Paper 14 46 – Committee Minutes for Governing Body

Oxfordshire
Clinical Commissioning Group
Oxfordshire Clinical Commissioning Group
Governing Body
Date of Meeting: 27 March 2014
Paper No:
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 and March 2014
Finance and Investment Committee meetings, the November 2013 Integrated
Governance and Audit Committee meeting and the December 2013 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
Yes
No
tick and attach)
Outcome of Equality Analysis
Author: Lesley Corfield, Committees Secretary
Clinical Lead:
Not applicable

Oxfordshire
Clinical Commissioning Group
MINUTES:
Finance & Investment Committee
27 February 2014, 13.30 – 16.30
Room 1, Jubilee House
Present:
In attendance:
Stephen Attwood - Chair
Mike Delaney
Ros Avery
Gareth Kenworthy (absent
between 15.55 and 16.20, left at
16.25)
Gina Shakespeare – Items 4 and 5
Lesley Corfield – Minutes
Julie Dandridge (JDa) – Items 10
and 11
James Drury (from 13.40)
Jenny Simpson
Matthew Staples – Item 12
Louisa Griffiths – Items 10 and 11
Apologies
Mary Keenan
Action
1. Declarations of Interest
No declarations of interest were made. The declarations of interest form
to be circulated to members and added to the Governing Body agenda.
2. Minutes of Last Meeting – 28 January 2014
Subject to Monitor being changed to Trust Development Authority (TDA)
in the final sentence of Item 7, the minutes of the meeting held on 28
January 2014 were approved as an accurate record.
3. Matters Arising
AQP Contracts
JS reported most AQP contracts had started in 2012/13 and would last for
three years. The three key areas which would impact on the forecast
outturn were: podiatry; elective acute; and audiology. JS would request
further information from AQP commissioning leads and would circulate a
briefing note between meetings.
Action: JS to obtain further information and circulate a briefing note
to members between meetings.
Financial Plan
SA expressed some concerns around cap and collar contracts but had
been assured there was more confidence in the data.
Oxford University Hospitals Trust (OUHT) Negotiation Strategy
To be circulated after the meeting and included on the agenda for the next
meeting. The draft strategy had been shared with the Trust and the
second formal meeting was due to take place that day. Contract
JS
2
envelopes had been set for the providers. It was noted the QIPP
programmes had not identified anything to come out of the OUHT
contract. The CCG would work with the Trust to achieve efficiencies
through the contract envelop or look at actions which could be undertaken
to achieve the envelope. JD advised the Area Team would expect the
Oxfordshire Clinical Commissioning Group (OCCG) to maintain the
existing mental health spends. GK reported the system had largely
maintained its mental health spends and benchmarking against other
CCGs showed OCCG spend was quite high.
Action: OUHT Negotiation Strategy to be circulated and added to the
agenda for the next meeting.
Contract Outline Proposals
GK explained there had been a timing issue and the proposals would be
available for the next meeting.
Year End
JD advised the Chief Finance Officer (CFO) would be required to take a
paper to the NHS England audit committee around year end
preparedness RA advised the year end timetable and plan had been
considered at the last Integrated Governance and Audit Committee. GK
commented assurance had been taken from the fact Alan Cadman was
employed by the CSU and would lead the year end process as he had
experience from working with Oxfordshire PCT.
4. Financial Challenge Board Report
GS attended the meeting for this item. GS observed OCCG had not been
designed as a contracting and procurement delivery organisation which
was one of the reasons for the failure of QIPP. A strengthened business
core structure reporting to the CFO had been agreed involving two new
posts: Head of Programme Management Office and Head of Contracting
and Procurement. The Head of Contracting and Procurement post had
been advertised and interviews would be held on 13 March 2014. The
Head of Programme Management Office post would be advertised in the
HSJ as well as on the NHS Jobs website.
JS/LC
Negotiation meetings were taking place with OUHT. The aim was to align
financial recovery of the CCG over the next three years with the recovery
of the OUHT over the next three years. A series of business cases had
been reviewed and would come to the next meeting for final sign off. The
Committee commented that the business cases would need to be quality
assured before coming to the Finance and Investment Committee. GS
anticipated new business cases arising all the way through the beginning
of the financial year. It was proposed to look at stretching the
opportunities identified by Deloittes as well as capping off the contract.
RA commented that the Committee was being asked to receive the report
and take assurance in respect of:
Improved core business capability and capacity to improve QIPP
yield and contracting controls in 2014/15
Progress in developing contract negotiation strategies and their
alignment with the 2014/15 Plan and the financial position for
2014/15 onwards.
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RA felt there was insufficient information to be assured on the second
bullet point. RA considered the quality of information was better but that
she had received less information than in previous years around the
numbers.
JD queried the SCAS £3m contract gap. GK advised a contract
negotiation meeting had taken place that morning. This had been framed
as a £3.3m gap but was the difference between the commissioner and
SCAS viewpoints. The negotiation was around growth risk and cost
pressures. There was a £1.2m cross pressure between Thames Valley
and SHIP (Southampton, Hampshire, Isle of Wight and Portsmouth).
5. Month 10 Finance Report
GK reported two additional material risks had surfaced; one around
prescribing and during negotiations with OUHT additional demand
emerged resulting in a contract risk. GS explained the Trust had identified
a very substantial elective care backlog in a failure to meet RTT and a
failure of internal systems. In monitoring patient treatment lists (PTLs) the
Trust had failed internally to monitor the orthopaedic list sufficiently. In
addition assumptions had been made about lists and the numbers that
would not move to procedure had been overestimated. The result was a
significant backlog that the Trust would not anticipate clearing in normal
capacity. A recovery plan to treat 1800 to 2000 patients before the end of
March has been put in place. The CCG was working with the OUHT in an
attempt to commission services elsewhere to cover the remainder. The
Trust would break RTT on a continuing basis for the rest of the year.
There is an issue of clinical risk to the patient, operational clinical
governance and reputational risk to be managed. The CCG needs to
consider any fine or penalty to levy. The Head of Planned Care Intensive
Support Team was working with the CCG to ensure all appropriate actions
were being taken. The TDA had also taken a close interest and it was
suspected CQC would do the same. GK estimated this represented circa
£2m additional risk. A formal recovery plan and root cause analysis would
be requested by GS at the meeting on 6 March.
JS advised the forecast outturn had been held at £6.1m. The Specialised
Commissioning £52.3m had crystallised at £52.03m. The prescribing risk
had arisen from a change in profiling which made the position worse.
Activity had increased and the profiling had impacted on the forecast
outturn. The underspend had moved from £2.2m to breakeven. GK
tabled draft prescribing figures for information. There was a higher spend
in December than forecast and this was being reviewed by the medicines
management team. It was confirmed the deterioration in OUHT run rate
figures in the report did not include the RTT and prescribing issues.
JD advised the GPIT figure was £0.5m too high.
GK reported not all of the property services benefit had been released into
the Month 10 figures. He advised there were £2.3m of gross mitigation
and £5m of risk.
4
JD informed the Committee he had been advised the CCG did not have a
partially completed spells provision and this might need to be put in place.
JD was seeking further clarification on notional guidance.
Responding to a query from RA, JS advised there was an outstanding
query with the CSU regarding the large variance in the mental health and
learning disability figures in appendix 3.
6. Management of Cash Year End Position
The briefing note was considered and GK advised a cash shortfall of
£2.2m had been identified. The shortfall would be mitigated by
management of the working capital. GK cautioned the briefing note had
been based on previous information and the prescribing situation might
have an impact. Plans to manage the situation were being put in place.
JD reported there might be some flexibility to revise the cash limit. GK
assured the Committee the situation was manageable.
