DRAFT Minutes of the NHS Trafford Clinical Commissioning Group Governing Body Meeting held in Public Held on Tuesday 24 April, 2018, 9.30 a.m. 12.00 p.m. Council Chamber, Trafford Town Hall, Stretford PRESENT: M Colledge Dr L Clarke (LC) A Foster (AF) T Grant (TG) M Irvine (MI) Dr M Jarvis (MJ) Dr P Nkwenti (PN) M Moore (MM) S Sherrington (SS) Dr C Tower (CT) J McGuigan (JM) S Radcliffe (SR) Chair GP Member Lay Member for Governance, Audit and Finance Accountable Officer Director of Performance and Quality Improvement Interim Medical Officer Lay Member Patient and Public Engagement Chief Nurse Governing Body Nurse Member Council of Members Chair Chief Finance Officer Corporate Director of Commissioning IN ATTENDANCE: R Demaine (RD) H Gollins (HG) H Fairfield (HF) A Prabarakan (AP) R Riddell (RR) L Walker (LW) Interim Director of Commissioning Public Health Consultant Healthwatch Representative Local Medical Council Representative Risk and Planning Manager Governance Support Officer (minutes) GB 1819/001 APOLOGIES FOR ABSENCE Apologies for absence were submitted from Dr A Harrison, GP Member; Councillor J Lamb and E Roaf, Interim Director of Public Health. GB 1819/002 DECLARATIONS OF COMMITTEE MEMBERS INTERESTS CONCERNING AGENDA ITEMS No declarations of interest were declared in conjunction with section 8 of the CCG s Constitution. GB 1819/003 MINUTES FROM THE PREVIOUS GOVERNING BODY MEETING HELD ON 27 FEBRUARY 2018 AND 27 MARCH 2018 Page 1 of 12
The Chair presented the minutes from the previous meeting of the Governing Body meetings held on 27 February and 27 March 2018 for member s perusal and approval. 1. The Governing Body approved the minutes from the previous meetings held on 27 February and 27 March 2018. GB 1819/004 PATIENT STORY. Governing Body members were presented with a presentation giving an overview of #End PJ paralysis (70 day challenge) and explained the work behind the story. The focus was about encouraging patients in hospital to get dressed every day, rather than in their pyjamas or hospital gown when it was not necessary. Governing Body members were asked to sign the pledge at the end of the presentation in order to show their support for the initiative. MC asked what can be done to support this further and MM responded it was important systems were in place to ensure support was available to promote the work, with things such as asking a patient on entering hospital if they had their day clothes with them as this would certainly help to promote the cause. SS reiterated the importance of gaining commitment from professionals and patients, as well as families. SS went on to say that when an organisation had turned up in their pjs for a meeting, one member had expressed his vulnerability, therefore promoting the need to make patients feel less vulnerable by being dressed in their day clothes. Work was also being undertaken with charities to help support those people who may not have day clothes and providing clothes for those patients. PN asked if carers were involved with the work, and MM responded that families and carers were involved which would promote empowerment within social movement. PN also asked whether this was being picked up for those people in communities affected by Windrush and were equality impact assessments being undertaken. MM advised she did not know the answer to that but would certainly look into this. 1. The Governing Body noted the presentation in relation to #EndPJparalysis. GB 1819/005 FINANCE POSITION JM presented the Governing Body with an update in relation to the finance and contracting position, and highlighted the key areas for noting. It was advised the year end controlled total had been achieved as agreed with Greater Manchester Health and Social Care Partnership (GMHSCP) of 8.6m, which would be reported in the provisional final accounts, and also informed Page 2 of 12
members it was the first year the CCG had failed to meet its statutory duty. A Section 13 referral letter has been sent to the Secretary of State, and this would have implications, but as yet are not fully known. The final accounts are being prepared and would be presented to Audit Committee for review and approval and presented to the next Governing Body strategy meeting in May for ratification. JM went on to advise most budgets had been achieved, with providers over achieving and agreements with all providers had been reached. QIPP savings against the original plan of 18.6m had not been achieved, with a slow start to some of the savings programmes, therefore it was important to start to bring the services together and ensure more efficient working was being undertaken. JM went on to say the CCG would start the financial year 2018/19 with a 10m deficit, and therefore there would be challenges going forward. JM concluded, as this was his last Governing Body meeting before leaving the CCG wanted to thank everyone and he was proud to have been the Chief Finance Officer during the last 4 years and thanked the Governing Body and staff, in particular the finance team for their support and hard work during this time. AF asked JM and NB about the process for approval of a recovery plan and NB responded she would be attending a meeting with Steve Wilson at GM partnership to discuss the financial plan, and there would also be a series of workshops taking place to look at what a realistic plan would look like in order to make a decision on the financial gap and the savings plans and what this means for Trafford. It was advised that a plan had to be submitted by 26 April. There was further discussion around the plan and the figures submitted, and TG advised the figures put forward would