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

Tuesday, 26 January 2016, 14.30 – 17.00The Theatre Room, Oxford House, Derbyshire Street, E2 6HG

1.1.1 Present

Name Role Organisation

Sam Everington Chair – LAP 6 representative – Bromley By Bow Practice

NHS THCCG

Archna Mathur Director of Quality and Performance NHS THCCGCate Boyle Vice Chair Lay Member (Patient Public

Engagement)NHS THCCG

Haroon Rashid LAP 2 representative – Albion Practice NHS THCCGHenry Black Chief Finance Officer NHS THCCGIsabel Hodkinson LAP 5 representative - Principal Clinical Lead - The

Tredegar PracticeNHS THCCG

Jane Milligan Chief Officer NHS THCCGJudith Littlejohns LAP 1 representative – The Mission Practice NHS THCCGLuke Addams Corporate Director LBTHMariette Davis Lay Member (Governance) NHS THCCGMartha Leigh LAP 4 representative – Wapping Practice NHS THCCGNoah Curthoys Lay Member NHS THCCGRichard Quinton Interim Director of Commissioning NHS THCCGShah Ali LAP 8 representative – Barkantine Practice NHS THCCGSomen Banerjee Director of Public Health LBTHTan Vandal Secondary Care Specialist Doctor NHS THCCGVictoria Tzortziou-Brown

LAP 3 representative - Principal Clinical Lead – All Saints Practice

NHS THCCG

Virginia Patania Practice Manager representative NHS THCCG

1.1.2 In attendance

Name Role Organisation

Charlotte Fry Commissioning Support Director NEL CSUEmily Fieran-Reed Corporate Strategy and Equality LBTHJacqueline Tottterdale Chief Operating Officer (item 2.4 only) Barts HealthJosh Potter Deputy Director of Commissioning NHS THCCGKeith Dickinson Interim Governance Manager NHS THCCGJames Friend Programme Director (item 2.4 only) Barts HealthLee Eborall Director of Acute Contract Management NEL CSUXena Cooke Director of Corporate Resources LBTH

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Enclosure B

1.1.3 Apologies

Name Role Organisation

Maggie Buckell Registered Nurse NHS THCCGOsman Bhatti LAP 7 representative – Chrisp Street Practice NHS THCCG

1.1.4 Welcome

Dr Sam Everington welcomed members and attendees to the meeting and introduced Noah Curthoys as the new lay member. Noah will be taking on a co-opted role as interim vice chair until a new PPI lay member is appointed following Cate Boyle’s departure. He went on to point out that as Kate Boyle was stepping down this was her final meeting and thanked her for her extensive contribution as the PPI lay member.

1.2 Declaration 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

1.3 Chair’s report

Sam Everington presented the Chair’s report highlighting changes to membership of the Governing Body and additions to Barts Health NHS Trust executive team. Reference was made to the importance of the approaching implementation phase of Transforming Services Together as one the two key priorities for the CCG. The meeting was also advised that, at this stage and contrary to misleading press reports, the junior doctors’ strike was still going ahead; the CCG intended to make the same preparatory arrangements as it did for the last strike. The Chair went on to commend

- A clear and practicable definition of seven day services that had been agreed across the NHS in Scotland

- a local initiative to create a staff college that would provide fourteen days leadership training for all staff; this would help engender a single vision across the area and develop young leaders as part of succession planning. Similar initiatives at UCLH and by a consortium of Birmingham CCGs had proved successful and provided opportunities for seeking out best practice.

There followed an update on the HSJ article ‘Choose and Consult’ and its means of operation whereby there was a revised process for a GP seeking specialist advice; responsibility for managing each step is clear and the interchange continues until all agree that full responsibility passes back to the GP. The patient, GP and specialist then all receive a summary of the action plan by email. Responsibility for managing each step is clear.

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Action Jan16 #1: JM to circulate the seven day service definition and the HSJ article to GB members.

Sam Everington informed the members of the Clinical Commissioning and GP Forum held on Tuesday 1st December and in particular Workstream 1 where there was four volunteer pilot practices involved in the first wave. Virgina Patania emphasised its success and the results it was producing around patient engagement and experience. Isabel Hodkinson added her support to these views.

The members NOTED the report.

1.4 Chief Officer’s report

Jane Millgan presented the item. The following highlights were reported

- Independent review of deaths of people with a Learning Disability or Mental Health problem

- Introduction of Nurse and Midwifery Revalidation - NHS preparedness for a major incident

Particular note was made that the CCG has secured £2.6m funding from the Section 106 programme. Along with the local authority it was an opportunity to this creatively and invest in new models of primary and secondary care.

