practice many examples Staff knowledge of the duty of candour (openness and transparency) is evident The emergency department has significantly improved the management and treatment of sepsis Staff understand their responsibilities to raise concerns, record and report safety incidents and near misses Staff are confident about reporting safeguarding concerns to protect adults and children from harm, abuse and neglect
the very best care for every patient, every day Good practice many examples There is shared learning from complaints through ward meetings, teaching sessions, huddles and newsletters Significant progress with governance a new committee structure enables the board to operate strategically Equality and diversity is promoted within the trust The trust board and executive team are focused on patient safety and quality of care
the very best care for every patient, every day Outstanding practice many examples Innovations in the children s emergency department to tackle mental health and suicide awareness. The design and space of this department enables quick interventions and is unique for a district general hospital The iseeu initiative enabling women to use face-time technology to see their baby receiving care and treatment on the neonatal care unit Focused recruitment and career development programme for band 5 nurses At Hemel Hempstead and St Albans, the phlebotomy service engages with people in vulnerable circumstances, for example home visiting
the very best care for every patient, every day Outstanding practice many examples At Hemel Hempstead staff take photos of X-rays, dressings etc to help people with cognitive impairment understand their treatment At St Albans the enhanced recovery care pathways are effective in helping patients recover more quickly after surgery The diagnostic imaging service audited best practice staff embraced the importance of changing practice, especially in difficult casualty situations Electronic referrals for infants with prolonged neonatal jaundice resulting in quicker referrals and results
the very best care for every patient, every day Areas for improvement Urgent and emergency services rated good for effective and caring but inadequate overall: We have restructured and strengthened clinical leadership in our emergency department, and opened a new, expanded clinical decision making unit We will improve reporting of incidents, identification of risk and management of risk registers to provide assurance that the service always runs safely and effectively Learning from incidents strengthen how we share learning across the trust Mental capacity where a patient lacks capacity to make an informed decision or give consent, make a formal decision-specific mental capacity assessment Minor Injuries Unit at St Albans ensure there are effective triage and streaming systems Quality our new Quality Commitment describes how the organisation can make it easier for our staff to deliver great service and care, and support collaboration between departments so they can work and learn from one another
the very best care for every patient, every day Our strengths Mortality rates consistently lower (better) than expected for over two years Stroke service consistently achieving the highest rating AA star Performance on cancer waiting times remains strong A new MRI/CT scanner means we now offer both modalities of cardiac imaging one of very few district general hospitals to do so Referral to treatment times have improved since the last inspection and are similar to the England average Staff engagement is good we scored highly in the 2016 annual staff survey
the very best care for every patient, every day Our ratings Ratings for each site Watford General Hospital, Hemel Hempstead Hospital, St Albans City Hospital Ratings for the trust overall Comparison of ratings in 2015, 2016, 2017
the very best care for every patient, every day Watford General Hospital Our 2015 overall rating was inadequate Overall Inadequate Safe Effective Caring Responsive Well-led Overall Key Urgent and emergency services Medical care Surgery Critical care Maternity and gynaecology Services for children and young people Inadequate Requires improvement Good Outstanding Not rated End of life care Outpatients and diagnostic imaging
the very best care for every patient, every day Watford General Hospital Our 2016 overall rating was requires improvement Overall Requires improvement Safe Effective Caring Responsive Well-led Overall Key Urgent and emergency services Medical care Surgery Critical care Maternity and family planning Services for children and young people Inadequate Requires improvement Good Outstanding Not rated End of life care Outpatients and diagnostic imaging
the very best care for every patient, every day Watford General Hospital Our 2017 overall rating is requires improvement Overall Requires improvement Safe Effective Caring Responsive Well-led Overall Key Urgent and emergency services Medical care Surgery Critical care Maternity and family planning Services for children and young people Inadequate Requires improvement Good Outstanding Not rated End of life care Outpatients and diagnostic imaging
the very best care for every patient, every day Hemel Hempstead Hospital Our 2015 overall rating was requires improvement Overall Requires improvement Safe Effective Caring Responsive Well-led Overall Key Urgent and emergency services Medical care End of life care Outpatients and diagnostic imaging Inadequate Requires improvement Good Outstanding Not rated
