Minutes of the Meeting of the Haringey Clinical Commissioning Group Clinical Cabinet

Thursday 5 June 2014 at 1.00pm Hornsey Central Neighbourhood Health Centre

Present:

Dr Sharezad Tang ST Chair of Haringey CCG, Central Collaborative

Dr Nazmul Akunjee NA GP Primary Care Lead, South East

Dr Christiana Aride CA GP Gynaecology Lead

Dr Daniel Beck DB GP West Haringey Collaborative

Dr Simon Caplan SC GP Governing Body Member, North East

Dr Peter Christian PC GP Governing Body Member, West Lead

Dr Martin Lindsey ML GP and LMC Representative

Dr Jackie Mansfield JM GP Primary Care Development Lead Central Collaborative

Dr David Masters DM GP Governing Body Member, West Collaborative

John Nunney JN LPC Vice Chair

Dr Jatin Pandya JP GP South East Collaborative

Dr Helen Pelendrides HP GP Governing Body Member, Central Lead

Dr Kate Rees KR GP, Cancer and End of Life Care Lead

Dr Elizabeth Young EY GP, Primary Care Development Lead West Collaborative

Nicola Davies ND Practice Manager West Collaborative

In attendance:

River Calveley RC Commissioning Lead, Haringey CCG

Jonathan Carmichael JC Head of Primary Care Development, Haringey CCG

Ray Hill RH Project Lead, Camden Integrated Digital Record (CIDR)

Andrew James AJ GPIT Manager NEL Commissioning Support Unit

Rachel Lissauer RL Assistant Director Clinical Commissioning

Denise Pettit DP Senior Primary Care Support Manager

Jill Shattock JS Director of Commissioning

Pauline Taylor PT Head of Medicines Management

Linda Roast LR Minutes

1. INTRODUCTION Action

1.1

Apologies for Absence

1.1.1 Apologies were received from Dr Nick Jenkins, Dr Elizabeth MacMillan, Dr John Rohan, Dr Richard Taylor and Sarah Timms.

1.2 Declarations of Interest

1.2.1 There were no declarations of interest pertaining to items on the agenda.

1.3 Minutes of the Previous Meeting

2

1.3.1 It was noted that Dr Helen Pelendrides should be added to list of those present. Section 3.2.4 of the minutes should correctly refer to “community optometrist” and section 3.2.6 should correctly refer to “Medifer”. Subject to these amendments the Committee agreed the minutes of the meeting held on 1 May 2014 as an accurate record.

1.4 Matters Arising

1.4.1 Item 1/05/14 02 – this should correctly refer to “providing” GP by-pass numbers. This work was on-going.

1.4.2 Item 1/05/14 03 – Dr Moaz Nanjuwany was not present but it was confirmed that this information had been communicated to the LOC.

2. CLINICAL DISCUSSION AND PRESENTATION

2.1 Camden Integrated Digital Record (CIDR)

2.1.2 Dr Sherry Tang welcomed Ray Hill, Project Lead for CIDR, who would present details of the development of this digital record system.

2.1.3 Ray Hill explained that CIDR was a database that allowed input from various systems and could be described as a patient’s “personal jigsaw”. It was a web based portal accessible only via N3 and in Camden was used to allow health and social care professionals to view clinical data, from multiple care providers, in one place. This web based record could be used to provide a holistic view of a patient’s history with the potential for input by acute, primary care, community, mental health and social care services. Access could be adjusted to limit the details viewed by different users.

2.1.4 Ray Hill provided an example of a patient’s demographic details and described that the system could match different name formats to ensure records were correctly linked. Consent to share data was recorded in the patient’s record and clinicians had to indicate patient consent every time a record was accessed. Information on CIDR currently included UCLH and RFH inpatient, outpatient and A&E SUS data. GP data including events, diagnosis, medications, risks and warnings. The local authority had had some concerns on sharing data and at present information for LB Camden included just a flag of “known to adult social care” but plans were in place to extend this data set. No information relating to sexual health, fertility treatment, termination of pregnancy or HIV status was visible. It was acknowledged that sharing of information required an enormous change of culture for public organisations and confidence in the system was key to success. This change and the governance considerations were much more complex to achieve than the technology. The benefits provided by CIDR were the availability of integrated health and social care data at the point of care, a secure and efficient method for sharing data which reduced time on calls, emails and faxes. ADT and pathology results from UCLH and RFH would also be available soon. Questions were invited.

