Item 2 MINUTES NHS Scarborough & Ryedale Clinical Commissioning Group Governing Body, held in public Wednesday 26 th March 2014, 9.30am Council Chambers, Scarborough Borough Council, St Nicholas Street, Scarborough Chair: Dr Phil Garnett Present: Dr Peter Billingsley GP Board Member Dr Greg Black GP Board Member Mr Simon Cox Chief Officer Dr Clive Diggory GP Board Member Dr Phil Garnett Chair Dr Kath Halloran GP Board Member Mr Tom Hall Consultant in Public Health Mr Philip Hewitson Lay Member Dr Ian Holland Secondary Care Doctor Mr Andy Hudson Lay Member Mrs Carolyn Liddle Primary Care Manager to the Board Mr Richard Mellor Chief Finance Officer Mrs Carrie Wollerton Executive Nurse In Attendance: Mrs Sally Brown Head of Programme Management Miss Stacey Mabbott Executive Assistant Mrs Barbara Buckley Head of Service Development (until item 7.1) Apologies: Dr Omnia Hefni GP Board Member Mrs Anne Marie Lubanski Co-opted Local Authority Representative Dr Douglas Lumb Co-opted LMC Representative Minutes Agenda Item 1 Welcome and Apologies Phil Garnett opened the meeting and welcomed members of the public. Action Some questions were received prior to the meeting and these were answered as below. Question: Despite NICE giving firm guidance that Type 2 Diabetics should have available an educational programme to give them the confidence to manage their long term condition there has been no such programme for about 3 years due to the PCT withdrawing the Expert programme. At the Diabetic Spa Day York NHS Trust had a stand showing benefits of their Good2Go programme and we were told the start date in Scarborough would be Jan/Feb 2014. This has not happened and we are told that funding has been pulled. Page 1 of 12
Although you are possibly not the lead commissioner for this type of service could you explain why this area does not have any such courses and is there a possibility of an Expert Patient Programme, as run by Hull s City Health Care Partnership. These courses are partly run by volunteers and are used for patients with long-term conditions such as Arthritis, Asthma, Epilepsy, Heart Disease, Multiple Sclerosis, Diabetes and long-term pain? Answer: Carrie Wollerton responded to the question stating that we haven t pulled any funding and we do fund the Specialist Nurses. Diabetes will be involved in our 2014-15 plan; we are aware of the gaps and we will review this over the months to get services in place with the right educational programmes in place. Tom Hall advised that self-care is identified as part of the Better Care Fund so some work will be done with the County Council on this. The Expert Patient Programme would not be ruled out and we would look at this with the stakeholders. The following questions are around the Walk in Service. Councillor Challen advised that he is leading the petition and has had a significant number of signatures. Question: Is the CCG carrying out an Equality Impact Assessment on its proposals? Cllr Challen advised that a number of the people signing the petitions are women with no transport or with young children Answer: Sally Brown answered the question advising that we have tried to capture details of protected groups in our questionnaires and that we will be looking into this. Question: What assessment is the CCG making of the consequences of its proposals on the performance of GPs surgeries in Scarborough and is it working with NHS England on this? Cllr Challen advised that a number of people signing the petition have stated they use the service as they are unable to get the desired appointment times from their GP practice. Answer: Simon Cox answered the question advising we have a public meeting on Saturday morning where we will explore a number of these issues in more detail. We are working with NHS England on the planning around GP access and trying to improve GP access in Scarborough and Ryedale, including extending GP opening times. The intention of the CCG and NHS England is to continue with the services in Castle Health Centre the only change would be the walk in service; if patients want to remain at Castle Health Centre they are able to register with the practice as their current list is very small and this would generate more income for Castle Health Centre Question: What assessment has/is the CCG making of the impact of its proposals on Scarborough's visitors? Cllr Challen asked that the CCG consults with the public again before the final decision is made to give all people a chance to give their opinion. Answer: Simon Cox responded to the question stating that although we can t predict who does visit Scarborough, there are trends of people who do visit. Page 2 of 12
