Enclosure B

Minutes of the NHS Tower Hamlets Clinical Commissioning GroupGoverning Body Meeting (Part 1)

Tuesday, 03 November 2015, 14.30 – 17.00

Room 205, Professional Development Centre, 229 Bethnal Green Road E2 6AB

1 General Business

1.1 Welcome, introductions and apologies

Present

Name

Role

Organisation

Henry Black

Chief Finance Officer

NHS THCCG

Archna Mathur

Director of Quality and Performance

NHS THCCG

Dr Tan Vandal

Secondary Care Specialist Doctor

NHS THCCG

Maggie Buckell

Registered Nurse

NHS THCCG

Mariette Davis

Lay Member (Governance)

NHS THCCG

Dr Sam Everington

Chair – LAP 6 representative – Bromley By Bow Practice

NHS THCCG

Dr Judith Littlejohns

LAP 1 representative – The Mission Practice

NHS THCCG

Dr Martha Leigh

LAP 4 representative – Wapping Practice

NHS THCCG

Dr Osman Bhatti

LAP 7 representative – Chrisp Street Practice

NHS THCCG

Dr Victoria Tzortziou-Brown

LAP 3 representative - Principal Clinical Lead – All Saints Practice

NHS THCCG

Dr Isabel Hodkinson

LAP 5 representative - Principal Clinical Lead - The Tredegar Practice

NHS THCCG

Dr Somen Banerjee

Director of Public Health

LBTH

Luke Addams

Corporate Director

LBTH

In attendance

Name

Role

Organisation

Justin Phillips

Governance and Risk Manager

NHS THCCG

Charlotte Fry

Commissioning Support Director

NEL CSU

Lee Eborall

Director of Acute Contract Management

NEL CSU

Rob Mills

Nurse Consultant Safeguarding Children & Designated Nurse

NHS THCCG

Dr Julia Hale

Designated Doctor - Safeguarding

NHS THCCG

Dr Ben Ko

Designated Doctor for LAC

NHS THCCG

Shola Yemi

Designated Nurse for LAC

NHS THCCG

Karen Breen

Managing Director

Barts Health RLH

Dr Angela Wong

Clinical Director

Barts Health RLH

Abigail Knight

Acting Associate Director of Public Health

LBTH

Apologies

Name

Role

Organisation

Jane Milligan

Chief Officer

NHS THCCG

Richard Quinton

Interim Director of Commissioning

NHS THCCG

Virginia Patania

Practice Manager representative

NHS THCCG

Dr Shah Ali

LAP 8 representative – Barkantine Practice

NHS THCCG

Dr Haroon Rashid

LAP 2 representative – Albion Practice

NHS THCCG

Cate Boyle

Vice Chair - Lay Member (Patient and Public Engagement)

NHS THCCG

1. Welcome

Dr Sam Everington welcomed members and attendees to the Governing Body meeting part I. Apologies were received for: Jane Milligan, Dr Shah Ali, Dr Haroon Rashid, Cate Boyle, Richard Quinton and Virginia Patania. It was noted for the purposes of quoracy that Archna Mathur was a nominated voting member as part of the requirement for two CCG senior managers to be in present. Luke Addams was welcomed to the TH CCG Governing Body replacing Robert McCulloch-Graham.

1.2Declaration of Interests

Dr Sam Everington asked Members for any declarations of interest. No additional declarations of interest were noted for Part I of the meeting.

The complete register of interests is published on the NHS Tower Hamlets Clinical Commissioning Group’s website: http://www.towerhamletsccg.nhs.uk/about/conflict-of-interest-register.htm or is available from the Governance and Risk Manager: justin.phillips@towerhamletsccg.nhs.uk

1. Chair’s report

Dr Sam Everington presented the Chair’s report. The following highlights were reported:

· Primary Care Transformation

· Alwen Williams Appointed as Chief Executive of Barts Health NHS Trust

· Prime Minister’s Challenge Fund (PMCF)

Members noted the Chair’s report.

Chief Officer’s report

Henry Black presented the item. The following highlights were reported:

· Tower Hamlets CCG Annual General Meeting (AGM)

· Integrated Personal Commissioning Event

Members noted the Chief Officers report.