3

2.1.5 Dr Kate Rees asked about requirements for patient consent and Ray Hill advised that a “drop down” box provided a prompt for obtaining consent on access. Dr Kate Rees asked about consent for originally uploading records and Ray Hill reported that there had been a mailshot to Camden residents and a programme of public engagement meetings and events. He confirmed that an individual “opt out” basis had been applied. Discussions with mental health service providers had highlighted that patients would not necessarily be willing to share their details and these could be excluded. The key part of the system was the GP record but again patients could opt out. He confirmed that there had to be inclusion of the patient’s name in order to identify opt out but in these instances no clinical record or confidential data was held. Names and addresses were publicly available via electoral rolls and so could not be deemed as confidential data. Dr Elizabeth Young expressed some concern about an opt out system, in that patients could say they were unaware/had not received any notification. Dr Martin Lindsey asked whether communication had included translation for non-English speakers and also access for the blind and visually impaired. Ray Hill confirmed that LB Camden had particular expertise and experience of public communication and had provided assistance in this respect. There had also been involvement of third sector agencies, such as Age UK. He noted that public response had inevitably included some dissenters. However, the majority of people had presumed that information was already shared within the NHS. Ray Hill emphasised that this was not a system accessible on the internet. It was only available on N3 which was an NHS secure network and had been subject to rigorous testing by external security experts.

2.1.6 Dr Helen Pelendrides asked about the timeframes for GPs to be included. Ray Hill advised that there would probably be a four/five month period of discussion, demonstration and working in shadow form. He explained pilots of the system with a GP led MDT and also in a practice working with the homeless. Three more practices were now going live and the aim was for all to be included by the end of the calendar year. Pilots were also underway in teams working on acute admissions prevention.

2.1.7 Jonathan Carmichael asked about timescale and the potential costs for full scale implementation in Haringey. Ray Hill suggested that the first phase of approximately six months would largely exclude technology issues and would be focussed on governance issues, data sharing agreements and contracts. The next phase would be work with stakeholders to establish willingness and ability to deliver data sharing. This could be time consuming and he cautioned that commitment at the top of an organisation might not always be so evident at all levels. He advised that a full time lead on information governance had been required in Camden, particularly as timing had coincided with changes associated with the Care Act. The technology set up probably required one/two months and similar for training and support. In total he estimated twelve to eighteen months. Costs would be dependent on population size and number of practices but in the region of £800k. Rachel Lissauer asked about phasing and whether it was necessary to proceed on a population wide basis. Ray Hill agreed this could be considered but restricting data from acute services could be quite difficult.

4

2.1.8 In response to Denise Pettit, Ray Hill agreed that the system could be valuable for research but again with IG considerations. Dr Kate Rees queried whether there could be an issue of drug companies trying to access information in relation to clinical trials. Ray Hill advised that standard ethical requirements applied and this had been discussed with UCLP. The security of the system would not allow unauthorised access and regular access audits also provided further safeguards. John Nunney asked about the inclusion of pharmacies. Ray Hill advised that services as part of an MDT were included. There had also been approaches from pharmacies and this would be a future stage of work.

2.1.9 Access time for data was discussed and Ray Hill advised that there was real time access to primary care data but currently weekly submissions for community, mental health and acute data. Pathology results, such as blood tests, were due to be available (in real time) by the end of July.

2.1.10 Dr Sherry Tang thanked Ray Hill for his attendance and for a very interesting and informative presentation.

3. PRIMARY CARE ITEMS

3.1 GP IT

3.1.1 Jonathan Carmichael reported on the current stage of discussions held by the GP IT Group and noted that the next meeting of the group would follow today’s Clinical Cabinet meeting. The issues of inter-operability, and access to data for patients of other practices, community and social care services, linked to the discussions of the previous item. Access to data was a key enabler for integrated care and for primary care working at scale. The key issue was availability of a solution, given all the factors of technology, affordability, practicality, time and IG as raised. In reflecting on the Camden approach, Jonathan Carmichael noted the significant levels of time, focus and financial investment made.

3.1.2 Jonathan Carmichael reported the commissioning of MIG for Haringey. This was a secure gateway, would allow access to a minimum set of GP data and a platform for two-way access to clinical data if agreed. The CSU were working with Islington, Enfield and NMUH. For practices using EMIS, it would be possible to use EMIS community as a data store to allow input alongside practice entries but practices using VISION would be limited to view only. This raised issues of timescale, cost and “appetite” of practices to transfer and this was difficult to gauge with only one GP representative currently attending the GPIT group on a regular basis. Questions and comments were invited.

3.1.3 Dr Naz Akunjee thanked Jonathan Carmichael for his helpful summary. He emphasised that the CCG could not move forward unless a solution was agreed. It was discussed that eleven practices were not on EMIS and Denise Pettit advised that seven of these would probably be interested to migrate. Dr Elizabeth Young noted that, as a VISION practice, it had been hoped to transfer in April. Frustratingly this had now been delayed until September which was particularly difficult timing. Dr Martin Lindsey offered to assist by raising this at the LMC. It was discussed that uniformity of a single system was preferable and, although not compulsory, migration should be encouraged.