The members NOTED the report.

1.5 Member Story – PCMF Engagement

Virginia Patania introduced a video of PCMF Engagement and in the ensuing discussion it was reported that good progress had been made with all hubs now open and the central fitting in with the seven day working and single point of access strategies. Shah Ali endorsed the success but it was noted that success would bring financial challenges. Cate Boyle advised of the need for an evaluation before further funding was released.

Action Jan16 #2: Ellie Hobart to include update in Newsletter

The members NOTED the report.

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

1.5.2 Minutes

The minutes for the Governing Body 3 November 2015 part I were APPROVED as an accurate record of the meeting, subject to the following change at para 3.3

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 so that GPs are being asked to bear the cost of a programme that does not directly provide benefit to them as an organisation, we need to move to a more system oriented way of thinking about supporting such work. Abigail Knight stated that she had taken this feedback on board.

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1.5.3 Matters arising

The matters arising were reviewed with outstanding actions carried forward.

2 Performance and Operations

2.1 Board Assurance Framework 2015/16

Jane Milligan summarised the risks set out in the Board Assurance Framework drawing particular attention to Risk 1.1 (Failure to ensure effective systems and processes are in place to monitor, challenge and support Barts Health NHS Trust delivery of NHS Constitution targets). It was explained that further detail around A&E performance would be provided later in the meeting by Jacqueline Totterdale the Chief Operating Officer of Barts Health NHS Trust. Turning to risk 2.2 (tight timeframes to deliver the system model and the long term financial model could impact on the ability to deliver the 5- year strategic plan within the timeline of the programme) it was explained that the reporting of the risk merited greater narrative to explain fully the range and impact of the extensive controls that were in place. In a similar vein, Cate Boyle added that Risk 3.6 (failure to deliver on the Operating Plan) failed to convey a true sense of what was happening and the actions that were being taken to demonstrate it was being properly managed.

Mariette Davis informed the members that the Audit Committee has reviewed the BAF the previous week. Audit Committee held the view that the BAF could usefully be used as a tool to help identify commissioning priorities. She highlighted the fact that in some cases the risk rating was considerably greater than the stated risk appetite and that actions planned should bring the level down towards the risk appetite. Mariette also noted that when the Bart’s Board had settled in, a Board to Board meeting should be held.

The members NOTED the report.

2.2 Finance and Activity

2.2.2 Finance report Month 8

Henry Black introduced the report explaining that, due to the deferred date of the meeting, the information contained in the report was now slightly out of date. On a positive noted he reported that the CCG was close to concluding and agreeing, with Barts Heath NHS Trust, the final value of the contract. Turning to the main areas of risk, it was reported that in respect of

- Primary Care Co-Commissioning was reporting a year to date underspend of £93k with a full year break even position. The year to date and forecast position has improved from last month due to a release from the CCG’s reserves to cover the underachievement of projected QIPP schemes.

- Prescribing were reporting a year to date over spend of £582k with a full year forecast overspend position of £873k. This was based on using the NHS Business Services new profiles on projecting expected expenditure levels. Prescribing costs in April and May this year were 5.8% higher than the same time last year

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- Acute Contracts: the total budget is £170.6m. At Month 8 the Acute position is currently showing a year to date overspend position of £2.3m with a full year projected overspend of £3.5m against plan though this position is being mitigated with additional QIPP Schemes that are bringing it back on track.

The main areas of over performance are

- BMI with the main pressures are within elective/day cases, outpatients procedures and outpatients first/follow ups – these relate specifically to the areas of T&O, Urology, Anaesthetics, Gynaecology and General surgery.

- Guy’s & St. Thomas’s with the main pressures are within maternity and obstetrics.

- Homerton with the main pressures are within outpatient first and follow ups, non electives and maternity.

Barts Health NHS Trust is experiencing an increase in day cases, indicating they are clearing the backlog previously reported.

Non Acute Healthcare Provision has a year to date overspend position of £750km with a projected full year overspend position of £1.3m. The main drivers relate to overspends in Prescribing and Continuing Healthcare; a more detailed update will be provided at the next meeting

In the discussion that followed Isabel Hodkinson expressed concern over the impact on Barts Health NHS Trust and Victoria Tzortziou-Brown thought a comparison between BMI and Barts Health NHS Trust would be useful. Tan Vandal wondered if both providers were seeing increased activity and queried whether value for money was being achieved, especially if BMI were ‘cherry picking’ the lucrative cases. Jane Milligan responded by explaining that the CCG had been helping Barts Health NHS Trust identify the right patients, especially the Royal London Hospital who have complicated cases, whilst BMI could only deal with cases of limited complexity. It was also recognised that the CCG had been challenged by NHSE over the uptake of provision by private providers, to ensure that there was full utilisation of alternative routes.