have to be based on organisational delivery and would not include areas the CCG would not be comfortable with. SS asked if the financial plan would be presented to Governing Body, and it was advised that information would be circulated to the Governing Body to advise on the position and a full plan would be presented in May. AP asked whether there was comparable information available in relation to prescribing costs and the overspend, and MJ responded work was currently being undertaken to look at this in order to understand where the CCG were compared to benchmarking which was quite difficult as the average population shows a gap in certain age ranges. A budget figure would not be agreed until this work had been undertaken to support the proposed figure. JM commented the information was clear as to where Trafford stands compared to other CCGs on a like for like basis, however within GM and across the country Trafford was compared to Bury and Stockport in relation to population size. Bury and Stockport are amongst the CCGs where better/more efficient prescribing takes place, therefore there was a considerable opportunity for savings and better management within Trafford, with Page 3 of 12
a suggested saving in the region of 6m to be made. Further discussion in relation to Right Care data and pharmacy cooperation took place, along with support to practices and community services understanding where savings could be made. MJ advised data sharing between practices need to be improved in order to understand how peers are working differently and where the areas of support are required. LC informed members work had been undertaken around antibiotic usage in specific practices where individual prescribing levels had been high. The Medicines Management team had worked closely with the practice and the individual to reduce the prescribing and it had proved to be successful. MC commented he recognised there was a considerable need to focus for the next period, however this was part of the integrated work and there would be a need to understand and be realistic and to where the savings could be made, and understand where the savings can be tangibly achieved. The Chair wanted to put on record his thanks for the dedication, professionalism, and unique care for the people of Trafford that JM exhibited every working day. The Chair passed on grateful thanks on behalf of the CCG Governing Body and Staff and wished JM best wishes for the future. 1. The Governing Body noted the financial update. 2. The Governing Body thanked JM for his contribution and hard work at the CCG during the past 4 years and wished him well for the future. GB 1819/006 BOARD ASSURANCE FRAMEWORK (BAF) RR presented a report which provided an assessment of the BAF which would be reported as part of the Annual Governance Statement. Overall significant progress had been made in relation to stakeholder engagement, integration workforce and the priorities. In relation to Risks 10 and 11 around finance, this was being reported as being crystalised. The assessment was agreed at Audit Committee at the beginning of April, with additional commentary being added to explain where we are at the beginning of the year and what we expect to achieve by year end. Any active risks noted in the report would be carried over into the 2018/19 BAF which would be discussed at the Governing Body Strategy session in May. SS commented it would be useful to have a session specific to BAF, possibly prior to May. RR responded the BAF had been presented to the Governing Body strategy session in March and any information which was gleaned from that meeting would be used to inform the 2018/19 BAF. Page 4 of 12
1. The Governing Body noted the BAF update. GB 1819/006 ORGANISATION UPDATE TG presented Governing Body with an update in relation to the activity within the organisation since the last meeting in March and asked members to note the report. The report covers the Governing Body strategy session held on 27 March, where financial plans, integration progress and some transformation activity was discussed. Part 1 of the meeting in March had been a meeting held in public whereby outline proposals for savings had been discussed. TG wanted the Governing Body to note all proposals were agreed except for the removal of the IVF service. It was also outlined the voluntary sector has been engaged with work being undertaken with the CCG and the Council, with Thrive Trafford to put in place working arrangements in order to maximise and show commitment in maximising the potential of voluntary organisations as part of the future work within health and social care. TG informed members Trafford Together for Health and Social Care went live as from 1 April, and significant work has taken place to date. There has been a new appointment for the Clinical Chair of the Governing Body, Sally Johnston who would take up her role from 1 July 2018; Mark Jarvis had been appointed as Medical Director from 3 April; Sara Radcliffe had been appointed as Corporate Director of Commissioning from 3 April, however would take up the appointment on a full time basis from 3 June. Nikki Bishop had been appointed as Joint Chief Finance Officer, and advised that there was a robust team in place in order to move forward with the considerable financial challenges that lay ahead. Members were also advised the Corporate Leadership Team would integrate with the Council in order to provide clear single leadership to both organisations. TG advised work was underway in relation to the existing QIPP Programme and that it was proposed to rename to Sustainability and Transformation programme and all corporate service arrangements would be reviewed. Going forward future Governing Body sessions would provide updated on the Sustainability and Transformation Programme, but would also include the Local Care Alliance (LCA), the Primary Care Organisation (PCO), New Models of Primary Care (NMoPC), Care Complex and Trafford Coordination Centre (TCC). In relation to the LCA, Richard Spearing would be acting as Chair going forward. Good progress had been made in relation to the PCO, and this would ensure there would be a single interface for practices and the CCG, which would form the model of the LCA. There had been an advisory board agreed and it would be a board made of shares, for which the details were currently being agreed and finalised. Page 5 of 12
