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Commissioning College Wednesday 17 March 2010, 1.00 pm – 5.00 pm Northorpe Hall, Mirfield

Present: Anil Aggarwal David Anderson Jim Barwick Gill Bell Chris Beith Clare Birkby Rachel Carter Kelly Chadwick Frances Cole Andrea Daley Sheila Dilks Sheila Dawson Jan Dod Peter Flynn Nadeem Ghafoor Jan Giles Dawn Gordon Anuj Handa Adrienne Harmon Paul Howatson Nicky Hoyle Mark Jenkins Dr Bert Jindal Dr David Kelly Mary Kiely Rachael Kilburn Dr Farhad Kohi Angela Ladocha Neill McDonald Carol McKenna Bryan Machin Dr Ajit Mehrotra Sarah Muckle Dr Y Patel Susan Perkins Mike Potts Julie Schofield

PEC Member, Chair - 3 Valleys Consortia PEC Chair Assistant Director, Commissioning & Strategic Development PBC Manager Clinical Lead, CHD PBC Performance Analyst Deputy Director of Commissioning & Strategic Development Secretary, Commissioning & Strategic Development Clinical Lead, MSK/Pain / Rheumatology Performance Information Analyst Executive Director of Patient Care & Professions On behalf of Dr Hamid, Stand Alone Practice PBC Manager Director of Performance & Information GP – Stand Alone Practice Assistant Director of Commissioning (PBC) PEC Member, District Nurse Team Leader Clinical Lead, Respiratory Exec Team Member for 3 Valleys Programme Manager, Older People & Intermediate Care Public Health Consultant Head of Primary Care, Contracting Chairman, Huddersfield Commissioning Consortia Chairman, North Kirklees Commissioning Consortia Consultant in Palliative Care, CHFT Practice Manager, Stand Alone Practice (Fox) Vice Chair, North Kirklees Commissioning Consortia School Nurse Team Leader, PEC Member Assistant Director Medicines Management & Prescribing Executive Director of Commissioning & Strategic D’ment Executive Director of Finance, PEC member PEC Member Consultant in Public Health Dewsbury Commissioning Consortia Vice Chair, Huddersfield Commissioning Consortia Chief Executive Executive Team Member, Three Valleys Consortia 1 of 10

Sue Richardson Carol Singleton Christine Springthorpe Trisha Walker Rob Willis Dr David Wood In attendance Jayne Conway Karen Gallagher

Strategic Development Manager Clinical Audit and Effectiveness Co-ordinator Kirkwood Hospice 3 Valleys Consortia Finance Manager, PBC Vice PEC Chair, General Dental Practitioner

Personal Assistant Facilitator


Apologies: Apologies were received from Pat Andrewartha, Carrie Bailey, Sarah Bow, Juliet Chambers, Tony Cooke, Vicky Dutchburn, Gill Hawksworth, Hayley Haycock, Jackie Holdich, Sally McIvor, Karen Poole, Naomi Raey, Helen Severns, Tracy Small, Sue Smith, Vanessa Stirum, Dr Thimmegowda, Mercy Vergis, James Williams and Karen Worrall.


Accuracy of the Minutes of the meeting held 10 February 2010 The minutes of the meeting held 10 February 2010 were AGREED to be a true and accurate record.


Matters Arising 12.1

Jan Giles tabled the Incentive Scheme and asked for any final comments to be forwarded to her by Tuesday 23 March 2010.


Finance Presentation

Bryan Machin gave a Finance presentation following discussions on the incentive scheme. Bryan outlined the scope of the PBC budgets. Neill McDonald will be using similar methodologies but taking out highcost drugs which will be put into a separate pot and apportioned to all practices. When using the new toolkit regarding thresholds, the impact of setting the threshold at consortia level rather than practice level was looked at and found there was not a significant difference. Therefore the PCT will continue to set thresholds at practice level. Where a practice is 2.5% outside the threshold, the PCT will move them up to the threshold. Bryan reported that an extended financial incentive scheme has been discussed. This will need to be recommended to the Trust Board if it was decided to take this forward. It was highlighted that clear definitions were needed of “like for like� expenditure eg the price of emergency admissions is 30% of what it is this year, therefore practices would not be rewarded for this. It 2 of 10

would need to be a saving against the expenditure practices incurred last year, not against the budget ie it is comparing expenditure to expenditure not expenditure to budget. 2.5% would be the maximum saving that practices would be rewarded for. It was noted that if a practice had achieved and exceeded the 2.5% target, this would assist the consortia to assist those practices that wouldn’t achieve the target. Bryan reported that Freed Up Resources earned to date ie 31.3.10 cannot be spent until the PCT has the resource to do so. The freed-up resources would become available only when the PCT is back in balance. It was confirmed that the freed-up resources had not been taken away. It was also confirmed that any funding that has been committed because of a business plan that has been approved and is underway, that this would be supported. CC/10/13

Declarations of Interest No declarations of interest were received.