the very best care for every patient, every day Hemel Hempstead Hospital Our 2016 overall rating was inadequate Overall Inadequate Safe Effective Caring Responsive Well-led Overall Key Urgent and emergency services Medical care End of life care Outpatients and diagnostic imaging Inadequate Requires improvement Good Outstanding Not rated
the very best care for every patient, every day Hemel Hempstead Hospital Our 2017 overall rating is requires improvement Overall Requires improvement Safe Effective Caring Responsive Well-led Overall Key Urgent and emergency services Medical care End of life care Outpatients and diagnostic imaging Inadequate Requires improvement Good Outstanding Not rated
the very best care for every patient, every day St Albans City Hospital Our 2015 overall rating was inadequate Overall Inadequate Safe Effective Caring Responsive Well-led Overall Key Minor injuries unit Surgery Outpatients and diagnostic imaging Inadequate Requires improvement Good Outstanding Not rated
the very best care for every patient, every day St Albans City Hospital Our 2016 overall rating was requires improvement Overall Requires improvement Safe Effective Caring Responsive Well-led Overall Key Minor injuries unit Surgery Outpatients and diagnostic imaging Inadequate Requires improvement Good Outstanding Not rated
the very best care for every patient, every day St Albans City Hospital Our 2017 overall rating is requires improvement Overall Requires improvement Safe Effective Caring Responsive Well-led Overall Key Minor injuries unit Surgery Outpatients and diagnostic imaging Inadequate Requires improvement Good Outstanding Not rated
the very best care for every patient, every day Overall trust rating Safe Effective Caring Responsive Well-led Overall 2017 2016 2015 Requires improvement Requires improvement Inadequate
the very best care for every patient, every day Comparison of inadequate and good ratings 45 Key Inadequate 32 Good 20 15 8 3 2015 2016 2017
the very best care for every patient, every day In conclusion We are no longer in special measures We are rated good for caring We ve made significant improvements across the board There is a positive culture Staff are proud to work at the trust We know where we need to improve Leadership is strong, supportive and visible Our Quality Commitment will help us to deliver great service and care, and support collaboration between departments Patient safety at the heart of everything we do Thank you to all our staff!
the very best care for every patient, every day
NHS Herts Valleys Clinical Commissioning Group Board Meeting 18 January 2018 Title Urgent Treatment Centre (UTC) and West Herts Medical Centre (WHMC) consultation Agenda item 15 Purpose* (tick) Decision Approval Discussion Assurance Information only Author and job title Responsible director and job title Director signature Juliet Rodgers, Associate Director of Communications and Engagement Ian Armitage, Programme Director urgent care David Evans, Director of Programming and Commissioning David Evans Short summary of paper In this paper we set out in broad terms the CCG s plans for urgent care services with a particular focus on Dacorum, together with some issues to be addressed in order to finalise the overall plans and move to implementation. Those issues will form the basis of a local public consultation to be carried out from the end of January. Recommendation(s) The board is being asked to: Engagement with stakeholders/patient/public Discuss and approve plans for consultation. The PPI committee has been made aware of the options in general for both UTC and WHMC and have been involved in presentations and discussion on the overall urgent care strategy. Any change to services will be the subject of full public consultation as set out in the paper. Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in west Hertfordshire. Board Assurance Framework Refer to assurance levels table below **and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\BAF Current version for front sheet reference Ref. Risk Risk description Target risk Owner score 1.1 JR Risk that we do not engage effectively with a range of our patients, population and stakeholders. 3.2 DE Risk that there will be insufficient support from local bodies and key stakeholders to transform the delivery of care in west Hertfordshire 4.1 CH Risk that we do not deliver a financially sustainable health and social care system. Current risk score and movement since last month 16 (no change) 16 (risk deteriorating) 20 (no change) Assurance Level 8 High 12 Medium 10 Medium 1
