YORKSHIRE AND THE HUMBER SPECIALISED COMMISSIONING GROUP Minutes of the meeting held on Friday, 20 November 2009 at the Thorpe Park Hotel, Leeds Present: Ailsa Claire David Cockayne Philomena Corrigan Ivan Ellul Alan Wittrick Chris Stainforth
Chief Executive (Chair) NHS Barnsley Director of Commissioning NHS North Yorkshire & York Director of Commissioning NHS Leeds Chief Executive NHS East Riding Chief Executive NHS Wakefield Executive Director of Commissioning & NHS Doncaster Strategic Development Julia Mizon Assistant Director of Commissioning NHS Hull Caroline Briggs Director of Strategic Commissioning & NHS North Lincolnshire and Development representing North East Lincolnshire Care Trust Plus Jan Sobieraj Chief Executive NHS Sheffield Ros Roughton Director of Strategy & System Reform NHS Yorkshire & the Humber Andy Buck Chief Executive NHS Rotherham Steve Hackett Director of Finance NHS Barnsley Steve Wainwright Director of Strategy & Commissioning NHS Barnsley Rob Webster Chief Executive NHS Calderdale Mike Potts Chief Executive NHS Kirklees and representing NHS Bradford Cathy Edwards Director Yorkshire & the Humber SCG Laura Sherburn Deputy Director of Commissioning Yorkshire & the Humber SCG Pia Clinton-Tarestad Assistant Director of Commissioning â€“ Yorkshire & the Humber SCG Specialised Services Lisa Marriott Assistant Director of Commissioning â€“ Yorkshire & the Humber SCG Specialised Services Frances Carey Deputy Director of Finance Yorkshire & the Humber SCG Kev Smith Medical Advisor Yorkshire & the Humber SCG In Attendance: Teresa Moss Becky Reynolds
National Director Specialist Registrar in Public Health
Director of Commissioning
Director of Networking & Collaboration
Ann Ballarini Simon Morritt
Director of Strategy & Commissioning Chief Executive
North East Lincolnshire Care Trust Plus Yorkshire & the Humber Collaborative NHS Wakefield NHS Bradford & Airedale
Minutes of the Meeting held on 16 October 2009 The minutes of the meeting held on 16 October 2009 were accepted as an accurate record.
Matters Arising (a)
Extranet Cathy Edwards advised that due to the need to resolve a number of technical issues, the use of the SCG Extranet would now be delayed until January 2010. PCTs would be advised once the Extranet was available.
Renal Mike Potts reported on the difficulties being faced in West Yorkshire in taking forward the work to reprovide/relocate renal satellite dialysis units. Leeds Teaching Hospitals had now advised that the replacement units in Huddersfield and Wakefield could not be accommodated in the Trust’s capital programme. Philomena Corrigan also advised of the discussions taking place in Leeds around services at the Leeds General Infirmary site. The Kidney Patients Association representatives were concerned about the progress being made and the lack of clarity around decision making. It was agreed that an urgent meeting would be convened, involving representatives from the West Yorkshire PCTs, Ivan Ellul, Chair of the Yorkshire and Humber Renal Network, and the Specialised Commissioning Team, in order to agree a way forward for the dialysis services in West Yorkshire.
Ros Roughton requested that the SHA be kept informed of developments. (c)
Gender Dysphoria Rob Webster advised that there had been some concern expressed locally regarding a perceived reduction in patient choice for gender services. It was confirmed that there was currently choice of two services within Yorkshire & the Humber The principle would be to extend this choice to other providers, once they had been through an appropriate quality assurance process, to demonstrate they met the Yorkshire and Humber policy and service specification.