7. Financial Plan including Contract Envelopes
GK explained there were four key variables in financial planning: surfeit
deficit position, QIPP, reserves and the contract envelope. The Plan
reflected the baseline issues and financial challenge. The draft
submission had reflected a deficit plan of £7.6m for 2014/15 although
further adjustments were required. The QIPP figure in the plan was a
gross £14m and was just in excess of two per cent. Reserves could only
be maintained at a gross figure of £6.2m. The CCG would not comply
with all planning requirements in relation to reserves until 2015/16.
Meeting the £7.6m deficit was predicated on achieving QIPP.
The QIPP plans were weighted on OUHT but this was not far out on what
would be expected from the contract value. The OUHT was a clear outlier
in performance which indicted efficiency savings was possible. Deloitte
had identified £20m, £3m was contract challenges but OCCG were
outliers in areas such as funded nursing care although were in the top
decile in other areas which needed to be understood. MD commented
that benchmarking identified outliers but there might be more potential in
areas which looked fine and the CCG should not forget to review these.
JD commented assurance on the plans would be required and the starting
point had to be a robust QIPP plan. Currently there was a lot of risk in the
QIPP plan which needed to be resolved as the contracts were signed off
as without this the plan was very high risk.
GK tabled a document providing more detail around the QIPP plans
explaining the dashboard reflected programme areas, owners and RAG
ratings. The target was the best estimate of full year impact. GK believed
risk adjustments for timing and implementation had been applied. The
total was £6.7m with additional/stretch projects possibly providing a further
£3m. JD cautioned that activity profiles were not significantly different to
other CCGs and recommended the assumptions be reviewed. MD agreed
the Committee needed to be assured the assumptions around activity did
measure up. GK advised there was pressure on the plan from the
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underlying position. Money was going in for demographic growth but
came out again in QIPP. The challenge was to deliver QIPP projects
which had a genuine effect on activity whilst agreeing contracts which
allowed for delivery.
8. Procurement: Contract Outline Proposals
Held over to the next meeting.
9. Assurance Framework and Risk Register
GK reported since the last meeting there had been a review of each risk,
mitigations and action plans.
AF13: agreed to remove ‘elective’ to just read ‘activity’. The scoring had
been amended. A proposal had been made to OUHT for a year-end
settlement.
AF5: related to a point in time; the negotiation, whereas AF13 was an in
year risk. The executive needed to consider whether the risk was
financial, performance and/or a clinical risk. How to frame the risk would
be debated. GS advised the RTT position would be discussed with the
Trust on 6 March and should provide more clarity.
AF1: the phrasing of the risk needed amending as was more an issue
around performance and performance management. GS explained the
new programme management posts would put right a deficit in
performance in the CCG. This was not taking functions from the CSU but
improving CCG capability. Negotiations were underway to release the
cross subsidy and it was hoped to achieve agreement over two years.
Another part of the problem was performance which was controlled
through the service mechanism. Each function was being reviewed for
what was specified, what expected, whether the service was being
provided and, if not, what the breach was. JD explained the SLA costs
were in running costs and monies could not be moved into programme
costs but would have to be offset at the end of the year.
AF12: updated to reflect work in year following final clarity on baselines
and allocation transfers. This had been reflected in terms of the risk
rating. It was not believed there were any material significant financial
report issues with the CSU.
AF6: JD commented some adjustments had not been reflected and might
need to be on a recurrent basis going forward. GK advised there was a
proposal from the Trust to transfer back £6m from specialised
commissioning. This was linked to outturn activity but there might be
some risk if there were issues with the waiting lists. The Trust had
interpreted national rules and agreed the position with Wessex. It was
agreed not to close the risk immediately.
GK advised the Operational Risks had not yet been reviewed.
10. Renewal of the ScriptSwitch Prescribing Decision Support Tool
Contract
JDa advised the contract had been in place since 2007. The paper was to
evidence ScriptSwitch did achieve savings. RA questioned why this was
not mandatory for all practices. JDa explained the system worked better
on some IT systems than others but it was hoped those moving to
EMISWeb might start making savings. There was also a charge so
practices had to weigh up the cost/savings implications. JDa explained a
6
single tender waiver (STW) would be required as ScriptSwitch were the
only provider. Work had commenced across the CSU footprint to see if a
better price could be negotiated although it had been 37p since 2007.
The Finance and Investment Committee supported renewal of the
ScriptSwitch Prescribing Decision Support Tool Contract. JD
commented that any savings were not bankable as it needed to be linked
to spending and was a saving over what would have been spent rather
than what was actually spent.
11. Wound Care Contract Approval
JDa outlined the ordering system which had been in place for three years
and had recently been retendered. The paper presented was the contract
award recommendation. JDa confirmed the procurement rules had been
followed and award of the contract would not be subject to any challenge.
RA observed the point of going to tender was to seek value for money. In
many instances the incumbent was awarded the contract because they
were able to supply more detail to meet the criteria as they knew how the
service worked. RA queried how it might be possible to make it better for
other providers to be able to compete more fairly. JS suggested this could
be considered by the procurement steering group. The Finance and
Investment Committee approved the tender award.
Action: The Procurement Steering Group to consider the retender
process.
GK/JS
12. 111 Review
MS attended for this item. JD commented on the fact the original contract
appeared to be virtually at capacity and this seemed an odd place to start.
MS explained Oxfordshire had launched 111 considerably earlier than
other parts of the country and a pragmatic view had been taken in order to
not destabilise the system. The figure was slightly above the limits
suggested as the cost for a call by the Department of Health. The CCG
had been required to extend the contract for a further year as CCGs were
not allowed to retender until April 2015. OCCG had written to Dame
Barbara Hakin to enquire whether it might be possible to commence the
procurement process prior to this date. MS advised some of the
dispositions within 111 were changed and were weighted towards
telephone consultations rather than base visits. Under the terms of the
clinical pathways licence one per cent of calls must be audited monthly.
Over the first nine to 12 months SCAS were strongly arguing this should
be collectively rather than per call handler. The Department of Health had
agreed with the CCG that it should be one per cent of all staff and this
target was being met. MS reported compared to other 111sites nationally,
Oxfordshire dealt with more calls within the call centre, sent out fewer
ambulances and conveyed less people to A&E. SCAS relative
performance had also seen decreased activity which was related to 111.
SA commented 111 had been a good idea badly implemented and not
given sufficient publicity when it first started. MS hoped the revised
specification would be more robust.
13. Finance and Investment Committee Work Plan
An updated version of the work plan was tabled. It was suggested there
might be exception reporting at the March meeting if there were to be a
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number of business cases on the agenda.
14. Any Other Business
None.
15. Date of Next Meeting
Tuesday 18 March 2014, 12.00 – 15.00, Conference Room A, Jubilee
House. It was agreed lunch should be provided.
8
Oxfordshire
Clinical Commissioning Group
MINUTES:
Finance & Investment Committee
18 March 2014, 12.00 – 15.00
Conference Room A, Jubilee House
Present:
In attendance:
Apologies
Stephen Attwood
Mike Delaney
Ros Avery
Gareth Kenworthy
Lesley Corfield - Minutes
Gina Shakespeare (12.40 – 15.00)
James Drury
Jenny Simpson
Mary Keenan
Action
1. Declarations of Interest
SA advised he was a profit sharing partner in a medical practice.
2. Minutes of Last Meeting – 27 February 2014
Subject to an amendment to Item 5, paragraph 2, the minutes of the
meeting held on 27 February 2014 were approved as an accurate
record.
3. Matters Arising
AQP
JS reported there had been insufficient information to circulate a
briefing note. RA explained the issue had been raised in order to
establish whether the Clinical Commissioning Group (CCG) was worse
off by being forced to undertake AQP. JS commented consideration
might have to be given to thresholds and clinical points if increases
continued. GK added the new form of contracting had introduced
volume risk beyond what had originally been planned. OCCG had
learnt that due to the mechanics of the contracts management
resources were required.
Cash Year End Position
The CCG allocation had increased by £4.5m and these monies had
been received.
