NHS Castle Point & Rochford CCG & Southend CCG Meeting of the Joint Procurement Committees 16th October 2019, 3-4 pm Audley Mills MINUTES
Members in Attendance: Tracey Grimbley (TG) Lay Member for Governance (Chair) NHS CP&R & Southend CCG Mark Barker (MB) Chief Finance Officer NHS CP&R & Southend CCG Charlotte Dillaway (CD) Director of Strategy and Planning NHS CP&R & Southend CCG Dr John Wier (JW) Independent GP NHS CP&R & Southend CCG Janis Gibson (JG) Lay Member for Patient Engagement NHS CP&R & Southend CCG Pauline Stratford (PS) Lay Member for Primary Care NHS CP&R & Southend CCG In Attendance Kevin Edwards (KE) Associate Director Attain Cariad Burgess (CB) Commercial Specilaist Attain Sharon Earl (SE) Committee Secretary NHS CP&R & Southend CCG Jo Dickinson (JD) Integrated Commissioning Team NHS Southend CCG Nancy Smith (NS) Integrated Commissioning Team NHS Southend CCG Matt Gillam (MG) Head of Nursing NHS CP&R & Southend CCG James Currell (JC) Associate Director of Operations NHS CP&R & Southend CCG Nyssa Paige (NP) Operations Commissioning Lead NHS CP&R & Southend CCG Apologies received from: Tricia D’Orsi
1. Welcome and Apologies 1.1 TG welcomed everyone to the Joint Procurement Committee.
1.2 Apologies were noted as above.
2. Declarations of Interest 2.1 Members of the Committee were reminded of their obligation to declare any interest they may have on any issue arising at committee meetings which might conflict with the business of CP&R/Southend CCG and that declarations declared by members of the Committee are listed in the CCG’s Register of Interests. The Register is available either via the Committee Secretary to the governing body or the CCG website at the following link: https://castlepointandrochfordccg.nhs.uk/about-us/key-documents/2508-declarations- of-interest-governing-body/file or https://southendccg.nhs.uk/about-us/key- documents/320-nhs-southend-ccg-governing-body-declarations-of-interests-register/file 2.2 With reference to business to be discussed at this meeting, there were no declarations of interest made.
2.3 The Chair declared the meeting to be quorate.
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3. Minutes from the meetings held on the 15th May 2019 3.1 The minutes from the 15th May 2019 were agreed as an accurate reflection of the meeting, with the exception of a typing error on Page 3.
4. Action Log from the 13th March 2019 4.1 The action log was reviewed and updated as below:
Action 92 – EPUT Diabetes Training – This is currently going through an extension to service and will form part of a future procurement. Close.
Action 94 – TUPE Issues – SE to contact JT for update.
Action 96 – Autism Diagnostic Report – Waiting data from provider and then report will be taken to Governing Body meetings. Close.
5. Procurement Support for Mid & South Essex CCGs 5.1 MB informed the Committee that the Attain contract expired on the 30.09.19 and an extension to contract has been agreed to the 31.03.2021 which fits with the possible organisational changes. Attain will be working across the 5 CCGs with a dedicated team of support.
There will be closer monitoring and control over how the CCGs access Attain support to ensure that we use their expertise wisely and MB will be monitoring all requests for support across the 5 CGGs. A communication has been sent out to all staff across the 5 CCGs explaining this.
5.2 JG queried whether this will allow us to maximise joined up thinking/working across the whole STP. MB felt that this would ensure that we were consistent across the patch and there would be a work plan which will be shared on a monthly basis. Part of the contract includes 100 days advice and guidance via a phone call and this need to be closely monitored with prior approval required if significant workload was expected. Attain to advise MB in such instances to seek agreement.
5.3 The Procurement Committee NOTED the update around Procurement services.
6. Procurement Progress Report 6.1 KE presented the previously circulated Procurement Progress Report, which was taken as read and highlighted the following points:
Pipeline
• IVF/Fertility Treatments – on today’s agenda.
• Primary Care Enabler Service – on today’s agenda.
• EWMHS – Suggestion is that contract is extended for a further two years until organisational changes in place. PS asked whether we were assured around MB EWMHS performance. KE informed that this question has been asked but it is felt that it would be too difficult to go out to market until the environment is sorted.
Current Procurements • Flu Swabbing Service – This is a contract management solution rather than a full procurement.
• Parachute Service – The issue around conflicts of interest is still outstanding but being looked into.
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• Core Community Equipment Service – Direct award being discussed, but difficult due to the unsettled landscape. MG informed that NHSE Procurement Hub are having initial discussions across Greater Essex.
• Neuro Rehab – There is currently a delay in confirming the preferred bidder due to the finances across the 3 STP areas not yet being agreed. Paper will be going to Governing Body meetings for approval.
Transition Projects • Nothing to report with the exception of the Offending Service For Adults and Domestic Violence, which are under discussion with TD as to whether to continue or stop.
STP Designated Projects
• Respiratory Services – CP&R leading on this new project.
• Patient Transport Service – 9 organisations who have bid will be invited to the ITT. JG queried whether this includes the new STP plans. MB felt that it took into account new pathways but may not address the wider transport issues.
• On-line Consultation – there are some queries around this service that have been passed to the Mid Essex CFO.
7. Dementia Business Case 7.1 NS presented the Dementia Business Case and explained that this had already been to various Committees and was here today for approval of the funding. The Committee are asked to approve a contract variation with EPUT to provide enhanced Dementia Community services from the 1st April 2020.
Discussion has been had with Attain and they have advised that there is minimal risk of legal challenge to this proposal.
7.2 MB pointed out that the value of the contract, £569,950, is across both CCGs. Due to the cost of the contract being almost 100% staffing costs which will take time to put in place, this will be paid on a cost incurred basis plus 10% for overheads and capped at the agreed total contract value rather than a block contract to begin with. Once satisfied staffing is up to full establishment the terms of the contract would be reviewed and possibly convert to a block agreement.
7.3 CD asked KE how comfortable he was around the risk of challenge if we go through a contract variation route. KE stated that he felt this would be very low, due to the amount of the contract with no upfront payment it would be unlikely to attract anyone from outside of the location.
7.4 The Procurement Committee APPROVED the Dementia Business Case paper.
8. Specialist Fertility Services 8.1 JC presented the Specialist Fertility Services Paper, which was taken as read. The Committee are asked to agree taking forward a restricted procurement for a 4 year framework for Specialist Services on behalf of the 5 CCGs.
There are currently 5 providers with a total spend across the STP of £657,000.
There are a relatively small number of patients that require/qualify for this service but they are costly procedures.
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The four year framework is flexible with no commitment to continue the service if the political landscape changes within this period of time.
8.2 PS queried whether there was a process in place for transferring of egg storage if required. NP explained that this would be an unlikely necessity but that there are processes in place to safely do this if required. There would also be communication to patients to inform them of what was happening as routine.
8.3 PS also queried whether as IVF in general was a very expensive service, do we have any advice and guidance to patients around the best time to have babies/lifestyle/age etc.
CD informed that there are national campaigns in place with regards to IVF age and BMI restrictions.
NP also explained that the first stage is to visit your GP who would advise whether patients qualify etc.
8.4 MB explained that having the framework in place would mean that each individual CCG would be able to choose what service they commission. Each CCG currently differs in their commissioning arrangements but at some point we may need to look at standardising which would then require a huge amount of public engagement.
8.5 The Procurement Committee APPROVED the Specialist Fertility Services paper.
9. Primary Care Enabling Service 9.1 CD presented the Primary Care Enabling Service paper, which was taken as read. We host the current Arden and Gem contract which provides corporate IT, but historically NHSE have commissioned smart cards/NHS mail etc for GP practices. NHSE have given notice on this contract. Part of this contract included procuring Clinical Safety Officer support, but we will not be continuing with this as we already have Data Protection Officers in place for the practices commissioned from other sources. The money for this service is aligned to the primary care allocation. The key things that are being asked of the Committee are: the change of procurement timeline, change of scope and also to delegate authority to the Essex IT Oversight Committee.
9.2 The Procurement Committee APPROVED The Primary Care Enabling Services paper.
10. Any Other Business 10.1 There being no other business the meeting was adjourned at 15.45hrs.
11. Date and Time of Next Meeting 13th November 2019 15:00 hrs Hockley Room
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Minutes of the Part I Meeting of the Sustainability and Transformation Partnership CCG Joint Committee (STPJC) Held on Friday, 7 June 2019 at 3.15 pm – 5.00 pm Conference Room, Brentwood Community Hospital, Crescent Drive, Brentwood CM15 8DR
Attended by Job Title/Position and Organisation Professor Mike Bewick (MB) Independent Chair of the STPJC Caroline Rassell (CR) Accountable Officer, Mid Essex CCG Lead Accountable Officer for Joint Committee Senior Responsible Officer – Mid and South Essex STP (Locality Health and Care) Dr Anna Davey (AD) Chair, Mid Essex CCG William Guy (WG) Director for Out of Hospital Commissioning (on behalf of Lisa Allen) Dr Boye Tayo (BT) Chair, Basildon & Brentwood CCG Dr Jose Garcia Lobera (JG) Chair, Southend CCG Terry Huff (TH) Accountable Officer, Castle Point & Rochford and Southend CCGs Dr Anand Deshpande Chair, Thurrock CCG (ADesh) Mandy Ansell (MA) Accountable Officer, Thurrock CCG Patrick Ruddy (PR) Lay Representative for Patient and Public Participation In Attendance Job Title/Position Dr Donald McGeachy (DM) Medical Director, Joint Commissioning Team Karen Wesson (KW) Director of Commissioning, Joint Commissioning Team Viv Barker (VRB) Deputy Director of Nursing & Quality, Mid Essex CCG (on behalf of Rachel Hearn) Andy Ray (AR) Chief Finance Officer, Acute Commissioning Team Viv Barnes (VB) Director of Governance and Performance, Mid Essex CCG & Interim STP JC Secretary Sara O’Connor (SO) Head of Corporate Governance, Mid Essex CCG (Minute taker) Apologies Job Title/Position Dr Sunil Gupta Chair, Castle Point & Rochford CCG Lisa Allen Accountable Officer, Basildon & Brentwood CCG Rachel Hearn Director of Nursing & Quality, Mid Essex CCG and Acute Commissioning Team
Item No Item 1. Apologies for Absence and Register of Interests: Presented by Professor Mike Bewick
MB welcomed those present to the meeting and introduced Mr Patrick Ruddy, Lay Representative for Patient and Public Participation (PPP). MB also noted apologies for absence as listed above and the register of interests.