SCG Infrastructure and Processes (a)
World Class Commissioning Cathy Edwards reported that work was in progress to set up the PCT “confirm and challenge” meeting in December or January. However in the meantime there was a need to ensure the SCG work was feeding appropriately into the submission of the PCTs’ evidence. It was agreed that the initial self-assessment undertaken by the
Specialised Commissioning Team should be shared with PCTs. (b)
Commissioning Strategy Cathy reported that a second draft of the SCG strategy had been circulated to PCTs a couple of weeks previously, which should assist PCTs in refreshing their commissioning strategies. The strategy had been revised, taking into account the new national guidance and previous comments from PCTs. There had also been a significant reorganisation of the document, focussing on the key messages, with detail provided in a number of appendices. The strategy now included a section on productivity and further work had been undertaken on the financial scenarios. The strategy also now described two proposed commissioning categories. The first was where SCG was responsible for the full commissioning cycle, from needs assessment through contracting and performance management. The second was where the SCG could add value without contracting, such as developing common commissioning policies, service specifications, eligibility criteria and strategy. In order to effectively focus the resources of the Specialised Commissioning Team (SCT), each service would need to be systematically reviewed to consider which category it fell into. For services in the first category, there would be an intention to risk share costs. Ailsa Claire emphasised the importance of PCTs considering the strategy and understanding what this would mean for their local systems, as well as sub-regional arrangements. There was a need to recognise that a number of specialties could be dealt with at a sub-regional, rather than local or regional level. Jan Sobieraj commented that this clarification was extremely helpful, but further granularity of the functions that the SCT would carry out would be useful. This could form part of an operational plan to deliver the strategy. Rob Webster advised that a taxonomy for this had been used in the North West, which may be useful. He emphasized the importance of looking at the system as a whole. It was agreed that a model would be populated for the next Chief Executives meeting, setting out which parts of the commissioning cycle should take place where for each service.
Cathy Edwards/ Laura Sherburn
David Cockayne highlighted the importance of considering the North Yorkshire and York position, as the PCT sits across two subregional arrangements. Cathy advised that adopting the strategy could result in some significant shifts of commissioning responsibility, such as neonatal intensive care and cardiac care. The approach outlined relied heavily on the whole system being aligned to deliver this agenda, particularly the sub-regional fora and networks. Cathy went on to describe the prioritisation criteria used within the
strategy to establish the goals and objectives. This was based on health needs assessment, known national priorities and the Quality Innovation Productivity and Performance (QIPP) agenda. Jan Sobieraj proposed that a grid be included within the strategy that set out the practical QIPP actions to be taken and the anticipated benefit of these, in order to enable the productivity programme activities to be prioritised. There was a discussion regarding the weightings used to prioritise different services. David Cockayne agreed to share the tool used in North Yorkshire and York.
Philomena Corrigan highlighted the importance of considering the impact on providers of any SCG wide productivity initiatives, as well as considering the impact on SCG of any local initiatives underway. Rob Webster suggested that consideration be given to how the designation process could be used to improve value for money. Ros Roughton advised that the Strategic Commissioning Board would be an appropriate forum to have wider discussions regarding the provider landscape and the cumulative effect of local and SCG productivity initiatives. It was agreed that the SHA would gather information on current proposals and plans, to enable that discussion to take place. Mike Potts suggested that discussion could also take place within sub-regional fora, which could then feed into SCG.
Cathy reminded PCTs of the commissioning strategy consultation process and the specific questions they had been asked. Responses would need to be sent to Laura Sherburn by 30 November.
It was agreed that the strategy should become an appendix of the PCT strategies. Rob Webster highlighted the need to consider workforce within the document. (c)
5 Year Financial Plan Frances Carey presented the baseline for five-year financial plans, as agreed at the previous meeting. The detailed figures had been circulated via the Finance Network Group. Signed, agreed contract baselines had been used, with the exception of Leeds, which was now very close to being agreed. Growth of 1.2% had been assumed for 2010/11, with growth of minus 1% in subsequent years. This reflected the worst case scenario planning figures. The next stage would be to add in horizon scanning information and planned policy changes, before beginning to factor in any productivity savings. Andy Buck commented that it was difficult to get a feel for the scale of the challenge and the actions in place to control spend and
queried how this intelligence would be gathered. David Cockayne advised that PCT financial plans would soon be submitted and there would be an assumption around SCG spend within those plans. Caroline Briggs confirmed that there was an acknowledgement at the Finance Network Group that a consistent position would need to be agreed. It was agreed that Steve Hackett would develop a process with associated timeline, which set out how figures would be discussed with PCTs to ensure consistency, in time for a further discussion at SCG in December.
Ailsa suggested that PCTs also needed to have internal discussion regarding their philosophy in approaching QIPP, such as their position on implementing all NICE guidance.
It was agreed that the December SCG meeting should focus on the commissioning strategy and the underlying financial plan (d)
Communications Strategy Laura Sherburn presented the draft communications strategy, which was currently out for consultation with Patient and Public Involvement (PPI) leads. The strategy incorporated the original Patient and Public Engagement (PPE) strategy, but also included an element around communications. Laura emphasized that the reference within the strategy to a central PPI team, related to existing staff and was not a proposal for additional resource. Caroline Briggs and David Cockayne requested greater clarity about the interface between SCG and PCT communications. It was agreed that this needed to be included within the strategy.