Retender Process
To be added as an agenda item for the Procurement Steering Group.
Action: GK to ensure retender process was on the agenda for the
next Procurement Steering Group.
4. Month 11 Finance Report
GK reported the key changes between Months 10 and 11 were the
deterioration in the Oxford University Hospitals Trust (OUHT) run rate
and changes around prescribing. OCCG was forecasting delivery of
the £6.1m deficit. The flexibility in the property budget had been
GK
9
released, a discussion was required with Oxfordshire County Council
(OCC) around the pooled budget situation and these, with some
underspend, had offset the deteriorations.
GK advised after the report had been written, a deal had been reached,
although was still being finalised, with OUHT on the year-end and
2014/15 contract. An absolute figure for the year-end would now be
agreed. GK considered this to be the best deal which could be reached
and provided mutual benefit and mutual pain while allowing real inroads
into activity issues.
Agreement had been reached with the Area Team (AT) around
identification rules and some areas for which the CCG had been billed
would become the responsibility of the AT. It had been further agreed
in view of the CCG financial position; an invoice for £1.2m could be
submitted as long as there was allocation adjustment for activity next
year. These two agreements might allow the CCG to move nearer to
breakeven but this would have to be carefully managed.
RA commented the winter pressures monies had been of assistance to
the CCG but there was no guarantee of these in the future. In view of
this, RA suggested a deep dive on the winter pressures programmes to
understand what had and had not worked and to look at planning for
the next year. GS advised an evaluation of each scheme was being
undertaken at the moment which had already provided indications of
the added value of gerontology senior staffing. She felt this would
provide some real learning on achievement as against expectations.
5. Financial Plan
GK explained the Strategic Plan document for the Governing Body
contained a high level section on the financial plan. The paper
presented to the Committee provided the detail. The CCG would be
announcing a £6.9m deficit plan for 2014/15. A 10 per cent reduction in
allocation for running costs was anticipated in 2015/16. The Plan
allowed the CCG to deliver the contingency reserve but none of the
other planning requirements and statutory duties. The proposal was to
be as close to flat cash as was possible with the QIPP initiatives largely
focussed on offsetting growth estimates. GS commented on the closer
grip on elective care demand, and the new incentive for the Trust to
work with OCCG provided more confidence.
Heads of terms for the agreement with OUHT were being drawn up and
upper and lower thresholds and marginal rates had been agreed. GK
advised there were some risks to the plan from other contracts which
had not been signed off. Financial risks were: QIPP non delivery,
demographic growth, prescribing growth and further growth in
continuing health care. Mitigations included: contingency, further QIPP
extensions, funding costs underspend and risk transfer in the contract.
GK advised:
CCGs were being asked to contribute to a national pooled fund
for legacy provisions. The OCCG contribution was £2.4m which
10
had impacted on income and expenditure. The annual
contribution had been included in the Plan
The OUHT had proposed changes to the specialised services
identification rules resulting in a £5.4m allocation transfer being
required between the CCG and NHS England
In 2015/16 the CCG would be expected to transfer £18m of the
baseline allocation to the Better Care Fund; a pooled budget to
be managed jointly with OCC. The total value of the pool would
be approximately £37m from 2015/16 onwards and was not new
money but a reallocation within the health and social care
system. OCC was assuming £10m of the better care fund would
support adult social services. Transformational changes would
need to be agreed to offset the risk.
JD commented that approval from the Finance and Investment
Committee on the better care fund had to be subject to the 2013/14
contract, the deficit figure and the 2014/15 settlement.
GK highlighted the need to be mindful of on-going negotiations
explaining last year the financial plan had been agreed and an update
brought back to the Committee once all the negotiations had been
concluded. He stressed the need to bottom out the impact of the
2013/14 agreement on the Plan position; assess how this impacted on
the 2013/14 Plan; and take a view on the benefit. In advance of the
Governing Body GK and GS would consider the investment of £5 per
head. GS observed there were complex interrelationships between the
teams on the ground and the pathways and there was a need to ensure
the narrative was consistent with the better care fund. The CCG
needed to be assured on where primary care could expect to be
supported over 2014/15 and beyond.
The Finance and Investment Committee:
Approved the high level control total budgets for 2014/15 to
2018/19
Noted the CCG’s compliance or non-compliance with NHS
England planning guidance and the CCG’s statutory
financial duties
Signed off the CCG savings and QIPP requirement for
2014/15
Approved the contract financial envelopes by provider
Approved the pooled budget contribution envelopes
Approved the approach to contract negotiation with the CCG
two main providers
Noted the current financial risk facing the plan and the CCGs
ability and approach to managing those risks.
Action: GK/GS to consider the £5 per head investment.
An updated plan to be brought back to the Committee.
6. OUH Negotiation Strategy
GS presented the paper providing a proposition for a negotiation
strategy with OUHT over the next three years. There had been a
successful negotiation and a proposal which gave significant assurance
GK/GS
GK
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on the main pressures. Heads of terms had been agreed and the CCG
was proceeding to put a contract together. OUHT believed the
agreement was challenging but feasible. The agreement would be
challenging for the CCG given QIPP in 2013/14 but GS felt the CCG
was building on a firmer foundation than in the previous year.
7. Business
b
Cases
Medicines Management
GS expressed confidence around the medicines management suite of
cases which she felt were very strong and securely owned. MD voiced
some concern around the numbers but was advised there were
spreadsheets supporting each project and was assured the figures had
been profiled. MD felt a section with some description of the
methodology should have been included to allow a lay person to
understand the approach. GS explained there should have been a one
page summary providing all the detail and this would be circulated after
the meeting.
Action: GS to circulate the one page summary.
Planned Care
GS advised there was a degree of confidence in the diagnostics
business case whereas first outpatients were in most direct control of
the referring physicians. SA advised there was a gateway at almost
every point in the pathway and was confident good systems were in
place. RA raised concerns around capacity and was advised by GS
that the structure was being amended on a temporary basis which
would address any issues. RA observed that historically QIPP plans
with disinvestment or lavender statements had not been successful.
SA expressed the hope that conversations at a senior clinical level
around those areas which lacked clear clinical evidence would
succeed. GS commented on the need to follow through discipline of
lavender statements in consulting rooms and secondary care.
Urgent Care
Three business cases had been prepared so far under the urgent care
banner and the OUHT had been very comfortable with the long term
conditions proposals. RA requested a review of the Oxfordshire
Primary Care Trust (OPCT) case management project which had not
produced savings. GS to ask Matthew Staples to double check the
costings for GPs to warm handle 111 calls.
SA felt the number of patients needing to be brought to practices by
ambulance had been over-estimated. He advised Rosie Rowe would
have the exact figures for the scheme run in the North. GS to cross
check.
Action: GS to cross check the patient transfer figures.
Mental Health
The mental health business case had not yet been reviewed.
Conversations were well advanced and the OHFT had a lead provider
model proposition which had been agreed with the third sector and it
was hoped to approve the contract variation in early May. Barbara
Batty would lead the frail elderly project. RA was slightly concerned
that the Finance and Investment Committee had only seen the Outline
Business Case.
GS
GS
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Primary Care
The primary care project was on a slightly slower track due to Mary
Keenan being absent and had not yet been reviewed. The second draft
was being reviewed and it was anticipated this would go to the next
Programme Management Board (PMB) meeting.
Pending outcome based contracts business cases, no one was actively
working on maternity at the moment but OUHT was undertaken quality
items. Outsource was being acquired for the funded nursing care
programme as there was insufficient in-house capability. The primary
care assessment, end of life and care homes projects were not yet
ready. People presenting to A&E who left with no substantial medical
outcome was being stripped out of the ambulatory emergency care
pathway. The dementia case was the least developed and required
more work.
