BNSSG Commissioning Executive Committee

Minutes of the meeting held on 14th February 2019 at 9.00am, CCG Conference Room, South Plaza, Bristol.

Minutes Present

Andrew Appleton Corporate Clinical Lead for Digital, BNSSG CCG

AA

Sara Blackmore Director of Public Health, South Gloucestershire Council

SB

Alison Bolam Clinical Commissioning Area Lead for Bristol, BNSSG CCG

AB

Peter Brindle Medical Director, Clinical Effectiveness, BNSSG CCG

PB

David Clarke Director for Adult Social Services, South Gloucestershire Council

AC

Terry Dafter Director for Adult Social Care, Bristol City Council

TD

Deborah El Sayed Director of Transformation, BNSSG CCG DES

Kevin Haggerty Clinical Commissioning Area Lead for North Somerset, BNSSG CCG

KH

Jon Hayes (CHAIR)

Clinical Chair, BNSSG CCG JHa

Geeta Iyer Clinical Corporate Lead for Primary Care Provider Development, BNSSG CCG

GI

David Jarrett Area Director for South Gloucestershire, BNSSG CCG

DJ

Michael Jenkins Clinical Care Pathway Lead for Integrated Care, BNSSG CCG

MJe

Kate Mansfield Clinical Care Pathway Lead for Children’s and Maternity, BNSSG CCG

KM

Lisa Manson Director of Commissioning, BNSSG CCG LM

Jeremy Maynard Clinical Lead JM

Shaba Nabi Clinical Corporate Lead for Prescribing, BNSSG CCG

SN

David Peel Clinical Corporate Lead for Planned Care, BNSSG CCG

DP

Justine Rawlings Area Director for Bristol, BNSSG CCG JRa

Julia Ross Chief Executive, BNSSG CCG JR

David Soodeen Clinical Care Pathway Lead for Mental Health, BNSSG CCG

DS

Sarah Truelove Director of Finance, BNSSG CCG STr

Page 2 of 13

Lesley Ward Clinical Care Pathway Lead for Unplanned Care, BNSSG CCG

LW

Alison Wint Clinical Care Pathway Lead for Specialised Care, BNSSG CCG

AJW

Apologies

Jon Evans Clinical Commissioning Area Lead for South Gloucestershire, BNSSG CCG

JE

Martin Jones Medical Director, Commissioning and Primary Care, BNSSG CCG

MJo

Kate Rush Clinical Leadership Development, BNSSG CCG

KR

In attendance

Gemma Artz Head of Performance Improvement, Planned Cared, BNSSG CCG

GA

Mark Bradford Programme Director, Integrated Urgent Care, BNSSG CCG

MB

Sarah Carr Corporate Secretary, BNSSG CCG (for items 14 &15)

SC

Lisa Collard Commissioning Policy Development Manager, BNSSG CCG

LC

Kirstie Cornes Head of Locality Planning – North Somerset, BNSSG CCG

KQ

Jacqueline Holden Exec PA to Lisa Manson, Director of Commissioning, BNSSG CCG (Note taker)

JHo

Julie Kell Head of Performance Improvement, Integrated Care, BNSSG CCG

JK

Carla Southworth Clinical Effectiveness Programme Office, BNSSG CCG

CS

Sara Stiddard Transformation Manager, BNSSG CCG SS

Kate Tamlin Commissioning Policy Development Manager, BNSSG CCG

KT

Adwoa Webber Head of Clinical Effectiveness, BNSSG CCG AW

Item

Action

01 Welcome and Apologies Jon Hayes (JH) Chair welcomed members and attendees to the meeting. Apologies were noted as above.

