Consultant in Public Health Medicine. Associate Director of Primary Care Head of Business and Corporate Services

Minutes NHS Leeds West CCG Governing Body Meeting Wednesday 27 January 2016 2:00pm 5:00pm Fulneck Room, Pudsey Civic Hall, Dawson s Corner, Pudsey, LS28 5TA Members Initials Role Present Apologies Dr Gordon Sinclair GS Chair Philomena Corrigan PC Chief Officer Dr Pete Belfield PB Secondary Care Consultant Dr Phil Dyer PD GP Representative Jo Harding JH Director of Nursing and Quality Dr Simon Hulme SH GP Representative Dr Steve Ledger SL Lay Member - Assurance Dr Mark Liu ML GP Representative Visseh Pejhan-Sykes VPS Chief Finance Officer Angie Pullen AP Lay Member PPI / Deputy Chair Susan Robins SR Director of Commissioning, Strategy and Performance Chris Schofield CS Lay Member Governance Dr Andrew Sixsmith AS GP Representative Dr Simon Stockill SS Medical Director Dr Fiona Day Additional Attendees Kirsty Turner Laura Parsons (Minutes) FD KT LP Consultant in Public Health Medicine Associate Director of Primary Care Head of Business and Corporate Services Members of the Public Observing the Meeting 6 (items 18-20) No. Agenda Item Action /1 Welcome and Apologies for absence The Chair welcomed everyone to the meeting. Apologies had been received on behalf of PC, PB, AP and SS. 1

It was confirmed that VPS was deputising for PC. Matthew Wallace, Communications and Engagement Officer was tweeting live from the meeting. /2 /3 Declarations of interest Members were asked to raise any declarations of interest in relation to agenda items. It was noted that GS, PD, SH, ML and AS had a personal interest in items 18, 19 and 20 in their capacity as a partner at a member practice, however no decisions were required therefore they would remain in the room and take part in the discussion relating to these items. Patient Voice Personal Health Budgets JH introduced the Patient Voice item relating to Personal Health Budgets (PHBs). Prior to the Governing Body meeting, members had met with a patient who spoke about her experience of having a complex disease (Ehlers-Danlos syndrome) and the impact that a PHB has had on her life. It had enabled her to make her own care plan, including purchasing an adapted wheelchair more suitable for her needs. This was an example of how a direct payment can be managed and be used to the benefit of the patient. FD noted that the patient had highlighted the benefits of using technology to help her in her daily life. This was also an important reminder that even though NHS England commissions specialised care, the CCG is responsible for general health needs. Listening to this patient had given the Governing Body lots to reflect upon, including the need to be adaptable and flexible. The CCG commissions mainstream care but there are patients who don t fit into this. /4 Progress Towards Strategic Objective 3 To use commissioning resources effectively VPS presented an update on the CCG s progress towards its Strategic Objective to use commissioning resources effectively, and compliance with the associated statutory duty to act effectively, efficiently and economically. The CCG has clear governance structures which have been subject to regular review and refinement. There is currently a comprehensive review of citywide governance arrangements. Feedback from both the internal and external auditors was included in the report which showed that the CCG has effective arrangements in place. JH asked how visible the CCG s arrangements were to staff and members of the public. It was confirmed that all relevant documents are published on the CCG s website, including the Annual Report, Annual Governance Statement and Governing Body papers and minutes. Few Freedom of Information requests are received for these types of documents. 2