For NMoPC, this was about developing a system to deliver primary care through a single system and ethos around 4 neighbourhoods. Work was underway in relation to MDT in care homes and to date had been good evidence of the outcomes of this work. Pharmacists were also embedded in practices now and GPs were now on a single IT system. Care Complex would provide timely intervention and an agile service focussing on keeping people in the community and would join with the Council to deliver services to the residents of Trafford. In relation to the TCC, it was there to support patients with the right care at the right time, and work was being undertaken with GPs in relation to referral management to acute and community providers, in order to deliver a consistent approach to care coordination and providing and effective discharge management process to patients. AF questioned the priorities for 2018/19, asking whether these had been agreed as a team to review. TG responded these would be reviewed by the Corporate Leadership Team going forward. She advised that priorities for herself as Accountable Officer would need to be agreed and set for the next 3 months with the Chair, and these would be shared at the next meeting once finalised. MC commented it was important that the Governing Body was informed and involved in the crafting and shaping of the priorities. SS commented on the change of name from QIPP, as in NHS terms people understand what this means, however would welcome a rename. TG advised this had been discussed with John Rouse who had been supportive of the change and approach set out for the future and this would ensure there would be clear direction around transformation and savings, with savings needing to be measured to ensure they are a reality. SS asked about the PCO and the interface with GP practices, and whether all practices would become part of the organisation, if not what would happen. MJ responded all bar 1 practice have agreed to a company limited by shares, however until it has been finalised and understood how many of the practices do not want to be part of the PCO then a plan could not be put in place until such time that this information was known. MC responded it was clearly something which needed to be addressed as there was a need to ensure the aspirations for the PCO would be achieved in order to make the system work better and needs to be attractive to everyone in order to achieve quality and common standards across practices. It was also important to ensure there was not a 2 tier system in place. There was some further discussion around progression of commissioning in parallel with the PCO which has to be done fairly quickly; otherwise it would not be Page 6 of 12
fit for the requirements of the population. A quality framework as part of the transformation had been developed and would be part of the specification for the GP contracts and work was ongoing to work with the GP practices in order to get everyone on board. TG commented the transformation bid had some fairly difficult challenges to delivery through the PCO and LCA and are predicated on certain conditions and activities being place. However, the PCO would not be in a position to commission anything for some time and these would need to be robustly developed. It was important to understand it would not be compulsory to be part of the PCO however it would be easier to deliver our ambitions, however there should be a plan in place for those practices who decide not to join up. There would be a need to ensure there was an overall plan with a number of facets around engagement and clarity of commissioning. AP asked who would oversee the financial accountabilities in relation to NMoPC and the delivery of the services. MJ advised the PCO would be an organisation formed by a company limited by shares and owned by those GP practices who have signed up. Whilst the organisation was still being finalised it would still sit with the CCG in terms of accountability. PN asked about enhancing engagement with communities as currently there was still no communication plan, with a need to review what currently exists. The Public Reference Advisory Panel need to understand how they fit within the new organisation in order to take things forward. MC responded there was a need to produce a communication and engagement strategy in order to ensure robust engagement with the public and stakeholders was mapped out. TG confirmed her agreement in relation to communication and transparency and in terms of resources, both the CCG and the Council have limited capacity, therefore there would be a need to work together in order to be more proactive in relation to any future activities. As part of the overall transformation programme, communication and engagement would be built into each of the programmes activity, and each programme would be bespoke to the activity required to ensure there was clear communication. There would be a need to use different channels for the communication, which would be dependent on the topic to ensure the right groups/people are targeted and this has been part of the thinking going forward. This would be something that would be brought back to a future meeting and also be discussed as part of the Board to Board discussions. MC welcomed this information as it would help to understand where things were going. SR advised integrated commissioning needs a change programme and there would be a final Deloittes workshop which would take ownership of the work and understand about communication and engagement, and ensure the need for Page 7 of 12