02 Declarations of Interest 02a. To consider any changes to attendee interests since the last meeting None declared 02b. To consider any conflicts of interest arising from this agenda None declared

03

03.1

Minutes of the meeting and matters arising from 10th January 2019 Subject to an amendment on Page 3, Sect. 4 “ongoing” to replace “going” the minutes were agreed as a true and correct. Action log from 10th January 2019: Item 61 – Deferred to March meeting Item 68 – Deferred to March meeting Item 74 – Closed Item 75 – Closed

Page 3 of 13

Item

Action

Item 76 – Closed Item 78 - Closed - Discussed under Agenda item 9 Item 83 – Deferred to March meeting – papers to be recirculated Item 84 - Closed

83

04 BNSSG 2019/20 Operational and Savings Plan Lisa Manson (LM) introduced the Operational and Savings Plan. Sarah Truelove (ST) explained the context of the finance elements of the Operational and Savings Plan as the CCG entered the third year of the financial recovery plan. ST advised it would be an extremely challenging year with the extra resource of £68M aimed at getting the system back into balance. ST took members through the control totals highlighting the estimated £100M deficit going into19-20 noting in order to achieve the projected £7.4M surplus in the plan £42M in savings was required. It was noted however two providers had already notified they be unable to achieve their control totals. Currently BNSSG had £13M in unmitigated risks in funding. Julia Ross (JRo) advised members the national drive was to shift the provider sector, namely acute trusts, into balance and that the Financial Recovery Fund had been specifically designed to assist acute trusts to achieve balance. A discussion took place around provider position on ability to achieve realistic control totals and the current position regarding provider agreement on the level of provider growth funding to be allocated. It was noted these issues were being discussed with providers at the weekly System Planning Group and it was a significantly difficult position in terms of getting agreement on growth funding, based on a blended, although mostly fixed, tariff. An agreed process was being worked through with providers with steps taken to ensure growth funding was accurately reflected. LM advised there were disparities between the BNSSG and provider assumptions on growth which were BNSSG 4.3% and Provider 8.3% in non-elective growth; in terms of elective growth there was a commitment through the System Oversight Group to maintain activity at current levels however the system planned to address that also. LM advised that although this was needed on a clinical risk basis it could not be applied across the board and the focus should be on ability to deliver within the current financial envelopes. LM presented the operational plan for 2019/20 covering the work programmes which formed part of the ten Healthier Together programmes. LM presented a slide deck to allow members a broader perspective of the CCG programmes of work currently being undertaken and which sat underneath the overarching system structure. Highlighted areas were: LD and Autism - identified as an area for development and an area to focus on with further investment of time allocated to this area. Stroke Pathway - part of the acute care collaboration work the business case for this pathway had two elements (the Hyper Acute Stroke Unit (HASU) and Rehab) – JR considered the programme to be less than

Page 4 of 13

Item

Action

need required and queried if there was sufficient GP and community based engagement in the programme, and be expanded to include prevention to reflect the population’s need rather than just the HASU. Localities: Justine Rawlings (JRa) gave an overview on Phase 3 of the Locality Development with some Phase 2 work being carried out. With regards to locality clusters JRo referred to the new contract arrangements and the need to consider how, if the localities choose to work in clusters, these are developed over time and how the resources coming through the new contract arrangements align and flow to the smaller groups of practices. It was noted that practices wishing to work in clusters should ensure their chosen cluster is within the same locality as being in a cluster in a different locality would not best serve needs of the population. Programme Success measures: It was agreed that programme success measures should be reflected in each area and form part of the Plan. ACTION: Slide-deck to be circulated to members.

85

05 52-week wait update Gemma Artz (GA) was welcomed to the meeting and presented the report on the 52-week wait position informing the committee that the main areas for focus were:

UHB - confident in attaining zero 52-week wait by end of year.

NBT - significant problem particular with MSK at the end of the financial year

GA advised remedial action plans were in place with both UHB and

NBT. A revised trajectory which went into the new financial year

(attaining zero in October 2019 – 40 cases being out-sourced to the

Spire in April) had been received from NBT. Challenge had and would

continue be given as to why the position has not been met by end of

year. The issue was directly linked to one particular surgeon who

provided this service to both UHB and NBT in addition to the Spire.