The Finance and Investment Committee approved the business
cases listed below:
Medicines Waste
Primary Care Prescribing Behaviour
Procuring Medicines and Services
Improving the Efficiency and Effectiveness of Diagnostics
Services
First Outpatient Incorporating Stretch Target
Planned Care Pathways
Prescribing Behaviour – Secondary Care
Oxford Health Urgent Care Services
Emergency and non-Emergency Patient Transport
Long Term Conditions
Planned Care - PLCV
RA expressed congratulations to all involved. She accepted there was
still a need to deliver but felt it was an excellent start and a rigorous
process.
8. Financial Challenge Board Report
GS presented the paper proposing a change in governance structure to
stand down the Financial Challenge Board but, as the business
conducted at these meetings was considered critical to the CCG, to
assimilate this business in to the CCG Executive meeting which would
help to reflect and reinforce the central role the clinicians played in the
leadership and direction of the CCG.
The Finance and Investment Committee approved standing down
the Financial Challenge Board and extending the CCG Executive
remit to include the responsibilities of the Financial Challenge
Board.
9. Finance and Investment Committee Work Plan
The Committee noted the Work Plan and agreed the Locality
Investment Scheme should be brought for information to the next
meeting along with the procurement contract outline proposals.
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Frequency of meetings was discussed and GK felt that although the
monthly meetings added to the workload they were an assurance
process. The Committee agreed to continue meeting monthly but to
reduce the meetings to two hours with the exception of the March
meeting which would remain at three.
SA thanked RA for all her hard work and effort on behalf of the
Committee. RA explained the plan was to engage two new lay
members who would replace Ian Busby and her. These two people
would be members of the Finance and Investment Committee. The
Vice Chair would Chair the Integrated Governance and Investment
Committee and the other lay member would Chair the Finance and
Investment Committee.
10.Townlands Commitments
GK explained the paper had been presented to the CCG Executive who
had approved it for recommendation to the Finance and Investment
Committee. The Townlands Community Hospital Business Case had
been approved by the OPCT and supported by the CCG. NHS
Property Services had taken the view if costs could not be regained
from sub leases to tenants these costs should be recharged to the
CCG. The proposed occupiers of the building were currently Oxford
Health Foundation Trust (OHFT), Sue Ryder and the Royal Berkshire
Foundation Trust (RBFT). The main risk was if Sue Ryder did not take
up their option. The recommendation to the Committee was to approve
an increase in revenue costs which would then be underwritten. Efforts
would then be made over the next two years to offset, manage and
mitigate the risk by ensuring the building was occupied. GK advised it
was a financial risk but was not material and could be managed through
the contracts and service risks.
The Finance and Investment Committee approved the
recommendations:
The commissioning intentions expressed in the Full
Business Case to be adopted by the CCG had not changed
The CCG would accept liability for the revenue
consequences of the development
The CCG would accept the increase in revenue
consequences of the scheme from £1.179m identified in the
original business case to the final £1.215m, an increase of
£36k
Plans would be put in place to manage and mitigate the
additional revenue costs of the scheme; and the risk of
‘void’ costs being passed on to the CCG to fund directly.
Action: GK to include in a letter to NHS Property Services the need GK
to ensure as much flexibility as possible around the design.
GK to discuss with NHS Property Services IPR costs if the scheme GK
was rolled forward.
11.Any Other Business
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There being no other business the meeting was closed.
12.Date of Next Meeting
The next scheduled meeting was 17 April 2014, 09.30 – 12.30, Room
1, Jubilee House but meeting dates might need to change. LC to check
and advise.
LC
15
Oxfordshire
Clinical Commissioning Group
MINUTES:
INTEGRATED GOVERNANCE AND AUDIT COMMITTEE
23 January 2014, 14.00 – 17.00
Conference Room A, Jubilee House
Present:
Ros Avery – Chair
Graz Luzzi
Paul Grady
Tony Summersgill for Sula Wiltshire
Maria Grindley
Michael Yates
Gareth Kenworthy
In attendance:
Apologies
Lesley Corfield – Minutes
Alan Cadman (until 15.40)
Gavin Bartholomew
Jenny Simpson
Adrian Balmer
Ian Wilson (from 15.00)
Mike Delaney
Sula Wiltshire
Action
1. Declarations of Interest
There were no declarations of interest.
2. Minutes of Last Meeting
The minutes of the meeting held on 26 November 2013 were approved as
an accurate record.
3. Matters Arising
Governance Flow Diagram
GK advised the flow diagram would be brought to the next meeting. He
apologised for the delay which had been caused by internal organisational
changes. A draft had been formed and shared with RA. The work on the
diagram and other issues has prompted the executive team to undertake a
deeper look at the governance arrangements and particularly those around
finance in February.
Action: Flow Diagram and revised governance arrangements to be
brought to the next meeting.
CSCSU Assurance
Discussed later on the agenda under item 12.
Security Management
Action: PG to check if guidance was available.
Payment By Results Audit
GK advised the current arrangement would continue and there would be a
PbR assurance framework for 2014/15. The Clinical Commissioning Group
(CCG) was waiting to hear whether Oxford University Hospitals Trust
(OUHT) would be included.
GK
PG
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Action: An update to be brought to the next meeting.
Status of S75 Agreement with OCC
GK reported the CCG was reviewing the legal documentation but there was
clear intent to sign the S75 Agreement.
Action: An update to be brought to the next meeting.
Counter Fraud Policy and Response Plan
GK informed the Committee the Bribery Awareness presentation had been
given at the Staff Briefing. Appendix A of the Counter Fraud, Bribery and
Corruption Policy and Response Plan had not been simplified as per the
Committee’s request at the November meeting as the Local Counter Fraud
Service had been advised by NHS Protect that the appendix should remain
as it was required as ‘best practice’.
The Integrated Governance and Audit Committee approved the
Counter Fraud, Bribery and Corruption Policy and Response Plan and
recommended it to the Governing Body for ratification.
Policies
A list of policies indicating which were and were not ‘prime’ was being
pulled together by Jill Gillett and the final list would be sent to RA. GK
advised at the Staff Briefing a revision of the intranet had been announced.
The plan was for the new intranet to contain a section on policies and
procedures and OCCG staff would be informed of the policies location and
which policies were available. GK suggested an internal audit check should
be undertaken in the next year to confirm that these plans had been
implemented.
Action: Full list of policies to be sent to the Integrated Governance
and Audit Committee members.
An internal audit to be undertaken in 2014/15 to confirm the policies
were available on the intranet and staff knew how to find the policies
and the policies available.
Gifts Register in Localities
GK advised a gift register was core for the CCG and the next step was to
extend this out to the localities.
Action: GK to pick up with Carolyn Hinton the extension of the Gift
Register to localities.
Audit Committee Impact Assessment/Self-Assessment
GK advised the contract/service level agreement (SLA) had been with
Parkhill and novated to TIAA. He suspected the SLA was with the Legacy
Team. RA suggested the key performance indicators (KPIs) were reviewed
once a year and requested this was added to the forward plan. RA was
slightly concerned the SLA had not be located and requested assurance
processes were working as she had difficulty understanding how payments
could be made without a contract to check against. GK expressed a high
degree of certainty there was a SLA and explained currently invoices were
on the system and authorised for payment. In future a purchase order
would be in place. GK was requested to check the authorising process was
in place for these payments. PG advised a revision of the self assessment
was being undertaken to make it more applicable to CCGs. PG would bring
the briefing to the Committee when it was available.
Action: Review of KPIs to be added to the forward plan.
GK to ensure proper authorisation processes were in place for
GK
GK
LC
TS
GK
GK
LC
GK
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payment of internal audit fees.
Briefing on the revised Audit Committee Self-Assessment to be
brought to the Committee once available.
Gateway Review Update on OBC
GB reported the interviews had taken place. GK advised the final report
had been received on Wednesday 22 January. A paper on outcome based
contracts was going to the Governing Body on 30 January and the
recommendations from the report would form an appendix to the paper.