a clear programme of commissioning and the teams would be clear on this. Delivery can only be achieved by working in partnership with others, therefore there was a need to move forward quickly and ensure as commissioners there was an understanding of what the changes are and those changes which need to be made and understand what integrated commissioning would look like and how it would work. SS confirmed the need for clarity as a Governing Body and members of the organisation as to whether it was the CCG or Trafford Together for Health. 1. The Governing Body noted the organisational update. GB 1819/007 QUALITY AND PERFORMANCE UPDATE MI presented an update in relation to quality and performance advising currently the CCG was in breach of performance standards; however Q1 improvement trajectories have been reset and work was being undertaken to provide a plan to review this. In relation to the 2018/19 performance standards, there are a lot of must dos and therefore there was a need to understand what the absolute must dos are. Ambulance response times are a major concern and a task and finish group has been set up to take conversations locally and MI attends the meeting in relation to contract negotiations. This would give an opportunity for clear asks to be presented, specifically in relation to response times improving. A risk has been highlighted around paediatrics seeing an increase in demand, however this was not a straight forward standard to deliver against and the Chief Executive would be undertaking work to review demand/capacity. Referrals to treatment, in light of the cancellation of most elective surgery in January and February at Manchester University NHS Foundation Trust (MFT) had not had a detrimental effect on the target. At University Hospital South Manchester NHS Foundation Trust (UHSM) there are still concerns in relation to plastic surgery targets, and it has been agreed a business plan would be produced and would be reported at the next Governing Body meeting. A never event was reported which included 332 patients not being called for breast screening across a number of practices. All patients have now been recalled with no harm reports as part of this process. A report would be provided once the investigation has been completed and an update provided. Concordia was still providing a poor service, however the service would be procured and an update provided. Page 8 of 12
There was an additional never event at MFT, UHSM, however no harm to patient was reported and a report would be presented when available. There are still concerns over the 62 day standard cancer wait times which have failed, however at the meeting with MFT in March it was confirmed that the standard had been achieved and it was expected to continue to be achieved throughout 2018/19. HF asked about mental health, LD and autism stating the information was not up to date and it needed to improve significantly, but would also like to see some information in relation to Children and Young Peoples mental health, in particular in relation to parity of esteem. MI advised mental health was now part of the performance team work and that a mental health dashboard was currently being developed and would be shared once available, with a detailed emphasis on mental health provided at the June meeting. The Governing Body noted the performance and quality update GB 1819/008 HEALTHWATCH END OF YEAR REPORT HF presented the end of year report for Healthwatch which provided an opportunity to highlight those areas of concern. The main areas of concern related to Delayed Transfer of Care (DToC), which as yet the queries raised had not yet been fully addressed and these need to be taken forward. Another area of concern was around Care Homes, especially with a high proportion not being of a very high standard. There was recognition that it was a difficult problem, however there needs to be ideas put forward as to how they could be improved, in particular around efficiency and effectiveness. The report also highlighted the work plan for 2018/19 and HF commented there was opportunity to work in partnership with other organisations to deliver this work. Members were also informed of a lot of feedback which had been received from the public, and this in turn supports public engagement and those people in the area who are in receipt of the services. It gives those people an opportunity to identify where they have concerns, but also suggest where potential savings may be made. There would be a requirement for wider public engagement, as currently it relies on small scale activity which has not been around improvements/services and where savings could be made. MC commented on the good work that Healthwatch undertakes Trafford and wanted to advise of the work that was currently taking place in relation to Care Homes in order to drive up standards, and this would be undertaken as an integrated footprint. Similarly work was happening in relation to intermediate care and it was recognised work would be required across all work streams. There was recognition of the key work around communication that needs to happen. Page 9 of 12