Chief Executive Report Dr Bert Jindal raised some issues from the Chief Executive report:1) Dr Jindal was aware of some issues regarding YAS. 2) Care Quality Commission – What steps are the PCT going to take to undertake the Care Quality Standards? It was clear that the PCT help and support provider and will assure the process through Care Quality. Sue Smith will support practices getting through the process. Sheila Dilks will be looking for support on delivering Care Quality. 3) TCS – this item would be discussed in more detail later in the meeting.


Chronic Pain Presentation Dr Frances Cole gave a presentation on Chronic Pain, particularly sharing the development of the pathway for care, focussing on long term pain to ultimately achieve less distress for people. Services for pain need to be re-designed as it is one of the national policy drivers as highlighted in the CMO report, it is part of Kirklees Joint Strategic Needs Assessment, to address health inequalities, improve patient experience, to meet World Class Commissioning objectives and to commission a higher quality and more cost effective service. £5m is currently being spent on drugs for pain. The Pain HIT has been looking at reviewing what is currently happening, looking at what patients want and have developed a pathway. The pathway shows that a person centred assessment needs to be done when a patient has long term pain (step 1). Step 3 of the pathway will be linked into step 2 3 of 10

seamlessly. Step 2 will be the main link into step 3. (See presentation slides for more detail) The service specification will help commission services for people with chronic / long term pain that will improve their health function and quality of life, are evidence based and patient centred and are sustainable and provide value for money. Service delivery for pain will involve a person centred assessment for all pain conditions to identify the impact of pain on health function, employment and their significant others. The provision of ICATS will give an integrated seamless service, ensuring fewer people are referred to step 3. Self care management and medication review will be integrated within each step. Expected patient outcomes include reduced levels of long term pain and emotional distress, improved patient confidence to self manage their pain condition, improved pain symptom control, health function and emotional well being, improved seamless continuity of care, receiving the most appropriate level of care, at the most accessible location and increased access for patients from a range of backgrounds and literacy levels. The Pain HIT aims to commission a range of evidence based long term pain services, reflecting a patient centred care pathway, aligned with the strategic priorities informed by the JSNA, NHS Kirklees 5 year strategic plan and World Class Commissioning. Members were asked in groups, to identify any strengths, opportunities and weaknesses presented by the proposed pain pathway. All notes would be collated from each group and fed back to the Pain HIT. CC/10/16

Performance Report Peter Flynn reported on the aspects of commissioning performance from a commissioning perspective and how they impact. The PCT needs to focus on areas where improvements are needed for next year. The following areas were highlighted: 

Ambulance Category A response – the PCT will continue to focus on this however the target will not be achieved. A&E as at 28 February the PCT’s year to date performance was below the required 98% (actual – 97.69%), however the figure has risen within the last few weeks. National Priorities – 18 weeks

Number of patients admitted in aggregate. Individual performance against specialities – the threshold goes to 0 by the end of the year. The PCT will not achieve this due to neurosurgery where performance is poor. This could be significant as it might negate all the 18 week targets. 4 of 10

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Primary Care Patient Survey has happened, but are awaiting outcomes. Access to primary care dental services is good – need to look at in terms of future expenditure. 2 week wait targets

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There is a mixture of targets within the 2 week wait, 31 and 62 day targets. New targets brought in sub-categories of cancer treatment eg proportion of patients with breast symptoms etc. Shadow indicator – year to date is 64.6% - the run rak is high and the PCT expect to achieve the target. . The PCT have too many breaches of cancer for 2 month target – most at Mid Yorkshire. Previously we have fined Mid Yorkshire. Chlamydia screening – is improving but still short of the target. Still work to do within Vicky Dutchburn and Helen Severns Team to move CAHMS forward. The PCT continues to do well with smoking quitters. Practices had a letter from Judith Hooper regarding coverage of breast feeding as part of 6-8 weeks. Concerns regarding systems and processes had been raised therefore we need a response to the letter sent to GP practices. Out of 73 practices that have been sent the letter, the PCT have had 52 responses, Peter therefore encouraged GPs to respond to the letter and encourage their colleagues to do so. Block of immunisation targets – doing well clinically but the PCT is falling short of the necessary levels. Children are being invited by practices but need to pick up with the immunisation team to say we cannot keep writing to patients. We need to understand the issues around this in more detail. Stroke – not done well in the past but starting to do well and significantly better than before. Teenage conception rates – not clear how significant social factors play. The figures displayed are last year’s. Things should start to improve in this area.