Market Assessment Cathy set out the background to the development of the draft criteria for market assessment. A number of providers were requesting to be designated as new providers of services and there was currently no clear process for how the SCG decided on whether to make a change to the market. The criteria were grouped into three clusters: primary criteria, which assessed whether a change to the market was needed; secondary criteria, which considered how the change could be made and the market status of existing providers; and tertiary criteria, which considered the potential impact of any change on existing providers. Cathy explained that further work was needed to set out the process by which this assessment would be undertaken and the appeals process, but initial views on the criteria would be helpful.
Rob Webster commented that the criteria were helpful. He identified that further work was required on clinical leadership and developing consensus on the need for change. NHS Calderdale had a similar
process that they could share.
Ros Roughton recommended involving Ian Holmes, who would be able to help with making the assessment process robust and able to withstand challenge. A number of PCTs had these criteria in place and it would be helpful to use consistent language. Andy Buck emphasized the need to set the criteria in the context of the discussion regarding Quality Innovation Productivity and Performance. The potential for increased activity as a result of increased supply needed to be considered. He suggested the need to construct an approach which identified exits from the market, as well as entrants. Kevin Smith emphasized the need to cross reference the criteria with the strategy, to ensure the values were consistent. Ros Roughton also highlighted the need to be clear about the geographical or population boundary of any market. It was agreed that a full policy document would be developed over the next 4 months. 5
Commissioning Policy Specific (a)
Fertility Services Pia Clinton-Tarestad presented the revised fertility policy, which had been updated following discussion at the previous meeting. It was recognised that there were two distinct parts to the policy: the eligibility criteria and the number of funded cycles. Following the last meeting, a number of comments had been received from PCTs and the policy had been considered by the Clinical Standards subgroup on the eligibility criteria. As a result a number of further amendments to the policy were proposed and it was recommended that legal advice be obtained regarding the rights of single women and the length of relationship within the policy. There was a discussion regarding the inclusion of smoking as an eligibility criteria. It was agreed that smoking should not be included as a specific eligibility criteria, but there should be a clear requirement within provider service specifications to deliver smoking cessation prior to instigating fertility treatment. Mike Potts highlighted the need to provide clarity within the policy regarding the funding arrangements for donor eggs, particularly where NHS patients wished to donate eggs, or where patients had identified their own donor. The proposed amendments and recommendations were approved by all PCTs.
Pia set out the advice that had been received from Diane Hallatt regarding the need to consult with patients on the changes to the
criteria in the policy. Diane had advised that most, possibly all, PCT members would need to engage individually in a suitable and effective involvement process, including consultation, proportionate to the issue. It was agreed that a common script should be developed for PCTs to use or adapt for their local areas, to ensure consistency of message.
Ros Roughton advised that there should be a discussion with the SHA regarding the service change assurance process before any consultation plans were finalised.
Cathy Edwards Pia ClintonTarestad
There was a discussion regarding the number of cycles to be funded. Almost all PCTs expressed a strong desire to move to a common position across the region. It was agreed that the most likely common position was one full cycle. There was also a discussion regarding the price for fertility treatments, as there was an apparent significant difference between providers. It was agreed that there should be a move to standardise prices and any changes to prices should be implemented by the 1st April 2010. Jan Sobieraj requested that a common briefing be prepared to accompany the policy to support discussions with PCT Boards. In conclusion it was agreed to:-
discuss the proposed way forward with the SHA
Produce a draft paper for PCT Boards setting out clearly the context and rationale for the change
Quantify the financial implication
Pia ClintonTarestad Pia ClintonTarestad / Finance Leads
Topotecan / Cervical Cancer The proposed policy for the use of topotecan in the treatment of cervical cancer, in line with the NICE guidance was approved.
Integrated Performance Report Steve Hackett presented the month 5 performance report. The year to date position showed an overspend of just over £5million, which related to the same areas of overspend as described in previous months. Both the Sheffield Teaching and Hull positions were currently being challenged via the lead commissioner. Payment of £250,269 was being withheld by the SCG against the STH contract.
The forecast year end overspend was £11.5m which was marginally lower than last months forecast. The performance to date, and actions being taken to resolve
overspending areas, were noted. 7
Cancer Services (a) Brain/CNS Cathy Edwards presented the paper on implementation of the Brain/CNS Improving Outcomes Guidance (IOG), which was a follow-up to the paper presented in May 2009. At that time, there had been agreement in principle to the plan to implement the IOG, but concern regarding the level of investment requested. The benefits realisation was described in the paper. Cathy highlighted the importance getting the basic multidisciplinary team infrastructure in place in order to track current patients and to provide networks with the information needed to put in place service improvement plans. The SCG were therefore asked to approve the first year’s funding. Caroline Briggs expressed concern that the figures within the paper remained unchanged from those presented in the previous report.
