Agenda and minutes

(1)  At the start of the meeting, the Chair asked Members and attendees to observe a one-minute silence to recognise the 75^th anniversary of D-Day. A Member of the Committee thanked the Chair and drew attention to the key role of Kent-born Lieutenant-General Sir Frederick Morgan in D-Day.

(2)  The Committee observed a one-minute silence to recognise the 75^th anniversary of D-Day.

There were no declarations of interest.

Simon Perks (Director of System Transformation, Kent and Medway STP) and Dr Bob Bowes (Chair, NHS West Kent Clinical Commissioning Group Governing Body) were in attendance for this item.

(1)  Mr Perks explained to the Committee that much had happened since the update to HOSC in November 2018, and that the current meeting was timely to update Members on the progress as well as future arrangements around commissioning health services across Kent and Medway.

(2)  Dr Bowes explained several of the drivers behind the proposal for eight CCGs to dissolve and a new single CCG to be created:

                      i.        The current structure made it difficult to make large scale strategic decisions.

                    ii.        There was a national mandate for CCGs to reduce their management costs by 20%.

                   iii.        A single, larger, CCG would allow for a wider pool of expertise.

(3)  Giving additional context to the second point in (2), Members were informed that only 3% of the NHS budget was spent on management.

(4)  Responding to the third point in (2), a Member commented that CCG responses to planning applications were not always robust. Dr Bowes explained that this was in part due to individual CCGs not having the required expertise due to their smaller size.

(5)  NHS representatives continued to explain the broader context behind the proposal. The creation of internal markets in the 1990s had led to a lack of integration across the sector and its partners. It had created an environment where, in some cases, individual patients had to deal with many professionals as there was no single point of oversight of a patient’s care. This led to duplication and inefficiencies.

(6)  The Long Term Plan set out the push for collaboration, though this would not be without difficulties due to the cultures embedded in each organisation, along with multiple, legitimate, views of what was best for individual patients. Integration presented an opportunity for a more patient centric view.

(7)  Mr Bowes acknowledged that there were mixed views around GPs leading commissioning of services, but he considered this clinical input very important as it gave decisions clinical authenticity.

(8)  Members were concerned that high level decision making would fail to meet the needs of individual districts and people, and that the changes echoed structures from the past. Dr Bowes acknowledged that arrangements for the health service had oscillated between strategic and localised structures. He explained that the new system would see a high-level partnership (the single CCG) set the desired outcomes, as informed by the Population Needs Assessment (and Kent Integrated Dataset), and then the four Integrated Care Partnerships (ICPs) would decide how best to deliver those outcomes based on available resources and needs.

(9)  The future arrangements would see each ICP held collectively responsible for its population’s health outcomes, whereas at that time they were only responsible for delivering the activity.

(10)               Members questioned where Social Care and Public Health, services delivered by the local authority, fitted into the future arrangements. Dr Bowes said there was  ...  view the full minutes text for item 134.

Ravi Baghirathan (Director of Operations, Kent and Medway STP) and Matthew Capper (Head of Seasonal Planning and Resilience, Kent and Medway STP) were in attendance for this item.

(1)  The Chair welcomed Mr Baghirathan and Mr Capper to the meeting and invited them to give their presentation (appended to these minutes).

(2)  The salient points from the presentation were:

·         Winter 2018/19 had been milder than average with little snow and few frosts.

·         There had been a lower seasonal flu outbreak than in previous years.

·         There was a general increase in demand at A&E departments and GP practices (which Mr Capper explained was in large part due to the ageing population).

·         The local acute trust A&E data showed that Kent and Medway’s performance during winter 2018/19 was comparable to that of the South East.

·         There were areas identified as requiring improvement before next year’s winter planning, as well as areas that had worked well following on from changes made in previous years.

(3)  Mr Baghirathan explained that winter planning was being carried out in a much more systematic way, with Local A&E Delivery Boards (LAEDBs) expected to have robust plans in place. These plans, which were assessed through a two-part bipartite process, had to explain the actions taken to improve on the previous year’s performance; how the national ten high impact interventions would be delivered; the flu programme for staff and patients; as well as work on Delayed Transfers of Care.

(4)  A Member asked for assurance that the historic system pressures around weekends, and the reduced level of staffing during that period, were overcome. Mr Capper accepted that there had been discrepancies between weekend and weekday performance but added that some of this was due to legitimate issues around discharge (such as some Care Homes not accepting new patients at weekends). He assured Members that the STP were implementing new systems across all their services to ensure performance was more consistent.

(5)  When asked if the reduced incidence of flu was down to milder weather or better prevention, Dr Duggall from Public Health explained that there had been a better match between the immunisation given to vulnerable people and the actual flu strain. There was also a bigger drive for vaccinating young children, and this also helped protect their older relatives.

(6)  The bed occupancy rate had reduced from 95.5% to 95.0% between 2017-18 and 2018-19. Members questioned if there was an optimum level, and whether different categories of bed were considered. Mr Capper explained the aim was for 85% bed occupancy, as this provided a level of flexibility. He also assured Members that the occupancy of different bed types was also considered.

(7)  Members asked for clarity around acronyms that had been used in the presentation and covering report:

                      i.        SHREWD – this was not an acronym but the name of a software product that provided a real time data dashboard by using a single source of data.

                    ii.        WOLF – “Weekly Operation Look Forward” –  ...  view the full minutes text for item 135.

Ivor Duffy (Director of Assurance and Delivery, NHS England – South East) was in attendance for this item.