New risks identified by this report Other significant risks related to this report Resource implications Potential conflicts of interest Equality and quality impact analysis (indicate the key points the analysis has identified relevant to decision required) Equality delivery system (identify which goal your proposal / paper supports) Report history Which groups or committees have seen this report and when? Appendices The cost of consultation would be in the region of 17,000 Each option has a different financial implication; this paper asks for agreement to consult on the options. An EQIA will be carried out for each of the options that we consult on, with a draft being produced and published on our website as we go out to consultation. Better Health Outcomes Improved Patient Access and Experience A Representative and Supported Workforce Inclusive Leadership None **Assurance levels Level Details Very high Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. High Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. However, we have identified issues that, if not addressed, increase the likelihood of the risk materialising. Medium Taking account of the issues identified in this report, whilst the Board can take some assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective, action needs to be taken to ensure this risk is managed. Low Taking account of the issues identified, the Board cannot take assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied or effective. Action needs to be taken to ensure this risk is managed. N.B. The executive summary for this paper must explicitly point to the evidence to support the assurance level indicated above. For example: Very high what is the evidence to support the current strong position & how will it be sustained? High what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium - what is being done to address gaps in assurance and how successful is this action proving? 2
Low - what are the urgent actions planned to address the lack of assurance? NHS Herts Valleys Clinical Commissioning Group Board meeting 18 January 2018 1. Introduction and purpose of paper Here at Herts Valleys CCG we have been developing our plans for the development of urgent care and looking in particular at services based in the Dacorum locality. In this paper we outline our overall approach to urgent care and identify the outstanding issues around those services that need to be addressed in order to finalise the overall plans and move to full implementation. Those issues, in the context of the wider vision, will form the basis of a local public consultation to be carried out from the end of January. 2. Current position The urgent care services currently available in Dacorum and serving the wider west Hertfordshire population - are as follows: UTC There is a UTC at Hemel Hempstead Hospital (was the UCC before December 2017) looking after people who walk in with urgent health issues. NHS England set a target of establishing 150 urgent treatment centres by 1 December and we were pleased that the service at Hemel Hempstead Hospital was identified as one of this first wave, following a recommendation from the CCG. UTC is currently open 8am 10pm every day. These are temporary hours dating from December 2016. Substantive contractual hours are 24/7. WHHT, as the provider, requested temporary night time closure on grounds of patient safety. We could not consult at that time due to the urgent need to address safety issues. West Hertfordshire Medical Centre Located adjacent to the UTC in Hemel Hospital is the West Herts Medical Centre (WHMC). WHMC, established in 2009, is run on an alternative provider medical services contract (APMS) and is time-limited. The contract comes to an end in October 2018. WHMC has two separate streams of patients: 1) those who walk-in to the service as they would to the UTC and 2) a relatively small number 2000 registered patients. Other urgent care services NHS 111 service operating 24/7 for all residents. GP out-of-hours service available via NHS 111 for people who need to see or speak to a GP out of normal practice hours. 3
Extended hours at GP surgeries increasing number of patients can have routine appointments with a GP outside of normal practice hours. Although based in Dacorum the services available within the UTC are accessible to the all those living in the area covered by Herts Valleys CCG. 3. Our developing urgent care strategy Our own strategy aligns with NHS England s national plan. A key objective is to strengthen urgent care provision so that more patients with needs that are not emergencies can be treated outside of hospital A&E departments, releasing pressure on hospitals and providing a more resilient and streamlined service for local people. The national drive is also about delivering a more consistent approach which is less confusing for patients. The plans include: GPs taking a lead on urgent care; GPs providing a service at the front door of A&E departments; and the establishment of GP-led UTCs open a minimum of 12 hours day (8am 8pm). These UTCs are a key part of the national plans and are designed to diagnose and deal with the most common ailments seen at A&E, providing a standardised service for patients in place of the current mixed array of walk-in urgent care and minor injuries services. Our strategy at Herts Valleys CCG has a number of key elements: 3.1 NHS 111 A firmer focus on the 24/7 NHS 111 service as the front door into urgent care for everyone. Enhancements to the local NHS 111 service which has been happening in recent months. This means that there is now more clinical input earlier, via the Clinical Assessment Service (CAS). The CAS give people access to conversations and face-to-face appointments with GPs, arranges visits to, and can organise visits from palliative care nurses. They can also call ambulances directly in serious cases. 3.2 GP extended hours Increasing access to GP services outside normal practice hours across the patch More than 50% coverage of extended hours by March 2018 Plans in place and progressing well towards all west Hertfordshire residents being able to see a GP locally during evenings and at weekends by 2019, making a significant difference to the ability of patients to access primary care services. 3.3 UTCs The UTC in Hemel will provide an enhanced service for patients. Enhancements include the availability of booked appointments at the centre - arranged through NHS 111. 4