1.3 Minutes and Matters Arising of the Meeting held September 1st 2015Minutes

The minutes for the Governing Body September 1st 2015 part I were approved as an accurate record of the meeting.

Matters arising

The matters arising were reviewed with outstanding actions carried forward.

Performance and OperationsSafeguarding Annual Report 2014/15 / Looked After Children Annual Report 2014/15

Rob Mills presented the Safeguarding Children Annual Report 2014/15 highlighting: the position for 2014-15 and current issues to be addressed; the impact of recent policy and guidance; the existing safeguarding children risks across health and specifically for the CCG; and the CCG’s plans to improve safeguarding children arrangements for the coming year.

The following points were raised in discussion:

Dr Somen Banerjee queried if the safeguarding data was considered as complete or if further work was required. Dr Julia Hale stated that Barts Health was identified as not having submitted data under the new arrangements; data is being submitted but it was estimated at 90% complete. The data is currently being extracted from maternity services and work is underway to extract data from gynaecology and CASH services. There is an expectation that safeguarding cases will increase with the improving data extraction and analysis.

Dr Isabel Hodkinson queried how Barts Health are going to communicate to GPs FGM cases as it is difficult to identify cases with the current discharge documentation. Dr Julia Hale stated that this should be captured in the current discharge documents as part of the action for GPs but that she would also raise this at a future FGM meeting.

Maggie Buckell thanked the Safeguarding team for the report. She welcomed Shola Yemi to the team as the full time designated professional for Looked After Children and thanked Anne Morgan for her work in the role.

Dr Ben Ko presented the Looked After Children Annual Report 2014/15. He highlighted the progress made in 2014/15: a substantive Designated Nurse was recruited, and has commenced in October 2015; a Nurse Specialist for LAC has been in post since August 2014 with remit for young offenders; meetings with CAMHS commissioners and providers has now taken place (Sept 2015), and further information will be included in the next annual report; and a new process for processing funding for statutory assessment and quality assuring reports from out of borough health providers has been set up.

Dr Ben Ko also updated the Governing Body on the CCG priorities for the following year: to continue to work with Social Care Service to ensure referrals for Statutory Health Assessments are made in a timely fashion; to monitor Bart’s Health’s responsiveness in carrying out Statutory Health Assessments; Mental Health Commissioners to review current pathways for mental health service for Looked After Children placed both in and out of Tower Hamlets, to ensure their mental health needs are identified and met in a timely fashion; to ensure adequate IT links between Bart’s Health and LBTH so that crucial information on LAC can be shared effectively; to improve monitoring of immunisation status of LAC and uptake of immunisation; to undertake an audit on the timeliness and quality of health assessment undertaken by external health providers for LAC placed out of borough; and establish formal links between designated professionals and Corporate Parenting Board, LBTH

The following points were raised in discussion.

Dr Judith Littlejohns updated the Governing Body regarding additional money from central government for CAMHS and it is the plan to invest specifically in LAC; there is a lot more work to be done on the design but the work should strengthen relationships and improve pathways.

Dr Osman Bhatti queried what the current situation is relating to the IT link between Barts Health and the borough. Dr Ben Ko stated that there is still difficulty accessing data between the Local Authority and the nurses and that the nurses were also given access to Emis for those based in the borough but that there are ongoing issues for those nurses that are based outside of the borough.

Action: It was suggested that a meeting with Dr Osman Bhatti, Luke Readman and the Safeguarding team would be useful to address current IT / data issues

The Members approved the Safeguarding Annual Report 2014/15 and the Looked After Children Annual Report 2014/15.

Performance and Quality Report

Archna Mathur presented the Performance and Quality Report and highlighted that the coversheet provided a comprehensive review. The key areas to note were:

The Trust achieved the cancer 2 week wait (2ww) standard for July with performance of 95.9% and also for August with performance of 95.7%. This is the third consecutive month of Trust level achievement of the 2ww standard. This standard for RLH site was also achieved in July at 93.7% for the first time in 3 months, and was also achieved on RLH site for 3 of the challenged specialities, colorectal, lung and urology. Performance has dipped slightly in August to 91.7%.