It was agreed that the first years funding would be approved, subject to further local scrutiny and negotiation of the finances by subregional fora and further comparative work across the networks. This funding was also approved subject to service improvement action plans relating to possible investment requirements in the second year. This work should focus on developing timed pathways, reducing avoidable admissions and reducing length of stay.
Cathy Edwards/ Cancer Networks
It was also agreed that the networks should consider where existing resources are in place to deliver some of the requirements, such as psychology.
Children’s Services (a)
Children’s Board Update Laura Sherburn presented an update on how the current arrangements for commissioning specialised services and collaborative commissioning arrangements had been strengthened. The key gap in governance and coverage related to the paediatric critical care services in the NORCOM area. The proposed revised arrangements assumed that the SCG Board would dedicate part of the agenda to children’s services 3 to 4 times a year. The South Yorkshire and Northern Lincolnshire PCTs agreed to provide the additional funding for the new paediatric critical care arrangements. However there was a need to clarify the impact for the Northern Lincolnshire PCTs. There would also be a need to secure the agreement of Derbyshire County and Bassetlaw PCTs. Ailsa Claire Laura highlighted the need to identify a Chair for the new Yorkshire and Humber wide Paediatric Critical Care Network. It was agreed that Ailsa would approach individuals outside of the meeting.
Paediatric Critical Care Transport Service Update Cathy Edwards reported that phase I covering paediatric intensive care, would start on the 1st December, with a central call system for the whole region and a partial paediatric retrieval service.
CAMHS Tier 4 – Age Appropriate Environments Laura Sherburn requested approval for the proposed approach to commissioning CAMHs Tier 4 services, provided in an age appropriate environment, with effect from 1st April 2010. Requests for information had gone out to adult providers but responses had not yet been received. Ailsa reported that the mental health peer review may also find relevant information on age appropriate services and it was suggested that Laura discuss the matter with the Collaborative to avoid unnecessary duplication.
National Reviews – Cardiac Surgery / Neurosurgery The briefing note on the two national reviews was received. It was noted that concerns regarding the national reviews had already been raised by providers with the SHA and the Leeds Overview and Scrutiny panel and PCTs needed to be aware of some of the issues. Ros highlighted that there was some concern that the standards did not set out what their potential cost implications would be. Teresa Moss acknowledged the need to be clear about where the standards were taking us, but this work had yet to be done. Mike Potts emphasized the importance of setting out the evidence base for all standards and ensuring a compelling case for change.
9 CARDIAC SERVICES (a)
Proposed PCI Centres in West Yorkshire Discussion of this item was deferred to the next meeting.
10 VASCULAR SERVICES REVIEW – SERVICES STANDARDS Pia Clinton-Tarestad set out the proposed standards for vascular centres wishing to undertake all vascular interventions. These would form the framework for the option appraisal being developed. The standards were approved as a building block for the next stage of work, accepting that there may need to be a review, once the options had been developed, depending on the service and financial implications.
11 BURN CARE UPDATE Mike Potts advised that there was currently some confusion regarding the future of the national burn care review. The North West SHA had not been able to sign off the service change assurance process and had expressed concern about the case for change and the service and financial implications. Given the SHA’s position the Secretary of State had written to confirm that the configuration proposals in the Northern Burn Care Network were no longer on the agenda. A national meeting was being held next week at which clarity would be sought on the implications of this position. In the meantime, the Specialised Commissioning Team (SCT) were continuing to work with local providers to ensure services were safe. The arrangement with Manchester Children’s Hospital would be continuing. 12 SPINAL INJURIES BRIEFING The briefing on the commissioning of spinal injuries services was noted. 13 COCHLEAR IMPLANTS – NOTTINGHAM SERVICE The proposal from Nottingham to offer a second implant to all patients with a unilateral implant who would be eligible under the NICE guidance for a bilateral implant was considered. However it was agreed that the SCG would work to specific clinical criteria for second implants to ensure equity across the region.
Pia ClintonTarestad/ Kim Cox
14 UNCONFIRMED MINUTES OF THE CLINICAL STANDARDS SUB GROUP MEETING HELD ON 6 NOVEMBER 2009 The unconfirmed minutes of the Clinical Standards Sub Group held on 6 November were noted. 15 ANY OTHER BUSINESS There were no items of any other business. 16 DATE OF NEXT MEETING 1.15pm to 4.30pm on Friday, 18 December 2009 at the Thorpe Park Hotel, Leeds