South Gloucestershire Clinical Commissioning Group Clinical Operational Executive Meeting

Item 3.1

Date: Tuesday 3rd May 2016 Time : 13:30 – 17:00 Location : Parkwall Hall, The Batch

Minutes

Attendees: Dr Jon Hayes (JH), Clinical Chair Anne Morris (AM), Director of Nursing and Head of Quality and Safeguarding Dr Andrew Appleton (AA), CCG Board Member Dr Joanne Hartland (JHar), Research and Development Manager, Avon Primary Care Research Collaborative Dr Kate Mansfield (KM), Children and Maternity Lead and Named Doctor for Safeguarding Children Dr Norman Douglas (ND), Primary Care Lead, South Gloucestershire CCG Dr Peter Bagshaw (PB), Mental Health, Dementia, Learning Difficulties and Adult Safeguarding Lead Dr Peter Young (PY), Planned Care Lead Dr Phil Simmons (PS), Clinical Evidence Fellow, South Gloucestershire CCG Guy Stenson (GS), Director of Partnerships and Commissioning, South Gloucestershire CCG Kate Lavington (KL), Deputy Director, Community and Mental Health Commissioning, South Gloucestershire CCG Lindsay Gee (LG), Head of Commissioning – Children, Young People and Maternity Lisa Harvey (LH), Deputy Nurse Director, Head of Safeguarding, South Gloucestershire CCG Louise Rickitt (LR), Head of Strategy and Service Redesign Melanie Green (MG), Head of Medicines Management Steve Rea (SR), Commissioning Delivery Manager Thom Manning (TM), Head of Performance and Information Dr Ann Sephton (AS), Deputy Clinical Chair / Urgent Care Lead Jon Shaw (JS), Head of Commissioning Partnership and Performance, South Gloucestershire Council

In Attendance: Beth Clibbett (BC) [note taker], PA, South Gloucestershire CCG Niall Mitchell, Head of Individual Funding, South West Commissioning Support Unit

Apologies: Jane Gibbs (JG), Chief Officer Sharon Kingscott (SK), Chief Finance Officer Martin Gregg (MG), CCG Board Member, South Gloucestershire CCG Jo Underwood (JU), Delivery Director North Somerset, NHS South, Central and West Commissioning Support Unit Claire Rees (CR), Health and Wellbeing Partnership Officer, South Gloucestershire Council Dominic Moody (DM), Communications Manager, South, Central and West 1

Commissioning Support Unit David Jarrett (DJ), Director of Operations Janet Biard (JB), CCG Board Member Dr Mark Pietroni (MP) Director of Public Health for South Gloucestershire, South Gloucestershire Council Sara Blackmore (SB) Consultant in Public Health, South Gloucestershire Council Ben Bennett (BB), Director of Strategic Projects, South Gloucestershire CCG Dr Alison Wint, (AW) Clinical Lead for Cancer, South Gloucestershire CCG Dr Jon Evans (JE), Long-Term Conditions Lead, South Gloucestershire CCG

Action 1. Welcome Everyone was welcomed to the meeting and apologies were noted. Due to the number of apologies noted the meeting was not quorate, therefore the present members of the Clinical Operational Executive will make recommendations for approval. Introductions were then made around the table.

2. Declarations of interest 2a) To consider any changes to attendee interests since the last meeting None. 2b) To consider any conflicts of interest arising from this agenda None 3. Minutes of Previous Meeting/Matters Arising

3.1 The minutes of the previous meeting were approved as an accurate record of that

meeting.

3.2 Matters Arising not on the agenda

Please see Appendix 1. 4. Chair’s update

 JG gave an update on the significant issues that are hot off the press this week  JH explained that in keeping with the CCGs history of supporting primary care development, the forthcoming CCG Membership Meeting on Thursday 12 May will be a practice only meeting and will be chaired by Tharsha Sivayokan, Neil Kerfoot and Simon Bradley as representatives of South Gloucestershire Primary Care Alliance. The meeting will be about how South Gloucestershire practices can continue to work together collaboratively in order to maximise the GP voice and influence the emerging NHS agenda, such as the Five Year Forward View and development of the STP. MG will be in attendance in order to offer support and guidance from the CCG.  JH announced that subject to Membership approval KM has been successfully appointed as the new GP Clinical Lead on the CCG Governing Body. 5. Update on financial position

The year-end processes are progressing well with timely submissions on the 22nd

April 2016 to NHSE and the Auditors. The contract negotiations with NBT are

very protracted with issues not reaching conclusion and are now being taken

forward through Chief Executive escalation, papers for which are being prepared for this Thursday. The CCG have also been put into the Arbitration process by NBT for which our panel is on Friday morning in London. The decision by the panel will be final and parties will need to action on this basis.

