Oxfordshire Clinical Commissioning Group Governing Body...May 28, 2015 · about cancelled elective work over the winter. DH would provide the figures and GK would provide the impact

Oxfordshire

Clinical Commissioning Group

Oxfordshire Clinical Commissioning Group Governing Body

Date of Meeting: 28 May 2015

Paper No: 15/55

Title of Presentation: Sub-Committee Minutes

Is this paper for

Discussion

Decision

Information

Purpose and Executive Summary (if paper longer than 3 pages):: To share with the Governing Body the minutes of the February 2015 Finance and Investment Committee meeting (following cancellation of the April meeting the March minutes will not be available until after the May meeting), the January and April 2015 Integrated Governance and Audit Committee meeting and the February 2015 Quality and Performance Committee meeting.

Financial Implications of Paper: None

Action Required: The Governing Body are asked to note the contents of the report.

NHS Outcomes Framework Domains Supported (please tick )

Preventing People from Dying Prematurely Enhancing Quality of Life for People with Long Term Conditions Helping People to Recover from Episodes of Ill Health or Following Injury

Ensuring that People have a Positive Experience of Care Treating and Caring for People in a Safe Environment and Protecting

them from Avoidable harm Equality Analysis completed (please tick and attach)

Yes

No

Not applicable

Outcome of Equality Analysis

Author: Lesley Corfield, Business Manager

Clinical Lead:

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Oxfordshire


MINUTES:

Finance & Investment Committee

19 February 2015, 09.30 – 11.30

Conference Room A, Jubilee House

Present: Mike Delaney (MD) Gareth Kenworthy (GK)

Roger Dickinson (RD) Paul Park (PP)

Diane Hedges (DH) Jenny Simpson (JS)

Duncan Smith (EDS) – Chair

In attendance: Ros Kenrick - Minutes Gary Heneage (GH)

Lukasz Bohdan (LB) item 3

Action

1. Apologies: James Drury (JDr), David Smith (DS)

2. Declarations of Interest There were no new declarations of interest.

3. QIPP Update LB noted the headlines from the QIPP pre-meet for the minutes. The end of year position had not changed. Next year there would be 18 projects with a joint savings target of £9.7m. Part year business cases had been discussed and OCCG had been seeking assurance of engagement of the provider trusts. A robust project document would be required to deliver assurance. EDS requested another QIPP pre-meet before the next meeting. Current year QIPP will be the topic.

RK

4. Minutes of Last Meeting The minutes of the meeting held on 27 January were approved as an accurate record.

Matters Arising Action Tracker: updated Locality Budget Setting: It was confirmed that this was not a high priority at present and that it would come to the committee when it had been discussed at locality meetings.

5. Finance Report Month 10 At 31st January (Month 10), NHS Oxfordshire Clinical Commissioning Group (OCCG) reported a year to date surplus of £1.5m (£58k deficit at Month 9) and a forecast outturn surplus of £1.5m (£1.5m at Month 9). The move to a forecast surplus was enabled by the underutilisation of the national CHC Risk Pool which was reflected in Month 9 reporting. The contribution was adjusted in Month 10 and is therefore now reflected in the year to date position as well as the forecast outturn. There had been no movement to the CCG allocation in Month 10.

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The mitigated risks totalled £2.7m (£2.7m at Month 9) and were offset by contingencies held. The best case forecast outturn would be £2.8m surplus (£2.9m at Month 9) and the worst case £1.6m deficit (£0.7m at Month 9). The worst case had deteriorated from last month due to the potential national clawback of additional funds allocated to CCGs for Referral to Treatment (RTT) activity. A risk of £2m (mitigated to £1.1m) had been included in the risk table this month, offset by reductions to other risks including the risk relating to property charges. There had been reductions to the forecast overspends for SCAS Emergency Patient Transport, Nuffield Manor and to a number of smaller contracts. The Pooled Budgets for Older People, Learning Disability and Physical Disability, after risk sharing where applicable, showed a projected over spend at year end of £0.922m (£0.923m at Month 9). The proposed charges from Property services and Community Health Partnerships (CHP) had not yet been finalised. The forecast remained at £0.2m overspend but the risk to the CCG had been reduced to £0.2m this month (£0.7m at Month 9) to reflect on-going negotiations. GK noted that the key concern for the OUHT contract was non-elective activity which would be unsustainable for the whole system. EDS asked about cancelled elective work over the winter. DH would provide the figures and GK would provide the impact on monies and the day case rates for this committee. DH would provide information on the large increase in endoscopy activity.

DH GK DH

6. Financial Plan 2015/16 and contracting update Contracting update: Negotiations were underway with OUHT, OHFT and SCAS, despite uncertainty linked to the tariff. Letters were received yesterday that would have a financial impact on OCCG (detail below). OUHT: Challenges were around activity and growth in urgent care activity in particular. There had been a proposal from OUHT of a change in the Marginal Rate Emergency Tariff (MRET) 2008-09 baseline on the grounds of service and population change. This could result in an extra £7m cost to OCCG. OHFT: The Trust’s position was being driven by the deficit of £4.4m this year. OHFT believed that seven day working introduced in 2014/15 would not be sustainable. EDS asked whether there had been an evaluation of the seven day working arrangements. The financial report showed large underspends in key areas. Committee members wondered how whole system working would affect these figures. The progress of whole system working would be discussed at a meeting of Chief Executives and Directors of Finance on 24 February. SCAS: The Trust had submitted a business case around internal recruitment challenges i.e. banding changes and accelerated training and development. Banding of SCAS staff is lower than elsewhere, so more highly-trained staff have been leaving the Trust. This would result in an increased cost for Thames Valley of £5m of which £1.6m would relate to OCCG. Discussions around this would go through the Whole System Group and Transformation Board. GK explained that separate letters to commissioners and providers had

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been received yesterday from NHS England and Monitor. Given that the original tariff proposals had been successfully contested, Providers have been given a choice of an enhanced tariff option (ETO) or Default Tariff rollover. It was expected that the enhanced tariff option would be chosen, although OUH has indicated that the two options do not have a significantly different overall impact. Under the ETO option, there would be a change to the deflator from 3.9 per cent to 3.6 per cent which could entail a £1.7m cost to OCCG. There was also a proposal to increase MRET further to 70 per cent at a cost to the CCG of £3.3m. The total impact is therefore estimated at £5m. It is anticipated that this will be mitigated by a share of approx. £1.5m of the nationally agreed additional funding of £150m. The letters would need to be discussed at the Whole System Group meeting.