LM advised of the challenges for the CCG should the trajectory extend

beyond the end of the 18/19 financial year this would take both the CCG

and provider into the NHSE fines regime and advised accepting the

trajectory was not an option. It was noted that the majority of the

backlog were BNSSG patients and fines would apply to these.

JRo reminded the members that there was zero tolerance on 52-week

waits from the CCG even if at patient request.

GA confirmed the waiting list had been closed with no new out-patients,

trauma or on-call.

Page 5 of 13

Item

Action

GA confirmed that a WAHT nominated consultant will carry out an

independent review of the list to identify patients who could potentially

be offered an alternative provider for knee procedures.

The report was noted and accepted by the Committee

06 Integrated Urgent Care Service Mobilisation Goes Live Mark Bradford (MB) was welcomed to meeting and presented the item for discussion. Following the successful BNSSG procurement of an Integrated Urgent Care (IUC) service the GP Out of Hours (GPOOH) service provider, BrisDoc, was the successful bidder along with its sub-contractor, Care UK, which currently delivers BNSSG’s 111 call answering service. The service will be branded as ‘Severnside Integrated Urgent Care’. The submitted paper was intended to inform the Commissioning Executive of progress on the mobilisation of the service. The process to assure on all these areas is ongoing and is overseen by the mobilisation project group and BNSSG Programme Board. All areas should be assured by 21st March 2019 in order to enable the Programme Board to recommend go live. Final authority to proceed will reside with the Directors of Transformation and Commissioning and the decision will be made on 2nd April 2019. In the event that BNSSG is not confident that the go-live should take place on the scheduled date of 2nd April 2019 the existing 111 and GP Out of Hours services will continue to serve the BNSSG population while remedial action is taken and a revised go-live date is agreed. SN noted concern at the level of need for clinical triage and the pressure this would put on the system as a whole. PB asked about the implications regarding the in and out of hours’ service for the Dental triage service. MD gave a brief description of how the service would be managed. PB asked about the level of confidence with regards to the clinical decision support systems as to whether this was fit for purpose? The intention was to commence with two groups and the process would be refined for those for whom the pathway was appropriate in addition to those whom required a quicker clinical assessment. JRo queried the current position on data sharing in the system and in particular flags in the system to identify the more complex patients. MD explained the current system was still at a basic level with no automatic notification of flags. It was agreed this was a major priority and noted as an important piece of work that should be highlighted everywhere to enable a solution. The report was noted by Commissioning Executive.

Page 6 of 13

Item

Action

07 Emergency Department Streaming Pilot - NBT Lesley Ward and Will Kenyon (WK) were welcomed to the meeting and presented the briefing report on item asking for agreement to go forwards with the pilot programme. LW updated the Committee on the development of the proposed streaming pilot to date which would help to inform the ongoing model going forward. Draft stream criteria and a letter for issuing to primary care was submitted for comments and approval. PB thanked LW and WK for driving this innovative work forward. PB asked consideration be given to how more clearly the report could define the precise aims, achievements and how this would be measured and also build evidence of that success. Funding of the scheme was highlighted as a risk area. JR expressed delight at the achievement in producing the model but

concern in relation to the business model around:

1. Potential for primary care to be double funded and how this could be justified

2. The risk share on the tariff basis between secondary and primary care ignored the significant cost of urgent care

3. The purpose of the pilot was to reduce attendance at ED however the business case assumed full NBT attendance before being passed to the steaming pilot. It was noted that patients should not be in attendance at NBT if they are Primary Care patients.

4. The level of physiotherapy and associated admin costs were discussed

5. The reliability of the financial model was based on a small number (15).

6. NBT requirement to triage before re-directing to streaming.- patients should be re-directed to streaming before they get to ED and triage.