Other Performance indicators    

MRSA - CHFT and MYHT are achieving targets. Choose & Book - the PCT is planning to discuss with CHFT & MYHT the possibility of only accepting electronic referrals – need future discussions. Number of emergency bed days – improved figure although still red has significantly improved. Chlamydia screening – the gap is closing.

Peter Flynn tabled indicators by practice for everyone to take a copy.

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Cancer Presentation Dr Bert Jindal, Cancer Lead for the PCT and Nicky Hoyle, Public Health Consultant presented an update on cancer and cancer screening. The presentation aimed to raise awareness of the work ongoing on improving cancer care. There is an intention to produce a Kirklees Cancer Plan. The quarterly performance report on page 75 was highlighted. Part of the Yorkshire Cancer Network comprises from representatives from NHS Leeds, NHS Calderdale, NHS Bradford, North Yorkshire, Wakefield and Kirklees and covers the acute Trusts in Leeds, Radford, York, Harrogate, Wakefield, CHFT and Mid Yorkshire. The YCN feeds back to the Strategic Commissioning Group which looks at cost effectiveness. Lean process mapping has been used to look at lung cancer. There are cancer local implementation groups at Calderdale, led by Janet Cawtheray and Mid Yorkshire, led by Loraine Turner. For governance and reporting there are network site specific groups and network cross cutting groups. Page 81 of the papers summarises the position for YCN at the moment. The Calman Tyne report 1995 recommended that cancer services should be nationalised and working to standardised guidelines. Services have been centralised ie head and neck and integration between local and specialist clinicians has been made. Developments have been made in improving urology services, at Mid Yorkshire they are planning a specialised urology service. Leeds has a cancer centre and at Bradford and Mid Yorkshire there is basic as well as some specialised services. The paper by Mark Baker (page 49) refers to standards to ensure all providers could meet the standards. The pathways listed have been implemented and are underway. There are difficulties in dermatology as this has to be provided by a credited clinician. We have GPSI’s but cannot obtain accreditation. Sheila Dilks pointed out that the PCT has a clear accreditation process for a GPSI and needs to go through this for which there is now an action plan in place. Regarding the lung cancer pathway it was fed back from the YCN to Chief Executives that not enough progress was being made, it was therefore asked what are we doing to make changes for patients and we needed to start implementing these changes. It was reported that long term conditions have started to implement across the board and that these should be implemented through the providers and need to be integrated through community. Cancer guidelines are available on the YCN website which everyone can look up and comply with. Recommendations based on the guidelines can be made and inform the Strategic Group about any implications there might be in terms of cost. 6 of 10

Pathways are available to look at on the YCN website eg lung cancer pathway (page 111). We need to ensure there are enough diagnostics to make an early diagnosis. The quarterly Performance Report shows areas listed that are looked at. Prevention in primary and secondary care is being looked at, for example alcohol, obesity and prostate are possible areas that will be looked at in the future. Nicky Hoyle presented the 3 cancer screening programmes. Bowel cancer will be commissioned within the PCT. Wakefield, Calderdale and Kirklees are all in the same programme led by CHFT. The PCT will be directly commissioning CHFT, in association with MYHT. There has already been an uptake of 53%, with the target at 60%. An age extension of currently 60-70 will be implemented by April 2011 to 75. Primary care commissioners were asked to encourage patients to take this up. Breast Screening is provided by Bradford and Pennine Breast Screening and has been put forward for an award. This has good coverage, with 2 targets of 70% for which we overachieve and 80% which we have not reached. Cervical Screening – the main provision is through primary care. The PCT are above the 80% but are underperforming in younger women, which is a national problem. Individual practices are under achieving, and the PCT will be sending information to practices on this. Incidents – most are in the Kirklees patch around code sharing and sample takers. GPs will be receiving letters regarding sample takers. The 14 day turnaround (from test to results) has to be achieved by December 2011. Last year the PCT achieved 30%, but now achieves 94%, with the target being 100%. It was therefore asked that all GPs dispatch samples to the laboratory as soon as possible. Practices have been written to regarding the 14 day turnaround and requested by secondary care to make sure that patients were available to attend within 2 weeks (ie not on holiday etc), since the letter was sent out we are now meeting the target. Action is being taken to ensure we comply with the cancer registration data set. Outcomes - across the country, age standardised mortality ratio has come down. We perform well in colorectol and lung cancer and less well with breast cancer mortality and prostate mortality. Dr Jindal reported that the YCN provides guidance to the PCT however highlighted the need for a HIT lead for cancer to support the work of the PCT.