7. Contracts with smaller providers The Committee considered the current forecasts for the contracts currently making up the Other Acute category in the finance reports. These are all relatively small (level 3) contracts (in terms of the CSU contract) and therefore do not receive the same degree of oversight as the larger contracts. The CCG leads are gradually working through these contracts to rationalise where possible and to ensure they are appropriately monitored by the CSU. Concerns about Circle Reading’s cashflow had been noted. Any Qualified Provider (AQP) audiology at Specsavers had seen a rise in hearing aid provision. It would be important to know whether this had been due to over-diagnosis or a previous lack of adequate provision. DH had been asked to report back on the relationship of the Nuffield Manor and OUHT contracts.

DH

8. Financial Assurance Framework and Operational Risks The paper presented contained the nine new assurance framework risks and the existing operational risks. The committee discussed the ratings for the new risks and agreed that they were appropriate. EDS had been concerned that metrics would be hard to measure. AF 24 would be discussed at Integrated Governance and Audit committee in July. AF18 Oxfordshire had not yet fully developed its GP Federations. The operational risks had been updated, but not yet reviewed in light of the new assurance framework. OR 725 was not considered to be a financial risk and would be discussed at Integrated Governance and Audit committee. MD noted that a robust programme management approach was necessary. It was agreed that John Jackson and Diane Hedges would be attendees at Finance and Investment committee when contracts were to be signed off.

9. RTT waiting times and targets Money had been invested to clear the backlog. The committee had requested a report on progress. Prior to the extra funding there had been over-performance on activity and because of that and the backlog the system was not on plan. There had been improvement, but admitted patients and orthopaedics were still pressure areas. OCCG would be confident that NHS Constitution standards would be achieved, subject to the contract negotiations for 2015/16 in which activity levels would need to be appropriately agreed.

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The RTT funding had been spent appropriately, but had resulted in some over-performance in other areas such as diagnostic imaging and high-cost drugs. More funding had been made available by NHS England, but there would be an element of clawback. The amount of the latter was not yet known. In contract negotiation with Oxford University Hospitals Trust (OUHT), the Trust proposal had included the non-recurrent money as recurrent. There being some duplication in the figures, more negotiation would be required. The committee asked DH to investigate what might still be stopping the clearance of the backlog.

DH

10. Approval of procurement decisions None

11. Finance and Investment Committee Work Plan

QIPP briefing to be arranged for before the March meeting.

Procurement work plan will not be discussed at March meeting.

Financial position and contract update to March meeting (to include OUH performance).

Year end value for money assessment to March meeting.

Prescribing update to March meeting.

Older People’s OBC most capable provider paper to March meeting.

12. Any Other Business There being no other business the meeting was closed.

13. Date of Next Meeting The next meeting was scheduled for 17 March 2015, 13:30-16:00, in Conference Room A, Jubilee House. A pre-meet will be held from 12:30 around QIPP.

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Action Tracker – Finance and Investment Committee – 27 January 2015

Item Action/ Issue Owner Date raised Date due Update Open/closed

Finance Report Locality budget setting update to December meeting if available

JS 20/11/2014 18/12/2014 27/01/2015

Not yet available. No date will be set for this action. The committee will await results from the locality meetings.

Open

Pooled Budgets: look into financial implications of repatriation of Learning Disability patients

DS 18/12/2014

27/01/2015 19/02/2015

On-going: Plans to sign off the Big Plan tomorrow

Open

Paper on smaller contracts (to include Foscote, Circle and Nuffield)

GK 27/01/2015 19/02/2015 Closed

High level RTT waiting times and targets paper

GK 27/01/2015 19/02/2015 Closed

Discuss possible impacts of over and under-performance at OHFT with DH and Sula Wiltshire

GK 27/01/2015 19/02/2015 Taken in contract monitoring meetings

Closed

Enquire about the overspend in endoscopy vs underuse of Witney unit

GK 27/01/2015 19/02/2015 Echotech Open

Provide figures for cancelled elective work over the winter

DH 19/02/2015 17/03/2015 Open

Provide the impact of non-elective activity on monies and the day case rates

GK 19/02/2015 17/03/2015 Open

Provide figures on the increase in endoscopy activity

DH 19/02/2015 17/03/2015 Open

QIPP QIPP pre-meet before next meeting RK 18/12/2014 27/01/2015 19/02/2015

27/01/2015 19/02/2015 17/03/2015

Closed Open Open

Make agreed amendments to the draft Terms of Reference and note these to Governing Body meeting on 29 January

RD 27/01/2015 29/01/2015 Closed

Contracts with smaller providers

Report back on the relationship of the Nuffield Manor and OUHT contracts

DH 19/02/2015 17/03/2015 Open

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RTT waiting times and targets

Investigate what might still be stopping the clearance of the backlog.

DH 19/02/2015 17/03/2015 Open

8 Sub-committee minutes

Oxfordshire


MINUTES:

INTEGRATED GOVERNANCE AND AUDIT COMMITTEE

22 January 2015, 09.30 – 12.30

Conference Room B, Jubilee House

Present: Adrian Balmer Philip Lazenby

Mike Delaney Graz Luzzi

Roger Dickinson – Chair Catherine Mountford

Maria Grindley Jenny Simpson

Gareth Kenworthy Duncan Smith

In attendance: Ros Kenrick Jeanette Oakley

Apologies Paul Grady

Action

1. Pooled budgets discussion: lay members with MG

2. Declarations of Interest There were no declarations of interest.

3. Minutes of Last Meeting With a couple of minor amendments to the wording, the minutes of the meeting held on 26 November 2014 were approved as an accurate record.