A discussion took place around the mechanisms involved and

associated costs and tariffs. JR summarised that there would be no

benefit to the CCG if the cost could not be reduced and that the

concerns be further explored. It was agreed that LM would review these

with LW.

DJ asked how this model would ultimately link with the GPST service

already significantly funded by the CCG within NBT and the triage

service and developing that into a single front doorway at NBT.

LW confirmed this pilot was an interim measure to identify a way

forward also an opportunity to look at what is happening in primary care

to identify the reasons for non-emergency attendance.

Page 7 of 13

Item

Action

JR noted it should be clearly identified that this was a short term project

with all parties involved.

Recommendation for Approval: That the pilot methodology is supported to proceed to enable BNSSG

partners to understand the benefits to be achieved if a longer term NBT

ED Primary Care Streaming could be put in place to support patients to

be redirected into alternative settings of care and reducing the burden of

demand upon the NBT ED Department. Specifically Commissioning

Executive is asked to support.

Recommendation outcome:

Approved: Circulation of item 7.1 letter to primary care practices subject to it being amended to reflect that the pilot was a short term model.

Declined: ED Streaming Pilot was not approved. It was agreed further work on the business modelling and financial aspects of the pilot was required.

86

08 BNSSG Commissioning Policies Review Group – Terms of Reference Adwoa Webber was welcomed to meeting. Peter Brindle (PB) gave a brief overview of the background of the Commissioning Policies and TOR. AW presented the Commissioning Policies Review Group (CPRG) Terms of Reference (TOR) for approval. These were discussed by the committee with the importance of having the right membership was highlighted and it was noted that further development was required around:

Membership –TOR should be widened to include clinical beyond localities, medicines management, lay, quality and mental health representation - Heads of contracts should not form part of membership but attend if required to support the group

Review – TOR should be reviewed on an annual basis

Process – TOR should include clinical, equality and quality of impact assessments

Recommendation for approval: To approve the draft Commissioning Policy Review Group Terms of Reference. Recommendation outcome: Further development of the TOR required around membership and process before being re-submitted for approval to the Commissioning Executive in March.

87

09 BNSSG CCG Commissioning Policies Lisa Collard and Kate Tamlin were welcomed to the meeting and with AW presented the BNSSG CCG Commissioning Policies for approval. A number of changes have been made to BNSSG CCG’s

Page 8 of 13

Item

Action

commissioning policies as a result of the commissioning policy review process and the committee was asked to recommend these for approval. JHa asked the Committee if there was any specific policy or area that required particular attention or clarification. AW asked for comments on the new policies, the existing policies amended with substantial clinical change and those amended to provide clarification to both patients and clinicians. JB-G asked if Equality and Quality Impact Assessments had been carried out on all policies. AW advised in relation to some policies created prior to the new process assessments would have been carried out in development of the policies but not necessarily evidenced. The new process did include Equality and Quality Impact Assessment and was more transparent and robust. JR asked if all the policies would be updated with regards to this and LC advised a work plan was in place to review all such policies promptly with support from the Quality team. It was noted that the policies should be evidenced based and provide links to evidence of financial and quality impact assessments having been carried out. JR queried Section 5. Financial Resource Implications and questioned

the statement relating to the financial impact of the Hydrocele policy for

under 16s and it was agreed that a proper understanding of the financial

impact was required.

LM advised that a financial impact evaluation would be carried out and it

would be factored into the exit plans going forward.

JP expressed concern regarding the Gallbladder Removal Policy and

the new criteria to enable a referral. It was agreed that the Gallbladder

Removal Policy would be sent back to the CPRG for clarification before

returning to Commissioning Executive with the necessary evidence and

justification so that a decision could be made.

Recommendation for approval:

Approval of the above 72 Commissioning Policies to allow these

policies to be adopted by the CCG

Recommendation outcome:

The Commissioning Executive Committee collectively approved the

policies with the exception of the Gallbladder Removal Policy and

subject to :

the prompt review of policies in relation to evidencing of Equality and Quality Impact Assessments.