MB reminded members of their obligation to declare any interests they held on any issues arising at the committee meeting which might conflict with the business of the committee at the beginning of the meeting, at the start of each relevant agenda item, or should a relevant interest become apparent during an item under discussion, so that appropriate arrangements could be implemented.
Declarations made by members of the committee are listed in the Register of Interests Item No Item available either via the Head of Corporate Governance at Mid Essex CCG or within the STPJC committee papers posted on each of the Mid and South Essex STP CCGs’ websites.
Declarations of interest from today’s meeting:
There were no additional interests declared.
2. Questions from the Public: Presented by Prof Mike Bewick
MB advised that questions had been received from Mr Steve Smith and Mr Majzoub Ali regarding the appointment of PG as the lay representative for PPP. Both sets of questions were very similar in nature, as set out below. MB advised that the responses to Mr Ali’s questions would also cover the issues raised by Mr Smith.
Questions from Mr Majzoub Ali
Q1. Is the appointment of the PPP lay representative on the Joint Committee a tacit acknowledgement that its patient and public engagement has been inadequate?
The appointment of a Patient and Public Participation lay representative on the Joint Committee was agreed by members in recognition of the value of the independent scrutiny and external experience that lay members bring to the work of CCG Governing Bodies. The role that has been developed therefore closely mirrors the national role description for CCG PPP lay members who are tasked with championing the patient and public voice and ensuring that that the CCG has appropriate arrangements in place to secure public and patient involvement and respond to feedback from patients, carers and the public. The role is not the same as a user representative, who is appointed to provide lived experience of using NHS services for service improvement projects.
Q2. In which part of Essex does Mr Patrick Ruddy live and which Essex hospital has he used?
The JC recognised that the PPP lay representative would need to have credibility to act as a representative of the 1.2 million STP population. It was therefore decided to invite expressions of interest from the 3 Essex Health Watch organisations to nominate a representative who would have access to Health Watch’s local knowledge and contact network to enable them to fulfil this role. The role is not intended to provide direct feedback on patient experience but rather to act as a conduit for the patient and public voice.
Q3. What experience does he have of patient representation?
Mr Ruddy has been a Mental Health Ambassador for Health Watch Essex since January 2018. Prior to this, he was secretary to the Patient Reference Group at his local GP practice for nearly two years.
Q4. Shouldn’t the public have a say in his appointment?
In line with the appointment process for CCG PPP lay members, this is not an elected role but is instead based on competency and experience.
PG advised that he was an independent representative and intended to use this role to promote the patient and public voice across mid and south Essex. PG confirmed that he had lived in Essex for 50 years.
Questions submitted by Mr Steve Smith Item No Item
The questions submitted by Mr Smith were similar in nature and related to the need for some background information about the lay representative for PPP, whether the appointment was sufficient and representative, the lack of an election process and the absence of any local engagement, for example with PPG Forums.
MB advised that Mr Eric Watts had submitted a number of questions regarding Pathology Services to which he responded as follows:
Q. Will the Joint CCG now monitor pathology performance in line with the recommendations of NHSI and specifically will they scrutinise the EQA report and reports to the CQC in the of poor performance?
If the Joint CCG decides against this course of action how will they monitor performance in the future?"
See https://improvement.nhs.uk/documents/2718/Clinical_Governance_Toolkit.pdf
The Joint Committee acute team monitor and oversee performance of the Mid and South Essex Hospitals services via their existing contractual forums as they do with all other acute services (this includes Pathology services).
The document in the link that Mr Watts shared, from April 2018, was aimed at Trusts who are consolidating their Pathology services and provides them with guidance on the governance for this consolidated approach.
With the three mid and south Essex hospitals coming together, they will be reviewing their existing governance across their Pathology departments. The approach detailed within the document will be considered by them.
CR advised that Mr Watts had also met with representatives from the Joint Committee and the msb group to discuss his concerns.
MB confirmed that written responses would be sent to Mr Ali, Mr Smith and Mr Watts.
[Action: SO to ensure that written responses are submitted to Mr Ali, Mr Smith and Mr Watts.]
3. Minutes of Previous Meeting and Review of Action Log: Presented by Prof Mike Bewick
Minutes of Previous Meeting:
The minutes of the Part I meeting held on 5 April 2019 were approved, with no amendments requested.
4. Action Log and Matters Arising: Presented by Prof Mike Bewick
The action log was reviewed and it was noted that all the actions, including the response to Mrs Henes regarding Ophthalmology services, had been completed. 5. Lead Accountable Officer Update: Presented by Caroline Rassell
CR advised that her report detailed progress that had been made since the last Joint Committee meeting.
Item No Item The Elective Care Programme Board (ECPB) would be established later this month which would provide the opportunity for all parts of the local health system to come together to talk about key improvements required across a number of pathways and against a number of NHS Constitutional Standards.
CR advised that further work had been undertaken to establish the Implementation and Oversight Group (IOG) which would oversee the implementation of the acute reconfiguration proposals and explained that it was proposed that the five mid and south Essex CCGs’ Risk and Assurance Sub-Committees, which met in common and were attended by each of the CCG Audit Committee Chairs, would take on the role of the IOG. CR advised that all of the Audit Committee Chairs were very experienced and would provide assurance to the Joint Committee that the proposals had undergone the appropriate scrutiny before implementation.
CR referred to a public consultation regarding a new purpose built site for Moorfields Hospital and advised that anyone was entitled to submit a response via the link provided within the report. CR also referred to a letter from the Chair of the East of England Cancer Alliance which reflected positively on the engagement that had taken place locally.
CR advised that the Joint Committee’s Annual Report was also appended to her report which set out the work that the committee had undertaken during 2018/19.
CR confirmed that all the Acute Commissioning Team (ACT) directors had been set objectives for 2019/20, relating to improving performance, developing integrated care pathways and implementing robust financial controls. There was also recognition that the team had to further develop its staff and maintain effective governance.
Resolved: The Joint Committee noted the Lead Accountable Officer update report and the Joint Committee’s Annual Report 2018/19.
6. Patient Story: Presented by Viv Barker
VRB introduced the patient story which related to Mr Clive Blanchard, who had recently attended the CCG’s International Nurses Day (IND) event to talk about his experience of care provided to him across the msb group of hospitals.
VRB advised that it had been a privilege that Dr Ruth May, Chief Nursing Officer (CNO) for England had attended the IND event.
CR advised that she was very grateful to all the local Directors of Nursing who had also attended the event. CR advised that although the quality and performance reports tended to focus on areas where improvement was required, it was important to note that in the vast majority of cases the patient experience was positive, as highlighted within many of the patient stories shown to the committee and at CCG Board meetings.
BT suggested the patient story videos should be used to help support initiatives to increase the nursing and medical workforces. VRB agreed to pass on this suggestion to Jackie Barratt, who was a nurse ambassador involved in promoting nursing as a career.
PR advised that he recently attended Anglia Ruskin University, which designed nursing courses, and he noted that a common theme was that the need to support the patient throughout their pathway was just as important as the end result of treatment.
Resolved: The Joint Committee noted the Patient Story.
[Action: VRB to suggest to Jackie Barratt that the patient story videos are used to help Item No Item promote nursing as a career].
7. Service Restriction Policies: Presented by Karen Wesson (on behalf of Dr Donald McGeachy)
KW advised that the proposals outlined in her report were to update the mid and south Essex Service Restriction Policy (SRP) relating to Botulinum toxin Type A (BTA), fertility preservation and vagus nerve stimulation (gammaCore). KW advised that the proposals were based on current best practice or changes in guidance.
KW explained that the proposal regarding BTA was to reflect a change in East of England Prescribing Advisory Committee policy to ensure that BTA was the only type of Botox therapy used and to confirm the number of treatments each individual could have in line with the guidance, to ensure equity of provision.
The inclusion of fertility preservation had been added to standardise the offer for this service across the five mid and south Essex CCGs and was in response to a recent letter from NHS England confirming local commissioners’ responsibilities for fertility preservation.
The amendment relating to vagus nerve stimulation was to ensure that the SRP was in line with the East of England Prescribing Advisory Committee policy that CCGs should not fund this procedure unless there was a clinical exception, which would be subject to an Individual Funding Request.
In response to a query from MB, KW confirmed that the proposals had been accepted in other areas outside of the mid and south Essex CCG.
Resolved: The Committee approved the recommendations to update the Mid and South Essex Service Restriction Policy relating to Botulinum toxin Type A (BTA), fertility preservation and vagus nerve stimulation (gammaCore).