4. Matters Arising (3) Service Auditor Reporting CSU response: JO reported that she had received the final report yesterday. It would be circulated as soon as possible. (9) In Year Progress Report: Topics for audit next year had not yet been finalised. Topics would be decided in relation to the Bribery Act. CM will bring a paper on suggested training for staff, in particular the lay members, to the next meeting.

CM

IGAC SELF-ASSESSMENT

5. IGAC Self-Assessment development plan The committee supported the plan. A discussion was held about how Governing Body might be encouraged to challenge IGAC, particularly around the Assurance Framework and Risk Register. GL suggested that Governing Body might undertake a similar self-assessment exercise. CM/RD to discuss with the Chief Executive and Chair.

CM/RD


FINANCIAL MATTERS

6. Final Accounts – Accounting policies, Timetable & Month 9 Financial Accounts The Department of Health has issued the following deadlines for the submission of the 2014/15 accounts:

23 April 2015 (noon) for the submission of the un-audited accounts to the Department of Health and External Auditors.

29 May 2015 (noon) for the accounts to be audited by and sent to Department of Health.

The committee reviewed the draft accounting policies. There are no significant changes for 2014-15 but information will be required from OCCG to tailor particular areas mainly relating to accounting estimates and critical judgements. The Committee reviewed the draft Month 9 financial accounts. Not all notes had been completed for this exercise but the main financial statements were complete. There had been some amendments between the date of submission to the Committee and the national submission. The Committee felt that it would have been more helpful if an analytical review had been completed. JO agreed that the CSU would complete this. The draft timetable was reviewed. JO confirmed that the CSU team was now in place and she was confident that the team would deliver on time. GK felt that the timetable was not explicit enough about the production of the Annual Governance Statement and Annual Report. An extra IGAC meeting to discuss the final accounts will be held on 20 April. MG informed the committee that based on last year’s experience, the fact that there is a new team in place at the CSU, and that the CSU would be merging on 1 April with two other CSUs. The committee and external audit expressed concern that there was a significant risk to the timely completion of the annual accounts. MG noted that there would be two difficult points - at the delivery of accounts and working papers to the auditors and at the final submission date. The committee requested a risk assessment be undertaken around the timetable with planning for key scenarios. MG agreed to work with JO to undertake a risk assessment with input from the CCG as required.

JO CM JO/MG

7. Process for approval of the Annual Accounts and Annual Report for 2014-15 Governing Body will be asked to receive and approve the accounts and annual report on 28 May 2015, with the national submission date being 29 May. The committee would review the accounts and annual report at its meeting on 21 May. It is proposed that authority to approve any changes to the accounts after that date would be delegated to three individuals i.e. Chair of the Audit Committee, the CFO and the Accountable Officer/one of the qualified accountant lay members. A paper will be submitted to the


March Governing Body to enable them to formally approve the delegated arrangements. CM agreed to review the Scheme of Delegation to see if this can be reflected as a permanent arrangement. MG informed the committee that external audit would be aiming to have the accounts finalised earlier than the statutory deadline.

JS CM

8. SLA Reports update OCCG is currently in negotiation over the 2015/16 contracts. There were two contracts outstanding for 2014-15. Both the Buckinghamshire hospitals and NHS 111 contracts have now been agreed and closed down. The 111 contract is for two years (2014/15 and 2015/16).

9. Co-commissioning update The options have been discussed at locality meetings and the proposal is for joint commissioning. A paper is to be submitted to Governing Body on 29 January.

10. Finance and Investment Committee Minutes Pooled budgets: the discussion is on-going. Finance and Investment committee required more assurance around whether current agreements are fit for purpose. There should be cross-organisation audits. Lay members should contribute to the scope of the audits and the section 75 agreements. RD will discuss this area with DS. The committee considered whether there was a conflict of interest for the role of Director of Strategy and Transformation. The committee asked to see Joint Management Group (JMG) minutes at the next few IGAC meetings. GK agreed to discuss this with CM and to scope the issue with Executive Team. It could then be discussed at a Governing Body workshop. There were concerns around QIPP delivery. These had been mitigated in the current year, but there would be no reduction in the requirement for QIPP delivery next year. An extra QIPP session had been arranged for the next Finance and Investment committee meeting.

RD GK/CM

EXTERNAL AUDIT

11. In Year Progress Report MG asked the committee to note that a King’s Fund survey found no respondents who were positive about the financial state of the NHS. Last year, a quarter of value for money audit conclusions had qualifications. This had been the highest number to date. EDS asked GK to consider writing a paper on contracting out services. GK would bring it to a future Finance and Investment committee meeting. The committee requested an update on the quality of CSU services which would come to the March meeting. This would be focused on individual CSU activities to give a regular oversight. The contract with the CSU terminates on 1 April 2015. Next year lead commissioners may be identified for CSUs. OCCG would have to go through a national process if it were to in-source any CSU functions.

GK GK

INTERNAL AUDIT

12. In Year Progress Report Three reports have now gone through to the final stage.


Non-contract activity received reasonable assurance; Partnership Governance received reasonable assurance; Information Governance Toolkit received reasonable assurance and would be brought to the next meeting. CM would bring detail on the toolkit submission to the next meeting. MD suggested an audit was required on the business risk if access to information was not forthcoming. GK/CM would action this. CM is working on a definition of partnerships. The next reviews would be on safeguarding and critical financial assurances (pooled budgets). The latter APM would be brought to Audit Committee for information. The report noted some outstanding follow up actions which are currently being reviewed. MD queried the relationship of OCCG with the Academic Health Science Network (AHSN). GK advised that there would be huge potential in a proactive relationship. Committee members asked about OCCG representation at Foundation Trust Governing Bodies. OCCG is represented, but there is a limited resource, so the effectiveness of representation was queried.