We are looking in detail at people that do use the services around the area and visitors aren t being ignored as part of the service. This is the period where we are seeking views from the public, stakeholders and partners on urgent care. We haven t consulted on a specific model and we aren t saying we are commissioning a service that will be based in the hospital or next to. Sally Brown stated that we do have a conflicts of interest policy that we are monitoring throughout the process as we are aware GPs are making decisions that impact their practice. 2 Minutes of the Previous Meeting The Governing Body accepted the minutes of the previous meeting as a true record. 3 Matters Arising Item 5, Care Bill: It was reported that Tom Hall has spoken with Richard Webb, Director of Health and Adult Services, who is keen to do a presentation to the CCGs and will schedule this in. Item 8.1b, Business Conduct Policy: It was reported that the policies have been amended as necessary. Item 10.1, Urgent Care Services update: It was reported that the Communications and Engagement committee are currently working with the hard to reach groups and focus groups are currently taking place. 4 Declarations of Interest None raised 5 Chair s Report Phil Garnett wished to thank the Governing Body and staff of the CCG for the effort put into the consultation around Urgent Care. The process has been inclusive and thorough. It was reiterated that there will be a further public meeting held on Saturday at 10am in Scarborough Library. 6 Accountable Officer s Report 6.1 Authorisation Conditions Simon Cox reported that when the CCG was established it went through authorisation with NHS England. As of the beginning of this financial year the CCG had six conditions remaining, two of which were later removed. The remaining conditions were the financial conditions. Due to the inherited deficit from the Primary Care Trust (PCT) the CCG was considered high risk along with the other North Yorkshire CCGs. Simon Cox reported that we are pleased to announce that these remaining conditions have now been removed, as of the end of January, and that the CCG is now fully authorised. This is a tribute to all of the staff in the CCG that have worked hard to get to this stage. 7 Planning 2014-19 7.1 SR CCG Strategic Plan, including 2 year operational plan Barbara Buckley, Head of Planning and Assurance, attended the Governing Page 3 of 12
Body to go through the Strategic Plan. She reported that we are obliged to supply a Strategic Plan to the Area Team. It is now available for the stakeholders to comment on and has to be finalised by 20 th June 2014. She went on to state that this builds on the plan we had last year but has a lot more emphasis this time on Mental Health and what we want to do to strengthen Community Services. Barbara Buckley reported that after today the plan will be shared with all our provider organisations for their comments. It is also available on the Scarborough and Ryedale CCG website for the public to comment on. The plan will also go to the Health and Wellbeing Board for comments. After we have collated all the comments we will make the relevant amendments. The final version will be submitted on 20 th June 2014. It was reported that we are finalising some engagement events to receive more comments from the public on this. 7.2 Finance Plan Richard Mellor stated that this layouts the work undertaken and improves the 5 year view of where this will take us. There are a number of rules we have to comply with in terms of creating the plan including an amount for readmission work; we don t pay for patients readmitted within 30days. These restrict the amount of funding we have available for everything we need to provide. Additional pressures are identified in our plans. We do have to identify changes to service that would release funds. The requirement for savings is 6m which is larger than we have previously had. We need to identify change to commissioning intentions or assume lower growth. The plan identifies things we expect to happen and the amount of financial challenge we have. This is still undergoing some work around contracts but the overall position is we are setting contracts which are at the right level. There is a challenging QUIPP requirement but we do have significant non-recurring funds available this year to help deliver these savings. There have been a number of budget changes; are we confident that all these adjustments are made and we are as near as we can be. There are still some adjustments to be made, there are 2 areas with Hull Trust where within our plan we have taken a view on the impact of this and with York Trust there are issues which are still ongoing with Specialist Commissioning where potentially money needs to transfer. We are asking York Foundation Trust to recalculate the 2012/13 position which should then come out with the final adjustment. This may not be to our benefit. It was discussed that the 6m is going to be a significant challenge for us and there is concern that we will need to take this out of non-recurrent spend. It was reported that the amount of QUIPP is a large amount and this would be more challenging if we assumed that things won t happen; if we have it in, in advance we can work on the QIPP programme to make it more rigorous and we can then work to manage those plans. Page 4 of 12
