Council of Members 17 May 2017 Minutes of last meeting: March 2017 - - PowerPoint PPT Presentation

Council of Members

17 May 2017

Minutes of last meeting: March 2017

Update on Council of Members Deputy Chair

Malcolm Hines, Chief Financial Officer

Update on NHS Constitutional standards

Andrew Bland, Chief Officer

Accident and emergency

April May June July Aug Sep Oct Nov Dec Jan Feb Mar GSTT 91.9 89.4 89.8 90.8 89.0 88.9 85.6 84.3 88.3 88.7 88.6 86.9 KCH 83.5 85.1 83.8 83.5 88.2 82.5 81.1 81.0 75.8 78.5 81.7 82.2 KCH (DH) 86.1 85.6 82.2 82.8 87.4 82.1 81.1 80.8 76.2 79.7 81.5 80.0

A&E waits all types (target 95%) - % of patients who spent 4 hours or less in A&E before treatment or admission Latest data reflects continued local pressure on the 4 hour target into 2016/17, in line with national pressures. Recovery plans had been agreed with both local acute providers, and are subject to constant review, noting that a number of key actions relating to estates at KCH and GSTT have been subject to delay which have negatively impacted on capacity and patient flow.

Whilst performance against the 4 hour standard has begun to improve at both GSTT and KCH, it is significantly below the national 95% target. KCH - KCH met its agreed performance trajectory in February, and was marginally below trajectory in March. March under-performance was driven by unplanned bed closures (related to infection control, and the decant of wards to allow for emergency estates modifications and staff training) as well as significant staffing issues related to the booking of agency staff through NHS Professionals. GSTT – Performance has begun to improve following peaks in attendances in March. GSTT continues to be affected by on-going estates works which will not be fully completed until 2018, but with a number of key milestones due to be met in the coming months. GSTT has also been affected by staffing issues, particularly regarding GP availability in the UCC and the loss of

• registrars. Additional Consultants are being recruited, and focus is on the on-going delivery of

the ED recovery plan Wider System – DTOCs and MFFDs continue to be low following an intensive piece of work in December, with KCH seeing some of their lowest levels for many months. An increase was noted at GSTT, but this may reflect the Trust’s ‘Helping Patients Home’ week which focussed on discharge pathways and caused an increase in reporting. Work is on-going with the Trust to ensure that best practice pathways are in place, and that discharge notifications are issued at the earliest possible stage to reduce delays.

Accident and emergency

King’s College Hospital Recovery Plan (1)

Overview and drivers for under-delivery of 4 hour standard

The national standard of patients being assessed, treated and discharged has not been consistently met at KCH since 2013/14. This, and subsequent slides, give details of the underlying causes for under-delivery, the improvement trajectory, and corrective actions being undertaken.

Key drivers of under-delivery:

Capacity – beds and bed management - Trust operating with fewer beds than had been

• planned. Although now built, Charles Polky ward at DH has been unable to be substantively

staffed, and planned site moves to Orpington and PRUH have not been able to progress due to bed pressures on these sites. Very high levels of bed occupancy (98% plus) at both DH and PRUH Discharge – Reduction of delayed discharges has been a key focus, with levels halving since

• Christmas. However, there is an imbalance between time to discharge between local and

non-local boroughs, with focus on embedding Discharge to Assess and Trusted Assessor protocols to reduce external delays. Repatriations consistently occupy around 28 beds at any

• ne time, with delays for non local Trusts a particular challenge, and accounting for two

thirds of delays.

