Minutes Nottingham North & East Clinical Commissioning Group Clinical Cabinet Meeting Held 20 th July 2016 at Gedling Civic Centre, Arnold Present Dr Chic Pillai (CP) Dr Sarah Bamford (SB) Jeff Burgoyne (JBu) Dr Ian Campbell (IC) Dr Aneel Bilku (AB) Dr James Hopkinson (JH) Dr Azim Khan (AK) Dr Caitriona Kennedy (CK) Dr Caroline White (CW) Dr Akila Malik (AM) Dr Suman Mohindra (SM) Colleen Mulvany (CM) Dr Amelia Ndirika (AN) Dr Jacques Ransford (JR) Dr John Tomlinson (JT) Sam Walters (SW) Sharon Pickett (SP) Jonathan Bemrose (JB) Kathryn Sanderson (KS) Dr Arun Shetty (AS) In Attendance Racheal Rees (RR) Candice Lau (CL) Dr Asrya Maula (AM) Sergio Pappalettera (SPa) Apologies Ben Teasdale Nichola Bramhall Dr Elaine Maddock Stephen Storr Dr David Hannah GP Representative, Plains View Surgery GP Representative, Newthorpe Medical Centre Patient and Public Representative GP Representative, Park House Medical Centre GP Representative, Torkard Hill Medical Centre Assistant Clinical Chair GP Representative, Unity Surgery GP Representative, Trentside Medical Practice GP Representative, Stenhouse Medical Centre GP Representative, Westdale Lane Surgery GP Representative, Om Surgery Practice Nurse Representative GP Representative, Whyburn Medical Practice GP Representative, Giltbrook Surgery Consultant in Public Health, Nottinghamshire County Council Chief Officer Deputy Chief Officer Chief Finance Officer Patient and Public Representative GP Representative, Apple Tree Medical Practice Head of Primary Care Senior Service Improvement Manager Registrar, Newthorpe Medical Practice Contract and Information Manager Secondary Care Consultant Director of Nursing and Quality GP Representative, Stenhouse Medical Centre Patient Representative GP Representative, Torkard Hill Medical Centre Actions CC 16/078 Welcome and Apologies Dr James Hopkinson (JH) welcomed members to the Clinical Cabinet meeting. Apologies were noted as above with Dr Page 1 of 9
CC 16/079 Aneel Bilku representing Dr David Hannah. Declaration of Interest No conflicts of interest declared. CC 16/080 Minutes of the meeting held on 21 st June 2016 The minutes were accepted as an accurate record subject to the following amendments; CC 16/060 should state Nottinghamshire University Hospitals. CC 16/081 CC 16/082 CC 16/063 should read EM queried if the expensive liver function fibroscans were always required. Matters arising and actions from the meeting held on 21 st June 2016 In relation to agenda item 16/063, the QIPP discussion is to be held in the meeting today as part of agenda item 16/083. Chief Officer s Report SW introduced the report and highlighted the following points: The new junior doctor s contract is expected to be introduced in August 2016 with doctors transitioning onto the new terms on a phased basis from October 2016. NHS England has published a revised statutory guidance on managing conflicts of interest for CCG s. There have been seven recommendations including; 1) minimum of three lay members on the governing body, 2) introduction of a conflicts of interest guardian, 3) a robust process for managing breaches within the policy and anonymised details of the breach to be published on the CCG website, 4) strengthened provisions around decision making, 5) strengthened provisions around the management of gifts and hospitality, 6) annual audit of conflicts of interest management within their internal audit plans and 7) a requirement for all CCG employees, governing body and committee members and practice staff involved in CCG business to complete mandatory conflicts of interest training. NHS England has launched a new scheme to test investment in recruitment and marketing support in GP practices which can evidence that they have historically encountered difficulty in recruiting GP s. The Targeted Investment in Recruiting Returning Doctors scheme also aims to attract GP s by offering up to 10,000 in relocation and educational bursaries. The pilot scheme offers individualised support to practices to help fill vacant posts. It was raised that there is difficulty recruiting clinicians. Question asked about how the CCG supports practices that Page 2 of 9
are finding it difficult to recruit? SW stated that as the CCG is not directly responsible for employing GP s recruitment is not within its direct remit. However the CCG is involved in work taking place across the East Midlands in respect of GP workforce recruitment, training and development. AN asked how much of an influence does the CCG have in supporting specific or individual practice problems with recruitment? RR stated that the CCG has a representative on the GPSET that links directly with HEEM, the LETB and the LETC. RR also advised that GP practice workforce information, including the identification of specific practices/areas that are underdoctored is derived from data uploaded by individual practices and is accessed on the HSCIC. Work on GP workforce data is also currently being undertaken at a national level and the CCG will be able to access this via the HSCIC. This information has not yet been uploaded for the CCG to review but RR reassured the clinical