There will also be a range of on-site testing facilities that will provide patients with results from the centre itself reducing waits at or trips to Watford General Hospital. The Hemel UTC is open to all west Herts residents. At the same time, the other three localities are currently working up how urgent care services specifically related to their needs, could be provided. 3.4 West Herts Medical Centre As part of plans to streamline the walk-in service and make better use of the resources, the walk-in element of the WHMC will be merged with the UTC; there will a single front door. This will make it simpler and more straightforward for all walk-in patients and give WHMC patients the benefit of the enhanced services at the UTC. Merging the walk-ins also means we can better use the GP resource. The full budget will be reallocated to the UTC. Patients will still be using the same building as they are currently located adjacent to one another. 4. Delivering the full strategy We expect this plan overall to deliver a strong, effective and convenient primary careled urgent care service for everyone living in west Hertfordshire. We also know that there are two outstanding issues that need addressing in order to finalise and fully embed our approach. These are: the opening hours of the Hemel UTC; and the future of care for the registered patients at WHMC. In addressing these issues, which will be the subject of consultation, we need to consider the following factors: GPs are at the heart of our urgent care service There is a national shortage of GPs, reflected locally here in west Herts. In Herts Valleys our ratio of GPs to patients is considerably lower than the British Medical Association recommends by nearly 30% - and is actually lower than the national average. Our strategy is based on making the best possible use of our limited clinical workforce so that people who need to talk to and see a doctor, can do so more easily than has been the case. Whilst a good deal is being done to meet the shortfalls, this will take some time to come into effect and it is realistic to assume our workforce challenges will be with us for years to come. Overnight services for people who need urgent care are available for everyone via NHS 111 including access to a GP - and the out of hour s service. Patient safety is of paramount importance; we need to avoid adhoc closures of the service with little or no warning as has been the case when the UCC in Hemel was open overnight. 5
5. Options for consultation 5.1 UTC We will be inviting local people for their feedback on the strategy in general, and will ask them to give us their views on the opening hours of the UTC. Our proposal is to ask for feedback from local people and stakeholders on the following three options: Table 1: UTC options Option one Option two Service model UTC Plus: NHS 111 open and available 24/7 Access to GPs out of hours service (via NHS 111) Access to GP extended hours UTC plus: NHS 111 open and available 24/7 Access to GPs out of hours service (via NHS 111) Access to GP extended hours UTC opening hours UTC open 8am 10pm; current temporary hours 8am midnight; an additional two hours over and above current hours UTC staffing UTC to be GP-led, with nursing, advanced nursing and reception support GP-led, with nursing, advanced nursing and reception support. Shift patterns to take into account additional two hours Implications 1. GPs will cover the existing services such as NHS 111 and the enhanced UTC. 2. No walk-in service overnight at the UTC 3. Walk-in services for emergencies continue to be provided for emergencies at Watford A&E. 1. Workforce issues: there is uncertainly around GPs ability to cover a shift that doesn t end until 1am, particularly given surgeries open following day at 8am and the other shifts that need filling in out- of- hours and extended hours. 2. Few patients arrived at the UCC after 10pm. See table below. 6
Option three UTC Plus: NHS 111 open and available 24/7 Access to GPs out of hours service (via NHS 111) Access to GP extended hours 24 hours a day. As per substantive contract, representing increase of ten hours over and above current hours GP-led, with nursing, advanced nursing and reception support 1. Workforce risk that we will not be able to fill shifts; likely to be more of an issue now than previously given greater demands on GP hours at practices. 2. Inability to fill all shifts leads to ad hoc closures which presents inconvenience to patients and patient safety risks. 