CS commented that the CCG s governance arrangements were clear and available to him as chair of the Audit Committee. Part of the Audit Committee s role is to ensure that systems are in place to ensure that financial figures reported are reliable, but this is different to wider discussions as to whether there is sufficient funding within the system. These types of discussions may not always be obvious enough to members of the public. Members discussed the CAPITA reviews which have taken place to assess the correct prices to adopt for services that are not mandated by a national tariff, such as assessment units and pathology. SH asked whether there was a process for reviewing costs from other trusts, as pathology is an outlier across the north of England. VPS confirmed that there are various forums for comparing costs such as the NHS Benchmarking Club and Chief Finance Officer meetings. In terms of mental health and community services, this was an area for development as they are currently procured under block contracts. Although the CCG is not the lead commissioner for these services it works closely with the other CCGs in Leeds to review costs. a) received the report as assurance of the systems and processes in place to ensure that the CCG uses commissioning resources effectively and is complying with its statutory duty to act effectively, efficiently and economically. /5 /6 Questions from Members of the Public The meeting was opened up to the public to take any questions they had at this stage. They were advised that there would be another opportunity for questions at the end of the meeting. No questions were received. Minutes of the last meeting held on Wednesday 4 November 2015 The minutes of the last meeting were reviewed for accuracy, and were agreed as a correct record. a) approved the minutes of the Governing Body meeting held on 4 November 2015 as a correct record. b) Matters Arising There were no matters arising to discuss. c) Action Log The Governing Body reviewed the action log and noted that all actions were completed apart from: 120-1 add 10CC review paper to work plan for January 2016 GS explained that the 10CC review was ongoing. A meeting would be held next week where a new Memorandum of Understanding and proposed governance arrangements 3

would be reviewed. A formal paper would be presented at the next Governing Body meeting for discussion. a) noted the status of the action log and the updates provided. /7 Chair s Summary of the Assurance Committee meeting held on 13 January 2016 SL provided a summary of the key items discussed, as follows: Yorkshire Ambulance Service (YAS) the Committee continues to give close scrutiny to YAS performance and will receive further details at its next meeting, on 9 March 2016. Delayed follow ups the Committee sought assurance that there are no clinical risks due to delays and this is being followed up by the acute commissioning team. There is an increased demand on appointments which will make it difficult to provide assurance that patients will be seen within the expected timescales without increased efficiency and/or capacity. Child and Adolescent Mental Health Services (CAMHS) the Committee has sought further assurance on the action being taken to reduce time from access to treatment. The risk rating is being reviewed. Integrated Quality & Performance Report (IQPR) it had been agreed that SL would present this item at Governing Body meetings and he would therefore provide a summary of the IQPR discussion at that point in the meeting. Continuing Healthcare (CHC) the Committee was assured that the citywide CHC team is performing effectively. CHC is an area of concern in some other areas but this is not the case for Leeds. Independent providers the Committee received adequate assurance of the CCG s oversight of these providers. Later in the year data on independent hospitals will be included in the IQPR so that it is publicly available like NHS providers. Any identified risks relating to Any Qualified Providers or voluntary organisations will be made available by exception. a) received the Chair s summary of the Assurance Committee meeting held on 13 January 2016. /8 Chair s Summary of the Audit Committee meeting held on 9 December 2015 CS informed members that the new internal auditors were working through their annual plan. The external audit work programme was also on track. The Governing Body was informed that the CCG will need to appoint its own external auditors from 2017/18 onwards. It was proposed to undertake a joint procurement process with the other CCGs in West Yorkshire, and potentially roll over the current contract if this was acceptable. The Governing Body was 4