cabinet that where there is a high significant vacancy trend, the CCG is notified. GP practices were therefore encouraged to keep their workforce data up to date. NNE CCG is working with the Nottinghamshire Fire and Rescue Service to improve health and resilience for the local population in South Nottinghamshire. This will support transformation and new ways of working in partnerships with other public service providers. CC 16/083 The Clinical Cabinet Acknowledged the Chief Officer s Report. Finance Update Finance Update Finance Position Activity Report Month 3 JB discussed the activity report and financial position and summarised the QIPP plan which has a target of 8.1million. The month three summary highlighted the delivery of financial duties by the CCG, the emerging level of risk across all areas (acute and continuing healthcare) and the challenging financial position. JB provided a presentation to the Clinical Cabinet that detailed the current financial position and recognition that action needs to be taken now in order to address the CCG s deteriorating financial position. The presentation highlighted plans to implement new savings schemes that have been agreed by the Governing Body, how the CCG will monitor progress and delivery via the FIG, and how regular updates will be provided to the Governing Body and Clinical Cabinet Page 3 of 9
via the Finance Report. JB advised the Clinical Cabinet that 6.4million of the overall QIPP target of 8.1m had previously been identified but with a realistic achievement of 4million. The implications on future years should the CCG not achieve the required level of QIPP this year were described including the real risk that the CCG would fail to meet its statutory duties. Potential new schemes as well as saving opportunities that had been agreed to be progressed by the Governing Body were discussed with the Clinical Cabinet. It was highlighted that Right Care information suggested the CCG could achieve 0.8million savings associated with prescribing. JB summarised the presentation by stating that if the CCG was to achieve savings from the current QIPP schemes, the additional schemes, and the Right Care and clinical suggestions, then a potential QIPP of 7.46million could be delivered. With regards to savings identified on hip and knee surgery, an audit is taking place with NUH to review patients who have had surgery without physiotherapy or therapeutic injections first. Issues were raised regarding the cost of patella resurfacing. A question was raised to how much leverage there is on Secondary Care, for example, if they do not follow the CCG checklist then they do not receive payment? The issue of community paediatrics was raised in the context of variation in the quality and appropriateness of referrals to the service. It was suggested that improvement in this area might be achieved via an education session provided at a PLT or to recruit a GP with a specialist interest in paediatrics to review all referrals. A suggestion was made as to whether macular degeneration can be dealt with in the community. It was stated that cataract referrals received by GP s are often sent to Ophthalmology. Clinical triage is still required but unsure of the cost of this service. Data is known about the number of referrals but assurance is required that we are getting maximum benefit from the service. There was a discussion around pain management services and the potential to deliver QIPP by improving efficiency through pathway/service redesign. There was also a discussion around the number of patients discharged from one speciality in NUH with a letter to the GP suggesting a further referral to a different speciality. As these letters are also copied to the patient Clinical Cabinet GPs highlighted the pressure they feel to comply with requests for further referral given that the suggestions have come from a Consultant at the hospital. It was suggested to ask hospital Doctors to change the wording of their discharge letters that would remove patient expectation of a further referral. Clinical Page 4 of 9
Cabinet GPs also agreed that many patients could avoid referral into the pain clinic and instead could be managed in primary care by the GP. The Clinical Cabinet also discussed the value of peer review of referrals in order to reduce variation and unnecessary referrals for the 10 specialities that receive the highest number of referrals. It was also suggested that high referring practices may wish to consider working with other practices to reduce referrals. This may result in investing in an additional member of staff to triage but would support the delivery of QIPP and promote collaborative working between practices. It was said that investment in GP practices is required if they are to take on additional work and time in supporting other practices. SP stated that there is an Extraordinary Primary Care Commissioning Committee to be held on 21 st July to consider business cases for an additional investment of over 1m into general practices across the CCG. The specification that is supported by the investment will have practice specific targets