item 24 Clinical Executive Committee formal Meeting Thursday 05 October 2017, 9.30am-12.00pm Beccles House Present Name: Position: Organisation: Dr Paul Berry (PB) Retained GP representing planned Careers Plus GP care (Chair) Melanie Craig (MC) Chief Officer GYW CCG Cath Byford (Y) Deputy Chief Officer, Director of GYW CCG Commissioning Dr Mark Lim (ML) Programme Director Acute GYW CCG Commissioning Sadie Parker (SP) Director of Primary Care GYW CCG Dr Lucie Barker (LB) Retained GP member representing Rosedale Surgery Lowestoft Dr Karen Mitchell GP member representing Great East Norfolk Medical Practice (KM) Yarmouth and northern villages Dr Abhijit Bagade Consultant in Public Health Medicine Public Health (AB) Lois Taylor (LT) Senior medicines Optimisation GYW CCG Pharmacist Paul Higham (PH) Head of Activity and Finance GYW CCG In attendance Name: Position: Organisation: Toni Penson (TP) Administrator GYW CCG 1. Apologies Action owner Apologies were noted from Dr Andy McCall, Rebecca Hulme and Dr Tamer Okasha. 2. Declaration of interest There were no new declarations of interest. 3. Minutes from the last meeting of 21 September 2017
The minutes from the meeting of 21 September 2017 were deemed to be a true reflection of the discussions held and were subsequently approved. 4. Action log and forward planner The committee welcomed the post-meeting updates included within the action log. Action 1 Community IV Service stated the CCG is still seeking further clarification from James Paget University Hospital (JPUH) regarding the full year cost of the service. This has been escalated to the joint executive working group and Mark Flynn, Director of Finance at JPUH has committed to providing clarification by the end of this week. Once the costings have been reviewed again the next step will be to present a paper to the senior management team and governing body. Action 2 Internal peer review for referrals It was advised that practices will shortly be submitting their first set of returns. It was requested that CEC should receive the first set of returns in one months time. Add to forward planner and close action. Action 3 MSK triage model ML has been asked to check the activity assumptions are correct, and will update CEC in two weeks time. Add to agenda and close the action. PB informed that this model was positively mentioned at the recent pain network meeting but it was commented that it will need some instruction regarding the referrals and also constructive engagement with the orthopaedic consultants. ML said he has spoken to the JPUH orthopaedic team and they had expressed some minor concerns and these will be addressed. Further project group meetings have been arranged to talk through these final issues. confirmed that this was approved at CEC in August and is now in the implementation stage, however there is still a possibility to review and look at further opportunities after the initial scope time. It was suggested letting the model embed for a while with the possibility of reviewing again at the new year. The committee queried the cost per session. PH confirmed NHS England has seen the business case and has not queried the costings proposed. Action 4 Health Optimisation This item is on the forward planner for 19 October. Close action Action 5 Locality updates
The committee noted the useful web links included within the action log, so the CCG should be looking at how best to utilise these. It was suggested raising these opportunities at individual practice meetings in the first instance. KM provided a briefing on the Great Yarmouth locality use of the productive general practice development programme, stating it has been beneficial but does need commitment and engagement to make it work. SP said she would ask Tracey Parkes to meet with the locality leads to discuss taking this forward within the other localities. SP Action 6 and 7 PTLs This is on today s agenda. Action 8 self-care and low value medicines consultation It was advised that letters have been sent to all practices and will be taken forward via the medicines management team. LT confirmed the consultation is going well and will be ongoing. It was agreed to receive another update at CEC in one month to review the outcome of the consultation. Action 9 low priority medicines It was confirmed that letters have been sent, alongside the policy. This has been discussed at various forums at JPUH to request support with the CCGs prescribing orders. It was requested that this be reviewed in November, once the result of the preferred bidder is announced on 19 October. Action 10 Stoma Partnership Project LT said the project is progressing quickly. Five practices have been involved so far and there are plans to roll out to a further ten practices. It was requested that further feedback be received in four weeks time. Recommend to close the action and place on forward planner. Action 11 Enhancing the JPUH clinical engagement with primary care clinical leads This is to be discussed under the PTL agenda item on today s agenda. Action 12 Dermatology business case update advised that correspondence regarding the termination of the business case will be sent later today. Action 13 250,000 Delegated limit This has now been addressed.