[Action: DMcG to ensure that the Mid and South Essex Service Restriction Policy is updated to include the amendments relating to Botulinum toxin Type A (BTA), fertility preservation and vagus nerve stimulation (gammaCore).
8. Joint Committee Terms of Reference: Presented by Viv Barnes
VB advised that she had updated the Joint Committee’s Terms of Reference in relation to:
Membership - to take account of the forthcoming arrangements for chairing the committee; Commissioning functions - to include community Dermatology services for South East Essex within the remit of the committee; and Decision-making - to clarify that each member shall have one vote per CCG, which would take account of joint appointments across the CCGs, and that urgent decisions would be taken via e-mail exchange and reported to the next Joint Committee meeting.
VB advised that the authorisation form for appointment of deputies had also been updated to make it clearer that deputies were able to exercise voting rights on behalf of the CCG member for whom they were deputising. VB confirmed that most of the proposed amendments had previously been debated by the committee.
CR advised that MB would shortly come to the end of his tenure as Chair of the Joint Committee and this was the last publicly held committee meeting that he would Chair. CR asked that her thanks to MB for leading and advising the committee were formally Item No Item recorded. CR confirmed that ADesh would take on the role of Joint Committee Chair for a period of six months following the departure of MB. ADesh added his thanks to MB on behalf of the committee members.
MB thanked the committee members for their help and support and asked that his thanks were also extended to members of the public that he had met during his tenure as Chair.
JG asked whether VB would accept nominations for deputies via an email exchange if this were necessary at short notice. VB confirmed that this was acceptable, but asked that the l nomination form was submitted as soon as possible thereafter.
Resolved: The Committee approved the revised Terms of Reference for the Joint Committee.
9. Patient Safety and Quality Report: Presented by Viv Barker
VRB advised that the report’s format had been updated since the last meeting and she would be happy to receive feedback on any further amendments required.
VRB confirmed that the backlog of harm reviews at Mid Essex Hospitals Trust (MEHT) had been cleared and the focus was now on completing the reviews that had accumulated whilst the backlog was being addressed.
Workforce issues across the msb group remained a significant concern. VRB highlighted that a regional meeting of the Directors of Nursing had recently taken place at which Professor Mark Radford, Director of Nursing (Improvement) from NHS Improvement, expressed his personal concern that the current shortfall of 40,000 nurses could rise to 80,000. Therefore, the requirement to review the way nursing care was delivered was of paramount importance. It had been decided that there was a requirement for a STP lead Programme Director to be recruited to lead on workforce issues and VRB understood that a recruitment exercise for this post had recently commenced.
VRB informed members that there had been an improvement in the May data for Summary Hospital-level Mortality Indicators (SHIMI) for Basildon and Southend hospitals, with Basildon now sitting at 0.9966 and Southend at 1.0797. However, there had been a slight decline at MEHT which now stood at 1.1205, although this remained within the expected range.
CR confirmed that she was supportive of the new report format and felt that it would be suitable to submit to CCG Boards to provide them with assurance on action being taken by the ACT in relation to patient safety and quality issues. CR requested that information on services commissioned from Barking, Havering and Redbridge NHS Trust (BHRT) and East Suffolk and North Essex NHS Foundation Trust (ESNEFT) were included in future versions of the report. CR noted that due to a recurrent theme of poor performance at MEHT, the committee was now at the stage where a specific report on performance and any patient safety and quality issues was required to facilitate a deep dive discussion. MA supported this suggestion.
VRB advised that the CCG and ACT Directors of Nursing updated each other on a weekly basis to enable ‘live’ intelligence on safety and quality issues to be shared.
BT asked whether information on medical vacancies was being provided by the msb group. VRB advised that she would check the position with regard to this data so that it could be incorporated into future reports.
AR referred to the falls data and noted that the report stated that there had been a downward Item No Item trend in the number of falls at Southend hospital, whereas there had been upward trend. VRB advised that there was a balance between supporting patients to rehabilitate and not deconditioning further, which meant that falls were always a possibility and, therefore, the focus was on ensuring that any falls occurring within the hospital setting resulted in low-harm. Root Cause Analysis reviews of falls which resulted in harm focused on trying to identify whether anything could have been done differently to ensure patient safety was maintained.
In response to a query from JG relating to the number and type of Serious Incidents (SIs) and Never Events (NEs) occurring each year, VRB advised that the main theme in relation to NEs was wrong site surgery. VRB confirmed she would include information on the number of SIs and NEs over the past three years within the next patient safety and quality report.
AD queried why there was no data included in the report relating to Sepsis at Basildon for February and March. VRB confirmed that there had been a number of challenges in obtaining some data and the re-established Clinical Quality Review Group was working with the msb group to consider how data could be gathered with ease. MB suggested that the report might be expanded to include trend analysis.
Resolved: The Joint Committee noted the Patient Safety and Quality Report.
[Action: RH/VRB to include the following information within future versions of the patient safety and quality report:
• patient safety and quality issues relating to BHRT and ESNEFT • medical workforce vacancies across the msb group.
Also, to provide a summary of the number of SIs and NEs over the past three years in the next patient safety and quality report].
10. Performance Report: Presented by Karen Wesson
KW advised that the March data for the msb group diagnostic performance standard stood at 96.7% against the expected standard of 99%. Areas of concern related to echo-cardiogram capacity at Basildon Hospital and endoscopy across the group. A recovery plan was in place to improve performance for these procedures.
The Referral to Treatment (RTT) 18 week standard for the group was 81.1% for March, which was below the standard. KW advised that work was being undertaken regarding capacity and demand to improve the position. Basildon and Southend hospitals’ position for 52 week waits had improved and it was expected that this would reduce to zero when the April data was available.
KW advised that April data was available for the cancer standards, due to a slightly different reporting timetable. The msb group had reported 2 week waits at 90.8% against a plan of 91.9%, which was an improved position reflecting the work undertaken by Macmillan GPs.
Cancer 31 day performance was reported at 91.6% against a standard of 92%. The planned trajectory for cancer 62 day performance was 71.2% and delivery was 77.7% which was encouraging. Basildon hospital had achieved the 62 day Constitutional standard in April by achieving 85.6% in line with the trajectory agreed with the Cancer Alliance. Work would continue to ensure performance was sustained. MEHT achieved 71.8% for the 62 day standard and Southend achieved 79.3% and both were on track to deliver against their agreed trajectories. KW explained that the work of the ECPB and the Cancer Programme Board (CPB) would support the hospitals to further improve performance of all standards. KW advised that the CPB included five patient group members and their feedback had been Item No Item taken into account regarding tracking delivery of the programme. A bid for funding had been submitted to the Cancer Alliance and the outcome of this was awaited. KW mentioned that the Cancer Alliance’s priorities had recently changed and they were also undergoing internal reorganisation, but this should improve relationships as there would be smaller, more local teams in place.
BT advised that concerns had been expressed by some GPs that patients who received diagnostic tests were not always informed of the outcome by the hospital and results were sent directly to GPs. KW explained that there had been an increase in the number of diagnostic procedures being undertaken prior to patients being sent an appointment for a consultation, which speeded up the patient’s journey through the pathway. However, the results of all diagnostic tests were reviewed by an appropriate clinician to enable a decision on whether to discharge the patient from the relevant pathway to be made. KW advised that it was her understanding that this process was being communicated to the patient as well as the GP and asked BT to provide her with any specific areas of concern so that she could raise this with the msb group.
In response to comments from JG regarding patients who received confirmation that their test results were non-cancerous but continued to experience symptoms, KW confirmed that there was a requirement that patients should be advised of the outcome of their tests. KW explained the process in more detail to PR, including work undertaken with the Macmillan GPs to ensure that cancer patients were on the correct pathway, the role of Health Navigators for specific tumour sites and other support mechanisms. KW also agreed to provide further information, including the number of patients referred straight to tests, within the next performance report if the information is reportable.
In response to further queries from JG and AD regarding non-cancerous symptoms, KW confirmed that work was being undertaken across the msb group regarding a pathway for patients with vague symptoms which would be managed by a multi-disciplinary group, including primary care, to review diagnostic tests and ensure that patients were referred to the appropriate team if a different disease was detected.
Resolved: The Joint Committee noted the Performance Report.
[Action: BT to provide KW with examples of GPs’ concerns relating to the issuing of diagnostic results, by specialty, so that she can escalate to msb group].
[Action: KW to provide further information, including the number of patients referred straight to tests, within the next performance report if the information is reportable.]
11. Finance Report: Presented by Andy Ray
AR advised that the report set out the 2018/19 end of year position of a £13.1 million adverse variance, which equated to 1.4% of the budget. AR also advised that there had been movement in the budget of £800k relating to Ophthalmology, the independent sector and critical care patients being cared for at St Bartholomew’s Hospital (Barts) in London, as reported during the previous meeting. AR explained that he was in discussions with Barts regarding the 2019/20 contract which he was aiming to agree on a fixed cost basis. AR confirmed that the format of the report would be amended for future meetings.
Resolved: The Joint Committee noted the Finance Report.
12. STPJC Risk Register: Presented by Viv Barnes
VB advised that the format of the report had been amended to include a summary of the Item No Item current red/extreme risks and acknowledged the work that AR had undertaken to highlight the current top risks for the Joint Committee.