(1)  The Chair welcomed Mr Duffy to the meeting and asked if he wished to highlight any issues to the Committee before taking questions.

(2)  Mr Duffy explained that it had been a challenging year, but significant work had been undertaken in order to improve the level of savings, though the CCG did not manage to reduce the deficit to the expected level by the end of the year.

(3)  He explained how the CCGs were moving forwards in line with the Long Term Plan which saw the CCGs working differently within East Kent and with the Regulator. The CCG had signed an aligned incentive contract with East Kent hospitals which focused on cost rather than income and expenditure – this was a forerunner to an Integrated Care Partnership (ICP). These contracts had worked successfully elsewhere in the country, including in West Kent.

(4)  Mr Duffy explained how the change in relationship between NHS England and NHS Improvement had helped, by leading to a single conversation instead of two.

(5)  Members questioned if the financial deficit would be written off if the 8 CCGs dissolved to become 1, and if not, would it ever be possible to escape the deficit position. Mr Duffy explained the deficit would not be written off but assured Members that the East Kent system was in the process of developing a long-term financial plan which aimed to restore financial balance by 2021/22. The aligned incentive contract with East Kent hospital trusts had already led to improved outcomes and efficiencies.

(6)  Referring to page 21 of the agenda pack, Members questioned the use of consultants in a number of reviews. Mr Duffy explained that in some cases it was necessary and right for an external party to carry out a review (such as the Governance Review by PWC). In other cases, such as the Strategic Review of the East Kent acute reconfiguration, it was incumbent for the CCG to seek expert advice that they did not hold in house. The QIPP review was nationally funded. Finally, work on the East Kent Financial Recovery Plan was being supported by NHS England/ Improvement’s Transformation Team and therefore was not using an external consultant.

(7)  The Chair thanked Mr Duffy for attending.

(8)  RESOLVED that:

a.    the report be noted;

b.    East Kent CCG provide an update on the financial position to HOSC at the appropriate time.

(1)  The Chair invited Members to comment on the written update on the procurement of dermatology services across Medway, Dartford, Gravesham and Swanley and Swale CCGs. The report confirmed that a procurement process had resulted in the North Kent Dermatology Service being awarded to DMC Healthcare as of 1^st April 2019.

(2)  Members questioned the need for, and cost of, the reorganisation and its impact on its patients. They were also unclear who DMC Healthcare were, and whether it was part of an existing NHS Trust or an independent company. Finally, they felt there was significant text on mitigation but no real resolution of the issues.

(3)  Steve Inett informed the Committee that Healthwatch Medway had received many calls from the public who were concerned about missing appointments. Healthwatch Medway had met with the CCG to feed these views back but considered the situation had not yet been resolved and deserved continued scrutiny.

(4)  RESOLVED that

a.    Medway CCG provide a written update addressing Members concerns as soon as possible. This update should include:

                                          i.    further information on DMC Healthcare;

                                        ii.    the reasons behind the need for reorganisation;

                                       iii.    the cost of the reorganisation and procurement process;

                                       iv.    the impact on patients and how these were being addressed.

b.    North Kent CCGs return to the Committee before the end of the year with an update on performance of the contract.

(1)  Members considered the written report by NHS regarding the review of the Frank Lloyd Centre in Sittingbourne.

(2)  The Chair outlined the background to the review for the benefit of the Committee:

The unit was an older person’s inpatient unit operated by Kent and Medway NHS and Social Care Partnership Trust (KMPT). It provided a bed-based service for individuals with complex dementia with behaviours that challenged and who were eligible to receive NHS Continuing Healthcare. The unit was accessed by all CCGs in Kent and Medway. A CQC review in January 2016 highlighted some concerns about the unit. A change to the approach in management of patients had resulted in a decline in patient numbers at the unit, making its future unsustainable.

(3)  Mr Inett, representing Healthwatch, informed the Committee that volunteers from their organisation had visited the unit in December 2018. They had spoken to carers who were concerned about the uncertainty surrounding the unit and how this would impact the workforce. Members agreed that it was highly disappointing this uncertainty continued after so many months.

(4)  The Committee agreed that continued scrutiny of the review was required. NHS representatives had already been scheduled to attend the following HOSC meeting on 23 July 2019.

(5)  RESOLVED that:

a.    the report be noted;

b.    the Kent and Medway CCGs attend the next meeting in order to provide a further update, which would provide additional information on (but not limited to):

                                          i.    the current standard of care for patients still accessing the service;

                                        ii.    how that standard of care was maintained;

                                       iii.    the progress made on alternative provision.

(1)  RESOLVED that the update be noted.

(1)  The Chair asked Members to consider the work programme.

(2)  Due to an imbalance between the number of items on the July and September agendas, the Chair resolved to work with Officers to ensure this imbalance was appropriate.

(3)  The published work programme showed the “Children and Young People’s Emotional Wellbeing and Mental Health Service and All Age Eating Disorder” item as being on the September 2019 agenda. Due to the unavailability of the appropriate NHS representatives on the 19 September, the Chair and Officers were looking into the possibility of holding an informal briefing in September (on a date the NHS representatives were available) followed by a substantive item at the November meeting.

(4)  In the meantime, the Chair informed Members that additional discussions around the Children and Young People’s Emotional Wellbeing and Mental Health Service would be taking place, including by CYPE Cabinet Committee around KCC’s related contract.

(5)  RESOLVED that the draft Work Programme be agreed.