It was reported that the Better Care Fund is a significant challenge this year. We are putting in under 1m into the Better Care Fund this year and this will increase to 5m next year. Phil Garnett reported that this is a realistic plan and he would rather have a difficult QIPP than an easy one that gives us trouble at the end of the year. The Governing Body agreed the financial plan 7.3 Better Care Fund It was reported that the Better Care Fund (BCF) was part of the Everyone Counts planning guidance that came out at the end of last year. The BCF will be formally in place in 2015/16 although we will need to consider the level of resource that needs to go into this and this will be done in collaboration with other CCGs. It is a national expectation that we would be involved in the BCF. Simon Cox advised that the paper circulated was the paper that was submitted on 14 th February 2014 and the final version won t be submitted until June 2014. Simon Cox drew attention to page 21 of the paper which includes a diagram on the expectations of how the BCF will be developed. Page 42 provides a table of measurements which will be used to measure the BCF. It was reported that this is an ongoing process which the Governing Body need to review and support. The BCF submissions are a joint piece of work with the 5 North Yorkshire CCGs; the view of the CCGs is local delivery in a county wide framework with consistency across the county. The Governing Body approved the outline plan. Memorandum of Understanding between Scarborough Borough Council and Scarborough and Ryedale Clinical Commissioning Group Tom Hall reported Scarborough and Ryedale CCG has specific needs, as is highlighted by the health profiles for Scarborough and Ryedale. These indicators can be improved by a number of programmes. The proposal is that we use additional Public Health resources to focus on these areas working in conjunction with Scarborough Borough Council, the CCG and Public Health at North Yorkshire County Council. This would provide the CGG additional resource and would help put new programmes in place. This paper has been brought here for general approval; the proposal is to bring back 6 monthly reports to the Governing Body. It was reported that the 15k for this is exclusive to SRCCG due to the needs of SRCCG. The money is non recurrent for 2 years; after the 2 years of funding there is still a benefit and it doesn t just stop. It was reported that the council are very supportive of this and there may be additional support for this further down the line. Page 5 of 12
Phil Garnett reported that we welcome the extra resource and is sure it will be used wisely. 8 Corporate 8.1 Changes to the Constitution It was reported that this has been through a consultation with practices, the Local Medical Council (LMC) and NHS England Area Team who are required to approve it before a final submission in June. There will be some consultation about future changes and will be under ongoing review. There were two changes recommended since the paper was done; this was to explain the role of the Executive Nurse and Secondary Care doctor and to identify the specific committee for Information Technology (IMT). There was a view this would be managed through the Data Group and it was proposed that in the terms of reference of the group it states that they oversee the development of the IMT strategy. This will go back through NHS England. The Governing Body agreed to the changes. 8.2 Assurance Framework Philip Hewitson reported that the next three documents are all related. The assurance framework shows the strategic risk of the organisation and states how to monitor progress. This has been an ongoing piece of work and there were no strict guidance on what CCGs should have in place. This was developed after speaking with advisors in the CSU and discussions in Governing Body workshops. The assurance framework will take the strategic risks and identify the lead committee member and lead Governing Body member who will be responsible in ensuring any actions are put in place. The document will be updated on a regular basis. It was reported that the Governing Body are requested to agree and challenge the risks but also to highlight any that have not been captured and agree the appropriate leads. The Governing Body agreed with this approach and that this would be reported on a quarterly basis. 8.3 Corporate Risk Register It was reported that these are the operational risks that have been identified. For the first time this financial year all of the elements of all the committees risks have been pulled together. It does report on the current financial year which has been a successful year in establishing the processes and engaging in commissioning for the population of Scarborough and Ryedale. This is a comparative piece of work to show how risks are changing overtime. It was reported that this work is driven by the committees and individual members of staff who identify risks and capture them. The inclusion of the matrix and scoring helps to understand the document. Simon Cox reported that this is a good document and it would be helpful to Page 6 of 12