therefore asked to approve the proposal to appoint a joint auditor panel with the other CCGs in West Yorkshire. a) received the Chair s summary of the Audit Committee meeting held on 9 December 2015; and b) approved the proposal to appoint a joint auditor panel with the other CCGs in West Yorkshire. /9 Chair s Summary of the Clinical Commissioning Committee meetings 18 November & 16 December 2015 The Chair s summary of the previous two Clinical Commissioning Committee meetings was submitted for information. a) received the Chair s summary of the Clinical Commissioning Committee meetings held on 18 November & 16 December 2015. /10 Chair s Summary of the Remuneration Committee meeting held on 25 November 2015 The Chair s summary of the previous Remuneration Committee meeting was submitted for information. /11 a) received the Chair s summary of the Remuneration meeting held on Chief Officer s Report VPS presented the Chief Officer s report and highlighted the following issues: Citywide governance review the review proposes 6 key recommendations including aligning the structure with the Health and Wellbeing Strategy, and eroding organisational boundaries. Dementia the dementia diagnosis rate for Leeds West (79.5%) is higher than the national average of 67.2%. Guidance on the Personal Medical Services (PMS) review has clarified that the investment in PMS resources must remain within the CCG and be spent in general practice. SH sought clarification on the timescales for PMS reviews. This would be confirmed as soon as possible. The CCG would look at the reviews as part of its co-commissioning responsibilities. PD raised a concern that the practices losing money under the PMS contract would find it difficult to sustain a continual improvement in care with fewer resources. He also highlighted that the enhanced patient participation funding has been removed from the General Medical Service (GMS) contract and asked that the CCG consider supporting practices to help the continuation of patient participation. Sir Bruce Keogh, NHS England s Medical Director would visit the CCG to learn more about the enhanced primary care scheme. The CCG has taken part in the Commissioning for Better Patient KT KT 5

Experience project commissioned by NHS England and Macmillan. CCG representatives attended a learning event and views from this indicate that the CCG has well developed and established patient engagement systems in place. Third Sector Partnership Social Value Charter the Governing Body was asked to endorse the Charter which sets out the city partners commitment to promote social responsibility and social value and to make the maximum impact in Leeds with the Leeds pound. It was confirmed that there would be engagement with the independent sector regarding the Charter. Members agreed to endorse the Charter. a) received the Chief Officer s report; and b) endorsed the Social Value Charter. /12 Integrated Quality and Performance Report (IQPR) SL introduced this item by providing a summary of the Assurance Committee s discussion in relation to this report at the meeting held on 13 January 2016. The Committee welcomed the refreshed Strategic Objectives dashboard but noted that some of the data was out of date. Separate dashboards were included for system resilience and cancer data. The Committee had been informed that the Emergency Care Standard would not be achieved for this quarter. The System Resilience Group was providing effective oversight and leadership and progress was being made on delayed discharges. Leeds had avoided declaring a major incident which had occurred in some other areas. However there have been significant pressures and Leeds Teaching Hospitals NHS Trust (LTHT) will be asked to confirm the number of cancelled elective procedures at the end of January, and this would be reported to the Assurance Committee. JH informed members that, since the report was written, an additional Never Event had occurred at LTHT relating to the insertion of an intraocular lens of the incorrect strength. A full root cause analysis would be undertaken. LTHT had also breached its C.difficile trajectory for December with 16 cases against a trajectory of 12. As at 22 January, the total for the current financial year was 117 against a trajectory of 104. Other trusts are experiencing similar issues. The CCG was monitoring action plans and was seeking to work regionally with NHS England regarding the expectations of CCGs in relation to such monitoring. LTHT had been informed that its next CQC inspection would take place during the week commencing 9 May. The first tranche of evidence would be submitted this week, and the Director of Nursing was leading on preparations. Sessions would be held with Lead Nurses to keep them informed, and the CCG was looking at what support it can provide. The CCG s level of involvement with the inspection team was to be clarified. It was noted that the dementia data did not correspond with the data in the Chief Officer s report. It was confirmed that the data in the Chief Officer s report was SR 6