A&E: The RLH site continues to be challenged in delivering the 95% standard and a Contract Performance Notice has been issued for non-compliance with this standard with the majority of breaches on average relating to ED triage (32%), and secondly bed management (29%). The Trust and CCGs were invited to a tripartite meeting in early October to understand root causes and plans for recovery. The RLH plan is robust however performance is still below trajectory. The tri-partite panel have therefore requested revision of the Trust trajectories to demonstrate a more realistic quarterly position. This is being reviewed currently. Key work streams within the plan relate to; urgent care and the initial assessment; emergency assessment; introduction of the “full capacity model acute surgical model; ambulatory care; and AAU process for discharge. Work streams are being rolled out early November but it is expected that they will take a bit of time to bed in.

The number of never events since the time of issuing the quality report had increased from 9 to 11; this compares with 2014/15 closing with 5 in total. Archna Mathur explained that external reviews were underway to address this concern.

The following points were raised in discussion:

Dr Osman Bhatti expressed his concern at the level of never events querying if trends could be identified. Archna Mathur outlined that there were numerous misplaced nasogastric tubes and retained surgical foreign objects.

Mr Tan Vandal welcomed and commended the improvement with cancer waiting times. He expressed serious concern relating to the number and type of never events stating that the situation is totally unacceptable. He requested further detail of the root causes querying if there were issues with the surgical team, team managers, pressures etc.?

Action: The Governing Body requested an update at next Governing Body meeting re: never event external review.

Cancer Performance Improvement- A Collaborative ‘Deep Dive’ Approach

Dr Sam Everington welcomed Karen Breen (Managing Director – RLH) and Dr Angela Wong (Clinical Director for Cancer Services – Barts Health). Dr Angela Wong presented the paper: Cancer Performance Improvement – A Collaborative Deep Dive Approach. The key areas to note were:

Barts Health was failing between 5 to 8 of the 9 cancer waiting time standards between April and June 2014. A collaborative Deep Dive Programme chaired by Archna Mathur started on 25th April 2014 resulting in Barts Health achieving compliance in 8 cancer waiting time standards in July 2015.

Dr Angela Wong highlighted that cancer referrals (2 week wait) had increased approximately 40% resulting in increased diagnoses; the increase in demand has had a significant impact on cancer waiting times. In response to sustained poor performance, the CCG had taken served a Contract Performance Notice (CPN) in June 2015. As a consequence of this poor performance and the impact on patients, a meeting of key clinicians and managers was held in mid-April 2014. From this the Director of Performance and Quality at the CCG and the Clinical Director for Cancer Performance & Improvement at Barts Health jointly agreed to adopt a Programme Management approach and established the Cancer Services Deep Dives. The aim of Deep Dives are: to understand the root causes at speciality level leading to underperformance; support and drive clinicians and managers to identify the issues, resolve the issues and use data to effectively track their own performance; and, to encourage clinical ownership.

Dr Angela Wong gave an overview of: the identified challenged specialities; a summary of all the deep dives meetings and their impact; speciality level data demonstrating improvements with the cancer waiting time standards; and the proposed next steps.

The following points were raised in discussion:

Mr Tan Vandal thanked Angela for her dedication stating that he was very impressed with the data presented. He queried if as an extension of this work, whether the MDT of the various tumour groups are mandated to discuss waiting times also questioning the level of engagement with other Trusts where the standards are inter-Trust dependent. Dr Angela Wong informed the meeting that a standard MDT template was in use and part of this process was to generate live data recording straight to the Somerset System. She also updated on a meeting that Archna Mathur had set up with UCLH and that this had improved dialogue but that going forward consideration needs to be given to setting up a meeting with Queen’s Hospital.

Dr Victoria Tzortziou-Brown agreed that this was an amazing piece of work. She queried if further analysis had been carried out to determine what proportion of the 31 and 62 day standard breaches are due to patient choice and whether we needed to consider patient responsibility and education which could possibly link with the integrated care programme. Dr Angela Wong explained that this data is already captured and that changes such as improving the spread of appointments had reduced patient choice breaches but they were still seen in certain tumour sites such as head and neck.

Dr Osman Bhatti asked if the referral forms could be unified and if these could all be e-mailed instead of faxed. Dr Angela Wong said this would be something to focus on going forward.

Mariette Davis expressed that she was very impressed with the process and outcomes and questioned whether any funding had been allocated to drive the deep dive process. Archna Mathur explained that there had been a small amount of funding for tracking etc. but mostly this had been achieved by the hard work of all those involved.