6. Papers for Decision

6.1 Clinical Policy Review Group Recommendations

NM presented this report, which sought review and approval from the Clinical Operational Executive to adopt/re-adopt a number of INNF policies. The following policy reviews were agreed to be readopted, subject to the revision set out in the Clinical Policy Review Group (CPRG) recommendations paper. The CPRG panel recommended retention of the following policies for 3 years unless otherwise stated below.

Epididymal Cyst This policy was presented without any significant amendments to the policy already in place.

Reversal of Vasectomy of Female Sterilisation

This policy was presented without any significant amendments to the policy already in place.

Laparoscopic Cholecystectomy for Asymptomatic Gallstones (not Symptomatic) This policy was presented without any significant amendments to the policy already in place. The name of the policy has been changed to clarify the commissioning stance for symptomatic gallstones.

Tattoo Removal

This policy was presented without any significant amendments to the policy already in place.

Testicular Prosthesis This policy was presented without any significant amendments to the policy already in place.

Chest Wall Deformity

NHSE now commission all non-cosmetic thoracic surgeries and are developing a pectus/chest wall deformity policy. However, NHSE has indicated that this policy may not include cosmetic requests and these requests may fall to the CCGs.

CCGs policy has therefore been revised to state that the correction of chest wall deformity for cosmetic purposes is not routinely funded by the CCG and any requests will require an IFR application form. This policy will be reviewed once NHSE policy is published to ensure all patient scenarios have been considered.

CPRG was asked to consider the revised policy and recommend adoption by CCGs for three years or until NHSE finalise their pectus/chest wall deformity policy..

Laser Eye Surgery for Refractive Error The remit of this policy was expanded to cover long sightedness as well as short sightedness. The name of the policy was changed to reflect this.

Surgical Foot Treatment

This policy has been altered from covering bunions and lesser toe deformity to reflect that foot surgery covers a number of conditions where CCGs would not wish 3

to commission treatment for in secondary care.

Hip Replacement Surgery

This policy has been considered by CPRG a number of times and various revisions have been sought to enable the CCG to better monitor this procedure in view of the significant waiting list issues in T&O coupled with the SARs over performance.

A revision has therefore been undertaken making it clear that patients with end stage osteoarthritis that have undergone a period of unsuccessful conservative management and remain symptomatic will qualify for surgery if appropriate. By stating the period of conservative management and the measures used during this period, it will allow the IFR team to undertake more robust auditing of the service to assure CCGs that only patients who qualify for surgery under the policy are being treated.

A further revision reflects the current NICE position on Orthopaedic Data Evaluation

Panel ratings of prosthesis to be used and where it is proposed that custom devices are to be used, funding approval will need to be sought from IFR panels setting out why the patient is unable to access the standard care pathway.

The policy gives primary care clearer guidance on when to manage patients and when to refer for surgery including lifestyle factors that should be addressed by the patient. The policy also links to the patient Decision Aid Tools available on the Right

Care website.

Hip Femoro – Acetabular Surgery including Hip Impingement

Since developing the ‘interim’ policy in 2011, NICE have produced new guidelines on open and arthroscopic surgery for hip impingement. This policy reflects the guidance and has been amended to reflect comments from surgeons and the MSK service. The policy remains as a Criteria Based Access Policy.

Knee Arthroscopy This policy is the most significantly altered policy proposed via this CPRG.

Patients will continue to be eligible for surgery where there is clear evidence of ligament rupture or loose body and conservative management (clearly documented) has failed to resolve the patient’s symptoms.

However, given the emerging evidence referred to within the policy, that arthroscopy for meniscal tears is in many instances no better than sham surgery, it is proposed that only patients with confirmed mechanical deficit and meniscal tears will qualify for arthroscopy under this policy. This recommendation is likely to lead to a significant reduction in the number of patients eligible for surgery.

It is proposed that the policy will remain CBA. However, by making other indications “exclusions”, clinicians will need to make a case to IFR panels as to why patients should be treated. This includes patients who have previously had a knee arthroscopy in the affected knee, do not have mechanical symptoms with meniscus tears or who have knee pain without meniscus tears.

Experience from audits conducted at the providers in recent months shows that this is likely to impact on the number of patients automatically qualifying for surgery but this does reflect current evidence.

In addition, the following new policies were presented by NM and reviewed for approval by the Clinical Operational Executive:

Alfa Pumps for the Removal of Ascites due to Liver Disease

This is a completely new development and is a Trust proposal to CPRG. The IFR team have worked with the Trust to develop this policy. The business case has been submitted and is proposed as being a cost neutral implantation for the CCG. The CPRG panel agreed to recommend adoption of the new policy for 3 years; implementation will be subject to funding being secured via the annual contract negotiations.