PL CM GK/CM PL

GOVERNANCE AND RISK

13. OCCG Assurance Framework A new Assurance Framework was proposed to replace the current one. This would be a more strategic level document. The committee endorsed the approach to take a step back to review the framework. The eight proposed risks were agreed, with a ninth one added around QIPP delivery.

CM

14. OCCG Operational Risk Register The lay members noted that they would be pleased to meet individual risk managers outside these meetings to discuss risks, rather than hold some of the discussions during the meetings.

15. Risk Management Policy and Strategy The document describes the organisation’s risk appetite and asks to what degree OCCG should reflect stakeholders’ risks and hold them to account. The whole system approach means that OCCG’s targets are dependent on others’ performance. This should be captured in the strategy. The committee welcomed the paper which would be taken to a Governing Body workshop. MG noted that other CCGs have similar documents and that she would look at them for comparison.

16. Quality and Performance Committee Minutes EDS attended this committee meeting in December because he was not assured from the minutes. He suggested that the Q&P committee could do more to get independent assurance on the challenges faced. The minutes need to provide assurance to GB. MD will attend one of these meetings in the next few months.

CM

GENERAL AUDIT MATTERS


17. Use of Single Tender Action Waiver There had been no single tender action waivers since the last meeting.

18. Integrated Governance and Audit Committee Work Plan The work plan was noted and the agenda items for the March meeting reviewed. A new plan is in draft for the next year and will be circulated with these minutes.

JS

19. Terms of Reference Review The committee approved the revised terms of reference within the draft constitution.


21. Date of Next Meeting The next meeting will be held on 19 March 2015, 09:30-12:30, in Conference Room A, Jubilee House


Oxfordshire


MINUTES:

INTEGRATED GOVERNANCE AND AUDIT COMMITTEE

20 April 2015, 13:30-15:30

Room 7, Jubilee House

Present: Mike Delaney Catherine Mountford

Roger Dickinson – Chair Jenny Simpson

Duncan Smith

In attendance: Ros Kenrick Jeanette Oakley (item 3)

Emily Somerville (item 3)

Action

1. Apologies: Graz Luzzi, Gareth Kenworthy Declarations of Interest There were no declarations of interest.

2. Formal Approval of Accounting Policies No major changes had been made to the policies for 2014/15. DS asked for an update re any potential changes for 2016-17. IGAC approved the policies.

JS

3. Review of Annual Accounts The paper presented was draft as at 17 April. An analytical review had been provided. The final position was a surplus of £1.5m. This was achieved after the £2m reduction to the allocation agreed with NHS England. This was possible due to the release of contingencies held, against risks that had not materialised. All financial performance targets had been met, i.e. revenue and capital expenditure did not exceed allocations. JS informed the committee that NHS England had sent a number of checklists for completion by next week. The updates made to the accounts since 17 April were:

The pooled budget memorandum accounts have now been added to the notes to the accounts.

The mental health pool contributions from OCC had now been correctly coded

The cash flow statement should read £655k for 2014-15 - an amended sheet had been circulated to the Committee

The deadline for submission of the financial template would be by midday on 23 April, with the full Annual Report and Accounts document on 24 April. OCCG would aim to submit the template on 22 April. RD asked whether the process was going to time. All deadlines to date had been met and the team was confident that this would continue. JO had met


the auditors and provided a list of responsible staff for each note. JS noted her thanks to JO, ES, Caroline Webber and the team for their work on the annual accounts.

4. Responses to Ernst and Young The draft responses were reviewed. Minor amendments were proposed before sign off.

RK/GK/RD

5. Review of External Audit The committee would ask GK to give management’s views. However, there were no concerns about external audit. RD informed the committee that he had attended a seminar at which it was announced that the external audit system would be changing. The implementation of local appointment of external auditors was likely to be delayed for two years. The contract for the current external auditors would be extended until the new arrangements come into place.

GK

6. Review of Internal Audit Comments on internal audit indicated that the committee sensed a lack of depth in the work. This included the Head of Internal Audit’s opinion which was to be included in the annual governance statement. Wording was the same as last year, but assurance had changed from adequate last year to satisfactory this year. JS to check with internal audit and circulate the response. [Post-meeting note: Internal audit confirmed that the definitions had changed in-year and there was no change in their assessment of the CCG.] JS would also ask Head of Internal Audit for commentary that supports the statement. Proposed audit plans are now seen in advance and the committee is able to influence the scope of the audits. The committee was concerned about obtaining assurance on jointly-commissioned work. Further comments on internal audit to be sent to RD. Executive Team to be asked to review the work of Internal Audit and also the engagement of the CCG with the internal audit process.

JS JS All CM

7. Review of Savings (QIPP) Audit draft terms of reference The draft terms of reference did not address the issue of reliance on data from other organisations. The audit would also need to look at:

Cross-organisational boundaries

Compliance with rules covering business cases and their submission

Senior clinical buy-in and locality engagement

Planning – how realistic is the plan? Is it SMART? The audit should not be checking whether or not there is a plan.

JS to give feedback to PG. PG to be invited to contact RD if he would like to discuss CCG expectations for the audit. MD noted that in all internal audit work, value would be added by giving examples of best practice from other organisations and the addition of suggestions for better practice in Oxfordshire. The auditor should be one who is undertaking or has undertaken similar audits in other CCGs. The terms of reference will be brought back to the next meeting.

JS RK


8. Draft Governance Statement Amendments would be made by CM as discussed.

The committee agreed to use the term ‘savings’ in place of ‘QIPP’.

External audit would be making reference to the non-achievement of the QIPP programmes in the value for money statement. This should be included in the governance statement.

CM to check with Sula Wiltshire about the non-NHS providers section.

The risk around maternity pre-payment was noted.

CM CM CM

9. Annual Report The draft annual report was discussed at length. Amendments would be completed by CM. Particular actions are listed below:

CM to write to individuals regarding the small (and identifiable) numbers of voluntary redundancy pay-outs.

JS to check guidance on disclosure of redundancy pay-outs.