linked to the delivery of QIPP and a reduction in unwarranted variation. CC 16/084 The Clinical Cabinet Acknowledged financial position and QIPP targets. Health Professional Engagement Programme Cancer Research UK Jon Stevens, Health Professional Facilitator of Cancer Research UK provided a presentation to the Clinical Cabinet and highlighted that Cancer is the leading cause of death from illness in every age group (except males aged 15 24) with more than 1 in 4 deaths, a total of 29%, in the UK. JS stated that when the NHS diagnoses patients earlier the treatment costs are much less and life expectancy for patients increases. JS stated that the Health Professional Engagement Facilitator Programme has been taking place in Nottinghamshire for just over one month and has been targeting CCG s and GP Practices. The support from the programme includes: Providing GP practices with cancer profiles and interpretation of data. Looking at referral patterns, current practice, screening uptake and safety netting procedures. Provide practical tailor made solutions to improve uptake for bowel, cervical and breast screening. Training on early diagnosis tools and interventions (cancer decisions tools etc) Training tailored to individual needs on a range of topics to clinical and non-clinical staff. Provide evidence, information and resources. Work with and provide training for community groups to promote public awareness. Page 5 of 9
Work across primary and secondary care to facilitate communications and pathways. Share best practice from elsewhere. Provide follow up practical support to help busy health professionals implement various early diagnosis activities. Provide training and support to pharmacy staff to support the early diagnosis agenda. JS offered to provide presentations at PLTs, Practice Manager Forums or any other event where this might be useful. JS to be invited to each of the three locality meetings to review priorities. It was agreed that JS contact details be disseminated via the practice newsletter. CC 16/085 The Clinical Cabinet supported Health Professional Engagement Programme Cancer Research UK. Voluntary Sector Mental Health Service Reviews Ellen Kinsley, Commissioning Manager for Mental Health, provided an update on the commissioned voluntary sector mental health services and highlighted that contracts are in place, and service specifications and outcome measures are agreed for both. The recommendation from the service reviews are to continue to fund both services during 2017/18; the Emmanuel House Mental Health Support Team and the Alzheimer s Society Dementia Support Service, subject to outcome measures and monitoring. It was acknowledged that there is work to undertake to better integrate mental and physical health. It was noted that the Alzheimer s Service is not fully funded and it was clarified that the shortfall is achieved through fundraising. The service is not provided across the whole of the NNE CCG area due to the location of rooms available and the number of people who need to access the service. EK stated that if rooms can be sourced at the right price in other areas of the locality then it would be possible to facilitate more session however after listening to patients, the demand is not as widespread. It was noted that 27,000 is a significant cost for only six patients accessing the service. EK stated the money also pays for the help and advice service as well as carer service and rooms. It was highlighted that patients are not aware of the dementia group service but the Clinical Cabinet recognised this would be useful for carers rather than patients so it would be worth advertising better. Members were interested in the views of other CCGs in the area in terms of the on-going commissioning of this service as these services would not be cost-effective to commission at a CCG level. EK advised that NNE is the first CCG to consider the future commissioning Page 6 of 9
intentions for these services. It was also suggested that the two contracts could be joined up when the contract is to be renewed. The current contracts are due to end in March 2017. EK asked the Clinical Cabinet if it was in agreement to continue to fund these two services for the period 2017/18. However the Cabinet felt that this is a decision that needs to be taken at a county level rather than by each CCG and therefore suggested that a paper should be presented to the Collaborative Commissioning Congress for a decision. EK stated that Dr Sue Bailey, the CCG s mental health clinical lead had recommended for these services to be continued. However the Clinical Cabinet deferred the decision. CC 16/086 The Clinical Cabinet deferred this item and advised that a decision should be made by the Collaborative Commissioning Congress. The Future of General Practice in NNE - discussion Dr Raian Sheikh provided a brief presentation in order to initiate a wider discussion around the future of general practice in the NNE area and to ascertain the level of interest practices have in taking some time to consider their future sustainability and opportunities for collaboration/federation/closer