King’s College Hospital Recovery Plan (2)

Key drivers of under-delivery (Cont.):

Staffing - Staffing has been a significant challenge, including overall staffing levels and sickness rates in ED, filling GP rotas for UTC, overall nursing levels and the numbers of experienced nursing staff available resulting in the enforced requirement to maintain safe staffing of the existing bed base. Overnight Delivery - Challenging out of hours performance - staffing and capacity constraints; ED ‘exit block’ leading to the regular displacement of Majors into Minors and the relocation of staff to majors. Performance management oversight strengthened to optimise Minors performance and preserve disaggregated flows. Best Practice Pathways - Inability to implement ambulatory care and frailty pathway improvements due to overall pressures and capacity constraints. Staffing issues have prevented the systematic application of RATing to rapidly offload ambulances. Urgent Care Centre (now renamed Urgent Treatment Centre) – High levels of non-admitted breaches due to sub-optimal pathway. UTC due to open during 2016/17, but now delayed until June 2017 due to estates issues. Specialty Response - Length of wait for specialty response continues to be an issue, with 1 hour standard

• nly met 50% of the time. There is a need to systematically apply and enforce inter professional

standards, alongside further work to understand barriers to compliance.

KCH Aggregate Trajectory Actual/Forecast (month end position) Target

2017/18 Trajectory April Delivery vs Trajectory

Additional beds (PRUH/Orp)

Additional Beds (DH) Dedicated UCC (DH)

Discharge to Access/Trusted Accessor

Improved System Flow - Occupancy >92%

Trust’s compliance has been steadily improving since February March/early April performance affected by unplanned loss of up to 38 beds due to Infection

• Control. Recovery mid April.

April aggregate of 85% versus end of April milestone of 86.29%. Encouraging evidence of improvement at both sites, with both delivering frequent above trajectory compliance but not yet fully stable.

2017/18 overall improvement trajectory

Recovery Plan: Planned actions to improve ED performance (1)

The following key actions are planned to improve performance against the 4 hour standard at Denmark Hill: Additional beds and bed management - 23 beds on Charles Polky ward due to open in July

• 2017. This will faciliate improved flow from ED and AMU reducing volumes of patients

waiting for beds in ED. DH will also move to a centralised bed management model to provide clearer oversight and ownership. Streamline medical referral pathway - granting direct admission rights for medical patients to ED to reduce waits for specialist opinion and have clearer pathway to AMU Establishment of dedicated assessment areas for medical and surgical referrals – Providing rapid intensive support for those patients at highest risk of admission which will improve flow from ED, embed ambulatory pathways and reduce emergency admissions and length of stay Implementation of frailty pathway - establishment of Frailty Assessment unit, including in- reach to ED to support better management of complex patients and support reduced admissions and LOS

Recovery Plan: Planned actions to improve ED performance (2)

Management of minors stream and physical separation of UTC - It is recognised that stronger management of the minors stream needs to be in place in order to keep minors breaches to a minimum. Senior oversight now in place 7 days per week. In addition, UTC is currently delivered as part of main ED footprint, which causes significant physical capacity

• constraints. From June the UTC will move into a dedicated space and operate 24/7 to reduce

risk of overnight breaches. Ring-fencing of Rapid Assessment and Treatment Space (RAT) – Ring fencing 2 ED cubicles to allow for Majors and Ambulance arrivals to be rapidly assessed by a senior decision maker. Will reduce decision making time and improve flow Discharge to Assess and Trusted Assessor - Work undertaken across SE London to reduce volume of patients staying in hospital whilst assessments are undertaken, with patients instead supported at home, in intermediate care or in residential homes. Trusted Assessor protocols will allow for assessments to be undertaken by ‘trusted’ health and care professionals to reduce discharge planning delays. Expected to significantly reduce levels of delayed discharges and better support ability of patients to regain independence post hospital admission

Referral-to-treatment: 18 weeks

Incomplete (target 92%) – The % waiting to start treatment who have been waiting less than 18 weeks

% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Southwark CCG 84.7 84.7 85.1 85.9 85.6 84.4 84.1 83.3 82.2 82.0 81.4 KCH (Trust wide) 80.7 80.9 81.3 82.0 82.2 80.8 79.1 78.3 77.1 77.3 76.9 GSTT (Trust wide) 92.1 92.6 92.1 91.5 90.6 89.5 89.6 89.8 88.8 89.5 89.2