VB highlighted that a new risk, ref 129, had been added to the register regarding the STP Estates Strategy. VB also sought the committee’s approval to close risk ref 85, which was obsolete as it related to the 2018/19 year; risk ref 89 which was a generic risk relating to NHS Constitutional Standards and had been replaced by specific risks relating to RTT and Cancer (Refs 130, 131 and 132); and ref 125, which had been recommended for closure by AR due to the msb group being on a block contract for 2019/20.
Resolved: The Joint Committee:
Noted the STPJC Risk Register set out at Appendix A of the report Supported closure of risk Refs 85, 89 and 125.
12. Summary Reports / Minutes from STPJC Sub-Committees: Presented by Prof Mike Bewick
12.1 Finance & Performance Sub-committee
The Joint Committee noted the summary report of key issues discussed at the Finance & Performance Sub-Committee meeting held on 17 May 2019.
12.2 Risk and Assurance Sub-Committees
The Joint Committee noted the minutes of the CCGs’ Risk and Assurance Sub-Committee meetings held in common on 25 February 2019 and 16 April 2019.
14. Reporting of Part II Decisions: Presented by Viv Barnes
VB advised that the report highlighted a decision that had been made at the Part II meeting held on 8 March 2019 regarding the Non-Emergency Patient Transport Service Procurement Project which could now be reported in the public domain.
Resolved: The Committee noted the report on Part II Decisions.
15. Any Other Business: Presented by Prof Mike Bewick
15.1 August Part I Meeting – Patient Story
VRB advised that there would not be a Patient Story shown at the August Part I meeting as the agenda slot was required to enable the Director of Nursing for the msb group to present the Quality Account for 2018/19.
16. Date and Time of Next Meeting:
The next Part I Joint Committee meeting will be held at 3.15 pm – 5.00 pm on Friday, 2 August 2019, Committee Room 4, Civic Centre, Victoria Avenue, Southend-on-Sea, Essex, SS2 6ER.
NHS Castle Point & Rochford CCG & Southend CCG
Joint Clinical Executive Committee Thursday, 19th September, 2019 1.00pm – 3.00pm Audley Mills Education Centre, Rayleigh
MINUTES
Members from Southend CCG: Dr Jose Garcia (Chair) (JG) GP Governing Body Member NHS Southend CCG Dr Taz Syed (TS) GP Governing Body Member NHS Southend CCG Dr Kate Barusya (KB) GP Governing Body Member NHS Southend CCG Dr Brian Houston (AS) GP Governing Body Member NHS Southend CCG Dr Kelvin Ng (KN) GP Governing Body Member NHS Southend CCG Ian Diley (ID) Public Health Representative Southend Borough Council Members from Castle Point & Rochford CCG Dr Sunil Gupta (SG) GP Governing Body Member (CHAIR) NHS CP&R CCG Dr Lucy Saville (LS) GP Governing Body Member NHS CP&R CCG Dr Riz Khan (RK) GP Governing Body Member NHS CP&R CCG Dr Sami Ozturk (SO) GP Governing Body Member NHS CP&R CCG Dr Kashif Siddiqui (KS) GP Governing Body Member NHS CP&R CCG Dr. Biju Kuriakose (BK) GP Governing Body Member NHS CP&R CCG Danny Showell (DS) Public Health Representative Essex County Council Members that sit across both Southend and CP&R CCG: Terry Huff (TH) Accountable Officer NHS CP&R & Southend CCG Charlotte Dillaway (CD) Director of Strategy & Planning NHS CP&R & Southend CCG Tricia D’Orsi (TD) Chief Nurse NHS CP&R & Southend CCG Simon Williams (SW) Director of Partnerships & Integration & NHS CP&R & Southend CCG Primary Care In Attendance Hugh Johnston (HJ) Mental Health Commissioning Manager NHS CP&R & Southend CCG Jo Dickinson (JD) Locality Development Manager NHS CP&R & Southend CCG Nancy Smith (NS) Commissioning Manager NHS CP&R & Southend CCG Spencer Dinnage (SD) Operational Service Manager NHS CP&R & Southend CCG Duncan Powrie (DP) Respiratory Consultant Southend Hospital (Item 6a) Beverley Blackwell (BB) Head of Community Nursing EPUT (Item 6a) Karen Sweeney (KS) Commissioning Manager NHS CP&R & Southend CCG (Item 6a) Paul Taylor (PT) AD Partnerships & Integration NHS CP&R & Southend CCG (Item 6a) Cathy Cunningham (CC) Executive Assistant (Minutes) NHS CP&R CCG
Page 1 of 5 Apologies received from: James Currell Dr. M Metcalfe Dr. Alex Shaw Dr. K. Chaturvedi Mark Barker Jacqui Lansley
1 Welcome and Apologies The Chair welcomed everyone to the Joint Clinical Executive Committee.
1.2 Apologies were noted as above.
2 Declarations of Interest 2.1 Members of the Committee were reminded of their obligation to declare any interest they may have on any issue arising at committee meetings which might conflict with the business of CP&R/Southend CCG and that declarations declared by members of the Committee are listed in the CCG’s Register of Interests. The Register is available either via the Committee Secretary to the governing body or the CCG website at the following link: https://castlepointandrochfordccg.nhs.uk/about-us/key-documents/2508- declarations-of-interest-governing-body/file or https://southendccg.nhs.uk/about-us/key-documents/320-nhs-southend- ccg-governing-body-declarations-of-interests-register/file
2.2 The Chair declared that the meeting was quorate and that conflicts would be raised as the agenda progressed.
3 Minutes of the meeting held on 18th July 2019 The minutes from the meeting held on 18th July 2019 were agreed as an accurate reflection of the discussion.
4 Matters arising and Action Log from meeting held on 18th July 2019 The Action Log was discussed and amended as follows – Log nos. 82, 83, 84, and 85 now closed No. 86 Sexual Health Clinic – TD asked for further information on waiting times for patients. ID will provide this. There was also concern raised about patients being told to go back to GPs. No. 87 – Test Results – CD has not been able to progress but will restart conversations with the hospital once other projects have gone “live”. IT options to also be looked at with regards to how JCEC engage as a group i.e. glass cubes / revised management portal
5 Priority Areas SG joined the meeting at 1.25 pm
CD presented a paper detailing our commissioning priorities for 2019/20 which were approved at June’s 2019 seminar GB meeting. The Project Progress Summary was discussed at length and the document also contained a project “on a page” which includes the key risks. Deep dives will be presented at various JCEC meetings going forward and TH asked how we highlight risks. It was suggested that an overarching risk register is put in place for JCEC members as they will be required to help with “unblocking” risks. ID said precision in the RAG register could lead to a “heat” map and QOF outcomes. This would give context to the “greens” and TH agreed this would be a good solution. It would also be helpful to have a forward plan in place to look at 2/3 priority areas for forthcoming meetings.
JG asked members if the document was helpful in its present format. SO suggested that a “live” document would be useful and LS was concerned
Page 2 of 5 about the various colours showing the project RAG rating. CD confirmed that the document will be circulated on a monthly basis to JCEC and updated with clinical leads on a regular basis. RK said he felt the document provided a good overview of the projects and agreed this should be a “live” document.
JG said this was an excellent piece of work. JG also thanked HJ for his work on mental health and said we need to look at measures of success overall. BH asked where MSK sits and TH agreed that this could be added as MSK is costly. BH said we need to make sure it does not fall off the radar. HJ said what does “good” look like? Everything could be green but the patient may not necessarily be getting the outcome they require.
CD asked about the Thursday afternoon time slot set aside for members to meet and asked if this was working. GPs confirmed this arrangement was working for them.
CD asked for the minutes to reflect that Michelle Angell has been crucial in “planning” this work and wanted to thank her for doing this so speedily.
6 Dementia Business Case SG explained the background to the community support model for the transformation of dementia community services. The model has been discussed at TTL/CMT and is regarded as sound. This model covers the whole pathway and will result in a reduction in GP workload, better links to social care and will help to keep people out of crisis. There is also concern when a carer is unwell meaning the process collapses for the family.
SD went through the slides and explained that everybody in the system has had an input and “tests and learns” have been carried out in some practices which helped to develop the community care model. The slides gave examples of various scenarios and showed how the new model will benefit the patient from the point of referral. This will also include all frailty elements. SD confirmed that every patient would have an assessment at point of referral and SO felt this would be an opportunity for patients to be referred to other services i.e. neurology.
TS asked if an MOU will be necessary. He felt that as care has been fragmented this new model will be very successful.
KB asked about weekends and OOH. SD confirmed that arrangements with 111 will be confirmed quickly as discussions have already taken place and the STP will be approached for expert advice out of hours. RK asked about the SPOR element and SD said there will be a remodelled SPOR and this will be another access point.
SG explained that the funding requirement of £569,000 will be agreed by GB members and TH advised that discussions are taking place with the Local JCEC approved Authority to see how they can help with funding. the clinical model
Discussion took place regarding the number of beds required in Clifton/Rawreth. There are 10 beds at present but it was felt that 3 or 4 would be sufficient going forward. This would release some funding.
Action – JCEC approved the clinical model and TD thanked the team for all their hard work
6a Respiratory Update PT, DP, KS and BB attended the meeting to present a report and
Page 3 of 5 presentation which outlined the future whole system transformation of respiratory services. This has been developed in line with PCN’s and localities. JCEC is asked to agree the case for change and the need for two respiratory GPwER across SEE.
The aim of the transformation project is to provide a full pathway and service redesign plan incorporating the initiatives already in place within the CCG. It was noted that across the STP there are variations across the 5 CCGs and 3 acute trusts but the SEE CCGs will be leading the changes needed across this footprint. Future services will be provided through a GPwER led, consultant supported, multi-disciplinary team who will also provide psychological support for patients. There will be a 12 month pilot period during which time the service can be developed and an evaluation will be undertaken to influence on-going commissioning decisions.