working for mutual benefit. RS outlined a number of options and also described the approaches taken by GP practices in other CCGs locally. A discussion followed that included the role of the CCG in facilitating GP practice provider development, the legalities and arrangements in place between the practices in City CCG including the financial contribution made by each practice joining the federation. There was also a discussion around the potential for NNE practices to join already established federations/gp provider organisations locally and whether this might be preferable to establishing something from scratch locally (assuming this would be acceptable to the established federation). After further discussion it was agreed that practices would meet to discuss this area in more detail. SP offered to organise a meeting to take place either in the evening or as a replacement to a practice based PLT event. Representatives from PICS, Rushcliffe and City CCG to be invited to present their model and aid the discussion. It was acknowledged that the CCG is able to provide support to practices but practices themselves need to lead the way and determine if and how they wish to take this forward. SP also agreed to promote the meeting via the weekly practice update. Clinical Cabinet GPs to start the discussion with their practice colleagues prior to the meeting SP The Clinical Cabinet supported the Future of General Page 7 of 9
CC 16/087 Practice in NNE discussion and agreed to support an initial meeting to discuss ideas. Falls Prevention and Management Candice Lau presented the Falls Prevention and Management business case to the clinical cabinet which highlighted falls as an issue due to an ageing community. The purpose of the business case was to: Describe the proposed falls prevention and management programme with an aim of addressing the unmet needs and service gaps in order to enable older people living in NNE to increase healthy life expectancy, reduce injuries from falls and emergency hospital admissions. Demonstrate the potential financial savings from the proposed falls prevention and management programme. Seek approval of the recommendations made to commission the proposed falls and bone health service. The business case has been discussed at the care of the elderly group to which they have proposed three core services to include fracture liaison service, specialist falls service and specific training for people who are at risk of falls. Question raised regarding the cost savings identified by IV infusion to which CL advised that cost saving in year would be 41,000. CL asked the Clinical Cabinet to approve the proposal of the falls prevention and management programme. If approved, work will take place on service specification and KPI s. CC 16/088 The Clinical Cabinet approved Falls Prevention and Management. Optimise Shelley Gibson from the Prescribing Team presented a brief overview of Optimise-Rx to the Clinical Cabinet. Optimise-Rx is prescribing decision and support software integrated within GP computer systems to support high quality, safe and cost effective prescribing. Messages are evidence based from both national and local guidance and tailored to individual patients. The annual cost is 34p per patient per year and totals 49,300 based on a population of 145000. A two week pilot is starting in four NNE practices on 25 th July, data from a similar pilot in Rushcliffe demonstrated a net saving of 8161. Jonathan Bemrose added support for this investment. CC 16/089 The Clinical Cabinet agreed to implement across all Nottingham North and East practices. SystmOne QRISK2 Calculator Practices using SystmOne as their clinical system will have Page 8 of 9
been made aware of an issue with the QRISK2 tool which is used to estimate 10 year cardiovascular risk. This issue has now been resolved and the tool has now been re-enabled and is available for use. TPP disabled the tool after identifying errors in the code mappings. New code mappings have been created and the QRISK2 calculator within SystmOne has been validated for use. As part of an operation coordinated by NHS England, GP Practices have been provided with details of patients registered at their practice that may require a review. This is provided using the Clinical Safety Task. Some system-wide reports have also been provided by TPP potentially affected patients can be reviewed. CC 16/090 CC 16/091 The Clinical Cabinet acknowledged SystmOne QRISK2 Calculator. Update from Localities No updates recorded. Reports *NNE Performance Report *BCF Update *BCF Finance & Performance Report CC 16/092 No comments were made in relation to the reports. Terms of Reference Medicines Management Committee Clinical Cabinet CC 16/093 To be discussed at the next clinical cabinet meeting. Minutes a) *Medicines Management Committee Minutes May 2016 b) *Health and Wellbeing Summary June 2016 c) STP Newsletter Issue 1 Summer 2016 CC 16/094 No further comments were made. Any Other Business Nothing to report. Date, Time and Venue of Next Meeting 16 th August 2016, Civic Centre Reception Room, 13:30 16:30 SIGNED:. (Chair) DATE:.. Page 9 of 9