PG
FINANCIAL MATTERS
4. Financial Update
GK advised the CCG was reporting a year to date deficit of £5.8m, a
variance against plan of £5.4m. The forecast outturn remained in line with
previous forecasts at £6.2m deficit, £9.4m variance against plan.
Pressures were as reported previously with the two most significant being
OUHT contract pressures and the Older People’s Pool. It was difficult to
say any QIPP savings had materialised in year but the CCG was
maintaining focus in year in order to ensure any savings were achieved and
that programmes were robust for implementation from 1 April. Two nonrecurrent items were available to the CCG: a benefit on property expenses;
and a budget transfer from NHS England for GPIT. These would be
released over the balance of the year. The CCG was trying to negotiate a
fixed year end position with OUHT. Risks to the organisation remained the
unresolved specialised commissioning position as well as the deterioration
in the OUHT run rate and the Older People’s Pool. GK believed the
forecast of £6.1m to be robust although not without risk and was supported
by the non-recurrent items.
Following a query from GL, GK advised the overseas patient charges were
being investigated but in the last year the Primary Care Trust had received
£1.2m of non recurrent allocation. The figure was consistent with what had
been seen before but there was a need to work through the figures and
identify whether any were specialist activity in which event a case would be
made to NHS England. GK stated CCGs were now expected to pick up the
bill for overseas patient charges.
RA believed although some of the uncertainty was crystallising, some
difficult decisions were being deferred to the next year giving rise to
insecurity with the 14/15 plan. GK commented the CCG was in a much
better position but confirmed some items would transfer to the next year.
He advised some legacy decisions had been delayed but in terms of impact
on the CCG position, activity performance remained the key item.
With regard to Continuing Health Care costs for 2014/15, GK advised these
were difficult to control due to it being the end of the urgent care pathway.
The CCG was trying to implement interventions earlier in the pathway but
this was a medium term strategy. He reported Oxfordshire was an outlier
for funded care nursing costs.
GK explained the CCG was attempting to bring stakeholders to the table to
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5.
6.
7.
8.
obtain a strategy that worked for the whole health economy but capped
expenditure and included more risk sharing. Proposals had been sent to
OUHT who would discuss with their Board.
Month 9 Prime Financial Statements
JS advised as requested by the Committee, a hard close had been
undertaken at Month 9. The report had been produced by AC.
Responding to a question from RA, AC advised he did not believe anything
had materialised in the hard close which had not been planned for or taken
into account except perhaps some legacy items which, the CSU had been
informed, should currently be ignored. GK explained if the legacy had
transferred in 2013/14 there would have been continuity of knowledge but
now work would have to be undertaken with external auditors around this
element. MG confirmed some of the assumptions would have to be
unpicked and advised Ernst & Young would be able to undertake this work
as soon as the CCG was ready. RA thanked everyone for the work
undertaken in producing the hard close. She appreciated the amount of
work that had been involved but felt it had been worth the effort and would
assist at year end. AC concurred advising the task had provided a template
for the year end accounts.
Update on 2013/14 Opening Balances
Covered above.
QIPP Update
GK reported the yield from 2013/14 was poor and disappointing. The move
to programme management office (PMO) working aimed to put the CCG on
a better footing for 2014/15. The QIPP programmes had been revised into
three areas concentrating on: first outpatient appointments; EMUs pathway;
and excess bed days. These three areas were anticipated to have the
most, if any, impact in the current year and going forward. GB advised
there had not been detailed consultation with the Locality Clinical Directors
(LCDs) but from a clinician’s point of view these felt appropriate areas for
focus as they were where the biggest impact could be made and where it
was possible to shine a clinical light. The move seemed to be sensible and
right to move away from the huge number of QIPP programmes which it
was difficult to understand.
Accounting Policies
AC explained the format for the accounting policies was prescribed in the
draft set of account templates from the Department of Health. The
Committee was asked to note the policies. AC expected the policies would
change before the year end and would notify the Committee when this
occurred.
GL queried whether legal liability for clinical negligence claims sat with the
provider trusts. TS felt it related to any qualified provider. AC observed it
could be contractual liabilities between the CCG and trusts but would
check.
RA felt the policies required more work as they referred to the trust not
CCG, acronyms were not explained, items did not apply to the CCG and
irrelevant items should be removed. It was noted adoption of the
accounting policies would normally be rolled into the final accounts process.
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JS reported there had been no further clarification on Charitable Funds. To
be dealt with outside of the room. It had not been possible to pay for the
Cobic Solutions work with Charitable Funds monies as after being
evaluated, it did not met the criteria. Oxford Health Foundation Trust
(OHFT) managed the Charitable Funds on behalf of the CCG. The funds
were below £100k. Cobics Solutions had been paid from the CCG running
cost allocation.
The Accounting Policies were noted but not approved as further work
was required.
Action: AC to check clinical negligence legal liability.
AC to review, tidy up and only include relevant items in the policies.
JS to follow up the Charitable Funds clarification.
9. Final Accounts Timetable and Plans
AC presented the final accounts timetable and plans and reported the
submission date had changed to 6 June 2014 not the third as stated in the
papers. AC advised the timetable was all encompassing and some of the
items might need to be checked rather than undertaken. The aim would be
to have a draft set of accounts for review by the Committee prior to Easter.
Dates for meetings to review the draft and final accounts by the Committee
had been agreed and were in diaries. RA requested resubmission of the
paper at the next meeting with a RAG rating included. AC advised names
and responsibilities of people in the CSU would also be included in the
plan. It was agreed other submissions such as the annual report and other
statements would also be included in the plan.
Action: AC to revise the timetable and plans to include RAG rating,
names and responsibilities and other submissions.
GK to double check the Integrated Governance and Audit Committee
had been delegated the authority to approve the accounts.
10. Finance and Investment Committee Minutes
The Integrated Governance and Audit Committee noted the minutes of the
Finance and Investment Committee meetings held in October and
November 2013.
AC
AC
JS
AC
GK
EXTERNAL AUDIT
11. Progress Report
MG presented the Progress Report and advised there were still some
uncertainties around the audit plan but expected the situation to become
clearer and the plan would be brought to the next meeting or shared in the
interim if it was available.
AB would work closely with the CCG and CSU around the accounts closure
and moving towards production of the final accounts.
MG reported on the requirement to consider reporting arrangements to the
Secretary of State when an organisation went into deficit or reported a
deficit at year end. The Section 19 report would be either a type A or B but
which had not yet been decided. All CCGs with a deficit balance at year
end would undergo a Section 19 report. MG would meet with GK to
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discuss before the report was shared more widely. The importance of
including context in the report was noted. The Secretary of State and
Department of Health would receive a copy of the Section 19 report. GK
believed the Governing Body was well sighted on the CCG position and the
driving factors.
Action: MG to bring audit plan to next meeting or circulate in advance
if available.
MG
INTERNAL AUDIT
12. Progress Report
PG reported field work had been completed, three draft reports issued and
action plans were being finalised. PG agreed there had been some issues
with lack of response from management but admitted TIAA had not pushed
for a response. Three other audits were underway. A risk management
presentation had been made to the Governing Body Workshop and it had
been agreed further work around developing content and controls and
action planning in the Assurance Framework and Risk Register would be
undertaken. PG had met with Liz Wragg to take this work forward.
On third party assurance, a detailed 24 page update had been received on
the work Deloitte had undertaken for the CSU and functions had been RAG
rated. The next step was for Deloitte to undertake further testing. Deloitte
had not specified in the report what assurance they would provide following
their audit of the CSU. MG commented other CCGs had received initial
findings which had raised some concerns and issues. Although MG did not
yet know what information they would receive, she advised as external
auditors, Ernst and Young had a right of access if they did not feel the
assurance was sufficient. Any concerns would be shared with the
Committee. GK advised the CCG had not yet had sufficient time to fully
evaluate the report and would do so with PG whilst bearing in mind the
comments from MG. A view of the level of assurance provided would be
reached and any gaps and how these could be addressed identified. PG
advised some days had been held back which could be used to firm up
assurances.