5

3.1.4 Jonathan Carmichael and Dr Naz Akunjee reported that midwives and district nursing staff were very keen to be able to access primary care data and this would enable significant savings of GP time. Information was already shared via email and Dr Elizabeth Young emphasised that integrated working was the basic concept of a primary care team. Dr Kate Rees agreed but expressed some concern regarding the associated issue of this being an enabler for a “federation” model and twelve hour/seven day working. Dr Naz Akunjee acknowledged that this was an issue but shared data access was also a positive enabler for improving service provision.

3.1.5 Dr Martin Lindsey welcomed that consent was at the point of contact with the patient. Rachel Lissauer queried how IG requirements differed for EMIS Community. Dr Naz Akunjee explained that access could be at different levels of information and patients could choose. Rachel Lissauer queried how this would apply for care plans. Dr Naz Akunjee explained that if consent was given this would be included on the associated documentation. It was noted that the EMIS team would be able to provide further clarification.

3.1.6 Issues of compatibility were discussed and Jonathan Carmichael advised that further work would be needed with Whittington Health having recently implemented a new electronic patient record system. It was noted that some community services also used the RIO system and links could be discussed.

3.1.7 Funding was discussed and Jonathan Carmichael confirmed that a bid had been submitted to NHSE. This was based on 200 users, at £500 per user licence plus additional running costs. It was hoped to hear by June as to whether the bid had been successful.

3.1.8 The Cabinet noted the current position. It was agreed that a further update would be presented at the next meeting.

3.1.9 ACTION 05/06/14 – 01: To receive a further update report from the GP IT Group at the next Clinical Cabinet meeting.

JC

3.2 Primary Care Co-Commissioning

3.2.1 Dr Helen Pelendrides reported on the NHSE announcement regarding new commissioning arrangements for primary care. Expressions of interest were sought from CCGs wishing to develop co-commissioning of primary care services between CCGs and NHSE. Three levels of co-commissioning were defined as summarised in the accompanying paper. These were - for greater CCG involvement in influencing commissioning decisions, for joint commissioning or for delegated commissioning with CCGs having defined functions on behalf of NHSE. Initial consideration by the local CCGs indicated that a solution with decisions at a five CCG level would reduce some of the risks of greater delegated authority and provide the required scale of patient population. Expressions of interest were required by 20 June and details were set out in the NHSE letter circulated.

3.2.2 Dr Helen Pelendrides acknowledged that this was a very complex area and the CCG had in the past held a different view to the other four CCGs. However, in recognising the pressures on NHSE, and the degree of inevitability presented, it was felt that early involvement was the best way forward. Dissent would achieve little and currently good GP practices were being closed and the CCG had no role in these decisions. Dr Simon Caplan agreed and gave an example of the closure of local practice without any funding to support that his own practice had been flooded with additional patients. He suggested the only way forward was to work with the other CCGs as proposed.

6

3.2.3 Dr Sherry Tang noted that the joint approach was suggested as the most attractive to Haringey but NHSE was known to favour the delegation model. Jonathan Carmichael noted that there was also a view that CCGs should manage contracts. Dr Jackie Mansfield noted that the CCG had been able to work with practices to support improvement and this would be compromised if the CCG were to change its role. Dr Sherry Tang agreed and that the complexities were acknowledged. As noted in the covering paper there would be issues of conflict of interest for GPs involved in decision making and for the CCG, as a membership organisation, in potentially managing issues of contractual compliance. Dr Jatin Pandya agreed that impartiality and neutrality were essential both from an ethical perspective and in respect to regulatory/legal implications. He also felt that there need to be ring fencing for primary care funding and Rachel Lissauer queried whether the CCGs had discussed this. Dr Helen Pelendrides suggested that the NHSE’s current underfunding was likely to be similarly experienced by the CCGs.

3.2.4 Dr Peter Christian agreed that the future decisions seemed unappealing. However, in many respects there had been similar reservations at the start of commissioning and the establishment of CCGs. Dr David Masters noted his concerns regarding resources but felt the problems experienced with NHSE suggested that greater CCG involvement would be a positive benefit. Dr Daniel Beck agreed that he also had concerns but could see potential opportunities.

3.2.5 Discussion of these issues with the wider CCG membership was discussed. Dr Martin Lindsey advised that there would be discussion at the LMC meeting tomorrow. Dr Sherry Tang noted that a membership event planned for QIPP could also included discussion of co-commissioning issues. Dr Helen Pelendrides advised that this would not be in time for 20 June but this date related to just an initial expression of interest which the CCGs would discuss further prior to submission. There would be plenty of opportunity for discussion of further detail with CCG members in due course.