Archna Mathur stated that as a consequence of this process, both parties are confident that improvements will be made with the cancer waiting time standards; although it is a slow process, it is sowing the seed for clinical engagement going forward and that it is a useful model to approach other quality and performance concerns going forward.

Finance and ActivityFinance report month 6

Henry Black presented the month 6 Finance Report. The key areas to note:

At month 6 the CCG is reporting a year to date surplus of £5.8m and forecasting a full year surplus of £11.7m, in line with the CCG’s Financial Plan. However, commissioning reserves are required to offset pressures on contract activity, particularly in the acute sector, continuing health care and prescribing, in order to achieve the targeted position.

The CCG had been required to submit its operating plan to deliver a surplus of £11.7m, which is higher than the minimum 1% business rules. This is a result of a request from NHSE to increase our surplus by an additional £2.3m, however there are still have sufficient resources to meet all of the recurrent and non-recurrent identified expenditure plans and this does not represent a risk to delivery of any statutory duties.

Prescribing is reporting a year to date over spend of £501k; this is in keeping with the national picture. Prescribing costs in April and May this year is 5.8% higher than the same time last year. The forecast position has improved slightly due to a release from reserves of £500k, to cover the identified growth increase. The CSU are currently reviewing the reasons for the increases, areas to address to reduce this increase as well as try to identify areas of where potential savings can be made to reduce the overspend position.

Barts Health continues to underperform against the national waiting time standards at speciality level. The Trust is currently not reporting on RTT although monitoring via the CCGs/TDA continues against the contract performance notice in June 2015.

Activity report month 6

Lee Eborall presented the month 6 activity report. The following highlights were reported:

•Acute has reported a £3.2 million overspend

•Non Acute has reported a £1.5 million overspend.

•With minor overspends and underspends across the SLA Portfolio.

The following points were raised in discussion:

Dr Isabel Hodkinson stated that there are quality issues with the BMI contracts; there needs to be something built in to ensure the provider is required to treat the ‘whole person’. Lee Eborall pointed out that BMI were not alone in that practice and that he agreed that quality of care of these providers needs to pick up through the contracting process.

Members noted the item.

Board Assurance Framework

Henry Black presented the Board Assurance Framework 2015/16 version 3 to the Governing Body explaining that the framework had been updated to reflect changes in programmes of work in the CCG. It was requested that Governing Body members familiarise themselves with those risks that link with their work streams and that where they sit on committees, that they ensure that appropriate controls are developed for the high level organisational risks.

Dr Osman Bhatti pointed out that John Wardell was still Governing Body lead for a couple of risks and the BAF needed to be updated to reflect his departure.

Mariette Davis informed the meeting that the Audit Committee would be reviewing this iteration of the BAF in more detail at the next Audit Committee.

Members noted the item.

BreakCommissioning and StrategyCommissioning Intentions

Henry Black presented the Operating Plan and Commissioning Strategy Paper explaining that the paper had been brought to the Governing Body to provide members an update since the September Governing Body. The following key points were highlighted:

· The CCG has been ‘Assured as Good’ in all categories apart from Delegated Functions where the rating is awaited.

· A 6 month stocktake meeting with NHSE is due on 9th November to consider performance against plan across planned activity; Constitutional standards; financial performance and commissioning.

· The Commissioning Intentions letters were issued by 30 September with the single exception of LAS two days later.

· QIPP continues to be developed with current draft figures in the range forecast of £7.7M - £10.2M.

· Integrated Urgent Care Standards were issued on 15 October that set out the vision for NHS 111 to be the single entry point to fully integrated urgent care services.

· The Government Spending Review is due to be completed on 25 November. This is expected to impact on spending and its impact will require detailed review and response.

Members noted the item.

Health and Wellbeing Strategy Development

Dr Somen Banerjee presented the Development of the Refreshed Joint Health and Wellbeing Strategy Paper explaining that the Health and Wellbeing Strategy 2013-16 and its associated delivery plans are due a refresh for 2016/19. Dr Somen Banerjee stated that the Health and Wellbeing Strategy sub-group has established a PMO to manage the strategy refresh process with key representatives from the CCG, Local Authority, Public Health and the Community Voluntary Services and he gave an overview of the progress to date and the strategy refresh timeline.