GK reported an update on progress against recommendations was being
prepared. This report would go the executive before coming to the
Committee.
RA requested clarity that the corporate governance audit had been
completed as she recalled the CCG had not been sufficiently formed to
enable corporate governance arrangements to be audited and ‘no opinion’
was formally given.
RA asked for the meeting forward plan to include those internal reports
which should be coming to meetings
Action: Review of the Deloitte report to be completed and any
concerns to be raised.
GK to complete the progress against recommendations report and
bring to the next meeting.
GK/PG
GK
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The corporate governance audit to be checked for completion.
Work plan to be updated with internal audit reports.
GK/PG
PG/LC
GOVERNANCE AND RISK
13. OCCG Assurance Framework (AF)
TS explained the CCG Chair had requested rather than the full AF being
presented to Governing Body only the executive summary would be taken.
It was important for the organisation to consider the reports in detail and it
was proposed this review should be undertaken by the Quality and
Performance Committee (QPC) and the Finance and Investment
Committee (F&I). GL liked the summary sheets and the inclusion of
numbers and supported the view the summary was the most important for
the Governing Body but felt the full reports did need to be considered. GL
thought it would be useful to see the date when a risk was entered on the
risk register (RR).
The proposal was for the QPC to consider the clinical risk and F&I the
financial risks. RA commented, given the current population of F&I, the
members were either also Integrated Governance and Audit Committee
members, Governing Body members or both and queried whether it would
add value. GK attended all the meetings but felt it would add value for F&I
to validate the scoring but more importantly to review mitigation and
controls. The Committee accepted the proposed changes.
RA commented that the progress made on the AF had made it easier to
understand but also easier to identify gaps. GL felt an expectation after
mitigation had been applied rather than target would be appropriate. RA
concurred stating the target date needed to be meaningful as some were
not credible. GK acknowledged the process to drive the procedure to
ensure the product matched reality was not yet embedded and took this as
an action for the Executive. TS suggested including steps within long dated
items to show the stages it was hoped to achieve by a certain time.
The Integrated Governance and Audit Committee noted the progress
made which had led to further questions due to transparency. The
Committee also supported the proposed new principal risk and the
proposed changes in reporting.
Action: Executive team to consider the risk around communication
with the public.
GK to discuss embedding process with the executive team.
TS to check whether the software allowed the numbers on the
summary sheet to be included on the detail sheets.
AF 12: to be reviewed and rating considered.
AF 1: to be reviewed and lead altered to Gina Shakespeare.
14. OCCG Risk Register (RR)
RA commented on the CCG being good at putting plans in place to mitigate
risks once identified but queried what scanning processes there were for
identifying new risks and how the CCG could be assured horizon scanning
for new risks was being undertaken. TS advised a QPC workshop had
been held and covered this aspect. The general view had been systems
GK
GK
TS
TS
TS
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were in place for picking up issues and it was felt this could be improved by
more unannounced inspections, public facing documents being more
transparent and the escalation policy being implemented more consistently.
RA advised she was following up a question raised by a member of the
Committee around whether the CCG was proactive in looking for new risks
and using intelligence nationally and locally to update the RR. The
Committee was provided with assurance that the CCG obtained information
from many sources including inspections, GP feedback, patient experience
and quality inspections. IW advised the CCG was also considering upskilling patients to undertake mystery shopping on the CCG’s behalf. PG
suggested reviewing other CCG AF and RRs as this might provide
information on other areas not currently covered by the OCCG.
Action: PG to review other CCG Assurance Framework and Risk
Registers.
15. Quality and Performance Committee Minutes
The Integrated Governance and Audit Committee noted the Quality and
Performance Committee minutes for October 2013.
16. Update on Constitutional Changes
IW advised the election for the Clinical Chair would close at midnight on
Friday 24 January. A threshold had to be achieved for the ballot to be valid
ie a certain proportion of practices had to vote. The count would be
undertaken by the Local Medical Committee (LMC) on Monday afternoon.
The result would be shared with the candidates on Monday evening. Staff
and the Governing Body would be advised on Tuesday morning. A good
field of candidates had been received for the Accountable Office role.
Shortlisting would take place and interviews held in early February. NHS
England had suggested implementation date for the new constitution
should be 2 February. The Governing Body would endorse the Clinical
Chair election result at its meeting on Thursday 30 January.
PG
GENERAL AUDIT MATTERS
17. Single Tender Action
JS presented the Single Tender Action paper advising the purpose was to
comply with best practice and to make the Committee aware of when a
single tender action waiver had been used. This would be a regular item
for the Integrated Governance and Audit Committee agenda.
RA commented historically in the Primary Care Trust a number of items
went through on single tender waivers due to lack of planning. By having a
list of all tenders and contracts it was hoped renewals and procurements
could be undertaken in a timelier manner without the need for single tender
waivers. GK reported the detail would be taken to F&I next week but a
Procurement Steering Group had been formed. At the initial meeting the
role and function had been agreed; decision trees and processes reviewed;
and a current work plan and a long list of contracts considered. The
decision tree and guidance would be used to work through the list and a
standard process providing a rationale for procurement or contract
extension would be applied. GK advised a number of contracts were
extended for a year due to the set-up of CCGs consequently these were
coming to a renewal date at the end of March.
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Action: The date of the Stroke Association extension to be checked
(queried whether should be March 2015 rather than 2014).
18. Integrated Governance and Audit Committee Work Plan
Action: Single Tender Action Waiver to be included as a standard item
and internal audit reports to be added.
19. Any Other Business
Integrated Governance and Audit Committee Meeting without the Executive
RA explained members of the Committee should meet external and internal
audit annually without executive officers being present. She proposed the
members should do this at the beginning of the next meeting and this
should be added as an item to the forward planner.
Action: To be included on the forward planner.
Department of Health Consultation on new Constitutional Requirements for
CCG Audit Committees
GL drew the Committee’s attention to the Department of Health
Consultation on new Constitutional Requirements for CCG Audit
Committees. It was agreed this would be an item on the agenda for the
next meeting.
Action: Item to be added to the agenda for the next meeting.
20. Date of Next Meeting
The next meeting will be held on 20 March 2014, 14.00 – 17.00, in
Conference Room B, Jubilee House. (NOTE: First 30 minutes without
executives)
LC
LC
LC
LC
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Oxfordshire
Clinical Commissioning Group
MINUTES:
QUALITY AND PERFORMANCE COMMITTEE
27 February 2014, 09.30 – 12.00
Conference Room A, Jubilee House
Present:
David Chapman, Clinical Lead (absent between 10.00 and 11.00)
Cécile Coignet, Assistant Director of Performance (until 12.00)
Andrew Colling, Lead for Quality, Contracts & Procurement
Joint Commissioning, OCC (for Sara Livadeas)
Julie Dandridge, Assistant Director Medicines Management
Nick Elwig, Clinical Lead (until 12.00)
Richard Green, Clinical Director of Quality
Damian Haywood, Senior Commissioning Manager (for Gina
Shakespeare)
Val Messenger, Deputy Director of Public Health (until 12.15)
Catherine Mountford, Associate Director of Strategy and Governance
Diana Roberts, Patient and Public Representative (until 12.20)
Tony Summersgill, Assistant Director of Quality (absent between 10.00
and 10.45)
Sula Wiltshire, Director of Quality and Innovation - Chair
In attendance:
Lesley Corfield, Committees Secretary - Minutes
Linda Collins (LCo), NICE Lead – Item 8
Claire Critchley (CCr), Medicines Management Lead (Quality
Improvement) – Items 13, 14 and 15
Bernadette Devine, Urgent Care Interim Programme Manager – Item 12
Jan Fowler, Director of Nursing and Quality, NHS England
Mishal Salih, Quality Improvement Manager and Locality Lead – Items 6
and 9
Helen Ward, Quality and Clinical Standards Manager
Apologies
Gina Shakespeare, Interim Chief Operating Officer
Louise Wallace, Lay Member
Action
1. Declarations of Interest
All GPs present had a potential conflict of interest around the prescribing
incentive. DC advised he had a contract with Southern Health for learning
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disability services.