show how we use the scoring matrix and assessment of severity. A separate piece of work may need to be done on the scoring assessment of a risk and scoring the severity to ensure that there is a common approach. Carrie Wollerton stated that this document picks up the whole register and that it needs to be agreed what we do and don t include in it. It was reported that this is picking up the risks that score above 12; this is done on advice from the CSU. The Governing Body accepted the risk register and confirmed that it is useful to have the scoring from 12 to enable them to see more of the risks. 8.4 Risk Management Strategy Philip Hewitson reported that this has been around for a while and is part of the papers that went to the authorisation panel last year; this is a refresh document. The main change is around the Partnership Commissioning Unit (PCU) and the way in which we handle the operational risk within that. The conclusion was that because the unit works across all four CCGs the risks are better under the PCU Board and it is then the Chief Officers responsibility to report any corporate risks to the Governing Body. It was reported that within the Risk Management Strategy it identifies that scores over 12 will go onto the Corporate Risk Register and this will need to be agreed. Simon Cox reported that there is a reference to the Chief Operating Officer on page 9 and this needs amending to say Chief Officer. 8.5 Operational Scheme of Delegation It was reported that this is built up on the document that was already in place. It specifies the maximum amount of delegation to individual officers that is allowed. There are three sections in the document in terms of Finance, HR and other issues. This document is the basis for the powers allowed. It was raised that the document lists committees but the Remuneration Committee is missing from there. The Remuneration Committee is a direct sub committee of the Governing Body and the outcome comes straight back to the Governing Body. It isn t a decision making committee in its own right but does bring suggestions. Richard Mellor reported that he is not aware of any other Remuneration Committees that had a risk register and is not sure if this has been looked at and decided not appropriate, but he will look into this. RM It was discussed that the Business Committee sometimes makes decisions and that this is currently being looked at to decide whether the Business Committee should be in the constitution and recognised as a decision making committee. It was reported that advice has been sought from the CSU legal team and the four North Yorkshire CCGs now have an honorary contract with the PCU. The Governing Body approved the scheme of delegation Page 7 of 12
8.6 Report from the Audit and Governance Committee held 7 February 2014 Philip Hewitson reported that there are a couple of upcoming dates. The next meeting is scheduled for 25 th April 2014 and there is then an extraordinary meeting on 23 rd May 2014 to consider final accounts. Philip Hewitson reported that the committee had received a report from Internal Audit on payroll; this came up with limited assurance and McKesson seem to be having great difficulty with expenses. The recommendation is the CCG puts in place measures to control this aspect of the payroll and Internal Audit will follow this up. Expenses are a small part of the remuneration and the payroll itself is significant. He stated that there was a report from the CSU which advised Deloitte s had done an audit which only came up with limited assurance. The reassuring message from Jon Cooke was that the recommendations were priority 2 and 3. Priority 1 being horrendous. By comparison with the work Deloitte have done across the country our CSU came out well. They are hoping to remedy their issues by the end of March 2014 when Deloitte will do another review. Janet Probert, Director of Partnership Commissioning, also attended the Audit and Governance Committee to give update on PCU which was very useful. This provided the proposals they had in place for the retrospective claims, the way they are managing equipment, the work she is doing with the Local Authorities and the work on Safeguarding children and adults. It was a narrative report and gave a good view of what has been done since she took up post. 9 Report from Communication and Engagement Committee 9.1 Exception and Progress Report Andy Hudson reported that there are two reports and that he will discuss these together. The main work has been the consultation on Urgent Care. An awful lot of effort has gone into this and it has been very comprehensive. Events have been held in Scarborough, Eastfield, Ryedale and Filey with three being held on an evening. The events have been productive meetings with beneficial question and answer sessions. It has given the CCG the opportunity to try and explain the proposals for the Urgent Care and listen to the views of the public. To that extent we have put aside more time for another meeting on Saturday 29 March; we have listened to key messages and this meeting is a result of that. 400 Surveys have so far been completed and there is still the opportunity for members of the public to go online and complete the survey, which is also in GP practices and public libraries. Andy Hudson confirmed that the Communications and Engagement committee are highly satisfied that the CCG have tried to consult as wide as possible and listening to the public. The results of the consultation will be analysed and brought back to the Governing Body as well as made publically available. The CCG patient representative group is going very well now and the last couple of meetings have been very productive. We have an agreed Page 8 of 12