Action Jan16 #3: Archna Mathur to liaise with Lee Eborall regarding the evaluation of BMI cases

Action Jan16 #4: Archna Mathur to arrange QA visit to BMI

Action Jan16 #5: Archna Mathur to explore feasibility of Healthwatch enter and view visit to BMI

Action Jan16 #6: Richard Quinton to ensure suitable contractual arrangements.

The members NOTED the report.

2.3 Performance and Quality Report

In respect of the special measure in place regarding RLH, Archna Mathur began by explaining that assurance meetings occurred each month. The focus of the meetings was to gain assurance on progress against key milestones within the RLH improvement plan.

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Further detailed key lines of enquiry at the January meeting will be based in assurance around clinical engagement in the Clinical Harm Review Process, safety standards for invasive procedures and mandatory training. The deep dive will be on outpatients and medical records. The Trust Oversight and Assurance Group was being reviewed so as to understand how it fitted into the wider operating framework for managing Barts Health whilst in special measures. There was now a heightened need to achieve systemwide impact on the issues the Trust was facing. An update was then given on the report in general with particular attention drawn to the following points.

There were positive outcomes and assurance on delivery of Cancer Waiting Times with Barts Health achieving all 8 standards in October; this included the standards for 2 week urgent referrals, 31 day 1st treatment standard and the 62 Day GP urgent referral. As a CCG Tower Hamlets achieved 7 out of 8 standards, in October, including the the 2 Week urgent referral, the 31 day 1st treatment standard and the 62 Day GP urgent referral. The Breast 2 week symptomatic standard was not achieved. Virginia Patania queried some of the data relating to cancers and in response Archna Mathur explained that the counting systems were not identical and rare cancers required a manual counting system. In discussion it was agreed that further information was needed in relation to non cancer performance. Virginia Patania concluded by stressing the importance of the 31 day target as well as the 62 day target.

The November 62 day position dipped just under standard at 84.3% and this is due to a reporting technicality where the 31 day position of rare cancers must also be included in the 62 day final position. If rare cancers were not included, performance would have been at 85.1%.

Deep Dives have been conducted for skin cancer, where performance on the RLH site had been a challenge but was achieved for the first time since March, in December. Head and Neck Cancer did not reach the 2ww standard on the RLH site for 2015/16 but have now been achieved for October and November. 62 Day performance for Head and Neck was also been achieved for October and November. Overall the Deep Dive for Head and Neck produced good results. As many of the issues relate to diagnostics, future cancer speciality deep dives will be extended to include diagnostics impacting on cancer.

In respect of Referral to Treatment Barts Health continues to underperform against the national waiting time standards at speciality level though the backlog and waiting list clearance is being met with a resulting overall reduction in the waiting list size. The main

Performance in relation to LAS Handover times has seen the Royal London fail to achieve percentage turnaround within 15 minutes thought it did deliver turnaround within 30 minutes for ambulance handovers in November. Performance against was substantially up from October.

Barts Health has 11 overdue Serious Incidents, of which are six are at the Royal London Hospital. Overdue Serious Incidents at ELFT number for November of which 4 relate to mental health and 8 to community services.

Barts Health has reported 11 Never Events this financial year; a Contract Performance Notice was issued on the 11 November 2015. The Trust has submitted a recovery action plan which is currently being reviewed. Virginia Patania emphasised the need for assurance around progress at a future meeting.

A Quality Assurance Visit was made on ward 14F Elderly Care at the Royal London Hospital. Staffing was seen to be a challenge with high numbers of bank and agency. The vacancy rate was 50% though a recruitment drive was underway. There was strong ward

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leadership and the ward manager was in the process of identifying ways to improve the ward environment to make it more suitable for patients with Dementia.

There were planned activities for patients. Every Thursday afternoon they had tea and cake for patients, relatives and carers. A successful ‘come dine with me’ event had also been held in December.

The ward environment was clean. Staff had a good awareness of the mental capacity act and deprivation of liberty. Feedback from patients and relatives was positive. Patients reported that they were satisfied with the care they received and felt nurses treated them with dignity and respect.

The members NOTED the report.

2.3 Royal London Hospital A&E Performance Update

Jacqueline Totterdale, Chief Operating Officer and James Friend, Programme Director of Barts Health NHS Trust introduced the report and gave a brief overview of performance adding that Tower Hamlets was of one of the 28 Challenged Health Systems recognised nationally. It was explained that the Trust was committed to change but it would not be a quick fix, rather a sustained programme approach was being adopted to drive the necessary improvements that involved winning the hearts and minds of everyone involved.