3. Additional cost for very few patients. See below. The team has assessed a further option: for the overnight service to be nurse-led to help overcome the issues around GP availability. We have concluded that this is not a viable option for consultation as it is not clinically sound. This is because of the infrequency of patient visits to the service over night; nurses whose job it was to work on the night shift at the UTC would have insufficient throughput of patients to maintain their competency and skill levels. In addition, there are patient safety concerns about running a service that had a different skill mix at night from the service experienced by patients during the day. The chart below illustrates the low levels of activity in the UCC after 10pm each evening when it was a 24/7 service. Also note that since the change in hours we have not seen a corresponding increase in A&E attendances or additional pressures on the out of hour s service. The average attendance has remained the same which would indicate that the service is still meeting needs, but during the core hours provided. Table 2: Comparative activity levels UCC attendance hour April to November 2016 Avg number of pts April to November 2017 Avg number of pts 12am to 3am 2.60% 2 0.00% 0 >3am to 6am 1.90% 2 0.00% 0 >6am to 8am 3.60% 3 0.10% 0 >8am to 12pm 27.10% 23 31.90% 27 >12pm to 3pm 18.10% 15 21.20% 18 7
>3pm to 6pm 17.60% 15 20.60% 18 >6pm to 10pm 24.60% 21 26.10% 22 >10pm to 12am 4.40% 4 0.00% 0 Total 100.00% 85 100.00% 85 5.2 WHMC registered patients As stated above, under future arrangements, all non-registered patients walking into the service will be looked after by a single service the UTC. There are two options relating to the remaining service the registered patients: Option one: Let the current APMS contract come to an end and in the meantime, support approximately 2,000 registered patients to re-register with other practices. There would be a year s transition payment for those GP practices accepting the registered patients to allow them to take on any additional activity and of course this would be in addition to the payments that are made to practices in accordance with size of patient list. There are a number of practices nearby and one that is extremely close to the WHMC. Alternative practices have indicated support for taking on the registered patients. Option two: Put out the WHMC contract for registered patients to a full commercial and competitive procurement. As outlined above we are not able to continue with the current contract beyond October 2018. The concerns with this option are that we are not confident that there would be new provider willing to take on what is a very small patient list size. With an APMS contract, a potential new provider would need to invest a considerable amount of funds in putting in a tender, for what would be a time-limited (five year) contract for an unusually small number of patients. Continuity of care is an additional risk with a service of this kind. 6. Consultation The consultation will raise awareness of the wider urgent care strategy and ask for specific views on the questions around opening hours of the Hemel UTC and contract options for the WHMC. As part of the development of urgent care strategy, the CCG is developing specific urgent treatment approaches for other parts of west Hertfordshire and we will engage with local people as we develop proposals within other locality areas. 6.1 Consultation methods The engagement will focus on a questionnaire with associated briefing information setting out the context and rationale for developments in urgent care, together with details of the range of options on which we are asking specific questions. We will carry out as much face-to-face engagement as possible to support a dialogue with interested audiences and will use a variety of additional communications methods primarily digital channels - to promote the consultation, encourage people to complete the 8
questionnaire and to provide an alternative means of feeding back and commenting for those unable to attend events or meetings. Will use existing patient networks, particularly PPGs and health and wellbeing ambassadors, to promote the consultation as widely as possible. Our consultation activity will include the following: Public meetings and drop-in sessions Presentations and discussions at patient and community groups, Information and questionnaire on the Herts Valleys CCG website Social, digital and traditional media Community media including town, parish and community magazines and community Facebook groups Use of partner communication channels Stakeholder briefings, including Herts Valleys Voices to 3,300 people Information stands and posters in public waiting areas within the UTC and WHMC Direct mail-out to patients registered with WHMC We have put together a draft activity plan which is being further developed further in the coming weeks and will be shared with PPI committee. 6.2 Target audiences Our engagement programme will be based on the principle of getting feedback on proposals from as many Hertfordshire residents as we can and to hear from those whose voices are less often heard. We will make efforts to engage younger people, those from minority ethnic groups and others who rarely come to meetings or give us their views in other ways. We will work with Healthwatch Hertfordshire, patient groups, local communities and voluntary organisations to make sure the consultation reaches as many local people as possible. We will specifically target patients currently registered with WHMC in relation to the future of that service. Our main audiences will include: Group Patients, carers and representative groups Patients registered with WHMC and their carers/families Patients using WHMC and the UTC and their carers Patients in those practices that may absorb WHMC patients Locality and practice patient groups and patient networks PPI committee members Carers in Hertfordshire Health and wellbeing ambassadors 9