Guy’s and St Thomas’: The drivers behind GSTT’s RTT performance is in part due to an increase in referrals, however there are also internal issues with capacity, booking practices, and waiting list management that are currently being reviewed. GSTT have submitted a trajectory to return to compliance in Q1 2018/19. King’s College Hospital: KCH performance has deteriorated. This has been a result of the increase in volume of patients requiring treatment, alongside the focus on treating the long waiters first. Other drivers behind performance at KCH include on-going RTT pathway validation which is revealing long waiters, and the continued focus on supporting the emergency pathway, which means only patients who are clinically urgent are being admitted for elective procedures. Performance at KCH has also been affected by the delayed opening of extra beds due to staffing issues.

Referral-to-treatment: 18 weeks

For KCH a revised recovery plan is being developed to address the issues highlighted in the external review undertaken by MBI. The ICDT are also working with KCH and CCGs to assess the costs of insourcing, as a means to provide additional capacity and improve RTT performance at the Trust. Both GSTT and KCH will be focussing on the following actions in 17/18:

• Internal demand and capacity exercises and action to improve internal

productivity and efficiency, including additional clinics and theatre sessions.

• Working with the independent sector to outsource work where possible.
• Both Trusts are working with Southwark, Lambeth and Bromley CCGs

participating in Referral Management groups focussing on 5 key specialties areas. (Neurology, ENT, Gynaecology, Dermatology, Ophthalmology)

Diagnostics

Diagnostic target: A maximum of 1% of patients should wait 6 weeks or more for a diagnostic test

% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Southwark CCG 2.9 5.7 5.7 4.5 0.95 0.9 0.6 1.2 0.99 0.96 0.87 KCH 5.8 8.1 9.4 6.8 2.0 1.0 0.8 0.9 0.98 1.2 0.93 GSTT 1.4 1.1 1.45 1.1 0.90 1.2 0.9 1.3 1.6 1.8 1.3 Overall diagnostics performance for Southwark CCG achieved the 99% target with 99.1% in February 2017. This brings the YTD position to 97.6%, with the overall trend showing an improvement over the last 12 months. KCH: Diagnostics performance at KCH for Southwark CCG was compliant with 99.11% in February 2017, a slight improvement from 99.03% in January 2017. KCH Trust wide reported position also achieved compliance with 99.1% in February 2017. GSTT: Diagnostics performance at GSTT for Southwark CCG was also compliant in February 2017 with 99.15%, an increase from 99.04% in January 2017. GSTT Trust wide reported position, however, breached the 99% target in February 2017 with 98.7%, although this is a slight improvement from 98.2% in January

• 2017. Non-compliant services at GSTT include CT, MRI, and Urodynamics. All non-compliant services at GSTT

have recovery action plans in place, with early analysis predicting performance to be compliant by April 2017.

Cancer waits

SCCG Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 2 weeks 93.4 90.1 91.6 94.4 93.1 92.1 92.9 91.5 92.3 90.0 92.6 31 days 97.1 100.0 97.6 98.6 97.1 100 92.6 97.2 97.1 97.1 94.3 62 days 85.7 83.3 82.1 93.1 83.8 69.7 73.5 82.9 62.5 73.7 79.2 2 weeks GP referral (target 93%): % patients seen within 2 weeks of an urgent GP referral for suspected cancer 31 days treatment (target 96%): % patients receiving first definitive treatment within 31 days of a cancer diagnosis 62 days treatment (target 85%): % patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer King’s – 62 day 87.2 80.8 89.8 77.3 91.1 84.6 90.6 83.7 86.8 85.8 80.1 GSTT – 62 day 70.9 69.7 63.4 65.3 75.1 62.4 68.3 68.4 65.6 66.7 63.9