The presentation was discussed in detail and BH felt strongly that a lead person should be present in each network. TS said that PCNs should share best practice and we should learn from other community projects.
BB advised that nurses have been attending workshops and there are now very good experienced practice nurses.
DP said this is not a stand-alone role and the hospital has a responsibility to help GPs. The hospital is in discussion with a consultant interested in joining their team and undertaking clinical academic trials at Anglia Ruskin PT to resend University, leading on COPD in the community and working with the GPwER. Respiratory Discussion was held on workforce and linking in with HEE. KN queried what presentation is different now than what we have seen before but this is a whole system approach and service redesign. Recommendations were approved by Action – JCEC approved the recommendations in the report JCEC
6b Frailty Ian Diley left 2.45pm
RK gave a presentation on frailty. Over the last six month there has been progression and monthly meetings with all stakeholders now take place. This has allowed for a proper plan to be put in place in order to move forward. The group also has local outcome measures in place which focus on education and training programmes. Funding is being sought on an STP level and the development of a single shared care record is a key part of progression. Rightcare has a tool kit which maps current services and shows the gaps and this will help to improve the frailty model. RK/TD to discuss re money for SW thanked RK for his hard work and said everyone is now working as a education team.
6c Mental Health JG gave an update on mental health. JG advised that the SEE MH Steering Group is ensuring that finances are being spent wisely and identifying priorities. There is a new development for adults and the group is looking at how we can meet their needs and what can be done differently i.e. Systm1. Money is available for complex patients and the group is looking at the triggers for depression. Resources are also available for the Recovery College and employment as we do not have skills for this at present.
HJ said that the voluntary sector is working much better with the statutory sector i.e. crisis café. It was noted that there has been 105 net reduction in
Page 4 of 5 permanently qualified staff and the system locally is making the right steps to address this. JG asked for GPs Community psychiatric nurses are working effectively through PCN’s but we to feedback any need to look at how we get more effectiveness in primary care if we have issues on services fewer qualified staff. not working
6d Dementia Covered above
7 Any Other Business CD advised that NHS mail in care homes will be mandatory but some care homes are pushing back on this. CD asked GPs to remind care homes when an opportunity arises that this will be a requirement.
Date of Next Meeting Thursday, 17th October 1-3pm Audley Mills Education Centre, Rayleigh
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NHS Castle Point & Rochford CCG & NHS Southend CCG Primary Care Co-Commissioning Committee PART I Meeting in Common Wednesday, 11th September, 2019, 1pm-3pm Audley Mills Education Centre, Rayleigh
MINUTES
Attendees from Southend CCG: Janis Gibson (JG) Lay Member, PPG NHS Southend CCG Dr Jose Garcia (JGL) GP Governing Body Chair NHS Southend CCG Attendees from CP&R CCG: Dr John Weir (JW) Independent GP NHS Castle Point & Rochford CCG Pauline Stratford (PS) Lay Member Patient Engagement (Chair) NHS CP&R & Rochford CCG
Attendees that sit across both Southend and CP&R CCG
Jennifer Speller (JS) Associate Director of Primary Care NHS CP&R & Southend CCG Vicky Cline (VC) Primary Care Lead Nurse NHS CP&R & Southend CCG Sally Simmonds (SS) Head of Primary Care Contracting NHS CP&R & Southend CCG NHS CP&R & Southend CCG Ellie Carrington (EC) Quality Assurance Nurse NHS CP&R & Southend CCG Lee Bushell (LB) Interim Deputy Chief Finance Officer NHS CP&R & Southend CCG Sharon Judge (SJ) Executive Assistant (Minute taker) Apologies received from: Charlotte Dillaway Dr Sunil Gupta Simon Williams Terry Huff Tricia D’Orsi Members of the public in attendance: Mr Ali Chris Gasper Brian Dawbarn Julie Chambers Jean Broadbent – Health Watch
1. Welcome and Apologies
The Chair welcomed everyone to the meeting in common of the Southend & CP&R CCG’s Primary Care Co-Commissioning Committee.
Apologies were noted as above.
2. Declarations of Interest
Page 1 of 7
Members of the Committee were reminded of their obligation to declare any interest they may have on any issue arising at committee meetings which might conflict with the business of CP&R/Southend CCG and that declarations declared by members of the Committee are listed in the CCG’s Register of Interests. The Register is available either via the Committee Secretary to the governing body or the CCG website at the following link: https://castlepointandrochfordccg.nhs.uk/about-us/key-documents/2508- declarations-of-interest-governing-body/file or https://southendccg.nhs.uk/about-us/key- documents/320-nhs-southend-ccg-governing-body-declarations-of-interests-register/file
JG declared an interest in relation to PCNs and Social Prescribing.
The Chair declared that the meeting was quorate and that conflicts would be raised as the agenda progressed.
3. Minutes from the meetings held on the 17th July, 2019
The minutes from the meeting held on 17th July, 2019 were agreed as an accurate account of the discussion with the following amendments:
4. Action Log from the meeting held on 17th July, 2019
The Action Log was updated as attached.
5. Quality Report
VC was in attendance to present the Quality Report and took the paper as read and highlighted the following points:
The report gives an overview of CQC reports and showed that 23/23 practices within CP&R are rated as good and 26/27 practices in Southend are rated as ‘good’ with one rated as ‘requires improvement’.
PA Patel has a closed list but is due to re-open in September and is receiving support from the Quality Team during this time.
Quality visits continue to take place and now that Ellie Carrington has joined the team it is hoped that two visits can be completed per week.
VC will be attending the Practice Manager meeting on 17th September to outline the procedure for quality visits.
Friends and Family Test returns were lower than normal in June but it is felt that this may be due to the holiday season. EC will support practices with the changes planned for next year.
Three practices in CP&R are working through serious incident reports. One report has been completed and is now closed, another was submitted on the wrong template and will be re-submitted and the third report in progressing. There were no reports submitted for Southend.
VC is chasing NHSE for outstanding complaints data.
PS referred to the Friends and Family Test and asked if the practices that have patients that would not recommend them would be supported by EC. VC confirmed that she would be visiting all practices.
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Dr Marasco’s practice has now closed.
The combined CCG Flu Plan has been written and reviewed and this will be shared with care homes to ensure they are informed about the importance of vaccinating staff.
Practices are aware of the Falsified Medicines Directive (FMD) and have been given full details of current recommendations.
The Flu Plan for 19/20 has been published in the GP Newsletter and has been sent out to all practices.
The Shingles update shows no change to the CCG position. An update was given at a recent Time to Learn session and is covered within the quality visits.
PS asked if the communications team were helping to promote the vaccines and VC confirmed that they have sent material out and have also published information on social media.
VC took the committee through the GP Patient Survey and asked them to bear in mind that when comparing results it was important to bear in mind that only 39% of patients responded.
Overall patient experience was rated at 82% for CP&R with The Hollies being the lowest at 68% and Riverside receiving 94% and 80% for Southend with Queensway the lowest at 68% and Leigh Surgery the highest with a score of 96%.
The survey will now be taken to all patient participation groups for discussion and comments.
SS asked the committee to bear in mind that the low score for The Hollies may be due to their list being closed. LB asked if there was a reason for the poor responses and PS asked if poor performing practices could be encouraged. VC said she was happy to liaise with practices. PS asked if the low satisfaction with receptionists was linked to practices that had not taken up the offer of training. JGL felt the committee should be mindful that if a member of staff has been through the training and are therefore more confident asking questions, some patients will not want to speak to a member of staff that is not clinical. PS hoped that in the future patient representatives may be happy to be at their practices helping and signposting fellow patients.
JG said there are lots of changes happening in primary care and a culture change in the way we work together and it takes time to embed changes and develop trust.
Flu plan
VC presented the 2019/20 Flu plan and asked the committee to approve the recommendations as presented. The following points were highlighted:
The criteria for vaccines is as follows: • all children aged 2-10 on 31/08/2019 • all pregnant women (including those who become pregnant in flu season) • people aged 65 and over
At risk children will be able to visit their practice for vaccination if they do not have it done at school.
Funding has been set aside for all CCG to receive the vaccination.
Page 3 of 7 Practices are aware that there will be a delay in the delivery of vaccines for people aged 65 and over and some have chosen to identify an alternative manufacturer to reduce this risk. Once the vaccine arrives flu clinics will start.
Commisceo will continue to provide outbreak services although there is an STP wide service review underway at the moment and the procurement of a service provider will start imminently.
The Joint Primary Care Co-Commissioning Committee were happy to APPROVE the recommendations as presented in the Quality Report.
6. Finance Report
LB presented the finance report and took the paper as read, highlighting the following points:
Castle Point & Rochford CCG
The annual primary care budget for the 2019/20 financial year has been allocated at £24.3m.
At this point in the financial year a break even position is being forecast.
At the end of Month 4 the Transformation Fund has a surplus of £693k. LB/JS are working hard to ensure that this money is spent within the current financial year.
Risks remain the same as last month and include premises cost/rate reimbursements, locum costs, prescribing and QOF.
PS asked if there was a risk to the GP IT budget and LB replied that this cannot be guaranteed as NHSE feel this has already been included in our allocation.
Southend CCG
The annual primary care budget for the 2019/20 financial year is £25.6m with a requirement to allocate £300k of this budget for Primary Care Networks.