programme on things to discuss and this is positive. Andy Hudson reported that the Communications and Engagement committee have drawn up some principles to ensure there is a coordinated and considered approach to patient and public engagement when commissioning services collaboratively between CCGs and/or when the decisions made by a CCG or related organisation (e.g. PCU) will potentially impact on patients living in a neighbouring CCG. It is suggested that the Governing Body adopt these principles. Andy Hudson reported that we are able to share our plans with other CCGs. It was discussed that the CSU has been asked to treat the PCU as a fifth CCG and we shouldn t expect there to be any dilution of our CSU capacity because we have the PCU. Concerns were raised that the PCU are tendering for a different engagement company to do their engagement work for mental health so this wouldn t necessarily be done by the CSU. It was suggested that Andy Hudson discusses the principles with the Lay Members of the other CCGs. Richard Mellor questioned whether the second principle should say significant impact rather than just impact? In terms of overall communication, if we have something significant for us, even if it doesn t affect them, we still share it with other CCGs so they are aware. Andy Hudson agreed to amend the principles based on this. The Governing Body agreed to adopt these principles. Simon Cox suggested that these are taken to the PCU Management Board as well as the Strategic Collaborative Commissioning Committee (SCCC) and to also discuss this with the other Chief Officers. It was also suggested that these are taken to the North Yorkshire and Humber CCG Collaborative meeting at a later date. 9.2 Principles for Collaborative Commissioning Item covered above AH AH SC 10 Service Developments 10.1 Urgent Care Services update Peter Billingsley reported that the timetable is doing really well and is on track. Four meetings have already taken place and there is an additional meeting scheduled for Saturday 29 March. There has been a lot of expressions of interest and a pleasing number of interest so far. 10.2 IVF Services It was reported that this has been discussed in previous forums. North Yorkshire and York PCT ceased to provide access to IVF therapy due to their significant financial challenges. When CCGs started they adopted all the PCT policies with the view to review them all in the first two years of CCG life. This policy is still in place from the PCT, as is the case with the other CCGs. The Business Committee discussed that for 2014/15 we would look at all financial challenges and asses how we best use the policies. We will look at IVF and review the policy and this may look differently to how it previously looked in this area. Currently patients can still have a request for IVF reviewed through the Independent Funding Review Panel (IFR). Page 9 of 12
The Governing Body agreed to continue looking into IVF and to bring a paper to the next meeting. 11 Report from Quality and Performance Committee 11.1 Quality and Performance Report It was reported that this is the regular report that is brought to the Governing Body. It has been amended to try and include more context and to also try and to contextualise it with numbers. The summary at the front states the areas of concern. Referral to treatment - this includes cancer targets and 2 weeks wait. There has been problems with this and we are working with the Trust to understand the waiting list better. As a result of this we have asked the national intensive support team to come and work with York Foundation Trust to review their waiting list policies and to ensure everything is running to the right guidelines. The trust have also asked them to look at cancer targets to ensure they are working to the right pathways. It is expected that this will be completed in the next few months. Breast 2 week wait there is a problem with radiology cover in Scarborough. When patients are referred from their GP they should be seen within 2 weeks, but as there isn t sufficient radiology cover, patients are given the choice of going to York; it is likely they won t be seen for 4 weeks in Scarborough. We have been working with Harrogate to try and have York staff to cover Scarborough but for the interim we need to give out a message on referral pathways for this particular referral. A&E there is continuing pressure, however, for the 4 th quarter there is some difference from the winter schemes that has been put in to try and get patients moving through quicker. Healthcare acquired infection rates as a CCG we are just within our target and we need to work towards