MM responded to the work in relation to Care Homes and highlighted the work that is being undertaken to ensure no further home closures happen in Trafford. There was further discussion in relation to CAMHS and ensuring there are mental health strategies in place. MI confirmed Pennine Care had struggled to provide date for the past 12/18 months, however from March the data sets would be live and would hope to see this data improve going forward and would be included in the monthly report. HG advised work was being undertaken in Trafford around CAMHS and more information was available if required. There was a comment in relation to the experience of NHS public health initiatives that never seem to be integrated within the services, however TG reassured members inclusivity would be part of the GM plan around public service reform, with such initiatives as start well live well and age well being part of the agenda and includes these three areas which integrate into services and plans. Vision 2031 would be the key factor that runs through all the pillars for this work. PN commented it would be useful to understand how much was being invested and was there an understanding of what differences are being made to the population for some of the initiatives. It would be valuable to see other interventions being put in place. HG advised that through the Health and Wellbeing Board start well live well and age well were part of this work, it would also include smoking and interventions, and this could be brought to GB to review and understand in more detail. MC said it was important to promote and adopt the daily mile and age friendly plan, with the need to start at home and take a step forward to live what was being preached. The Governing Body noted the Healthwatch end of year update report. GB 1819/008 KEY ISSUE REPORTS Public Reference Advisory Panel PN presented the key issues for the recent PRAP meeting with the main messages being in relation to a communication plan being produced; ensuring members of the panel knew their input was being acted upon and to understand how the panel would fit into the new governance structure of the organisation. Clinical Committee CT presented the key issues from the meetings held on 20 th February and 20 th March 2018 with no major areas of concern identified. Quality, Finance and Performance Committee Page 10 of 12
SS presented the key issues from the meetings held on 13 th February and 13 th March 2018 identifying the information reported in relation to performance and quality issues. SS and TG would be reviewing the Terms of Reference for the committee with a view to including social care as part of the work plan. There would be a need to change the language of the report in order to take into account the change of name of QIPP. Audit Committee AF referred to the Secretary of State letter to which JM had referred to earlier in the meeting. He raised concerns around counter fraud as there was very little data to support this and further information had been requested. RR advised that the next Audit committee would review and approve the Annual Governance Statement and Q4 Year-end Conflicts of Interest return, and recommend the Governing Body ratify for sign off before submission to NHS England. 1. The Governing Body noted the key issues highlighted from the various committees. GB 1819/009 QUESTIONS MEMBERS OF THE PUBLIC TG advised that for future meetings held in public questions would be required to be submitted 2 weeks prior to the meeting and this information would be published on the website. Questions Which GP practices have pharmacists in house? o This would be answered via email From a public perspective can there be a decision on whether the preventative model was of any use and could it be put into practice? o MM responded it would be nice to help everyone who has an ask, however the information has been looked at and there would be no decision around investing in the service. MM would email with any further decisions and copy MC in on the email. From a cancer awareness perspective there has been work undertaken in relation to GM cancer awareness which crosses over with the work being undertaken by public health, much on the same theme. How far has this been communicated and would it be dependent on volunteers helping to promote the service. The GM initiative was looking for 20,000 cancer champions, however there does not seem to be much response, and could there be a concerted effort from GP practices to get the message out. HG responded there were a number of initiatives with a real focus on cancer screening and improving outcomes, with a number of successes. Currently work around beating bowel cancer was underway and GP practices are Page 11 of 12
involved in this work in calling patients to ask if they would like to be volunteers. There was engagement in relation to the cancer champions, but it was hard work getting social engagement at the level required. A paper would be presented to the Health and Wellbeing Board and Governing Body about how the cancer champion work could be promoted. MM then asked members to sign up to the PJ paralysis pledge. 1. The Governing Body noted the questions raised by the public. 2. LW to arrange for notice to be added to the website in relation to questions for the Governing Body sessions. 3. Email responses to questions raised. GB 1819/010 DATE AND TIME OF NEXT MEETING The date and time of the next meeting would be 26 June 2018, 9.30 a.m. Council Chamber, Trafford Town Hall, Streford. Page 12 of 12