Syndactyly – Surgical Correction

Syndactyly relates to joined or webbed fingers. As these are normally simply a cosmetic concern and therefore surgical separation with the inherent risks would not normally be funded. The BNSSG panel have received applications for these conditions to be treated and this policy has been developed to clarify the funding position.

The policy reflects the view of CPRG that funding will be approved where the patient has extensive polysyndactyly and significant functional impairment.

The CPRG panel therefore agreed to recommend this policy for 3 years.

Open MRI Scanner at Cobalt Health Cheltenham

For some years now, patients who are unable to use standard MRI scanners are referred to Cobalt Healthcare in Cheltenham for an Open Scanner and these are funded by South Gloucestershire CCG. This policy reflects this de facto position but clarifies only patients who suffer from significant claustrophobia or obesity should be referred and this is not an option under patient choice.

The CPRG panel therefore agreed to recommend this policy for 3 years.

Chronic Fatigue Syndrome

South Gloucestershire CCG had previously included on the INNF list that CFS referrals outside local commissioning arrangements were not routinely funded. CPRG have recommended this new CBA policy, and that will replace the existing INNF list entry.

The introduction of a policy will allow the IFR team to have a baseline to review/ monitor the CFS service and conduct CBA audits.

The CPRG panel therefore agreed to recommend this policy for 3 years.

Skin Camouflage

This new policy sets out criteria to access this service at the Acute Trusts which provide advice and support for patients with cosmetic concerns. It must be noted that the CCGs do not routinely fund any cosmetic treatments and therefore this service could be said to be an anomaly in commissioned services.

This policy sets out the criteria for patients to access the acute trust services, including having used the Changing Faces service without success and the disfigurement must also be facial i.e. cannot be covered by clothing. The policy also

sets limits on treatment funded by the CCGs.

The CPRG panel therefore agreed to recommend this policy for 3 years. The Clinical Operational Executive Committee noted the reviewed and new IFR policies, subject to JG and SK approval the COE will agree to the policies for adoption and implementation.

Post meeting note. The recommendations made by the Clinical Operational Executive members were accepted and approved by JG & SK 6.2 BNSSG Elective Care Access Policy

TM circulated a rewritten BNSSG Elective Care Access Policy which has previously not adhered to national standards.

TM has worked closely with the CSU to rewrite the Policy to ensure compliance with national standards such as the NHS Constitution, Patient Choice and Safeguarding. The Policy has now been accepted by provider organisations.

The Clinical Operational Executive noted and supported the new policy with the proviso that JG and SK approve the policy for publishing.

Post meeting note. The recommendations made by the Clinical Operational

Executive members were accepted and approved by JG & SK

6.3 Comprehensive Geriatric Assessment – Q&A

SR gave a further update to the Clinical Operational Executive on the proposed development of the CGA in primary care which is planned to be funded via the Membership Agreement and to answer questions raised at the April COE meeting. The following questions and answers were provided regarding implementing the CGA in Primary Care:

Question 1: Why is the proposal being offered as a two year pilot? This will limit

opportunities for other developments via the GP Membership Agreement next

year.

Answer 1: As with any service development, the benefit of CGAs in Primary Care will need to be evaluated. If this were only trialled for a year then there would not be enough time (before a decision on future funding needs to be made) in order to carry out a sufficient number of CGAs and then be able to demonstrate, or not, the impact on the wider health system in the months following a patient having a CGA. Agreeing to fund the pilot for two years via the Membership Agreement will ensure that Practices are reimbursed appropriately for the work whilst allowing

sufficient time to evaluate and decide on next steps.

Question 2: The paper proposes that patients with a Rockwood score of 5 or

more will be suitable for CGA. As we haven’t got Rockwood scores identified on

our IT systems, how will we be able to identify patients who would benefit from

CGA? Are these the same patients we identify as at risk of avoidable unplanned

admissions?

Answer 2: Patients can be identified by anyone in the MDT and it is anticipated the MDT will frequently be the place where appropriate patients are discussed. Emis does not

yet have Rockwood as a frailty entry but does have mild moderate or severe frailty. Emis is soon to include the Electronic Frailty Index (EFI) which is an algorithm validated for identifying frailty from primary care records and which will be useful to identify unrecognised cases. It is not anticipated that any one method of identifying patients will be mandated to allow for flexibility and teamwork The Rockwood scale is a very simple pragmatic scale that anyone in the MDT can use and is meant as a guide to those who are most appropriate.

Question 3: What support will be given to me/my practice to help me carry out a CGA effectively?

Answer 3: The CCG will deliver a PLT on CGA in June to which other members of the MDT will also be invited The CGA will be supported by a fairly self-explanatory EMIS template Advice will be available from the community frailty team and NBT geriatrician(s).