correct and the data in the IQPR would be updated. SH sought clarification regarding the meaning of the number of Delayed Transfers of Care (DTOCs). SR explained that this was a daily count of how many patients fit for discharge are awaiting onward transfer but are not able to be discharged. The number of DTOCs was currently 70-75, but had increased to 100 in November/December. The number was increasing again this week, and there was commitment from all partner organisations to manage this. a) received the IQPR. /13 Finance Report VPS presented an update on the CCG s financial performance as at month 9 (up to 31 December 2015). The CCG was on plan to meet its increased surplus. Communication had been received from NHS England to encourage CCGs to reinvest sanctions and penalties levied on providers against an action plan with the provider. Leeds Teaching Hospitals NHS Trust was meeting its planned deficit, and the contract was running to plan. Under tariff proposals for next year, trusts are being asked to deliver 2% efficiency. The independent sector is overtrading on elective activity, and there was also an overspend within Continuing Healthcare. It was confirmed that the learning disability budget is also due to be overspent due to complex needs, and the need to use specific facilities. In the longer term, there may be a need to provide such services closer to Leeds. Next year the budget would be reset and would include some contingency. Running costs were under budget, and the CCG would lose 160k of running costs over the next 3-5 years. It was confirmed that the CCG s new premises were within running costs and the cheaper of two options had been chosen following consultation with staff. The CCG will need to reduce its surplus to 1% by the end of year 3, and will be required to ensure that 1% non-recurrent headroom and 0.5% contingency is held back until the sustainability of the whole system is assured. SL noted that LTHT s Cost Improvement Plan position was rated as red, and sought details on the implications of this. VPS explained that alternative solutions had been found this year, but this would result in a need to secure additional recurrent savings from next year. LTHT s ability to secure national funding may also be affected if they do not meet their target position. As there is likely to be little scope for the CCG to invest recurrently, it was noted that there would be a need for either more efficient commissioning or decommissioning of services. AS requested an update on actions to reduce the use of agency staff. VPS confirmed that LTHT have undertaken a recruitment drive and have had some 7

success. Cross-organisational working will give more staffing flexibility. FD noted that the population growth estimates appeared lower than expected, given the planned housing growth. The CCG was awaiting details of how the allocations have been derived and can challenge this when the details are known. GS highlighted that there was a need for the CCG to be further involved in the planning process. PC ML asked whether there was a threat to the ability to transform services without affecting the quality of care, giving the housing growth and lack of funding growth to match this. VPS explained that additional funding is available for those who want to transform services. a) noted the report; b) noted the month 9 financial position including the CCG s altered surplus position (for the CCG and across the Leeds Health Economy); and c) noted the latest developments in the transfer of commissioning support services from Yorkshire & Humber Commissioning Support to a new provider. /14 Corporate Risk Register JH presented the Corporate Risk Register, which contained three risks, relating to LTHT s under achievement of the cancer 62 day target, failure to achieve the two week wait breast symptomatic standard and LTHT s ability to maintain elective, urgent and cancer activity affecting the quality of care provided. SR provided an update and explained that risk 545 (two week breast symptomatic standard) had now been reduced to a score of 12 (amber) because additional staff were now in post and extra clinics were taking place. There was also additional capacity in the private sector. It was confirmed that this was a national standard based on NICE guidance. Risk 339 (cancer 62 day target) had been reduced from a score of 20 to 16 (red) as some progress was being made. It was clarified that this risk related to LTHT s 62 day performance as a whole. There was a separate risk specifically relating to Leeds patients which was rated as 12 (amber). a) reviewed the current red risk on the Corporate Risk Register and the summary of the Assurance Committee s discussions. /15 Governing Body Assurance Framework (GBAF) JH presented the latest version of the GBAF for review. The template was currently being reviewed and the GBAF would be presented in the revised format at the next meeting. 8