2. Minutes of Last Meeting
The minutes of the meeting held on 19 December 2013 were approved as
an accurate record.
3. Matters Arising
Patient Stories
The patient story had been well received at the Governing Body meeting.
Feedback had been received from Oxford University Hospitals Trust
(OUHT) requesting Oxfordshire Clinical Commissioning Group (OCCG)
ensured experiences from other organisations were also presented and
they felt there should have been opportunity for an action plan to address
concerns raised. The CCG accepted the comments but the view was the
stories were to focus discussion and were about the patients’ perspective.
Flu
A suggested slogan for next year’s campaign was “flu goes viral”. To date
the number of flu episodes had been low and it was anticipated this might
make uptake of flu vaccine more difficult next year.
Horton General Hospital (HGH) Clinical Protocols Update
A public meeting had been held on 5 February 2014. The Health
Overview and Scrutiny Committee (HOSC) would discuss whether a
consultation was required. The Trust had agreed more surgical presence
was required at the Horton. The clinical protocols had been reviewed and
issued to GPs for consultation. Subject to receiving assurance around the
process for evaluation of protocols and there being a more surgical
presence, OCCG would close the contract query. A survey using the
questions which were the best indicators of overall experience had been
undertaken of 200 patients from the Horton and 200 from the rest of
Oxfordshire. The results found only a very small difference between the
Horton and rest of the cohort. The survey did pick up some significance
issues on the SEU and these were being investigated. Data around the
volume of transfers had also been requested.
CQC Communication Process with NHS England
Christine Skeldon, from NHS England, and HW had met. It was felt a
review of the system was required as some of the information was
received by both the CCG and NHS England. The CCG involvement in
quality improvement in primary care was receiving more focus. The CCG
could provide some safeguarding and infection control advice to localities
although it was felt some more formal training might be required. This will
be reviewed once more clarity around the CCG position was known.
Action: Provision of training to primary care to be reviewed at a later
date.
Update on District Nursing (DN) Services
Meetings had been held with Oxford Health NHS Foundation Trust
(OHFT) every two weeks. Some short term actions had been taken to
improve staffing. The recruitment process was on-going although the
localities had advised they had seen no improvement on the ground. The
CCG would be looking at the interface between DN and primary care and
this would form part of performance management. CC advised there had
been a five per cent increase in DN activity in 2013/14 compared to the
previous year and suggested this might have had an impact on the
service. Action: Summary report to be brought to next meeting.
TS
TS/DH
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Unannounced Visits
The legal position had been checked and the CCG had written to the
smaller providers. Visits would be scheduled.
SW
4. Forward Planner
CQC reports to be included as standing item. Individual Funding
Requests (IFR) Annual Report to be added for June. It was agreed the
Forward Planner should also reflect the development of quality schedules.
Action: The Forward Planner to be updated.
LC
5. Quality and Performance Report / Quality at a Glance / Risk Register
SW suggested, as the Quality and Performance Report was presented to
the Governing Body and was in the public domain, it could be improved to
still be sufficiently robust but more streamlined and focussing on the ‘so
what’. She requested the Committee consider this as CC presented the
report.
The Oxfordshire health system remained under pressure and a
£6.1m deficit was forecast at year-end
The QIPP programme had been narrowed down to four projects to
maximise yield in the financial year
Data issues and growth in elective and non-elective bed days
needed to be understood
Four performance notices were open and there were four open
contract queries with providers
Urgent care: The Urgent Care Working Group were holding weekly
multi agency summit meetings to identify and resolve problems with
patient flow
o 111: for all months except December monthly call targets
were met; a SIRI had been declared concerning poor call
answering performance on 15 December; patient feedback
remained positive
o Out of Hours: activity had reduced by 12.3 per cent
compared to the previous year
o Ambulance Service: year to date there was a 5.9 per cent
increase in activity; the Cat A8 target was not met in Quarter
3 or January 2014; handover targets had improved and were
being met on the Horton site but not at the JR
o A&E: type 1 attendances were up 0.5 per cent on the
previous year; performance against the four hour standard
was failed in Quarters 1 and 3; the proportion of A&E
attendances turning into admissions was up for the third
year running
o Emergency Admissions: OUHT was 2.6 per cent up on the
previous year; the proportion of emergency admissions
resulting from A&E turning into admissions had increased for
the third year running and reached 27.2 per cent between
April and December
o Delayed Transfers of Care (DTOC): the planned reduction
had not materialised; work in Quarters 3 and 4 was focusing
on streamlining and improving the discharge process; the
main reasons for delays had been identified as waiting for a
community bed, choice and assessments.
Planned care:
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o Elective Admissions: OUHT referral to treatment targets had
not been met; 173 operations were cancelled in Quarter 3; a
number of cancer waiting time targets were not being met, a
contract query had been issued. The CCG had not
accepted the action plan developed and actions were being
taken to address the issue
o Outpatient: first appointments were up 2.1 per cent on the
previous year; follow-up appoints were 0.9 per cent up after
a decline in the last month; GP referred follow-up
appointments had grown by 6.4 per cent; the first to followup ratio was stable; the action plan for improvement to the
Musculoskeletal hub had been implemented
o Diagnostics: the waits target was being picked up in the
contract review meeting
Other non-acute sector specific report:
o Flu: the immunisation target was being investigated as
initially data showed the CCG had met the target but new
data indicated it had been missed
o Community Services: the level of activity in community
hospitals was lower than in the previous year
o Learning Disability: concerns about Southern Health had
increased following a CQC investigation. There had been a
coordinated response to the issues. Monitor was reviewing
governance arrangements. Other agencies might undertake
another review as the internal investigation had been
completed. Further details around the service specification
would be brought to the next meeting if available
System Wide Aspects:
o Medicine Management: A contract query had been issued to
OUHT re monitored dosage system (MDS) at discharge.
The response was not satisfactory and a one week audit had
been requested
o Infection control: antibiotic prescribing needs further
attention.
There had been a significant dip in ‘Friends and Family’ responses in
December which was being reviewed. The Waitrose style ‘token voting’
system had been implemented although concerns were raised as this
method would not provide quality information. A paper on the OUHT staff
survey would be brought to the next meeting.
CC advised Ros Avery had suggested for Governing Body meetings the
main body of the report should be removed and the executive summary
expanded whilst the Quality and Performance Committee would continue
to receive the full report. Some concerns were raised around this
proposal.
SW queried whether the Committee felt the balance of the report was
right, that quality had not been lost over performance and comments on
the length of the report. RG felt more quality was appearing in the report
and the direction of travel was right. It was commented other CCGs used
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reports which were more like a dashboard than commentary and
explanation. TS observed the quality section of other CCG websites
tended to focus on authorisation rather than quality of care. HW
suggested from a member of the public viewpoint, the report read as very
cold but the amount of effort to make the document more public facing
would need to be debated.
Action: Details of the Learning Disability Service specification to be
brought to the next meeting if available.
OUHT staff survey paper to be brought to the next meeting.
Comments on the Quality and Performance Report to be sent to
SW/CC.
Quality at a Glance
The Committee reviewed the report and noted in particular:
Duplication of maternity discharge summaries had been reduced
and the hub was much safer. The hub manager was a joint
appointment. The OUHT was going through the business
information taskforce and a business case was in place. Funding
was required and this was partly tied up with the contract
negotiations for the next year
The OUHT clinical communication audits had been unacceptable.