Question 4: How long will a CGA take and who in the practice would need to undertake this?

Answer 4: The evidence suggests that a doctor needs to be involved in doing the CGA and other clinicians and professionals contribute as required/indicated. This may include non-registered nurses (HCAs and nursing assistants eg doing initial observations, falls and dementia assessments etc) district nurses, physios, OTs, social workers, pharmacists and voluntary sector workers depending on the patient’s needs. Exact time commitments for carrying out a CGA and managing the patient cannot be given as this will depend on the patient’s needs and who from the MDT needs to be involved in the management.

Question 5: What evidence will my practice have to provide in order to achieve payment?

Answer 5: Emis search and report will be used to record the number of CGAs and the coded data within data. CCG clinicians may ask to view a sample of completed CGAs for quality and learning purposes

The membership agreement will clearly describe actions which need to be completed in order to achieve the payments. It is likely practices will be expected to carry out the following:

1. Describe the methods by which they are identifying the cohort of frail patients within their practice population who would benefit from a Comprehensive Geriatric Assessment.

2. To gain the £4500 initial payment for the practice, undertake 10 CGAs in each of

the two years for patients from within the identified cohort. 3. To gain the extra payment for the practice, undertake additional CGAs on a cost- per-case basis. An upper limit (maximum number per year for which a cost-per- case payment will be made) is stated. 4. Maintain a record of all CGAs undertaken and agree to participate in and support the evaluation of CGAs in primary care. This evaluation will then guide the CCG’s

decision on the future commissioning decision on CGAs in primary care. An exact

minimum dataset will be issued as part of the Membership Agreement.

Question 6: What happens at the end of the two year pilot? Will Practices be expected to continue this work without funding?

Answer 6: The pilot is currently funded for 2 years. No decision has been made about how or whether the work will be funded thereafter and any decision will depend upon evaluation of the pilot

The Clinical Operational Executive supported that sufficient evidence had been provided to now support roll out of CGAs in Primary Care via the GP Membership Agreement subject to agreement by JG and SK. It was noted that AS and DM will discuss communicating through different channels, for example across GP practices and rising as an item at PLT. ACTION: AS and DM to discuss communicating the roll out of CGA’s through AS & DM different communication channels. Post meeting note. The recommendations made by the Clinical Operational Executive members were accepted and approved by JG & SK 7.1 Final Report on the Membership Commitment to the Commissioning Plan 2015-16 Each year the CCG agrees a Membership Commitment to the Commissioning Plan with General Practice. Previously the 2015-16 Commitment included two sections: 1. The Commitment – sign up to the Agreement to include meetings attendance and commissioning oversight of General Practice 2. Performance Related Scheme – Incentivised clinical improvement element Within the Performance Related Scheme there were four improvement areas with associated metrics to assess improvement. 1. Increased utilisation of the ICE diagnostic test request system for colorectal ‘Two Week Wait’ referrals. The ambition was to refer 60% of CCG referrals via this route 2. Increased utilisation of N-terminal pro-B-type natriuretic peptide (NTproBNP) testing in primary care for the diagnosis of heart failure. The ambition was to increase the volume of requests in 2015 over that reported for 2014 3. Increased utilisation of faecal calprotectin testing in primary care for the diagnostic differentiation between inflammatory bowel diseases and non- inflammatory diseases of the bowel. The ambition was to increase the volume of requests in 2015-2016 over that reported for 2014-2015 4. Development of automated reporting via EMIS Web on the specialty level details of referrals made by general practice TM summarised the key issues of the four improvement areas. The improvement aims for ICE diagnostic test request, NTproBNP testing and Faecal Calprotectin Testing schemes have all been met in full. Development and implementation of EMIS Web referrals has been unachievable in the timeframes which have been communicated. TM explained that an amended plan has been put in place to develop practice level reporting and although the initial intended aim has not been met Practices will still be eligible for performance payment. The Clinical Operational Executive noted the contents of the report and the 8

improvements made in 2015-16 8. Papers for Information

8.1 2016/17 South Gloucestershire CCG QIPP Plan

SR presented the 2016/17 South Gloucestershire CCG QIPP Plan which explained the key programme areas and start dates.

The Clinical Operational Executive Committee noted the circulated document.

8.2 Final review of COE Terms of Reference The Clinical Operational Executive noted the amendments to the final version of the Terms of Reference. All sub committees who report to Committee were agreed apart from Primary Care Steering Group which will be removed from the list before being approved. 8.3 Clinical Leads’ Update on QIPP Delivery The Clinical Operational Executive Committee noted the circulated update.

The meeting closed at 5pm. Date of next meeting: Tuesday 7th June 2016, Parkwall Hall, The Batch