The Committee agreed that the main financial statements would be included in the annual report again this year in order that it could be read as a stand-alone document.

CM to discuss with Executive Team and Comms inclusion of the five-year plan highlights and achievements against this to date. There was no obvious reference in the report to whether or not OCCG delivered on its plan for 2014/15.

Townlands hospital occupancy: GK to provide a report to Finance and Investment committee.

Reference needed to be made to the Operation Bullfinch investigation and report.

CM CM JS JS CM GK/LF CM


11. Date of Next Meeting The next meeting would be held on 21 May 2015, 09:30-12:30, in Conference Room A, Jubilee House


Action

1. Declarations of interest There were no declarations of interest.

2. Minutes of Last Meeting Subject to the following minor changes the minutes of the meeting held on 18th December 2014 were approved as an accurate record. Page 1 – change of title for AC to “Designated Nurse & Safeguarding Lead” Page 2 – to read after Involvement (PPI) member an insertion saying “DH queried whether this could be linked in with the Locality Patient/Public Forums”.

3. Matters Arising & Action Log There were no matters arising. Action Log The Action Log was discussed in detail. Action 10/14/1 - OUHT Board paper Scrutiny TS mentioned that the papers have been reviewed and there is no evidence of any issues with test results. SW/TS have written to the Medical Director, Tony Berendt, of Oxford University Hospitals NHS Trust stating this fact and they are awaiting a response. LW confirmed that there should be one lay member and one executive who should attend the OUH/OFT Board meetings. OCCG representatives have concerns in relation to test results and clinical communication; they feel that these subjects are not being discussed at board level. Action: LW to speak with OUHT Vice Chair in regards to the OUHT being more transparent to their Board members in regards to reporting safety concerns raised by the commissioners. This should also include the management of test results. A Management letter is to be written to follow this action up by SW Action: SW to write a letter to the Board members highlighting safety concerns raised by commissioners. Action 10/14/3 – Primary Care Programme Board This has been actioned and all agreed that this can be closed. Action: TS is to close Action 10/14/3 Action 12/14/1 – Review of OCCG’s approach to PPI

LW

SW

TS


CM stated that this paper is due in April. CM will present the paper at the next meeting. Action: CM is to bring the updated paper to the next meeting on 30th April. Action 12/14/6 – Safe Guarding Issues on Risk Register AL confirmed this has been reviewed and this is not to be a separate risk, this can be incorporated into AF10. This action can now be closed. Action: TS to close action 12/14/6 Action 12/14/7 – Changes in Cauda Enquina Pathway The pathway has been reviewed and there is no evidence that the process is unsafe. TS stated that there has been no negative feedback. This was confirmed by RG. However, this should be monitored. DC highlighted that the pathway needs to be communicated clearly as this is paramount. There needs to be both monitoring and measurement. LW stated that this action cannot be closed until there is more solid information. Action: RG to discuss with OUHT and find out more detailed information on pathway monitoring and measuring. Action 12/14/8 – Friends and Family Data OUH HW stated that a report had been received by the OUH. This has now been in place over a 2 year period. There has been a massive amount of work carried out and response rates need to be around 15%. There is a major focus on qualitative data. This data highlights that the majority of patients seem to be happy with the service. This outcome is positive. HW will bring an updated paper to the committee when there is more up to date information. Action: HW to bring an updated paper to the committee when more data is received. Action 12/14/9 – Reviewing OCCG’s Contract to incorporate MSk waiting list into CRM TS stated that OUH has confirmed the backlog and that this would be cleared by end of February. We are still awaiting confirmation from OUH that this has been carried out. Action: TS to keep monitoring OUH on their backlog and if/when it is cleared. Action 12/14/11 – Finalising Commissioning for Quality & Innovation

CM

TS RG

HW


(CQUIN) list SW confirmed that agreement of CQUIN for 2015/16 is linked to the on-going work around the proposed tariffs. This may mean that only the national CQUINs are applied in 2015/16. Therefore, this will hamper progress for the 2015/16 contract. We are awaiting a response from the Trusts. This will need to link to the Transformation agenda and the work being undertaken to consider whole system impact. SW pointed out that National CQUINs related to acute kidney injury and sepsis. The CCG would want to see improvements where needed irrespective of a CQUIN. We need to engage with Trusts to agree service improvement plans and this may need to be via the Service Delivery Improvement Plans. DH expressed the importance of the focus on solving the financial issues, delivering on the contract and maintaining quality. It was agreed that both DH and MD will meet to discuss the links that could be made between the Quality & Performance and Finance and Investment Committees. Action: DH and DC to meet to discuss possible links between committees and advise the lay chairs on improving these links to oversee delivery on contracts.. RG expressed his concerns over quality and stated that GPs have used CQUINS to support development and delivery of some basic requirements. However, the CCG needed some levers to encourage providers to improve their services. Action: TS is to close this action and bring back to committee at a later date when there is more detailed information available. Action 12/14/12 – Stroke Performance at Trust Sites TS explained that the CCG has been allocated a Project Manager to develop a business case. The aim of the CCG is to adopt the “London” model and improve early supported discharge service. The plan may look at the number and location of rehabilitation beds, but this will be dependent on the modelling of the pathway. Upon completion, TS will bring the final proposal to the Committee. LW stated this action could be closed but, is to be brought back to the Committee at a later date. Action: TS is to close this action. When there is more detailed information TS is then to update the Committee with findings at a later date.

TS

DH/DC TS


TS

4. Forward Planner The Forward Planner was discussed in detail and the committee agreed that this document should stand as is. DHu raised a concern in regards to the Health and Wellbeing Strategy and how the public health initiatives can be included. Action: DHu and VM are to populate the Forward Planner with Health and Wellbeing information. JD queried why both the CQUIN proposals and CQUIN completed were on the same list? It was explained that one set of information is looking forward and the other is reviewing the past allowing for analysis. JD questioned whether there was a way to include the quality schedule to demonstrate to the committee current performance TS advised that the Quality and Performance report and the risk register is intended to alert the committee to key concerns. TS advised that any key issues arising from schedule 4 would be reported to the committee via these documents. LW suggested that the current Schedule 4 should be removed from the Forward Planner. Although the final Schedule 4 is to be used at the start of each financial year and should be reported to the Committee, as it gives the group an understanding of what indicators will be monitored in that year. Action: TS is to update the Forward Planner to reflect the removal of the current Schedule 4.