Cancer waits

Southwark CCG did not meet the target of 85%, reaching 79.2% (5 out of 24 patients) in February 2017, although this is an improvement from 73.7% in January 2017. This brings the YTD position to 78.7%. Of the 5 breaches, 2 were attributed to capacity reasons, 1 to complex diagnostic, 1 to other medical condition prioritised, and 1 to patient choice. All of the breaches were allocated to GSTT. GSTT Trust wide position did not meet target with 63.9% for February 2017. GSTT performance is linked to late referrals into the Trust from other providers and internal administrative processes. A pilot for Standard Operating Procedures and Key Performance Indicators to manage cancer performance was launched in March 2017 to improve administrative processes, with full roll-out across the Trust expected to be completed by the end of May 2017. KCH Trust wide position did not achieve target with 80.1% in February 2017. However, the YTD position remains on target at 85.5%. The TCST has confirmed a time and motion study will take place with the MDT coordinators at KCH in Spring 2017, in an effort to review, analyse, and improve administrative processes. Performance continues to be monitored through the 62 day Cancer Leadership Group. Additional funding was made available to bid for by CCGs from NHS England under STP Transformational

• Fund. Bids were submitted to NHSE on 18th January 2017, focusing on key themes of early

detection, stratified follow-up, and recovery packages, with bid outcomes expected at the end of this financial year.

London Ambulance Service performance

Performance for LAS as a whole has gradually improved throughout 16/17, though LAS has highlighted performance issues due to significant demand pressures, where call volumes are consistently high. The national standard is for Category A calls to be responded to within 8 minutes, 75% of the time. Whilst LAS as a whole have performed at between 62% and 68% during 16/17, Southwark’s performance has consistently been above 70% and has regularly exceeded the 75% standard. Review of ED assessments of ambulance borne patients. Offloading delays at hospitals continue to represent an

• perational challenge KCH have implemented a new RAT model St Thomas’ breach the 15 minute target 58.9% of

the time, but their average overrun time is relatively low, with very few breaches over 30 minutes. Demand Management – SEL are taking forward demand management actions, looking at HCPs, Care homes and ACPs to try to reduce demand on the LAS in SEL over 2017/18. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 8 minutes red 1 65.1 65.6 65.8 64.1 68.3 64.7 67.6 67.5 64.1 62.4 67.8 73.5 8 minutes red 2 73.0 73.9 75.2 73.8 75.5 70.8 75.2 75.7 72.7 72.0 78.8 81.2

8 minutes red 1 (75%) - May be life threatening and the most time critical conditions - emergency response within 8 minutes 8 minutes red 2 (75%) - May be life threatening, but less time critical than Red 1 - emergency response within 8 minutes

Development of a Clinical Effectiveness Group

Mark Kewley, Director of Transformation

Working in Partnership

We have been working together to think about how best to support general practices to continue to improve the quality of care

Aim

To support quality improvement and reduce unwarranted variation in Southwark general practice.

Mission and objectives

We have been working with many of you on this too – through practice discussion and PLT workshops

CEG Workshop – Chair’s closing remarks:

• Sense that there is a real appetite for this work
• He is committed to making this happen
• There is a clear need to identify resource to support and deliver capacity to achieve this
• We need to understand what good facilitation looks like
• We need to quickly act now while there is support and momentum!

In East London we have seen some tried and tested ways to

• ffer practical and systematic support to improve quality

What we’ve seen elsewhere

• A Clinical Effectiveness Group (CEG) is about

improving quality of care for patients. They are a recognised source of advice and practical support to practices.

• CEGs can help to improve the delivery of

clinical processes set out in contracts, which should positively impact clinical

• utcomes and create income benefits

for practices

• CEGs are clinically-led and evidence-driven. The

teams include senior GPs, data analysts and facilitators, and they bring together other experts in the system, such as the Medicines Optimisation Team, senior consultants, and EMIS template designers

• CEGs are based on tried and tested methods

Clinical Effectiveness Group: Making the right thing to do the easy thing to do

This can be used to improve detection, prevention and management of things like AF, which reduces strokes

QOF

This also has income benefits for practices, and savings for the system Southwark figures

We have seen that a CEG can make a big difference to this over time: the average and the variation improved in East London

2012/13-Q4 2013/14-Q4 2014/15-Q4 Over two years the average went up and the variation reduced

We want to adapt and adopt this approach for use in Southwark

What we’ve seen elsewhere What we are trying to do in Southwark

• A Clinical Effectiveness Group (CEG) is about

improving quality of care for patients. They are a recognised source of advice and practical support.