Provider partners GPs and practice staff GP federations Herts Urgent Care West Herts Hospitals NHS Trust East of England Ambulance Service Trust Hertfordshire Community Trust Hertfordshire Partnership Foundation Trust East and North Hertfordshire CCG Other partners Herts County Council child and adult care services Herts County Council scrutiny and health and wellbeing board Care homes / nursing homes Home care agencies (via HCC) District/borough councils scrutiny and health and wellbeing boards MPs Schools and colleges Charities/voluntary/community groups Healthwatch General Residents all residents are potential customers of these services Residents/patients who had responded to previous urgent care survey People who work in the area and may require urgent treatment Voluntary sector organisations Business organisations eg. Chamber of Commerce Regulators and NHS England others STP including urgent care workstream Staff Those working in services subject to consultation Other NHS staff including CCG and providers 6.3 Evaluating feedback We expect the consultation to run for a period of eight weeks. We are engaging an external, independent agency to host the survey and they will also provide a report that sets out an assessment of the feedback from the survey, the face-to-face meetings and the comments received via social media too. This agency is also providing advice on our consultation plan and documentation. The agency will provide a report for the board to consider before it makes decisions. 10
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FINAL APPROVED Item 16.1 Meeting : Primary Care Commissioning Committee (PCCC) Date : 26 October 2017 Time : 10.40 12.45 Venue : The Box Moor Trust Present: Thelma Stober (TS) Alison Gardner (AG) David Buckle (DB) Diane Curbishley (DC) Trevor Fernandes (TF) Mike Edwards (ME) Clair Moring (CM) to PC/107/17 Caroline Hall (CH) In attendance: Brian Gunson (BG) Lynn Dalton (LD) Sue Fogden (SF) Peter Graves (PG) Charlotte Earl (CE) PC/108/17 Rod While (RW) Lay member and meeting chair Lay member Medical Director Director of Nursing and Quality Board GP Member (Dacorum) Board GP Member (Hertsmere) Board GP Member (Watford and Three Rivers) Chief Finance Officer Healthwatch Representative Assistant Director of Localities and General Practice Development Assistant Director, Premises East and North Herts and Herts Valleys CCGs Bedfordshire and Hertfordshire Local Medical Committee Ltd (LMC) Senior Pharmaceutical Advisor, Pharmacy & Medicines Optimisation Team Head of Corporate Governance PART 2: MATTERS TO BE CONSIDERED WITH THE PUBLIC AND PRESS PRESENT PC/97/17 Chair s introduction and apologies for absence 97.1 Apologies were received from Jim McManus and Kathryn Magson. 97.2 It was noted that Jim MacManus had not attended any meetings of the Primary Care Commissioning Committee (PCCC), or indeed its predecessor the Joint Commissioning Committee. The committee expressed disappointment that the health and wellbeing board was not being represented on the committee as was required by NHS England s guidance. It was suggested that public health input was desirable at the meeting and the public health consultant should therefore be invited. 97.3 ACTION: RW to invite public health consultant to attend future PCCC meetings. PC/98/17 Interests to declare 98.1 The chair thanked attendees for interests declared in advance of the meeting. A schedule of interests declared was discussed and is appended at appendix 1 to the minutes. It was agreed that specific potential interests would be discussed and a course of action agreed prior to each agenda item. PC/99/17 Minutes of previous meeting (Chair) 99.2 The committee approved the minutes of the meeting of 21 September 2017 as a true and accurate record. 1 P a g e
PC/100/17 Primary care contracting and procurement report 100.1 LD introduced the report with the following points: The New Surgery (Tring) APMS contract is now live. A planned CQC inspection has been delayed to 2018/19 in view of the change in contractor. West Herts Medical Centre (WHMC) - the committee had agreed a contract extension in order to align the WHMC consultation with the consultation for the urgent care centre. It was noted that the contract has been extended over a number of years by NHSE and the CCG is taking legal advice on this. We have not identified premises for Meadowell surgery at the present time. The CCG has been actively working with a range of organisations to secure suitable premises. If we can t secure suitable premises there is a risk that the practice will need to close. It was clarified that our preferred option is to continue with the practice. On the GP patient survey, HVCCG is ranked 29 out of 209 CCGs. We need to share this positive news with our practices. 100.2 The committee noted the primary care contracting and procurement report PC/67/17 PC/101/17 SMS text messaging in general practice 101.1 TS noted that the GPs presented were conflicted and should not take part in the decision making for this paper. 