reducing this. The Trust are doing a lot of work to try and reduce infection. With regards to the breast referrals it was discussed that the referral routes and pathways should remain the same and patients should still be seen within 2 weeks. When there is full cover in place in Radiology we are meeting targets. The Governing Body discussed that GPs need to be made aware of the current issues to be able to advise patients that to be seen within 2 weeks it is likely they will need to go to York. However, it was noted that due to demographics patients often can t afford to go to York to be seen. 11.2 Quarterly Quality Report It was reported that there are some notes at the front of the report to draw attention to certain areas. Mortality rates- these are improving and we are working with the Trust to move towards 7 day service and with better consultant cover. Ambulance turnaround times these have improved which was significant in Page 10 of 12
Quarter 3 at Scarborough Hospital Stroke services in Quarter 3 we were given accreditation and we will pick this up in any other business. Maternity services there is the friends and family results and some information on perineal repairs during delivery which the Trust are working towards improving. There is an aim to improve HCA s in Primary Care and there is a planned improvement event. We haven t been able to get the Quarter 3 data to put in this report but this will be included in the next report. It was reported that the Quality and performance reports are the reports that have changed the most and we have now seemed to have settled down to a good monthly report. The Governing Body now need to think if they would like any further amendments 12 Report from the Finance and Contracting Committee Financial Report Richard Mellor reported that there is a small written section that states where we are in month 11, which is just about where we wanted to be. There are still some areas where we do have risk to achieve the forecast position, especially around the spend on Continuing Health Care. We have had to agree a figure with York Foundation trust (YFT) and we have reduced some of the risk on that. There is a small risk with Hull, which is another of our providers. Whilst there is still some risk at this point it is still predicted that we will meet the forecasted target for the CCG. It was discussed that there have been discussions in the patient representative groups that we never mention the costs involved in the service changes and the financial reasons behind decisions. It was suggested it would be better to have a line that we agree to use with the public and there prospective would be a lot better. Richard Mellor reported that he would attend the next patient representative group and will do some work on presenting the complex figures in a meaningful way. It was reported that there is a line in the patient public involvement section of the document where it looks as though nothing has been spent when it has. It was reported that one of the former comments of the PCT was that it was dishonest, but there is a sense where we do need to be more upfront; with the Malton MIU we were very clear that it was about money and people felt we were quite open about it. 12.2 Sign off of draft accounts Richard Mellor reported that in terms of the timescales there is a prescribed timescale for production and submission to NHS England and Auditors which is 23 rd April 2014. Subsequent to that there is a report to Auditors from the account and ultimately submission of a full set of accounts which needs to happen by 6 th June 2014. We are looking to meet with the Auditors on 23 rd May 2014 to do the sign off at that point. This paper brings the timetable to the Governing Body to notify that there is no Page 11 of 12
Governing Body meeting between now and 23 rd May and to ask the Governing Body to give delegated authority to the Audit and Governance Committee to receive the report from the Auditors on 23 rd May and if there are no problems with it to accept the accounts on behalf of the organisation. The final set of accounts would be brought to the May Governing Body meeting. The Governing Body agreed to this approach 13 AOB Stroke Service at Scarborough Hospital the service now has provisional accreditation and we are starting to get data though from the national database which looks at the parameters of care in stroke. From this it shows a higher proportions of patients which are not on anticoagulation. Last year there were a large number of patients requiring nurse care after a stroke, but the most recent data shows that this is reduced; although it is still 3% above the national figure it is not as bad as expected. The mortality rate for stroke is less than neighbouring hospitals. There is still some monitoring but there has been significant improvement. It was noted that it was the Governing Bodies decision to keep this service in Scarborough Hospital and the patients have benefited from this. 14 Date and Time of next meetings: Wednesday 28 th May 2014 (9.30-11.30am) at the Council Chambers, Malton Council Page 12 of 12