Uncommitted money from the Transformation Fund is £88k which is significantly lower than CP&R but this is due to schemes being progressed further in Southend.
Risks remain the same as last month and include premises cost/rate reimbursements, locum costs, prescribing and QOF.
JW asked why the transformation surplus is higher in CP&R and JS informed him that this is because there are more care homes in Southend and First Contact Physio has a full year affect in Southend.
The Joint Primary Care Co-Commissioning Committee were happy to APPROVE the recommendations as presented in the Finance Report.
7. Contract Update Report
SS presented the Contract Update Report and took the paper as read, highlighting the following points:
A number of small contract variations have taken place but nothing significant with no decisions needed by the committee.
Page 4 of 7 SS continues to work with NHSE to ensure a consistent approach is followed by all practices.
Practice visits continue to take place.
The Locally Commissioned Service Review Group has undertaken a full review of all specifications and these have been agreed for this financial year. Contracts have been prepared and are ready to be sent to practices.
SS confirmed that more practices had signed up this year to provide services which will ensure good coverage across both localities.
PS asked how patients would be informed about the services available in their practices and SS replied that practices would be referring patients to the relevant provider but it would be the responsibility of the practice to keep patients informed.
PS made a suggestion for a representative from the communications team to attend these meetings to take any actions relating to patient information. JGL agreed that communication is a big issue but practices do have an obligation to ensure their patients are aware of services available to them. It is also down to practices to regularly review their communication methods to ensure messages reach as many people as possible.
Action: JS to speak to CD in regards to Claire Routh attending future meetings.
PS asked if the Terms of Reference for the Locally Enhanced Services Review Group could include a nurse and contracts manager as part of the membership and JS confirmed that a finance manager is part of the group along with VC and a member of the medicines management team. PS was concerned that practices may end up getting paid twice for providing services but SS felt that this was very unlikely as they are paid per activity. SS added that the purpose of the group was to look at all of these things and review all implications for all service. JS thought it would be sensible for the PCCC committee to review services in six months’ time and see how patients access the service and if there are any financial implications. LB asked for confirmation that they were not a decision making group and asked for the minutes to come to this committee for oversight.
Action: SS to update the Terms of Reference to reflect that the group are not decision makers
The parachute policy went live on 7th September and SS has received five expressions of interest. An update will be brought to the meeting in November.
SS pointed out that quality visits are also looking at outcomes that are unmeasured such as improving engagement of practices that were not responsive in the past. There are three new practice websites.
The Joint Primary Care Co-Commissioning Committee were happy to APPROVE the recommendations as presented in the Contracts Update Report.
8. Primary Care Work Plan Update
JS gave an update on the Primary Care Work Plan and took the paper as read, highlighting the following points:
There are 50 GP practices and 9 PCNs across both localities.
Page 5 of 7 There are a variety of funding pots available to develop PCNs to deliver on national access requirements. The utilisation of appointments has reached 75% and PCNs will look at the needs of their population in order to improve this.
Regular meetings are taking place with Clinical Directors and PCN staff and the CCG are giving them support while they establish themselves. Public Health are involved in these meetings.
There are a range of things available to assist telephone appointments and many online tools but support should be given to anyone struggling with these technologies.
PS said she was happy with the way the report had been formatted and felt it gave a good insight into what progress is being made. JS informed the committee that there was a new member of the Primary Care team, Marina Muirhead, who would be looking at how primary care funding is spent and whether it was having a positive impact. JS felt that the Primary Care Strategy was linking nicely with the national policy.
PS to meet with MM over the next few weeks to look at current schemes and spending.
The Joint Primary Care Co-Commissioning Committee were happy to APPROVE the recommendations as presented in the Primary Care Work plan Report.
9. Items for Decision
There were no items for discussion.
10. Information Items
There were no items for discussion.
11 Any Other Business
There were no further items for discussion.
12. Questions from the public
Question 1 Mr Gasper asked about PCNs and the facilities offered by each one and felt that the CCG should provide information on what each PCN offers along with performance rates. As there is funding available to help with the development of PCN Mr Gasper suggested putting details on TVs in waiting rooms and asked if the CCG were providing practices with information that they could display in their waiting rooms.
Answer 1 JS responded by saying that a key focus of PCNs is to work with their local communities but as TV screens were owned by practices if would be their decision of what is shown on them. The CCG communications team had made an offer to assist practices with advertising materials and some have accepted this offer.
CP added that we need to be conscious that PCNs are new and they are a group of practices working together not an organisation and they are in the early days of their development. Funding has been made available to develop these groups of practices and help deliver the national enhanced services in addition to their GMS contract.
Question 2 Mr Gasper asked if the CCG has a five minute presentation to give to practices to share with their patients.
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Answer 2 JS responded by saying that Claire Routh and the Communications Team have asked practices what material they would find helpful and will support them where they can. PS added that a GP Newsletter is sent out regularly to all practices.
Question 3 Brian Dawbarn referred to the many new homes being built in the area and asked if the CCG had any plans to support the growing population.
Answer 3 JS said that the CCG work closely with planning authorities in regards to any new housing developments in the area.
Question 4
JB reported that Health Watch have seen a big increase of telephone enquiries in Southend in regards to prescriptions and reported manufacturing issues.
Answer 4
JS suggested sending all the information to Lin Teasdale who deals with complaints and VC said that she would also look into this. JGL asked her to include meds management in this and PS said that the names of medication would also be helpful.
Question 5 Julie Chambers thanked everyone for the hard work they are doing and felt it would be good if each surgery could deal with minor injuries to save people attending A&E.
Answer 5 SS highlighted that practices are not set up to deal with emergencies but pointed out that as part of the locally enhanced services some practices do provide a minor injury service.
13. Next Meeting Date:
Wednesday, 13th November, 1pm-3pm Venue tbc
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Patient and Community Reference Group Minutes
Date: 9 July 2019
Time: 6pm – 8pm
Venue: The Hockley Room, Pearl House, 12 Castle Road, Rayleigh
List of attendees Ann-Marie Fordham (AMF), Chair (in alphabetical order): Kath Daly (KD), Patient Representative Castle Point Chelsea Felstead (CF), Implementation Manager for the Midlands and East Region Lindsey Gillingham (LG), Head of Operations, Castle Point Association of Voluntary Services (CAVS) William Guy (WG), Director of Integration and Partnerships,Basildon & Brentwood CCG Hillary Gerrans (HG), NHS App Implementation Lead Lorraine Holditch (LH), Patient Representative Rayleigh Rev Richard Jordon (RJ) Cheryl Kirby (CK), Patient Representative Castle Point Kathleen Leech (KL), Patient Representative Castle Point Barbara Oliver (BO) Patient Representative Rayleigh Kelly Redston (KR), Strategic Partnership Officer, Rochford District Council Claire Routh (CR) Head of Communications and Engagement Amanda Shears (AS), Patient Engagement Officer / Minutes Neeve Simpson (NS), Chair of Rochford District Youth Council
Apologies Sam Glover (SG), Public Health England/Healthwatch Essex (in alphabetical order): John Hall (JH), Patient Representative Castle Point Victoria Marzouki (VM), Rayleigh and Rochford Association of Voluntary Services (RRAVS) Pauline Stratford (PS), Patient Representative Castle Point
Item Subject Action
1. Welcome and Apologies
The Chair welcomed members to the meeting and said a special
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thank you to Neeve Simpson and Kelly Redston who were representing the Rochford Youth Council.
2. Draft minutes dated 7 May 2019
The draft Minutes dated 7 May 2019 were reviewed and the following revisions were made:
Add Barbara Oliver (BO) to the list of apologies Ensure consistency throughout minutes with regard to a person’s title.
Once these amendments had been made members were happy to approve as an accurate account of discussions.
3. NHS App
HG, Implementation Lead, NHS England and NHS Improvement and CF attended the meeting to give an overview of the NHS App.
HG confirmed that all GP practices within the south east Essex locality are now connected to the NHS app software and patients should now be able to download the app.
HG gave a summary of the benefits of the NHS App which included: Booking appointments Cancelling appointments Ordering repeat prescriptions Viewing personal GP medical record Signposting to other health related information Symptoms checker Register as an organ donor
The NHS App currently offers the same service as the online booking system currently in use. As part of these discussions members noted that the CCG were currently involved in a mid and south east Essex online consultation procurement.
Discussions focussed on the discrepancies regarding age restrictions and proxy access. Patients from the age of 13 years old were able to download the NHS app. Members debated whether patients were able to make decisions about their health at the age of 13 and queried whether proxy access would be granted to the young person’s patient/carer. HG confirmed that proxy access was not currently a feature of the NHS app and patients aged 13-15 would need to go into their GP practice to register. Speaking from experience NS challenged these discussions noting that young people were more informed nowadays and were able to make decisions about their health.
Members of the group also noted that people under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment (Gillick competent).
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There were discussions about the various health related apps currently available and the confusion that this could potentially cause for members of the public.
Members generally welcomed the introduction of the NHS App. However thought should be given to length of time it takes to complete the online booking form and patients needed to be clear what the appointment was for so they could be triaged appropriately.
CK raised that triaging had to be included in the online booking system otherwise it circumnavigated the Care Navigator triage process introduced at Rushbottom Lane Surgery.
KR suggested that there may be an opportunity for Patient Participation Groups to sanitise the online consultation descriptions currently used by their surgeries. KR went onto suggest that PPG members may also want to consider engaging with their patients with a view to raising awareness and showing patients how to navigate around the NHS app to encourage sign up.