SL noted that none of the risks were rated as red, which showed that they were being managed to a reasonable level. The revised template would show the controls and actions in place more clearly. a) received and agreed the Governing Body Assurance Framework 2015-16. /16 Annual Research Report 2014/15 JH presented the Annual Research Report for 2014/15. The research service is provided by the Commissioning Support Unit and will be hosted by the Bradford CCGs going forward. During 2014/15, 16 new studies were granted NHS assurance by the research team on behalf of the CCG. Currently 51% of the CCG s practices are offering patients the opportunity to take part in research which is well above the National Institute for Health Research (NIHR) Clinical Research Network target of 5%. The Clinical Directors have considered how to further improve the uptake, and it has been agreed that members of the Research team will attend a TARGET training session to promote participation in research. AS informed members that three practices were jointly recruiting a research nurse. JH requested to receive contact details once the nurse was in post so that she could put him/her in touch with the research team. Members considered how research should be integrated into the neighbourhood teams and newly developing models of care. JH felt that it would be useful to agree criteria to be applied to any excess treatments costs arising from studies that are applicable to the CCG s revised strategy. SL was supportive of the CCG s funding of research, and was impressed with the content of the Applying Research in Commissioning Decisions (ARC) forums, which had looked at some key areas of clinical care and commissioning. a) accepted the report as a summary of 2014-15 research activity and assurance that the CCG is complying with its statutory duty to promote research and the use of research. /17 Public Sector Equality Duty JH presented the CCG s evidence for compliance with the Equality Act 2010 public sector equality duty, including the Public Sector Equality Duty Report 2016, the NHS Equality Delivery System (EDS) evidence and a summary of grades. The CCG s grades were reviewed and agreed by members of Leeds Involving People and patient leaders. All areas were rated as green (achieving) apart from the requirement to evidence equality related impacts and risks in board and committee reports, which was rated as amber (developing) as further work was required to improve 9

the quality of equality impact assessments and ensure that they are routinely carried out when required. CS sought clarification regarding section 2.3 (people report positive experiences of the NHS) as to whether the rating related to the systems in place or the feedback received from patients. JH confirmed that this was relating to the systems in place. FD highlighted that it was important to review outcomes. The CCG is aware that that there is more work to do to improve health inequalities. GS commented that equality is fundamental to commissioning, and the Governing Body should be proud that it is given due regard. a) approved the documents as evidence of compliance with the Equality Act 2010 public sector equality duty; b) approved the NHS Equality Delivery System evidence; c) approved the equality objectives performance for 2015. /18 Enhanced Primary Care Interim Evaluation KT presented an update on the enhanced primary care scheme which was approved in September 2014. This was the second evaluation and covered the period up to October 2015. Since the last evaluation, additional groups of practices were invited to provide 7 day services over Winter. Overall, 125,000 additional appointments have been made available and there has been an increase in telephone consultations. The evidence suggests that the biggest increase in attendances has been from more deprived areas. There has been a marked increase in out of hours attendances as compared to the other Leeds CCGs. Emergency admissions have decreased but there has been no financial impact. Patients have provided positive feedback but there have been some comments about lack of knowledge of the scheme. The Communications team have distributed a mail out to local residents and work will continue to raise awareness. Staff experience has not yet been evaluated in detail but this will be included in the final evaluation. There have been some comments about pressure but also that the scheme has helped to manage peak times. It was noted that there were still 7000 Did Not Attends (DNAs) in total each month. The rate was static despite the additional appointments. The use of MJog (an automated reminder system) had an impact initially but this had since lessened. SL asked whether the Governing Body would need to decide whether to continue with 7 day services, given the neutral impact on the wider system. SR confirmed that an analysis of the differing impacts of level 2 and level 3 services would be included in the final evaluation. There would also be a further discussion about the potential future of the scheme under the next agenda item 10

(Local Commissioning of Primary Care Schemes in 2016/17). FD highlighted the comments regarding GP stress, and the importance of giving frontline staff access to psychological and resilience building tools. She informed members that she was leading some work on primary care wellbeing and the development of proactive prevention interventions. PD commented that the original scheme was set up to provide additional appointments, and practices were not asked to achieve specific outcomes. SR confirmed that the scheme was about providing capacity, which had been achieved. a) received the evaluation update; and b) noted the next steps. /19 Local Commissioning of Primary Care Schemes 2016/17 KT presented a proposal for Leeds West specific primary care schemes for 2016/17. It was proposed that the enhanced access and quality improvement schemes be amalgamated which would align with the national context and the Five Year Forward View, and the Governing Body s previous commitment to continuing the enhanced access scheme. The new scheme would build on learning from previous schemes and would be clearer on outcomes, including system outcomes as well as local outcomes. It would build on the collaboration of practices and would be co-produced to encourage ownership from practices. The Governing Body was asked to provide comments and support the proposed direction of travel. The specification would then be finalised and presented to the Governing Body for approval in March. Members welcomed this paper and were supportive of the proposals. The following comments were made: Payment based on outcomes practices will need clarity as to whether any funding is protected. KT confirmed that this was a principle, to encourage ownership and accountability. The detail was still to be finalised. The specification should encourage a different skill mix/transformed workforce. There should be more detail on reducing health inequalities. There may need to be targeted investment to reduce inequalities. How would the scheme incentivise collaboration between practices - practices would need leadership from the CCG in this area. KT explained that conversations have started with practices. Collaboration is central but there could be collaboration at different levels. Conversations were ongoing as to whether there was any assistance for practices with regards to indemnity. CS sought an update on progress towards getting 10% of patients to use online 11