101.2 DB introduced the paper with the following points: Patients have access to a texting service which is funded by the CCG. There is huge variation in usage across practices but if every practice used as much as the highest users then the budget would be used very quickly. It is therefore proposed that cap is put in place of 0.75 texts per patient per month. 101.3 The following points were made in discussion: CH stated that this is paid for from the GP IT budget. By using texts, practices can generate income so it is reasonable to expect them to pay themselves for texts above a certain cap. AG stated that from her role in engaging with patients it seemed that the practices offered a texting service were well received by patients. PG stated that Meadowell was high usage and this could reflect the needs of the patients, so maybe a case for them to have higher usage. PG stated that some practices may already have reached their cap during this financial year. BG was interested in seeing outcome data, but there did not seem to be any. DB proposed that a cap should commence on 1 January 2018. ME asked whether the CCG would take the saving on any use below the cap the response was in the affirmative. 101.4 The GPs left the room before the decision was made 101.5 The committee approved the SMS cap at 0.75 texts per patient per month from 1 January 2018. 101.6 ACTION: CH to ensure GP IT group to carry out a review of texting service next year. This should include any outcome data and also benchmarking vs. other areas. /17 PC/102/17 Primary care commissioning panel minutes 102.1 PG pointed out two errors: On point 2 it refers to GPs resigning their GMS contracts, it should say resign from. Page 5 point C should say standalone, not standard lone. 102.2 The committee noted the primary care commissioning panel minutes subject to the amendments noted above (102.2) /17 GP Prem 2 P a g e
PC/103/17 GPFV plans progress update 103.1 LD introduced the update with the following points: An MOU has been put in place to release funding and funding has been released to all 4 localities. Implementation of the plans is being monitored on a monthly basis at the primary care working group, with locality chairs being held to account. We are currently reporting 33% achievement on the GP access target due to 26 practices in Watford funded in the national pilot. This figure also includes WHMC. 103.2 The committee noted the update report PC/102/17 PC/104/17 Winter resilience plans 104.1 LD introduced the paper with the following points: For the last 3 years winter resilience funding has been provided to practices to the value of 1.5m. 1.10 per patient has been offered to practices for this winter. The CEO had proposed that budget was not simply applied to core hour s work but used to fund multi professional working including the use of community pharmacists and new ways of working. The committee has been sent three plans and to note the St Albans and Harpenden plan is not yet available. Dacorum wish to use the budget to increase capacity in core hours in general practices this is on the basis they have secured 5 clinical pharmacists and will be utilising these over the next 1 2years. In the previous 3 years when increasing capacity funding has been available e. The Dacorum funding has been used to support the Dacorum Holistic Health Care Team (DHHCT). The DHHCT has also recently started providing the rapid response service it is therefore considered a reasonable request their winter resilience funding should be invested in general practice. Watford locality benefits from extended GP access service and their proposal for winter resilience funding is for practices to work at scale during the in-hours period providing additional capacity in networked hubs that are within close vicinity. Hertsmere is looking to utilise community pharmacists in addition to investing funding for additional capacity in general practice, but we have a concern about the budget being channelled to the federation for work that we as a CCG are able to do. 104.2 The following points were made in discussion: TS requested clarification of what the committee is being asked to do. LD stated that the total budget requested was above the sign off limit for this committee and that we were looking for the PCCC to make a recommendation to board or F&P. CH asked whether the requested budget was weighted as this made a big difference to the total being requested. This requires clarification. DC felt the plans could be a little more innovative in terms of the workforce attributes, particularly around nursing roles. It was noted that this was difficult in terms of meeting the needs of winter. The committee were broadly content with the Dacorum plan and the Watford plan but the Hertsmere plan should revise the proposed utilisation of the federation. 104.3 The committee recommended approval of the total budget being requested ( 1.10 per patient), subject to the receipt of satisfactory locality plans. The GPs present did not take part in the decision as they were conflicted. PC/102/17 PC/105/17 Review of primary care plus phlebotomy service 105.1 DB introduced the paper with the following points: The review of the service has been triggered by an issue in Hertsmere where HCT provides phlebotomy for general practice even though it is not contractually obliged to 3 P a g e