KL queried whether there was a function for reminders to be sent via the app. HG advised that this is not currently available but would be developed in a latter phase. Members noted the different online text messaging providers currently used locally which included MyGP and iPlato.
Members asked what mental health information was available via the NHS App. HG explained that patients would be able to access a symptom checker and there was a function to be signposted to other mental health related apps.
There were discussions regarding the addition of other useful features which could be accessed via the NHS app including information relating to the local offer and access to the Choose and Book system.
There were concerns that patients could misinterpret the information contained within their own medical records which could lead to an increase in a patient’s anxiety.
HG and the CCG welcomed the opportunity to undertake a further digital engagement exercise with members of the Rochford Youth Council (to be arranged).
4. Non-urgent Patient Transport Procurement
William Guy, Director of Integration and Partnerships, Basildon & Brentwood Clinical Commissioning Group attended the meeting to give an overview of the Mid and South East non-urgent patient transport procurement.
WG explained that in excess of 180,000 journeys are delivered through the current service provision. The current patient transport
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service has various providers. However the new service specification will focus on procuring one provider with a single point of access for those patients who are not currently in hospital.
The level of engagement to date included: Two stakeholder workshops Clinical engagement Market engagement event Patient engagement events and surveys
WG explained that feedback from the surveys was generally positive. The key areas for improvement and consideration were the communications with patients regarding specific pick up times and the reduction in waiting times.
WG outlined the scope of the procurement and gave a brief summary of the three core elements: Booking and eligibility assessment. Transportation of patients.
On-site support at NHS Acute Trusts.
In response to a query regarding patient transport eligibility for those living in a care home. WG confirmed that only those that are Continuing Health Care (CHC) funded are eligible for patient transport. It was also noted that if a patient is transported ‘out of area’ it is the responsibility of the local CCG to fund.
There was further discussion regarding the various methods of transportation of patients. WG advised that inter hospital transfers do have the capability to go to ‘blue lights’ in the event of a deteriorating patient and could also be used once a patient has been stabilised and requires onward types of vehicles.
With regard to future service developments. WG explained that TPS cars converted mini buses to accommodate multiple wheelchairs, stretcher vehicles, bariatric vehicles(discharges can be up to 10p) if a patient required acute care but was assessed as low risk instead of waiting for an ambulance which could take anywhere from four to six hours there would be potential to use the non-emergency patient transport service. This would have a positive impact on the ambulance service, staffing and allow for earlier admittance.
BO sought clarity over the procurement process. WG advised that this would be a two way procurement whereby providers would need to demonstrate their capabilities.
KR queried the hospital’s use of private taxis as a means of transporting patients to their home after discharge. WG explained that the hospital would need to make that judgment upon discharge although commissioners discourage this particular method. WG reassured the group that the patient transport service will also ensure that the patient arrives home safely.
CK asked what would happen if the procurement failed. WG advised
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that the current contract could be extended if necessary.
5. Terms of Reference
CR presented the revised Patient and Community Reference Group’s Terms of Reference (ToR) which reflected the CCG’s recently approved Communications and Engagement Strategy.
CR explained that the CCG were currently in the process of developing a forward planner which was aligned to the organisation’s key priorities.
KR was keen to raise the profile of the district councils in CCG discussions and was keen to understand how the CCG linked with the Health and Wellbeing Strategy and Health and Wellbeing Board. Some members expressed an interest in attending a future Health and Wellbeing Board meeting. KR confirmed she would be happy to send invitations to those that had expressed an interest. KR to action.
Round Robin
CR referred to recent media coverage regarding the outbreak streptococcus in mid Essex. CR reassured members of the group that the report outbreak was isolated to mid Essex.
BO referred to her recent experience of end of life services and gave thanks to the Hospice at Home Palliative Care Nurses.
LG congratulated KD for being a finalist at the 2019 CAVS Volunteer Awards.
LG referred to the Castle Point Show which was taking place on 21 July 2019 CAVS
LG asked members of the group for their assistance in recruiting volunteers to help CAVS at the Castle Point Show which was taking place on 21 July 2019.
CK asked whether there were any future engagement opportunities for Primary Care Networks (PCN). As PCNs were in their very early stages no dates had been agreed but this would be something that would be developed in the future.
AMF raised her concerns regarding the difficulties she had encountered in connection to data sharing between the local acute neurology services and an issue with GP’s who could not access tests results which were carried out at Basildon hospital.
KS acknowledged the issue stating that it was a work in progress which was due to the different IT systems used by the hospitals and primary care.
AMF and AS gave members of the group a brief update on Essex County Council’s Learning Disability 100 day challenge.
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Date of next meeting venue and time: 10th September 2019, Hockley Room, Castle Road, Rayleigh at 6pm – 8pm
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Patient and Community Reference Group Minutes
Date: 10 September 2019
Time: 6pm – 8pm
Venue: The Hockley Room, Pearl House, 12 Castle Road, Rayleigh
List of attendees Ann-Marie Fordham (AMF), Chair (in alphabetical order): Michelle Angell (MA), Director of Assurance Dr Chana (DrC), GP Rushbottom Lane Surgery Kath Daly (KD), Patient Representative Castle Point Lindsey Gillingham (LG), Head of Operations, CAVS John Hall (JH), Patient Representative Castle Point Lorraine Holditch (LH), Patient Representative Rayleigh Kathleen Leech (KL), Patient Representative Castle Point Claire Routh (CR) Head of Communications and Engagement Amanda Shears (AS), Patient Engagement Officer / Minutes Kashif Siddique (KS), Governing Body Member Karen Sweeney (KS), Commissioning Manager Paul Taylor, (PT) Associate Director of Commissioning
Apologies (in alphabetical order): Sam Glover (SG), Public Health/Healthwatch Essex Rev Richard Jordon (RJ), Parish Priest Cheryl Kirby (CK), Patient Representative Castle Point Victoria Marzouki (VM), RRAVS Barbara Oliver (BO), Patient Representative Rayleigh Pauline Stratford (PS), Patient Representative Castle Point
Item Subject Action
1. Welcome and Apologies
The Chair welcomed members to the meeting and said a special thank you to PT and KS who had been invited to talk to the group about the respiratory transformation work.
2. Draft minutes dated 9 July 2019 and matters arising
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The draft Minutes dated 9 July 2019 were reviewed and the following revisions were made:
Add RJ to the list of attendees
Amend CK comments on page 3 paragraph 2 regarding the triage element of the app.
Once these amendments had been made members were happy to approve as an accurate account of discussions.
Matters arising
JH referred to previous discussions regarding future engagement opportunities for future Primary Care Networks (PCN).
CR confirmed that communications and engagement opportunities would form part of the future development of PCNs. JH was keen to ensure the involvement of PPGs in these discussions from an early stage.
CR confirmed that the CCG communications team had developed a CR PCN Communications and Engagement Guide which had been shared with the PCN Clinical Directors. CR to share a copy of the guide with JH for information purposes. CR also noted that the CCG’s website had been updated to include the details of practices broken down by PCN which could be found in the “About Us” section.
3. Meeting etiquette
AMF informed the group that this would form a standing item on future Patient and Community Reference Group agendas.
Members of the group were asked adopt certain protocols during the meeting these included:
Keeping to agreed times to ensure meeting finishes on time. Members of the group to go through the Chair before commenting on any particular agenda items. Any additional questions to be taken outside the meeting and contact details shared to progress further discussions. Limit the use of acronyms.
Members of the group were happy with these proposals.
4. Terms of Reference
AS referred to the revised Terms of Reference which had been circulated with the agenda and supporting papers and asked members of the group if they were happy to approve the changes.
In line with the revisions made LH asked that a representative be AS invited to a future meeting to explain the impact on the local health
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economy in line with the Council’s future development plans.
Members of the group were happy to approve the Terms of Reference.
5. Transformation of local respiratory services
In line with the Castle Point & Rochford Clinical Commissioning Group’s (CCG) key priorities and the Long Term Plan KS and PT had been invited to give a presentation relating to the transformation of local respiratory services which members noted was one of the CCGs biggest spend areas. The redesign of services primarily focused on COPD and pulmonary rehabilitation.
KS gave an overview of the national and local respiratory data and the contributing factors to respiratory conditions which prompted the following discussions.
Ageing population.
Smoking is one of the leading causes for respiratory related illness. The proportion of current smokers among residents living within the STP aged over 18 years has mostly decreased since 2011. However Castle Point had the largest proportion in 2017 and increased by nearly 3% since 2011. Members asked whether these figures related to a particular age group. PT advised that data evidenced an increase in younger people. KL asked whether the smoking cessation services were linked to the schools. LG asked whether there was an opportunity for CAVS volunteers to undertake smoking cessation training so they could offer advice to people in the community. There were discussions regarding the increase use of electronic cigarettes. It was acknowledged that there was little data available to determine whether vaping had the same effects as smoking tobacco although it was noted that vaping does not have any of the carcinogenic properties associated with tobacco.
Members were keen to ascertain whether the data took into account those who smoked cannabis and the increase in social use of Nitrous Oxide. KS advised that she did not have any data to suggest that this had any direct impact.
KS advised that COPD prevalence in 2017/18 was the highest in NHS Southend and NHS Castle Point and Rochford CCG was significantly higher than the England prevalence. Data evidenced that there were approximately 8,000 COPD patients and 21,000 asthma patients. KD asked whether pollution levels were a contributing factor and whether the figures took into account those people who had moved from an area with poor air pollution. KS advised that this level of patient data wasn’t available however there is evidence to suggest we have a higher percentage of occupational lung disease. Members discussed other contributing factors to the level of pollution which included the increase use of Southend airport, local
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housing developments and traffic congestion. Members asked whether there was any data supporting this? PT to investigate further and share his findings.