TS and RG would meet with the Deputy Chief Operating Officer
The OUHT weekend mortality rates were being investigated and a
report was due next month.
Risk Register
RR704: 111 performance was still inconsistent and a performance notice
was in place but the CCG was assured appropriate auditing was taking
place. It was agreed the likelihood should reduce to unlikely.
AF10: The risk had been downgraded but would be reconsidered once the
CQC report on the OUHT had been received.
AF12: Gareth Kenworthy to be asked to review this risk.
RR707: It was agreed not to close this risk but to review and possibly
revise once the Department of Health targets for next year were known.
Action: SW to ensure amendments were made to the Assurance
Framework and Risk Register.
6. Quality Premium Update
MS attended for this item to provide an update on the CCG’s performance
against the Quality Premium targets for 2013/14.
The preventing people from dying prematurely target was not being
achieved
The reducing avoidable emergency admissions target was not
being achieved
The Friends and Family Test had been rolled out to maternity a
month ahead of schedule
The CCG failed to meet the zero MRSA target set by NHS
England. However, Oxfordshire did not breach the annual CDi limit
set by NHS England
The Flu immunisations and radiology requests made via ICE
figures were being checked
The reduce average LOS of DTOC patients target was not being
achieved.
HW
HW
All
SW
29
The CCG would also have its quality premium reduced if the providers
from whom services were commissioned did not meet the NHS
Constitution requirements:
Patients on incomplete non-emergency pathways should not have
been waiting more than 18 weeks from referral
Patients should be admitted, transferred or discharged within four
hours of their arrival at an A&E department
Maximum two month (62 day) wait from urgent GP referral to first
definitive treatment for cancer
Category A Red 1 ambulance calls result in an emergency
response arriving within 8 minutes.
If a provider failed an NHS Constitution target, the value of the quality
premium payment would be reduced by 25 per cent.
MS reported the Area Team had advised if a CCG had a planned deficit
and that deficit was hit, it would be deemed to not be in serious measures
and the payment would be made for 2014/15.
MS requested a steer from the Committee around the local quality
premium target to be selected. Electronic clinical communication or
antimicrobial prescribing of co-amoxiclav were suggested and considered
to be acceptable.
Action: Further work to be undertaken outside the meeting on the
proposed options. Director of Quality and Innovation to agree final
indicator.
Patient Safety
7. Care Quality Commissioning Reports Summary (including Primary
Care)
The Committee noted the report and felt although further work was
required it had been helpful in its present form.
Clinical Effectiveness
8. OUH Nutrition Audit
LCo attended for this item and presented the paper on the results from a
re-audit of screening for nutritional status at OUHT. This was difficult to
monitor as it affected all patients. All patients should be reviewed on
admission to check they were not malnourished and for longer term
patients’, a review should be undertaken every week. It was felt the
OUHT was addressing the issues and the contract route did not need to
be followed. The report would be taken to the meeting with the Director of
Nursing and Medical Director.
Action: The Director of Quality and Innovation to take the OUH
Nutrition Audit to the meeting with the OUHT Director of Nursing and
Medical Director.
9. OUH Stroke Audit Update
MS attended for this item and presented the paper highlighting the
performance year to date of stroke services at the OUHT against the
national standards in the national stroke audit. The OUHT had achieved
green in most of the key performance indicators (KPIs). The action plan
was not considered to be satisfactory and this would be taken up with the
OUHT.
TS/MS
SW
SW
30
Action: The Director of Quality and Innovation to pick up with the
SW
OUHT that the CCG felt the Stroke Audit action plan was
unsatisfactory.
10. Lavender Statements: Varicose Veins; Gender Dysphoria
JD explained the statements had been agreed by the Thames Valley
Priorities Committee and the CCG needed to decide whether or not they
should be adopted.
Varicose Veins Lavender Statement
The clinicians present felt the criteria was appropriate and would not result
in a huge increase in referrals or patients being treated. JD advised the
measurement of ABPI (anti brachial pressure index) would be discussed
with the Local Medical Committee (LMC) although she felt this was part of
normal practice before the use of compressions. The Committee
requested clarity around the definitions of significant haemorrhage and the
class of hosiery.
Subject to the amendments the Quality and Performance Committee
approved the varicose veins policy.
Gender Dysphoria Lavender Statement
JD advised that it had been thought Specialised Commissioning would be
responsible for all gender dysphoria treatment but a recent communication
stated that non-core procedures could be funded by the CCG. However,
many of these fell under the aesthetic treatment policy. As a result the
recommendation was the re-instatement of the 2009 gender dysphoria
treatments policy with appropriate revisions.
The Quality and Performance Committee approved the gender
dysphoria policy.
11. DAAT Service Update
VM explained following a change in national measures, the Oxfordshire
Drug and Alcohol Action Team (DAAT) services had moved to being the
worst in the country. The issue had been reported to the Public Health
Governance Committee. Performance had been analysed and a slight
improvement on the last quarter had been seen. The providers of shared
care services as well as other services had worked together with Public
Health England and an event was due to take place on 5 March 2014. All
GPs had been invited but to date only 10 had accepted. VM confirmed
there had been no specific communication with GPs around performance
issues but communication around training events and any change in
telephone numbers had taken place.
The clinicians’ present expressed grave concerns around the service. VM
advised several services were commissioned and it was only one
measure which was poor. It was agreed to take the issue outside of the
meeting to establish the root cause. This needed to be done quickly to
ensure patients were not at risk.
Action: SW, RG, VM, TS and DC to meet and update the Committee at SW/RG/
the next meeting.
VW/TS/
DC
12. DTOC Update
BD attended for this item and explained:
The new governance arrangements for urgent care within the CCG
The review of both the plan and sub plan every week at the summit
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meeting
The resilience calls taking place every day
The anticipatory care planning
The continuation of some projects beyond the winter monies for
which all organisations had agreed to fund some of the work
The review of the outcome of the CQC inspection of the OUHT.
BD expressed confidence the actions being taken would have an impact,
there was dialogue between organisations, proper communication and
responsibility was being assumed.
BD
Action: BD was requested to provide an update to the next meeting.
13. Prescribing Incentive Scheme
CCr presented the proposed prescribing incentive scheme for 2014/15.
The scoping document had been circulated to localities and the scheme
was based on the feedback received. Three elements were agreed:
Budget allocation but within 0.5 per cent of budget rather than 1 per
cent. There was some debate over the 0.5 per cent in excess of
budget and the problems this could cause the CCG if all practices
were to exceed their budget by 0.5 per cent. The Quality and
Performance Committee agreed this element.
Antimicrobials. The current method of measuring this element was
recognised as not being ideal and two options were proposed. The
Committee agreed Option 1 but with an appeal process. The
Quality and Performance Committee agreed this element.
Prescribing in long term conditions. It was proposed practices
could choose different options from a menu of four choices:
asthma, COPD, diabetes equipment and poly pharmacy restricted
to in care homes. The Quality and Performance Committee agreed
this element.
The Quality and Performance Committee approved the proposals for
the Prescribing Incentive Scheme for 2014/15.
14. Emergency Preparedness, Resilience and Response (EPRR) Annual
Assurance 2013/14
JD presented the paper detailing OCCG adherence to the NHS core
standards for Emergency Preparedness, Resilience and Response
arrangements.
The Quality and Performance Committee on behalf of the Governing
Body:
Noted compliance with the NHS core standards
Noted assurance by Thames Valley Local Health Resilience
Partnership that OCCG would be fully compliant by 31 March 2014
Approved the improvement plan.
Inspections and Reviews
15. Waste Audit
Carried over to the next meeting.
Papers for Information
16. Any Other Business
There being no other business the meeting was closed.
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17. Date of Next Meeting
The next meeting will be held on 24 April 2014, 09.30 – 12.00, in
Conference Room B Jubilee House.
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