DHu/VM TS

5. Quality & Performance Report This was discussed in detail Page 3. 111 Call Answering Time TS informed the Committee that the 111 system experienced technical issues over the Christmas period in the south of the region. It is unclear if this was caused by exceptional demand or other technical problems. However, generally the call handling has improved in January and February. LWr advised that the SIRI that was raised was due to the telephone system being down and a report will be provided to the CCG for comment on March 15. Contractual issues TS stated that all three contract queries with OUH remain open these include:


Management of test results 62 day cancer target Speed of OP communication

Updates are reported to the Contract Review meeting and cannot be closed until the remedial action plans have delivered and the expected improvements have been made. The first exception report relating to the roll-out of the Direct Booking Service (DBS) remains open. However, the OUH have suspended the roll-out due to technical issues. RG was concerned that OUHT does not put enough effort into finding timely solutions. TS stated that there is a Choose-and-Book meeting being held on the 3rd March, issues can then be discussed and understood. DC mentioned that the Urology department cannot accept patients through Direct Booking Service (DBS) it appears that the services that have gone live have been suspended. TS stated that the OUH had advised the CCG the reason for the suspension of the roll-out would not affect services that were already live. Action: Both TS/DC are to raise issues with Sara Randall in regards to the Choose-and-Book system. Both RG and DH are concerned that safety concerns highlighted by the CCG to the OUH are not being addressed in a timely manner and the contract does not seem to give the CCG enough traction Action: SW and DH to meet to discuss/identify the key 4 or 5 quality issues relating to OUH. They are then to escalate to the Contract Negotiating Team. This will ensure that we have more effective levers in the 15/16 contract. Page 3 - Category A Ambulance calls DH stated that there is a down-turn in the performance of the service and this trend is dropping further. SCAS are unable to maintain the 75% target and the Trust view is that unless commissioners’ support and fund, this will continue to deteriorate. DC explained that these drops in service could be related to flu activity earlier this year. Therefore, this situation may have been due to the exceptional demand. Page 4 - A&E 4 Hour wait & DTOC DH reported that OCCG is down on target, although we are using the Emergency Care Intensive Support Team (ECIST) to support/help diagnose data to find out what happened and why there is bed blocking and high numbers of Delayed Transfer of Care (DTOC). Work is being carried out to try and understand the root causes so focused solutions

TS/DC SW/DH


can be implemented. TDH stated that the linkage between DTOC and A&E performance cannot be the only issue as DTOCs have reduced but A&E performance has not improved. SW queried whether the figures on Page 4 were correct and whether they should be part of a further discussion with Emergency Care Intensive Support Team (ECIST). DH highlighted that the process has changed significantly in the last year. The trusts are trying to get the patients back in their own home as soon as possible after a Hospital stay. LW suggested that these figures need to be reviewed and discussed on a constant basis. MD queried where on a spectrum from anecdotal evidence to full analysis/modelling would the diagnosis of the problem be. DH stated the diagnosis would be a mix across the spectrum and that the Emergency Care Intensive Support Team (ECIST) had carried out two pieces of work. One being a whole system diagnosis (what is the data/information telling us) and the other is focused on the Acute Trust. Page 5 – The Referral to Treatment Times (RTT) DH reported an improvement on trend since November 2014 though this is under constant review. Page 6 - 52 Week Waiters DH reported an improving picture from last month. It has been agreed that OCCG and The Trust will focus on backlog plans and patients that have been waiting the longest. The Trust has committed to have zero patients waiting 52+ weeks by the end of March 2015. 62 day Cancer target DH reported that the CCG still had concerns over the delivery of this target. The OUH has 3 remedial action plans in place and they expect to meet the target in April 2015. This data should be available in June 2015. TS/LC reminded the committee that at the time of the contract query, OUH had originally agreed to meet the target in November 2014 reported in January 2015. The OUH missed this date and subsequently proposed a revised achievement date of January 2015 reported in March 2015. The Trust anticipate that the January data will also breach and the CCG may wish to consider escalation if the January data shows no improvement. However the committee agreed to keep a watching brief at this time.


CM highlighted that it appears we are meeting the 2 week wait, but not the 62 day cancer target. DH stated that this could be due to the rising numbers of 2ww referrals. DC agreed with DH and reiterated that the issue for GPs is spotting the different types of cancer and the diagnosis, as this takes time. CM believed this could affect the 2ww target, but was unlikely to affect the 62 day cancer target as the number of patients diagnosed with cancer remains the same. LC stated at the last meeting OUH said stated that they were not going to hit the target. December’s data has been received and they have committed to achieving the target by April 2015. There are two outstanding actions and two missed deadlines. SW stated that the contract query is already open but the CCG may wish to escalate the concern. DC queried whether the hold-up is (PET) scans. Action: LC to update the committee on next month’s performance and on the effectiveness of the OUHT actions. Page 11 - 111 inspection of call handling service LWr visited the site and reported generally call handling has improved. There are some issues around lack of visibility of senior management, long shifts/few breaks and a lack of awareness of the standard operating procedures. An action plan is being developed to address issues. Page 12 – SCAS CQC Inspection TS reported SCAS had their CQC inspection and on the whole it was positive. There are a few areas for improvement such as more training to meet targets, understanding the Mental Capacity Act 2005, Leadership to be strengthened in relation to safeguarding, emergency calls answered more efficiently and emergency medical dispatchers to dispatch ambulances within the target times. Page 13 - Serious Incidents TS reported that there are five Never Events open and reported by OUHT. These events consisted of:

Two events were foreign objects left in the patient post operation Two events relates to wrong site surgery One other event relates to misplaced nasogastric tube

Each of the above is being investigated and a report is in progress. This should be ready for inspection by the beginning of March 2015. OCCG have escalated their concerns to the Medical Director at the OUHT via the Quality Review Group. The OUHT are expected to produce a plan to address these events/serious incidents.