The following points were raised in discussion:

Dr Sam Everington queried what savings were expected to be made in the Public Health budget. Dr Somen Banerjee explained that as part of the comprehensive spending review, Public Health were being asked to make savings of £2.3 million in 2015/16 and that currently a consultation was taking place to review 2016/17 onwards. Dr Somen Banerjee stated that it was his opinion that the more ‘deprived budgets’ appeared to be potentially more disadvantaged as part of this process. Luke Addams stated that for Adult Social Care, Savings of £5.5 million were to be found in 2015/16 and that for 2016/17 that the council was being asked to make savings of approximately £70 million but that the Adult Social Care savings were yet to be confirmed.

Dr Isabel Hodkinson pointed out that there are lots of programmes running in Tower Hamlets and the current Vanguard programme echoes a lot of the areas of the Health and Wellbeing Strategy; there is a need to harmonise although this could possibly be difficult for certain programmes as the Vanguard timelines are much tighter.

Maggie Buckell expressed that she thought a lot of good work was in place between the CCG, Local Authority etc. to co-produce the Strategy but that often in the process the prevention agenda suffers and that it is important that we keep the prevention agenda embedded in the development process.

Members noted the item.

Making Every Contact Count (MECC)

Abigail Knight presented to the meeting the paper: A prevention-orientated system: Making Every Contact Count. It was explained that MECC is a public health initiative which aims to encourage those who work with the public to make the most of every opportunity to have a conversation about a healthy lifestyle and offer signposting information to facilitate behaviour change. This is part of the national programme of the same name, with a locally tailored approach to training and prevention approaches. Frontline staff receive training in how to pick up on conversational cues about healthy lifestyles that someone may be willing to discuss, and how to encourage them to take action. Abigail Knight gave an overview of the implementation of MECC in Tower Hamlets, the services where MECC had been rolled-out and an evaluation of the system thus far.

The following points were raised in discussion:

Dr Victoria Tzortziou-Brown suggested that the MECC system could be incorporated in the GP Network Improvement Scheme and the Vanguard programme and that the same outcomes could be set across the system. Dr Victoria Tzortziou-Brown thought it would be useful for Abigail Knight to meet with the relevant programme leads to explore this suggestion further.

Dr Isabel Hodkinson expressed that it was difficult for General Practice to get on board with the MECC system as the Tower Hamlets Community Education Provider Network (CEPN) had decided not to pay backfill for GP staff and that there was no financial incentive for GPs to engage. Abigail Knight stated that she had taken this feedback on board.

Charlotte Fry suggested that in terms of opportunity, two areas had been overlooked; community pharmacy with a higher footfall than GP practices and dental alcohol and smoking cessation services. Charlotte Fry thought it would be good to link the MECC outcomes into their contractual frameworks.

Members noted the item.

For informationAudit Committee Summary

No further comments were raised. Members noted the item.

Finance, Performance and Quality Committee Summary

No further comments were raised. Members noted the item.

Locality Board Summary

No further comments were raised. Members noted the item

Executive Committee Summary

No further comments were raised. Members noted the item

Primary Care Commissioning Committee Summary

No further comments were raised. Members noted the item.

Questions from the Public

No comments or questions were raised by the attending members of public.

Any Other Business

No comments or questions were raised by the members.

End

Matters arising

Action reference

Action

Lead

Due Date

Update

Nov#1

It was suggested that a meeting with Dr Osman Bhatti, Luke Readman and the Safeguarding team would be useful to address current IT / data issues

BK

Jan 2016

This has been raised as an issue within the Vanguard IT workstream and the plan is to integrate as much of the systems together. It is advantageous to improve links easier with users of EMIS and now with cedrner and the challenge going forward is integrating with Framework system.

We will clarify going forward with Dr Ko how best to take this forward together.

Nov#2

The Governing Body requested an update at next Governing Body meeting re: never event external review.

AM

Jan 2016

Update being provided as part of Performance and Quality Report.

Jan#2

Scorecard to be discussed at future SMT with view to update metrics.

JP

TBC

Discussed at SMT 2/2/15 – to be discussed after the NHSE CCG assurance scorecard is developed.

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