3.3 Working Together at Scale: Update

3.3.1 Jonathan Carmichael reported that, as raised in earlier discussion, a national move was anticipated towards practices being expected to offer services 8am-8pm and 7 days per week. This could either become contractual or with some form of strong financial incentive and, with the PM Challenge Fund pilots underway, this could become a reality from April 2015. Strategically, practices would need to work together at greater scale to meet such access requirements and other challenges facing primary care.

3.3.2 It was recognised that there needed to be a joint approach. The paper presented outlined the plan to offer pilot funding to groups of GP practices. This would be in order to test and demonstrate methods of working together at scale on topics that would improve access and involve seeing each others patients. The aim was to stimulate different ways of working. The Primary Care Strategy Steering Group had agreed the proposal but CCG Finance Committee approval was required before bids could be submitted. In the meantime the proposal was being made available to all practices for preparation and the development of ideas.

7

3.3.3 Jonathan Carmichael explained that the criteria were explicit in order to structure the bids received. The scale required would be a group of at least 5 practices. It was also made clear in the proposal that there would be pilot funding for October 2014-March 2015 only. There would need to be reasonable confidence that the pilots could be continued from April 2015 but this would not be with Primary Care Strategy funding.

3.3.4 Dr Kate Rees emphasised that plans for extended access raised patients’ expectations that this would enable them to see their named GP. This would not be possible and patients would inevitably be seen by locums. She suggested that the same outcomes could be achieved by re-shaping OOH services. Dr Peter Christian agreed the dangers of encouraging demand without being able to meet the results. Dr Jackie Mansfield suggested that core services would be further diluted and that non-recurrent funding could be better used for smaller scale innovative schemes, also improving access. Dr Daniel Beck agreed that there was a risk of focussing on meeting demand rather than need but, with political will to introduce these changes, there were other providers that could see the opportunity to take on the less complex aspects of care. Providers such as acute trusts would also have the advantage of premises. Dr Helen Pelendrides noted that expectations would also be driven by the GP Quality Standards and the public would use these for comparison to local services.

3.3.5 Dr David Masters suggested that collaboratives working together also provided opportunities. Dr Naz Akunjee agreed and that pilots provided the potential to test out ideas. Jill Shattock noted the reference to OOH services and that pilots were an opportunity to look at use of these existing links. Jonathan Carmichael emphasised that OOH services were only part of the overall picture. There were many potential benefits to explore by working between practices.

3.3.6 The Cabinet noted that, subject to approval by the Finance Committee bids would be invited by 25 July. An approval process would be agreed to enable pilots to commence in the autumn.

4. COMMISSIONING ITEMS

4.1 2013/2014 QIPP End of Year Report

4.1.1 Jill Shattock advised that the End of Year QIPP Report for 2013/2014 was presented to the Cabinet for information. There had been regular reports of progress during the year and the CCG had delivered QIPP savings of £12.9m against its plan of £13m. Points for reflection to support future QIPP plan delivery were summarised in the covering paper. An event for the CCG’s wider membership was planned for July in order to share this year’s results and to discuss the coming year.

4.1.2 Dr Sherry Tang expressed the Cabinet’s congratulations on the savings successfully achieved in 2014/2015.

4.1.3 The Cabinet NOTED the QIPP report.

5. COMMUNITY SERVICES

5.1 Gynaecology Pathways

8

5.1.1 Jill Shattock advised that the gynaecology pathways as circulated were first drafts on which feedback from member practices was invited. Alisha Pearl explained that these clinical pathways for six key conditions had been developed as a result of collaborative work with NMUH, Whittington Health and Islington CCG. The pathways were intended to support GPs, reduce variability in clinical practice and promote efficient patient care based on clinical best practice.

5.1.2 Dr Sherry Tang noted that, due to the time, a number of members now had to leave. Dr Helen Pelendrides suggested that the pathways could be discussed at the next meeting of each Collaborative with individual feedback invited. Alisha Pearl advised that it was aimed to launch the pathways by August and it was agreed this timetable would still be workable. It was agreed that the pathways would be marked clearly as drafts and circulated to all GPs in advance of the Collaborative meetings and with details of the timescale for comment. Alisha Peart added that comments were also welcomed as to whether the format was “user friendly”.

5.1.3 ACTION 05/06/14 – 02: To circulate copies of the draft gynaecology pathways to all GPs for discussion at the next Collaborative meetings.

AP

6. ANY OTHER BUSINESS

6.1 There were no other items.

7. DATE OF NEXT MEETING

7.1 3 July 2014 1.00pm – 3.00pm