LC


The Quality and Performance Committee considered how it may decide that the sum of all the concerns indicated that there were serious widespread failings in an organisation. It was confirmed that the Quality and Performance Committee will concentrate on ensuring issues were evidenced.

6. Quality and Performance Report / Quality at a Glance / Risk Register Clinical Risks Paper (1 Page Report) TS addressed the paper. It was highlighted that AF22 is the same as and has replaced AF10. The risks are being managed however, we still need to improve. As reported earlier the CCG still has issues about the length of time to rectify some of these issues.

Quality Issues at a Glance TS highlighted the entry on page 5 about British Pregnancy Advisory Service (BPAS) in regards to the safeguarding process. All short-term safeguards are in place. The SIRI report has been received and all recommendations have been agreed. CCG are waiting for assurance that all recommendations have been implemented.

Clinical Risk Register – Full Paper This was discussed by the Committee. Page 5 - 458 RG feels that this paper should reflect the telephony risks, so this needs to be updated. Action: TS to add telephony risk analysis to the Risk Register Page 13 - 705 HW discussed Southern Health and their CQC inspection. The overall assessment is “requires improvement”. Overall there were more areas rated as good than requiring improvement. The breadth of the inspection provides some assurance of quality of service provision. There is intensive monitoring and management of this organisation. The Trust received no warning or enforcement notices. Two of the services treat Oxfordshire patients. Community services for people with LD which was rated as good and inpatient wards for people with LD which requires improvement.

TS

Patient Safety

7. Quality Premium Update TS presented the paper. The ‘Quality Premium’ is intended to reward clinical commissioning


groups (CCGs) for improvements in the quality of the services that they commission and for associated improvements in health outcomes and reducing inequalities. CCGs are expected to comply with NHS Constitution targets. For 2013/14 the CCG met the RTT (incomplete pathways) and Cat A Red 1 calls. Four hour A&E waiting time and Cancer waiting time (62 day) failed. The OCCG have achieved three out of seven goals. OCCG were not able to achieve:

A reduction in people dying prematurely

The healthcare associated infection target due to MRSA Cases in 2013/14.

Unable to achieve the locally set target to reduce the length of stay of DTOC patients.

OCCG did not attain a high enough financial surplus in 2013/14 to receive any payments and no monies were awarded.

For 2014/15 the CCG are achieving two targets, awaiting data on two and are failing on the target for the Improving. Access to Psychological Therapies service. The CCG are actively working with Oxford Health to improve this target, but it is unlikely it will be met this year.

DH queried how dying prematurely is calculated. CM explained that the data is related to years of life lost from conditions considered amenable to healthcare for people aged under 75, it is built up from a range of indicators. However, this cannot be monitored on an on-going basis and is only a once a year snap shot. Action: TS and RG are to explore the current data on premature dying data. Quality Premium Target Measures TS stated that suggestions were put forward for the Quality Premium Target measures. These would need to be agreed by Health and Wellbeing Board. The suggestions were as follows:

Percentage of clinical results actioned within 5 days of test being completed.

Percentage of Outpatient letters sent electronically from OUHT to primary care.

Percentage of women initiating breast feeding – suggested 80% target.

Prevalence of smoking at the time of delivery amongst women booked with the OUH for antenatal care – suggest less than 8%.

TS/RG


LW queried whether the breast feeding should reflect duration rather than initiation. LW stated that 80% rate for initiation could be meaningless when there is not a clear measure of what they are taking into account i.e. recording data when baby is put to breast. Data for duration of breast feeding is already recorded by our health visitors. At moment there seems to be less than 5% variation and LW feels that there should a review and a realistic improvement target. This is one of the OCCG’s indicators. Action: DHu is to investigate breast feeding measurements vs targets and see where there can be some improvements or suggestions. .

DHu

8. Proposed Framework for responding to CQC Inspections of GP Practices SW presented the report and discussed with members. The paper is the proposed approach to supporting practices following CQC inspections. The CCG will work with NHS England to offer support where practices have been identified as inadequate (Special measures), where the practice is rated as requiring improvement and is rated as requiring improvement in one of the key domains or is rated as requiring improvement. SW stated that it is very important that this proposed approach is understood by all the Locality Clinical Directors. If all the LCDs agree with this proposal this will be taken to CCG Executive to be signed off. The approach will be developed locally with the GP practices. Where there is a practice in special measures The Royal College of General Practitioners has a support team. There is a cost for this support and this should all fall within the remit of this committee and integrate with co-commissioning. DC queried the links with the LCDs and what responsibility they will have in terms of delivery and the approval plan. It is his understanding that the contract sits with NHS England. SW replied that this is part of co-commissioning of primary care. SW will be meeting all the LCDs to explain the plan/approach to get them on board. This is an early phase at the moment.

9. Monitoring & Improving Performance in General Practice TS presented the report. There was an agreement that the High Level Performance Indicators are to be sent out to various practices for information. Action: TS to send out High Level Performance Indicators to the

TS


Locality Co-ordinators to share with practices. The 14th August 2014 report was shared with practices via the localities. The practices were encouraged to download their individual practice report and make improvements. The Practices were not expected to provide any updates on the work they had undertaken. This report suggests how the OCCG can build on the existing mechanisms by adding a range of information available to the CCG, but currently not used to triangulate the quality of GP services. This will include: 1. Information on complaints provided by NHS England:

2. More extensive patient survey information;

3. Feedback from secondary care via Datix;

4. Primary Care Friends and Family results;

5. Information gathered from RCAs related to c.difficile & MRSA bacteraemia.

6. Safeguarding alerts

7. Learning from serious incidents

8. Locality dashboards including more timely and comprehensive data on prescribing trends and outliers.

9. Output from the practice commissioning pack reviews.

TS informed the Committee that the OCCGwill be appointing another GP to support the quality functions. LW highlighted that all practices should have Patient Participation Groups (PPGs) and they should be involved.. DH queried whether the data/targets are accurate. TS explained that NHS England produces this report and all the information is shared amongst all the GP practices. LW suggested that there could be an additional paper added to explain the data in more detail. CM pointed out that on page 4 of the report there are data points outside the expected range, but on some charts these Practices are not identified as outliers Action: TS to contact NHSE to understand this discrepancy. In conclusion: It is expected that this information will help member practices to continually improve the service to patients without putting excessive burden on practice workload. Once data queries are resolved

TS


the paper will be presented to CCG Executive Team.