Action 14 CEC Summary to external colleagues The committee were not aware this has happened as yet, but agreed it would be useful. to review the draft minutes from today s meeting then forward to the communications and engagement team to prepare a briefing for circulation. Action 15 Norfolk Health Improvement Service This has been escalated and a meeting has been arranged. The committee then reviewed the forward planner and reviewed the items identified for the next agenda. It was requested that the SWAN out of hospital team model be deferred to the November meeting. 5. Locality Feedback Forward Plan Lowestoft LB mentioned there had not been a locality meeting in Lowestoft since the last update. The locality is getting on with things and responding to crisis well and feels progress is being made. A very positive environment is emerging. Great Yarmouth KM updated there had been a meeting with the council to develop the Care Connections programme and it became apparent the councils, CCG and practices are working separately. to discuss this with Chris Scott to request he find out what is happening and triangulate the findings. Chris will be asked to work with Suzanne Meredith in Public Health to triangulate all the information in Great Yarmouth. The locality group can then review the results and if necessary arrange discussions with public health and councils to request closer working. The committee requested to receive a briefing around the findings to the next CEC for deciding the next steps. Gorleston SP advised there have been discussions around the Gorleston locality adopting a similar approach undertaken by the South Waveney locality. SP reported there are a couple of issues which remain the focus for the locality. South Waveney There have been two positive meetings with the South Waveney practices. There is a focus on out of hospital team, resilience and looking at minor injuries and phlebotomy services. The practices have agreed to the approach going forward. A paper around the out of hospital service will be presented to the primary care commissioning committee (PCCC) setting out the process and will then be presented to CEC and governing body in November. SP mentioned the positive dialogue between the CCG and the practices, and commitments around the dashboard have been accepted for further investment into the locality.
LB said the CCG needs to be fair with its focus, and be explicit as to what it expects from the individual localities, particularly for Lowestoft. SP felt a large number of team time and investment has been available for the Lowestoft locality. SP acknowledged the work being undertaken amongst the practices which is progressing well. SP said there are performance issues within Lowestoft which the CCG would like to work with the locality to address, but there is a need to recognise that the CCG cannot do everything at once. MC said this also comes down to autonomy and feels that the performance issues are being addressed in Great Yarmouth. South Waveney had requested CCG support and the locality is now in a positive place. The CCG acknowledges the problems in Gorleston and will take a more directive approach with them. MC assured the CCG will meet with Lowestoft practices to see what is to be done. said the CCG needed to focus on the main concerns and therefore will need to focus on areas of crisis and this is driving the priorities. MC said the desired outcomes will be evidenced by having resilient practices and a plan to manage demand and this remains the CCGs main objective. PB said this clearly shows the need for locality leads meeting to discuss these issues in depth. PB wished to thank locality leads for their work. 6. Prescribing Policy of Freestyle Libre LT mentioned Freestyle Libre is a new type of device to monitor blood glucose levels. This device, unlike other devices uses a sensor which is attached to the skin to monitor blood glucose levels. Users are able to install an app which they can scan over the sensor to pick the reading up. All other devices available require the patient to perform a finger prick test. Freestyle Libre becomes prescribable on the NHS from 1 November 2017. This device is currently being heavily marketed to patients and clinicians, including the supply of free samples. This particular device is significantly more expensive than other available devices. There is also no evidence to suggest that this device is any better than existing devices. The CCG has developed a policy to reflect the current double red (no prescribing) status of Freestyle Libre which is based on the East of England Priorities Advisory Committee recommendation. The rest of Norfolk has also given Freestyle Libre a double red; no prescribing status. It was confirmed that communication has been issued to practices that it is double red and not to prescribe Freestyle Libre. JPUH is also aware that this should not be prescribed. Appropriate messages on ScriptSwitch are also in place. The risks to containing the prescribing of Freestyle Libre were described as:
- Secondary care not adopting the same approach - Patient pressure received by GPs to prescribe this particular device - Diabetes UK s positive statements about the new device The committee agreed to implement the policy and the template patient letter was approved. will arrange for the policy to be included on the JPUH clinical quality review group agenda. It was also commented that the CCG will need to give the same message to the Norfolk and Norwich University Hospital (NNUH) as they also treat GYW patients. LB also suggested sending an email direct to all the doctors, attaching the policy and letter, to guarantee that the message does not get missed. SP/LT 7. Advice and Guidance business case The Advice and Guidance Business Case sets out a proposal by GYW CCG for the introduction of a local tariff to support the further utilisation of the advice and guidance scheme via ERS across planned care specialties in order to ensure patients receive the most appropriate care in the most appropriate setting and timescale. NHS England s commitment to this approach is evident through the National CQUIN supporting secondary care providers to deliver advice and guidance. The advice and guidance scheme has been identified as a 2017/18 QIPP scheme with a projected reduction of first outpatient appointments. It is essential to ensure a robust business justification to the financial implications and cost to benefit analysis to assess the potential of the proposal and the impact on in-year QIPP planning. ML highlighted the operational and financial risks associated with the business case. This includes not achieving the proposed QIPP target, contractual negotiations resulting in delay with implementation, JPUH not aligned to the reduced clinic activity and GPs deciding to refer to NNUH instead of JPUH. mentioned RAS, a similar system to ERS, but RAS would enable a back and forth dialogue which makes up part of the patient notes. The committee noted concerns that if the advice given was not adequate whether it would generate a new episode and tariff. It was commented that GPs are not aware how the service will be funded or that contacts will not be double charged if advice and guidance converts to referrals and that there will be an option to reply to responses received. This is worth promoting as this may be a source of reluctance. will arrange for appropriate communications to be prepared and circulated. The committee queried the measures to be put in place to monitor quality of the advice given and some unsatisfactory examples were shared. These issues have been taken up with Liz Eyre, but show the need to have quality requirements processes prepared. ML assured quality measures are included as part of the specification and will be managed at a GP level.