In relation to the Hydrocele Policy a Financial Impact Assessment be carried out.

88

Page 9 of 13

Item

Action

10 Approval of Primary Care Pathology Profiles for monitoring of Chronic Diseases Carla Southworth was welcomed to the meeting to present Item 10. The aim of the Primary Care Chronic Disease Monitoring profiles work was to standardise tests requested by primary care for chronic disease monitoring across Bristol, North Somerset & South Gloucestershire (BNSSG) and enable the profiles to be loaded onto the three acute hospital ICE systems to support adoption across BNSSG. PB gave the background to the request and asked for formal sign off of the profiles. AA indicated the changes made following feedback gained from Commissioning Executive Committee, various membership groups and consultants. Recommendation for approval:

Approval of the Primary Care Pathology Profiles for monitoring of

Chronic Diseases to enable the profiles to support adoption across

BNSSG.

Recommendation outcome:

Approved.

11 Healthy Weston Crisis Café Service Kirstie Corns was welcomed to the meeting to present the item. The purpose of paper being to firstly provide Commissioning Executive with a recommendation regarding the development of a Crisis Café service for the Weston Locality and secondly request guidance on two key elements:

Confirmation that the Commissioning Executive supports the project group’s recommendation to proceed with a stand-alone social model in the event that AWP’s timelines for formalising support do not align with CCG commissioning plans.

Ask Commissioning Executive to approve the project group’s recommendation to proceed with a market questionnaire to validate the financial envelope of £217k thereby increasing the likelihood of a successful procurement.

A discussion took place around the widening the provider choice to others providing specialist mental health input, triage provision, clinical expertise required and procurement process involved. JR noted that whilst testing the market this should include both social only and mixed models. KC confirmed the ideal would be to procure and have the contract held by a mental health provider however if not possible, from a service user perspective, they would still experience a mixed social and medical model.

Page 10 of 13

Item

Action

DS recommended liaising with other providers/schemes in other areas such as Cornwall where similar work was taking place. KC confirmed that conversations had taken place with Leeds and Aldershot with information received from Cornwall. KC talked about the level of engagement with service users undertaken under the Healthy Weston in early 2018 followed by a November re-engagement event with service users, representatives and advocates to discuss the service specification in more detail. Following this the service specification had been updated to reflect the November feedback. INHN had raised a concern around their level of involvement and contact had been made resulting in the service specification being submitted to North Somerset PIF with a proposal that there would be a representative from Clarity and Healthwatch to ensure representation of the wider population of Weston and INHN were very happy with this approach. Clarity members however considered a greater level of co-production in the specification was needed therefore a further engagement workshop was planned within the next few weeks with Clarity and other user representative groups to gain an understanding of their needs. KC advised the procurement process may be delayed because of this but considered it necessary to provide consistent approach in public engagement. JR asked whether the co-production done to date on the specification was considered to be enough. KC advised it was more about the process than the specification itself. JR advised this issue needed to be addressed without extending the timeline and suggested that DS become involved. CB asked that the market testing request be approved and the model and specification come back next month following further work and engagement It was agreed a mixed model was preferably but the market should be tested for both models. Actions:

1. KC to liaise with MH provider regarding a social care model 2. Service Specification engagement to be reviewed in light of

discussions on the service model and returning for decision in April

3. Testing of both social and mixed market model to be actioned Recommendation for approval:

Commissioning Executive is asked to approve the project group’s recommendation to proceed with a market questionnaire to validate the financial envelope of £217k thereby increasing the likelihood of a successful procurement.

Recommendation outcome: Approved.