• We are planning to invest in a CEG for Southwark,

as a partnership between your CCG and your federations

• CEGs can help to improve the delivery of clinical

processes set out in contracts, which should positively impact clinical outcomes and create income benefits for practices

• This will build on practical work that we have

already started, for example: ‒ through our M.O.T and virtual clinics ‒ through federation’s cluster meeting ‒ through federation’s QOF dashboards

• CEGs are clinically-led and evidence-driven. The

teams include senior GPs, data analysts and facilitators, and they bring together other experts in the system, such as the Medicines Optimisation Team, senior consultants, and EMIS template designers

• We want to allocate available clinical time and

leadership to provide a point of recognised expertise

• We will focus our analytical teams and facilitators
• n providing the right support to look at data and

to design helpful tools and templates

• CEGs based on tried and tested methods
• We plan to use the same systematic processes of

support to practices

Clinical Effectiveness Group: Making the right thing to do the easy thing to do

This builds on the good approaches we have developed locally, whilst adding focus and alignment to initiatives

IHL Cluster Meetings CCG M.O.T. QHS QOF Dashboard CCG Quality Committee

Discussion

• What are the most practical types
• f support that you think a CEG

can provide to practices?

• What particular areas of clinical

focus do you think would benefit from a CEG approach?

Appendix

AF – more detail The issue we found in Southwark

Detect

• Embedding pulse checks
• Use of new technology –

Health Innovation Network device review Protect

• Increasing anticoagulation,

reducing antiplatelets

• Nursing homes, sheltered

housing, residential care Perfect

• Delivering excellence in

anticoagulation care

• Reviewing commissioned

services

• Simplify patient pathways

AF – more detail Work undertaken by the MOT has helped practices to improve

• Prescribing incentive scheme 2016/17

– Review all patients on the AF register not currently anticoagulated – Virtual clinic with specialist a/c pharmacists from KCH – Agree action plans

• Data submitted by 41/44 (93%) of

practices – 566 patients were reviewed in virtual clinics – An additional 725 AF patients anticoagulated across 44 practices – Expected to prevent up to 25 AF related strokes per year

Clinical leads election

Andrew Bland, Chief Officer

Election of CCG clinical leads

Background

• On 30 June 2017 the 3 year terms of three current CCG GP clinical leads will

expire.

• As there is currently a vacant post, there will be four GP clinical lead posts

available from 1 July 2017.

• The CCG’s constitution mandates a ‘selection-election’ process for the

appointment of GP clinical leads to its Governing Body. Rationale for proposing a change

• We see part of our role of as a CCG as being to proactively support the

development of clinical leadership both in the CCG, federation, LCNs and in many other ways. Federations and LCNs will in time have a greater presence in our system.

• In a difficult financial environment we must continually look at the way we use
• ur limited resources.
• In this context it is prudent for the CCG and Council of Members to consider

two approaches to the recruitment of clinical leads to serve on the CCG’s Governing Body from July 2017.

There are two options for this recruitment, which we would like members’ views on. Option A

• Run a selection/election process in line with that completed previously and

recruit to four vacant posts to replicate the current make-up of the CCG’s Governing Body. This will involve the following course of action:

• Contracting an independent external provider to run an election.
• CCG and the independent external provider will obtain an up-to-date

register of Southwark GPs eligible to vote in the clinical lead election.

• Candidates will be interviewed by a panel including the Chief Officer / Chief

Financial Officer; CCG Lay Member; and an external clinical lead.

• Candidates successful at interview stage will be put forward for election.
• The contracted independent provider will run the ballot via both postal and

electronic voting. All GPs registered in Southwark (including locums working a minimum of one session per month) will be eligible to vote.

• The process is likely to take approximately three months.