services/apps. KT confirmed that awareness had been raised via the Challenge Fund work. 10% would be achieved and it would be possible to exceed this. It was confirmed that the final scheme would be presented to the Governing Body for approval as soon as the CCG s financial plans could be finalised. An extraordinary meeting would be arranged if necessary to ensure that the scheme could be approved as soon as possible. a) noted the proposed new approach to schemes; b) supported the proposed direction of travel. /20 Primary Care Co-Commissioning Update KT presented an update on the CCG s progress towards taking on delegated responsibility for primary care commissioning from April 2016. The CCG s application had been approved by NHS England (NHSE) along with the other CCGs in Leeds. A financial update was attached to the paper reflecting the amendments that were reported verbally at the last Governing Body meeting. Work is being undertaken across the city to reduce duplication and a citywide co-ordination group has been established. Discussions are ongoing with NHSE to determine who will be responsible for each function. The transfer of responsibilities will be a transitioned approach so the CCG can focus on the transformation aspects of co-commissioning. The CCGs in Leeds have attended a Scrutiny Board meeting to provide assurance, including our arrangements to manage potential conflicts of interest. The key priorities include managing the primary care estate, PMS reviews and impacts. It was noted that decisions on local primary care funding would be agreed by the Primary Commissioning Committee. The Governing Body s role would be to ensure alignment with the overall CCG strategy. It was agreed that further work was required to document the risks associated with co-commissioning. Relevant risks would be added to the risk register. KT/LP a) noted the progress being made in respect of developing the CCG s cocommissioning approach; and b) requested that risks associated with co-commissioning be developed and included on the risk register. /21 Forward Work Programme GS presented the Governing Body forward work programme for 2015/16. a) noted the current dates and agenda items for 2015/16. 12

/22 Questions from Members of the Public The meeting was opened up to the public for the second opportunity to ask any questions. No questions were received. /23 Any Other Business ML had noted from the Leeds Adult Safeguarding Board Annual Report that there had been an increase in safeguarding referrals, and asked whether this had impacted the service. SL confirmed that this issue was discussed at the Assurance Committee meeting on 13 January 2016, where it was confirmed that there had been no negative impacts and the service had the capacity and capability to manage the increase in referrals. GS reminded members that the next Governing Body workshop would be held on 3 February 2016, and the topic would be the CCG s strategy. Date of Next Meeting: 23 March 2016, 2pm at Hinsley Hall IFI 1. Leeds Safeguarding Children Board and Leeds Safeguarding Adults Board Annual Reports 2014/15 The Governing Body was asked to receive the Leeds Safeguarding Children Board and Leeds Safeguarding Adults Board Annual Reports 2014/15 for information. a) received the Leeds Safeguarding Children Board and Leeds Safeguarding Adults Board Annual Reports 2014/15 for information. IFI 2. Summary of Procurement Activity & Plan for 2015/16 The Governing Body was asked to receive a summary of the CCG s procurement activity and the plan for 2015/16. a) received a summary of the CCG s procurement activity and the plan for 2015/16 for information. Approved and signed by: Dr Gordon Sinclair, Clinical Chair Date: 13