Keith friend added that as with the other sites and the Trust overall, the Royal London has an agreed performance improvement trajectory. The aim was to achieve 90% of patients attending Emergency Department being discharged or admitted within four hours by March 2016 (92% at Trust level). The RLH achieved the trajectory during the Christmas week with the benefit of bed occupancy reductions; this is a better performance than last year. Changes to achieve this consistently in future include

- the appointment of an ED manager

- working with Archna Mathur on the front door of A&E

- change from a complex to a streamlined pathway, including one queue’ at RLH front door to remove up to 30 minutes from the start of the assessment process

- commencement of Emergency Care Programme Director since December 2015

- the appointment of McKinsey to review information and reports from the Urgent Care Working Group and System Resilience Group effectviness

- work to review very high bed occupancy rates (a reduction of bed occupancy to less than 80% on Christmas Eve that sustained the Trust until 3 January)

- ensure trauma patients are admitted to theatre within 12 hours

- MDU working more effectively.

To achieve this greater clinical engagement and involvement was needed. Also better patient flow was required so in addition to the ED Story Board there needed to be an In Patient Story Board. There were four pathways to be managed: children and adults; admitted and non admitted. The key was to ensure the Adult Non Admitted Pathway as once

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its patient flow and performance was right the other pathways would fall into place and the target would be achieved. Sam Everington queried the discharge process and in response it was said that patients did not need to be in a hospital bed to be assessed. James Friend was pleased with the partnership process but thought it could be improved. In the discussion that followed it was felt that much could be done on both sides. Victoria Tzortziou-Brown said there were many instances of hospitals referring patients to their GPs after the treatment was complete. There was general agreement over the value of social workers on wards for the early referral for social care. Responding to Jacqueline Totterdale’s exhortation to improved partnership working amongst clinicians, Isabel Hodkinson volunteered to liaise with hospital consultants.

The members NOTED the report.

2.5 London Ambulance Service UpdateArchna Mathur introduced the report explaining that London Ambulance Service had been inspected by the CQC in June 2015. They issued a warning notice to LAS following the inspection, prior to publication of the report, and subsequently the Trust was placed in special measures.

A quality summit was held in December to consider how to provide LAS with support in relation to

- recruitment and retention- training and staff support- improving staff morale and creating a positive culture- whole systems response to improving response times- whole systems approach to building emergency prevention, preparedness

and response- medicines management- quality- governance.

Subsequently the North East London LAS Contract Management Forum met where further more local mechanisms to support improvement were discussed as well as wider issues relating the contract management processes for LAS. Recruitment and Retention, Improving Response Times and Managing Demand, and Quality Governance were all considered. In addition forum also raised concerns with regards to the robustness of the contract management process with the recommendation that a letter be written to the lead commissioners to offer a more collaborative and supportive approach from WEL CCGs going forward. Martha Leigh supported the view that there must be a commission failure at the core of the problem.

The members NOTED the report.

3 Commissioning and Strategy

3.1 TST Strategic Investment Case and Engagement PlanNeil Kennet-Brown presented the report saying the TST Strategy and Investment Case was a response to the agreed Case for Change published in December 2014 developed by over 1,000 clinicians, managers, staff and public and patients. The strategy has been through

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informal discussions with various governing bodies over the past six weeks and aims to eliminate the following risks:

• Due to population growth, the health economy will need an additional 550 inpatient beds by 2025 – the equivalent of a new hospital. The cost of building this capacity would be about £450 million; the cost of running these additional beds would be about £250 million a year. We wouldn’t have (or be able to recruit) the workforce to support this, and we know that hospital is not the right place for many people

• Patient experience will decline and patient safety will be put at risk. People will need to wait longer for operations or travel outside of east London for some routine elective care. People with a mental health illness will continue to be poorly treated compared with patients with a physical illness; too many people will continue to die in hospital rather than in a homely surrounding. Patients and staff will have to cope with poor environments. If we don’t resolve the IT and urgent care challenges we won’t be able to bring care closer to home and patients will face a confusing health system

• We won’t take advantage of the major opportunities to transform the morale of our workforce

• Our finances will deteriorate further. The East London health economy deficit is £398 million by 2020/21 and we will not be able to make efficiencies to improve care.

Success will depend on having an open, engaging and iterative process that harnesses the energies of clinicians, patients, carers, citizen and local community partners.

THCCG was the first to receive the report but it would go to other Boards who could seek to make changes; if that happened the Strategy would be re-presented to THCCG by way of Chair’s Action.