Election of CCG clinical leads

Option B

• The CCG runs the same process of selection/election but for two clinical

leads posts reducing the number of GPs in the Governing Body Note: In both options, if the number of candidates successful at selection stage is less than or equal to the number of positions they will be elected unopposed

Election of CCG clinical leads

Option B (contd.)

• This option would reduce the number of clinical leads positions on the

Governing Body by two.

• This option would still leave a clinical voting majority on the CCG’s

Governing Body.

• The option would bring Southwark CCG in-line with the numbers of elected

voting clinical leads employed by other CCGs across south east London.

• The proposal would still satisfy the CCG’s constitutional requirements for

elected clinical lead representation on the CCG’s Governing Body and prime committees.

• The budget used for the additional two Governing Body clinical leads (c.

£90k) will be used to fund other clinical leadership roles in Southwark. The Governing Body proposes that this funding be directed towards the clinical leadership of the Clinical Effectiveness Group (CEG)

Election of CCG clinical leads

For discussion / decision

• This proposal represents a real choice for the Council of Members.
• The Council of Members is asked to discuss and vote on either option A or
• ption B.
• Should the Council of Members go for option B, this will necessitate a

change of the CCG’s constitution so that the minimum GP clinical leads employed by the CCG are changed from eight to six. In this case, the Council of Members will be asked to approve this constitutional change.

• The proposal was presented to north and south locality group meetings on

27 April 2017 and the CCG’s Governing Body members on 4 May 2017. Issues raised at the locality meetings together with a response from the CCG team is provided for reference as part of the CoM papers.

Election of CCG clinical leads

Option A Run a selection-election process in line with that completed previously and recruit four vacant posts to replicate the current make-up of the CCG’s Governing

• Body. No changes required to the CCG’s Constitution.

Option B Undertake the selection/election process described for option A but for 2 vacant posts, described on the previous slides and approve the following changes to the CCG’s constitution:

Election of CCG clinical leads

Paragraph in the Constitution Change 6.6.2 – Composition of Governing Body Change ‘eight’ GPs to ‘six’ GPs 7.3 - GP Representatives on the Governing Body and other Primary Care Health Professionals Change ‘eight’ GPs to ‘six’ GPs Appendix C – Standing Orders Quorum for Governing Body meetings to be changed from 5 GP clinical leads to 4.

Proposal for the election of the CCG Chair by practice representatives

Andrew Bland, Chief Officer

Election of the CCG Chair by practice representatives

Context

• CCG Governing Body clinical leads are elected by the GP electorate.

The CCG Chair is therefore elected by Southwark GPs.

• The role of the CCG Chair is to lead the Governing Body in the

exercise of its duties.

• At present the elected CCG clinical leads vote for the CCG Chair.
• Any candidate for CCG Chair must pass local and national

accreditation.

• At the January 2017 Council of Members meeting, Dr Humphrey

(Albion Street) suggested the CoM reviews the way the CCG Chair is

• elected. Dr Humphrey suggested an alternative option and proposed a

CoM vote.

• This proposal represents an amended version of Dr Humphrey’s

proposal, which takes into account NHS England regulations on the appointment of CCG chairs.

Election of the CCG Chair by practice representatives

Proposal The CCG should amend its Constitution to change the way it elects the CCG Chair so that Council of Members representatives elect the CCG Chair rather than Governing Body clinical leads as at present. Council of Members representatives will vote for the CCG Chair only in the following circumstances:

• that there is a vacancy in the role of CCG Chair due to the current Chair

standing down or their term of office ending.

• more than one elected clinical lead on the Governing Body wishes to stand as

CCG Chair (should there be only one candidate they will be elected unopposed) provided they fulfil the below criterion.

• candidates for CCG Chair have passed the relevant national and local

processes and hold the confidence of the voting members of the Governing Body.

Election of the CCG Chair by practice representatives

Option A Retain the current process for the election of the CCG Chair Option B Change the process in line with the proposal described in the previous slide

Question and answer session of CCG Governing Body

Close