KS advised that there is variation in care across the area which can lead to suboptimal management of the patient’s condition. There is a big focus on early diagnosis and prevention within primary care/community services.
Low vaccine uptake (flu vaccinations) is also exacerbating the current situation. Evidence suggests that 50% of patients are having the flu vaccinations. It was acknowledged that there was a need to improve communications methods between practices and patients. CR confirmed that this was something the CCG could support via the National Flu Campaign materials.
High A&E attendance and high emergency admissions.
CR asked whether there was an opportunity for members of the group AS to be involved in any future patient engagement. KS provided details of the Respiratory Group who meet on the first Friday of every month at Southend University Foundation Trust Hospital. AMF expressed an interest in joining these discussions. AMF to be added to the Respiratory Steering Group distribution list
6. AS explained that the Care Navigation/Wellbeing Partnerships working across Essex were planning to re-brand all of the partnerships to Live Well Link Well within the next few months. There are currently four different types of patient facing promotional resource in circulation advertising the service. The aim is to have one design which would be individually tailored to be specific to each CCG area and the relevant delivery partners. The contact details, telephone number and email address will be the same for all areas. Members of the group were asked for their views on each of the leaflets and this feedback would be taken into consideration as part of the rebranding.
It is important for members to note that this is a different offer to that provided by CAVS who are commissioned to provide local community services including a befriending scheme, Ways to Wellness and Essex Children and Young People’s Services to name but a few.
The group reviewed the leaflets and made the following comments:
Basildon & Brentwood CCG
Front cover doesn’t tell the patient anything Did not like the colors used What is Care Navigator Partnership – bee keeping? the average person will not understand Felt the wording on the back did not give a clear indication of what the service offered.
Castle Point & Rochford CCG
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Thought “Castle Point and Rochford Wellbeing Partnership” was too long Dr Siddiqui commented that it is the GP’s view that they know the partnership exists but they are unclear as to the reasons why they would be signposting their patients to the service They liked the speech bubble “Do you need help with issues that might be affecting your health and wellbeing?” and wording used to explain what the service offers
West Essex CCG
Didn’t like the colours used. Thought it looked like every other leaflet in the surgery waiting room Didn’t like the term “Care Navigator Partnership” (as above)
Mid Essex CCG
What does “Live well link well” mean to a patient? A patient wouldn’t necessary know what social prescribing is AS and how it can help the patient. Information on the back of the leaflet is too wordy.
In conclusion the CPR Wellbeing Partnership leaflet was the preferred choice. Members of the group agreed that the leaflet should be in an assessable easy read format. AS to share the feedback with members of the CPR Wellbeing Partnership.
7. Skype Pilot Consultation
MA and DrC had been invited to give a brief overview of the Skype Pilot Consultation.
The Skype consultation service would initially be used for patient where no further treatment escalation is appropriate between a members of the Palliative Care Team and GP. The Coroner’s guidelines currently state that the patient would need to be seen by a GP 14 days prior to their death.
Reducing unnecessary delays in administering death certificates. Unnecessary delays with coroner. Avoiding the need for a post mortem. Making better use of GP time
KL asked whether there were issues in connection to consent. MA explained that if the patient had capacity they would be asked to give consent or consent could be given via Power of Attorney for each Skype consultation which would be recorded in the patient’s notes and on SystmOne by the PCN along with notes and outcomes of the consultation. Patients do have the option to opt out.
There were discussions about the use of Babylon in some local surgeries. MA confirmed that if the pilot was successful Skype consultation would be rolled out into all surgeries. The next phase
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would be to introduce Skype consultation/SystmOne into care homes.
There were discussions regarding levels of security. MA explained that patient notes would be updated using SystmOne.
Appointment times for the pilot will be between 12-2pm. If the appointment is missed due to a technical issues this will be rearranged. CR asked whether the patient would see the same GP for each consultation. MA advised that the consultation would be with the patient’s named GP as opposed to the current process where there is no consistency. MA was keen to stress that a GP will also see the patient in person if necessary.
Members of the group were presented with the “14 day visit Skype booking process” which was being piloted at Rushbottom Lane Surgery. MA confirmed that the CCG has taken legal advice and the proposed booking process did meet guidelines and would be shared with paramedics and police once finalised. MA confirmed that feedback from this session will be used to develop a patient leaflet which will be shared in due course. AS to share with members once AS approved.
8 Any other business
CR provided a verbal update regarding the proposed CCG merger. Members noted that a decision would be made by the CCG’s Governing Body by December 2019 as to the proposed plans. Members of the group were concerned that the patient voice, local knowledge and contacts would be lost if the proposed merger went ahead.
There were discussions regarding the impact the increase in future AS housing developments would have on local healthcare services. Add as a future agenda item as per earlier discussions.
LG gave an update on behalf of CAVS and provided details of two new health and wellbeing projects:
Never too old to play – Castle Point, Rayleigh and Rochford (over 18) Starts 4th October
Walk, Talk and Be Healthy – Castle Point (over 18) Starts 30th September
Date of next meeting venue and time: 12 November 2019, Hockley Room, Castle Road, Rayleigh at 6pm – 8pm
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Background
Since the last update to the CCG Board, the Mid and South Essex STP CCG Joint Committee has met in public on one occasion and considered and addressed the following issues:
Part I Meeting held 4 October 2019
• The minutes of the Part I JC meeting held on 7 June 2019 were approved, with no amendments requested. A copy of the minutes is provided to the Board. • The Lead Accountable Officer (LAO) advised that a draft submission relating to the NHS Long Term Plan had been forwarded to NHS England/Improvement and that a number of ‘check and challenge’ sessions would take place before the final plan was submitted at the end of November. The LAO also advised that the MSE Group of Hospitals had decided to expedite the reconfiguration of Cardiology services to enhance winter resilience at Broomfield and Basildon hospitals and that the Mid and South Essex STP had been recommended by the Cancer Alliance as the South Alliance Rapid Diagnostic Centre flagship site following a successful application. • The Chief Nursing Officer from Mid and South Essex University Group of Hospitals attended the meeting along with senior nursing colleagues from each of the three hospitals, to present the group’s Quality Account 2018/19 and to provide information on action being taken to continuously improve patient safety and quality. The presentation is available on the Joint Committee’s webpage. Joint Committee members acknowledged how challenging it was for hospital staff at the current time due to the demand on services coupled with organisational changes. • The Patient Safety and Quality Report highlighted that there had been three Never Events reported by the MSG Group up to August, with two further incidents reported during September. The hospitals were trying to understand the reasons for these so that appropriate action could be taken. A number of inspections had been undertaken by the Acute Quality Team. Feedback from these visits would be used to enable hospital managers to take appropriate action in preparation for Care Quality Commission inspections. • The Performance Report highlighted that a detailed piece of work to understand demand and capacity at the hospitals was being undertaken down to clinic level within five specialties, namely Dermatology, Urology, Neurology, Trauma and Orthopaedics (T&O) and Gastroenterology, including Endoscopy capacity. The Joint Committee will receive a report on work being undertaken to address referral to treatment times at its next meeting. • The Finance Report confirmed a forecast deficit of £8 million and that of the £12 million QIPP target, only £6.5 million of savings had so far been identified. KPMG had been commissioned to try to identify where further savings could be achieved. The main financial risks related to recovery of Referral to Treatment performance and the cost of critical care provided by London providers. However, ongoing work by the Acute Nursing Team to implement packages for relevant critical patients would help to address the financial forecast going forward. The Chief Finance Officer confirmed that the £8 million forecast deficit had been taken into consideration within the five mid and south Essex CCG’s financial forecasts. • The committee received an overview of progress on Mental Health (MH) transformation. Feedback from NHSE/I had recently been received on the first draft of the MH Long Term Plan, the key theme being a need for triangulation and coherence throughout the plan. Members were informed that there was considerable pressure regarding the perinatal MH agenda as mid and south Essex was slightly behind when compared with national progress. A bid for non-recurrent transformation money was successful and the MH team had written to EPUT to invite them to the next Perinatal Steering Group meeting to discuss building some short term capacity. Three school mental health teams would be put in place within Thurrock, Southend and one covering the whole of the STP for further education and the 24/7 MH Crisis Team was due to ‘go live’ on 1 April 2020.
• The Joint Committee reviewed its risk register and supported closure of one risk relating to the STP Estates Strategy which had recently been reviewed by NHSE/I and rated as ‘Good’. A copy of the latest Joint Committee Register is provided to the Board for information. • The JC received a summary report of items discussed at the Patient Safety & Quality Sub-Committee meetings held on 19 March 2019, 21 May 2019 and 16 July 2019. • The JC received a summary report of items discussed at the Finance & Performance Sub-Committee meetings held on 21 June, 19 July and 16 August 2019. • The JC received a summary report of issues discussed at the JC Risk and Assurance Sub- committees in common meeting held on 17 June 2019. • A Joint Committee Emergency Powers decision relating to the Commissioning Case for the Mid and South Essex Non-Emergency Patient Transport Service, which was taken to enable the award of the contract and mobilisation of the new service, was reported in public.
Recommendations
Members of the Board are asked to note the business conducted by the STP CCG Joint Committee at its Part I meeting on 4 October 2019, the minutes of which will be submitted to a future Board meeting following their approval by the Joint Committee on 6 December 2019.