In the discussion that followed there was widespread recognition of the importance of the strategy, together with overwhelming support. Isabel Hodkinson highlighted the broad geographical nature and asked how the Governing Body would ensure that the impact and value locally was exploited to the greatest possible extent; in response was agreed that this topic would be considered at a forthcoming OD Seminar.

The members APPROVED the report.

3.2 Allocation Update

Henry Black began by explaining that the paper advised the Governing Body of the CCG’s allocation for 2016/17 and the changes to the previously announced allocation; a major feature was the change from a 1 year to a 5 year allocation which offered advantages in some regards but disadvantages in other. The report provides comparisons with other CCGs in North East London for illustrative purposes but the main points for Tower Hamlets CCG were

- programme allocation for 16/17 - £353.2m- administration (Running Cost Allowance) - £6.299m - the programme allocation includes the policy cost pressures of 1.4%

In practical terms it means an overall increase in allocation of 2.94%, which is 1.59% more than in previous planning assumption. The baseline now includes 1.4% of policy cost pressures and so the real growth for THCCG was £1.54%. A broad discussion followed but Henry Black pointed out that the formula was deliberately opaque so as prevent close

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analysis leading to a large amount of challenges. In response to Sam Everington’s question, he advised that any opportunities for canvassing, campaigning and appeals should be deferred until the final analysis of the allocation and its implications was available.

The members NOTED the report.

3.3 Voluntary and Community Strategy

Emily Fieran-Reed and Xena Cooke presented to the meeting, the local authority Voluntary and Community Sector Strategy 2016–19. It was explained that the key planks of the strategy were to: create resilient, self-supporting communities; use the capacity and skills of the VCS and the council to co-produce services that meet community needs; provide the conditions for infrastructure support; and, develop an outcome and impact focussed approach. Whatever the local authority funds must support the strategic priorities and they would work with VCS and voluntary groups to achieve the maximum value from resources. As part of that there would be a move from the grant making model to a commissioning model supported by capacity building, a step change in volunteering and closer working between businesses and VCS.

It was added that the local authority was exploring how to develop partnership working and the co-production of action plans with other organisations; this consultation was a key element of that. There followed a discussion around the role of individual organisations and it was explained that the local authority had only a facilitative role but that VCS was key as it added value, brought a cohesive feel and was a significant step forward. Martha Leigh pointed out that access to VCS was problematic; to help overcome this there ought to be outreach and GP Networks were a suitable vehicle for that. Somen Banerjee suggested that VCS should consult the Health and Wellbeing Board to ensure a consistent, cohesive feel to health and wellbeing issues which were a golden thread running through most issues. In conclusion there was general agreement on the need for alignment between VCS and the Health and Wellbeing Board. Sam Everington summarised by saying co-production, sustainability, business engagement and volunteering were all key elements that the Governing Body supported and would support.

Members NOTED the item.

4 For information

4.1 Audit Committee Summary

No further comments were raised. Members noted the item.

4.2 Transformation and Innovation Committee Summary

No further comments were raised. Members NOTED the item.

4.3 Finance, Performance and Quality Committee Summary

No further comments were raised. Members NOTED the item.

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4.4 Executive Committee Summary

No further comments were raised. Members NOTED the item

4.5 Primary Care Commissioning Committee Summary

No further comments were raised. Members NOTED the item.

4.6 London Health and Care Collaboration Agreement

No further comments were raised. Members NOTED the item.

4.7 Estates Strategy

No further comments were raised. Members NOTED the item.

4.8 Health London Partnership beyond 2015/16

Richard Quinton briefly explained the report. The meeting was in accord with its purpose.

Members NOTED the item.

5 Questions from the Public

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

6 Any Other Business

No comments or questions were raised by the members.

The meeting ended at 5.15pm.

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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.

Jan15 #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.

Jan16 #1 Jane Milligan to circulate the seven day service definition and the HSJ article to GB members

JM March 2016

Completed.

Jan16 #2 Ellie Hobart to include update on PMCF and hubs in Newsletter

EH March 2016

Completed.

Jan16 #3 Archna Mathur to liaise with Lee Eborall regarding the evaluation of BMI cases

AMLE

March 2016

Completed.

Jan16 #4 Archna Mathur to arrange QA visit to BMI

AM March 2016

Completed.

Jan16 #5 Archna Mathur to explore feasibility of Healthwatch enter and view visit to BMI

AM May 2016

Completed.

Jan16 #6 Richard Quinton to ensure suitable contractual arrangements

RQ March 2016

BMI Lead contract arrangements across London still under discussion.

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Action reference Action Lead Due

Date Update

Board will be updated as soon as any changes are confirmed.

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