10. Prescribing Incentive Scheme for 2015/16 scoping Paper CC presented the paper. It will be a requirement of the scheme for each practice to meet with a CCG Prescribing Adviser to discuss the incentive scheme and prescribing priorities in general. The proposal will be that every practice would sign-up to the use of ScriptSwitch. Although there are financial and clinical effectiveness benefits some Practices did not want to sign-up. CM had met with a Practice recently and they reported that the cost of the service would be larger than the potential savings. JD said the OCCG are looking to use this information to aid the practices in terms of a knowledge base system, not just financial savings. Both RG and DC agreed that the benefits of ScriptSwitch system were the immediate effects of any changes or updates to a patient’s medication. LW asked the Committee if ScriptSwitch should be mandatory in practices. All agreed. MD asked CC if there has been any thought in regards to medicines wastage issues in terms of performance. CC replied we are changing some calculations in the budgets, so this has not been a priority to address at the moment. CC mentioned that she has the Asthma Audit Templates. These have been provided by the Medicines Management Team. LW asked whether the Asthma Action Plans are shared with the patient and also are there Rehab plans for patients? Antibacterial CC reported that we are doing quite well in this area at the moment. JD stated that we are in line with national policy and are continuing to promote good antimicrobial stewardship. There is a meeting next week to discuss this in more detail and a proposal will be put forward to start up the Incentive Scheme again. CC stated that the proposed Incentive Scheme has four elements to it. Both elements 1 and 2 were compulsory and each practice had a choice for elements 3 and 4 from a list of options. This model has proved successful and it is proposed to develop it further for 2015/16 by including a wider range of options.


Action: CC to check to see if the patient is part of and has access to the Action Plans. CC is to check to see if there are Rehab Plans in place. The Action Plans will need to run parallel with the Rehab Plans.

CC

11. C Difficile & MRSA Targets CWJ presented paper. The paper addressed MRSA, Clostridium difficile and surgical site infections. The paper also gives an overview of influenza activity in Oxfordshire for the year 2014 – 2015 to date MRSA NHS England has set a zero tolerance to MRSA. Nationally the rate of MRSA cases assigned to CCGs for 2013 – 2014 was 0.8% per 100,000 bed days. Oxfordshire finished 2013 – 2014 with a rate of 1.2%, this represented 8 cases of MRSA blood stream infection. CWJ discussed the post infection review and explained whether some cases were avoidable or unavoidable and what action will be taken 13/12/14. The PIR review meeting deemed a particular patient case avoidable for the following reasons:

Incorrect antimicrobial prophylaxis given. Patient was known MRSA colonised, however flucloxacillin and gentamycin given pre–operatively. Guidelines state this should be vancomycin.

Poor pre-operative skin prep with no documented evidence of the type of skin preparation used.

An action plan has been agreed with the Trust to rectify these shortfalls Clostridium difficile There has been a reduction in cases and we are doing well. The rates of Clostridium difficile in Oxfordshire are declining with progress being made year on year in reducing the number of cases across the Health Economy. To keep this reduction the proposed plan is as follows:- Update the Clostridium difficile ‘at a glance’ document for GPs to

ensure this reflects current guidelines.

Circulate amended document.

Identify GP practices according to antimicrobial use and sampling rates for Clostridium difficile.

Re-launch Clostridium difficile ‘at a glance’ document by visiting those practices identified, providing training and offering the ability to discuss guidelines and ask questions.


Extend visits and training opportunities to all GP practices.

Establish a network of identified ‘infection control link’ practitioners across GP practices to assure continuity and continuous feedback of changes and challenges faced in meeting guidelines.

Reduce the number of prescriptions of antimicrobials known to promote Clostridium difficile.

Ensure stool samples are only sent when appropriate to avoid

inappropriate testing of patients and assist in the reduction of Clostridium difficile.

Surgical site infection (SSI) At the present time the level of SSI is, as a whole, in the CCG provider hospitals is not known. Mandatory data on surgical site infections in total hip replacement, primary knee replacement and hip fracture surgery is collected by the OUH and submitted to the Public Health England surgical site surveillance system. This data is collected for one three month period in every twelve and thus is a snapshot of the activity occurring. There is no continuous monitoring. The CCG are working locally to improve the monitoring of SSI and intend to increase the number of SSI indicators in contracts where possible. Influenza Public Health England is leading on the monitoring, treatment and management of outbreaks of influenza nationally. There have been outbreaks of influenza in Oxfordshire during the 2014-2015 influenza seasons. Substantial activity has been noted in the north of the county. To date there have been 14 care homes affected with influenza type illness. Of these 14 care homes 8 have had laboratory confirmation of the presence of influenza A, there have been 26 hospitalisations over 8 care homes, 12 deaths from 7 homes and 8 homes have given prophylaxis during their outbreaks. The vaccine may have been a mismatch but, this is not clear.

12. Safeguarding Report An update on safeguarding work in adults and children was presented to the committee. The serious case review addresses the Child Sex Exploitation cases and will be published next week.

Papers for Information

13. Any Other Business The meeting was closed.

14. Date of Next Meeting


30th April 2015 09:30-12:00 CRB

Documents

Oxfordshire Clinical Commissioning Group Governing Body...May 28, 2015 · about cancelled elective work over the winter. DH would provide the figures and GK would provide the impact