89

Page 11 of 13

Item

Action

12 Evaluation of current Discharge to Assess (D2A) Pathways across BNSSG. Julie Kell was welcomed to the meeting to present the item. JK took the committee through the tabled D2A Evaluation key themes from the review which consolidated data provided previously advising these themes were consistent across all pathways. JK highlighted the close working with and strong engagement of Local Authorities in this extensive piece of work advising that to ensure an adequate amount of social care allocation the evaluation should align with the Better Care Funding as an integrated model. JK asked the Committee to consider the risk appetite on the reduction of beds in Bristol and South Gloucestershire, how BNSSG worked with acute providers recognising the home care delays, endorsing the recommendations around P3 to include CHC, and the inclusion of an evaluation of North Somerset but to look at different types of beds in Bristol and South Gloucestershire and the savings that would potentially give. LM referred to the Action Plan particularly around Bristol and advised that this was an expensive resource and the need to utilise the budget more wisely. JR highlighted the Bed Light model which had been very successful. JB-G asked about CHC beds and whether any modelling had been done around that. JK referred to Appendix 3 and confirmed modelling had been undertaken. PB spoke about the complexity of the data provided and asked how the true demand for P1 could be understood and judged to be correct. LM advised of the process involved, the level of information that was not previously available and confirmed the period reviewed was over a 9-months in terms of total activity. JK confirmed that community providers had a full data set which was completed each month, also used was LHPD, Green to Go in addition to three audits of the acute trusts being completed. JR asked the Committee to start to focus on admission avoidance measures. LM suggested that with the Committee’s permission a pilot could be worked up on this piece of work and this was agreed. Actions:

To forward a copy of the slide deck tabled at the meeting

Design of Admission avoidance pilot to commence Recommendation for Approval: The Commissioning Executive is recommended to:

90

Page 12 of 13

Item

Action

Note the data submissions from the current contract

performance and actions already in place to improve

performance.

Agree the actions that require changes within current pathways

and the timelines

Note the recommendations for future development of D2A

pathways and nominate project leads

Agree the recurring funding for the transfer of North Bristol

activity for Rehabilitation transferred in January 2018 on a

contract variation with a reduction in P2 capacity in Bristol and

S. Gloucestershire as defined in Appendix 5.

Recommendation outcome: Approved

13 Urgent Care Activity & Performance Update CT presented the Urgent Care Activity and Performance update report to the committee and it was noted that February was a very challenged period. It was agreed that due to time constraints any questions should be emailed to Claire Thompson for a response.

14 Contract Performance – Non Acute Helena Fuller presented the Contract Performance report on Non- Acute. It was agreed that due to time constraints any questions should be emailed to Helena Fuller for a response.

15 Corporate Risk Register & GB Assurance Framework Sarah Carr was welcomed to the meeting to present the item. SC highlighted the movement on the risk register and specifically the change made to the risk score for the over performance against planned activity. SC noted the need to review the risk register on a monthly basis and highlighted some new additions relating to the EU Exit and ambulance service which had resulted in changes in the risk score. SC advised the GBAF document recently updated would be circulated to members following the meeting. JR clarified the register held the major risks which required direct GB management and gave a brief summary of the types of risk which might need to be escalated to this level. JHa asked for questions around the Corporate Risk Register and JR advised colleagues should take the opportunity to review the document outside of the meeting, noting any unexpected or missing risks and feedback to SC. Action:

Committee members to review the Corporate Risk Register and GBAF in line with above.

91

Page 13 of 13

Item

Action

16 Any Other Business 1. JB-G asked if the Committee would welcome more Quality items

on the agenda and although it was noted that the performance report captured an element of this, it was agreed that consideration be given to widen the breadth of information the Quality Directorate could share with Commissioning Executive Committee.

2. Timings of the Committee were discussed and JHa asked members to consider extending the meeting by commencing at 8:30am and incorporate a short break.

Date of next meeting: Thursday, 14th March 2019 at 8.30 – 12:00pm CCG 4th Floor Conference Room, South Plaza

Lisa Manson

Director of Commissioning

NHS Bristol, North Somerset and South Gloucestershire CCG