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Mike Potts suggested we needed to action the pathways and ensure we contract with providers to ensure the pathways are followed but recognised changes in behaviours were needed. CC/10/18

End of Life Care Dr Mary Kiely, Lead Clinician for Palliative Care, Christine Springthorpe, Director of Clinical Services, Joint Chief Executive Kirkwood Hospice and Dawn Gordon, Clinical Lead for End of Life Care presented an update on End of Life Care. The HIT have worked locally and regionally to share best practice around DNR CPS and referral forms to be made easily identified. The Team will look in more detail at poverty and cost effectiveness to meet the objectives. There is a need to ensure EOL care is linked with long term care pathways. The provision of EOL care should be a benchmark in all areas and this has been included in CQUINS. It was pointed out that death happens to us all therefore the quality of care is so important. In a recent audit of 100 deaths on the Care of the Dying pathway in CHfT, 30% were admitted from care homes. 5 patients out of 100 started on care of dying pathway on the day of admission (the majority started on the pathway within a week of admission). All 5 patients came from care homes. Support frameworks are in place eg Gold Standards. In addition to this there are EOL Care Facilitators that work in community. The 3 main strategic goals for EOL care are: To ensure all patients who are at the end of their lives have the opportunity to state their preference as to where they die.  To ensure that those preferences are always respected and facilitated, wherever possible.  To ensure that all services which people receive at the end of their lives are of high quality. Members were asked to consider the recommendation to roll out advance care planning for all care homes. A pilot was done on the elderly care ward, however patients couldn’t complete this due to lack of capacity. There is also the lack of good relationships in hospital, however GPs know their patients therefore this needs to happen out in the community. Care Homes and Private Nursing Homes were discussed and GPs felt that staff did not adhere to what was written in patients notes, therefore people were being admitted to hospital. It was felt that if a planned process and system was in place that involved family members, then the GP notes would likely to be followed more rather than waiting until a crisis and the patient being admitted to hospital. It was highlighted that there will be very specific standards around EOL care that were very strictly applied.

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The Outcomes of the EOL strategy would: Reduce inappropriate admissions at end of life  Reduce drug costs on incidental drugs  Reduce unnecessary hospital appointments  Reduce complaints and increased satisfaction / experience for patients, carers and staff. The following questions were given to members to discuss and feedback on:Delivering Advance Care Planning for all Patient newly admitted to Care Homes -

What benefits does the commissioning college see this achieving for the people of Kirklees? What obstacles / challenges can you envisage in making ACP part of routine practice? How can these obstacles be overcome? How can specialist palliative care services work with NHS Kirklees to deliver an improved service?

The following comments were fed back from members:-


To have an enhanced service for EOL care. Education and Training – didn’t know that syringe care training was done in nursing homes, we need to take training to the homes and embed in NVQ qualifications. To make sure homes have access to all teams available and to all the support available in the community. Common set of notes in the Nursing Home for everyone to use to enable effective communication for all agencies. Look at how we contract. Core competencies. Community planning has been put into CQUINS though the HIT. Training is needed around confidence. New health dialogue tool to identify vulnerable patients and to target advance community planning.



Members to forward any further feedback and comments to Jayne Conway via email.

Transforming Community Services Sheila Dilks gave a verbal update around Transforming Community Services (TCS). In 2006 Nigel Crisp produced “Shifting the Balance of Power” which ultimately led to less PCTs, less SHAs and community services being managed in different ways. PCTs must separate community services away from the function of the PCT, and therefore we need to decide a different model.

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Members were asked to think about the function as well as which model to choose. Options need to be considered at the Commissioning College and Trust Board. A small working group would then be set up. Jim Barwick suggested that TCS would be a standing item on future commissioning college agenda. It was highlighted that there was no blue print on how to take this forward, however we must have clear principals, shared values and goals, strong clinical leadership, services must be properly integrated, financial risk and reward must be aligned, clear governance structures, clear co-operation and clearly defined roles and responsibilities. Torbay have integrated health and care around localities and GPs, pooled budgets, agreed frameworks, they know their population and the most vulnerable, and have advance care planning in place. The acute trusts and Local Authority need to work out the sensible way forward. A decision is needed by the end of the month for which model the PCT would like to follow eg integrated care organisation. Good progress then needs to be made to deliver this by 1.4.11. There was general AGREEMENT that we want to deliver an integrated service. CC/10/20

Any Other Business No further business was discussed.


Date and Time of Next Meeting The next meeting of the Commissioning College meeting will be held on Wednesday 14 April 2010 at 1.00 pm at Northorpe Hall, Mirfield. Lunch will be available at 12.30 pm.

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