The committee recommended that once the system is up and running it would be beneficial to pilot a practice or specific specialties where advice and guidance is mandatory. The committee recommends to governing body, via chairs action, that this business case be approved, on the proviso that the advice and guidance service is not used for urgent referrals but for routine referrals only and a 5 day response is an adequate timeframe rather than the suggested 48 hours. 8. New policies from the clinical policies development group The enclosed policies had been recommended for approval from Clinical Policy Development Group (CPDG); however the heavy menstrual bleeding was withdrawn as it not been discussed at the September 2017 CPDG meeting. Trusts had been given until the end of the previous week to respond; one comment, that it was possible for the wording of the benign skin lesions policy to prevent proliferative hemangiomas being appropriately referred to paediatrics, has led to further discussion. ML has discussed this with AB and agreed that this argument had merit; this policy was therefore withdrawn pending further discussion at CPDG. ML updated the committee on the correspondence received from the James Paget regarding patellar resurfacing which was received the previous day, and after the requested deadline for inclusion in papers. This principally related to rheumatoid arthritis patients and potential misalignments following surgery. West Suffolk, North Norfolk and Norwich CCGs have approved the proposed policy; the reasons being the cost-effectiveness study not demonstrating clinical effectiveness thus rendering the cost-effectiveness question moot; the systematic reviews which had identified quasirandomisation in some of the trials, significant heterogeneity, lack of effect on anterior knee pain, and an absolute risk reduction of reoperation of approximately four percent. The committee therefore approved the policies listed on the summary sheet with the exception of benign skin lesions and heavy menstrual bleeding. 9. PTLs survey results SP said the survey is still live so the presentation today reflects the current results only. Data had been collected via an online survey which had been distributed to all clinical leads, GPs and practice staff. There had been 17 responses received to date. Generally the PTLs are valued and responders would like to see them continue. The responders acknowledge the importance of having quality time out and appreciate the networking opportunities. However, it was also commented that the quality of the sessions has been variable and not always relevant. The survey had also asked views around clinical leads meetings. There had
been 4 responses; with mixed opinions. It is felt it is not always certain what the purpose of clinical leads is and there needs to be a clear direction as to the focus of the meetings. There is concern around the clinical leads meetings moving into the four localities. SP said there is a plan to continue with the joint clinical leads meetings so there will still be opportunity to network with neighbouring localities as it is agreed it would be unfortunate if that chance is lost. SP advised that the survey is due to finish this week, so there is to be one last effort to get colleagues to complete it. SP to recirculate the link to the survey and consider extending the deadline if appropriate. SP It was felt PTLs should focus on local pathway information for clinical staff; with the CCG teaching primary care how to use systems better i.e. MSK triage service and the advice and guidance system. And for non-clinical staff there is the opportunity to undertake mandatory training sessions. PB will continue to bring PTL via CEC, so it would be good for to do the same for clinical leads and produce a forward plan for topics to be included. MC said she supports the PTL and providing time out for practices to do this; however practices should be aware of the cost of organising these events, and it is unacceptable for GPs to leave half way through a session as the CCG does cover the cost of GP emergency cover. We will review them in light of the feedback and will propose a revised approach to the SMT and then CEC. The CCG will now move forward with planning and redesign. 10. Minutes from Therapeutic Advisory Group (TAG) and the Drugs and Therapeutics Commissioning Group (DTCG) LT invited the committee to note the draft minutes from the September TAG and the August DTCG meetings. Items of particular interest LT wished to highlight were; - The TAG has agreed to a double red (no prescribing) status for trimipramine and dicycloverine. - There are now updated shared care agreements on Knowledge Anglia covering a number of scenarios. The minutes were noted by the committee with no further comment. 11. Any other business It was agreed to defer the discussion around ME/CFS medical reports to the next meeting and will provide a briefing. Place on forward planner and close the action. / KM asked about the Hep C nurse coming out to practices. said this
service is commissioned by the council and the CCG had been asked to provide permission for the changes, and confirmed approval had been given. MC requested an item be added to the next agenda regarding the commissioning cycle. MC would share correspondence the CCG has received from the Norfolk and Suffolk providers. It was advised that as the CCG had entered into two-year contracts last year there will be no need for producing formal commissioning intentions; however it is intended that one letter from all five CCGs will be sent to providers charting the commissioning outlook and strategic planning. Date, time and venue of next meeting Thursday 19 October 2017 9.30am 12.30pm Beccles House, Meeting room 3