Download Governing Body - South West Lincolnshire CCG

Public Meeting of the
South West Lincolnshire Clinical
Commissioning Group (CCG)
Governing Body
To be held on Wednesday 30 November 2016
at 10.30 am
Jubilee Church Life Centre
5 London Rd, Grantham NG31 6EY
RECOMMENDATIONS TO THE GOVERNING BODY –
GLOSSARY OF TERMS
To approve
To endorse
To ratify
To consider/receive
To discuss
For information
(to note)
An item of business that requires the Governing Body to make a
formal decision.
An item of business that requires the Governing Body to endorse the
actions taken by the NHS South West Lincolnshire CCG to a multiorganisational decision.
An item of business where the Board is required to ratify the actions
taken on behalf of the NHS South West Lincolnshire CCG, eg
decisions taken by the Governing Body Committee.
A report containing a positional statement relating to the delivery of
NHS South West Lincolnshire CCGs functions for which the
Governing Body has a corporate responsibility but is not explicitly
required to make a decision.
In some circumstances there may be requirement for the Governing
Body to adopt the measures contained within the report.
An item of business that requires discussion by the Governing Body
prior to agreement of a formal resolution or a general policy steer to
the CCGs Officers.
An item of business that is of general interest but is not of
significance to the Governing Body’s corporate or operational
activities. These items will be included on the agenda but will not be
for significant discussion or require a decision.
All these terms apply to the Governing Body and its Committees and Sub-Committees.
All members of NHS South West Lincolnshire CCG Governing Body understand and are
committed to the practice of good governance and to the legal regulatory frameworks in
which they operate.
All members of the NHS South West Lincolnshire CCG Governing Body abide by the
Standards for Members for NHS Boards and Clinical Commissioning Group Governing
Bodies in England.
http://www.professionalstandards.org.uk/docs/psa-library/november-2012---standards-forboard-members.pdf?sfvrsn=0
GOVERNING BODY PUBLIC MEETING
South West Lincolnshire CCG will meet on Wednesday 30 November 2016 at 10.30 am
Jubilee Church Life Centre, 5 London Rd, Grantham NG31 6EY
Chair: Dr Vindi Bhandal
AGENDA
Standing Items
Lead
Time
To receive apologies for absence
All
10.30
2.
To receive any declarations of pecuniary and non-pecuniary
interests and conflicts of interest
All
3.
To receive the minutes of the meeting held on 26 October 2016
Enclosure
All
4.
To consider matters arising from previous minutes
Enclosure
All
5.
To receive an update from the CCG Chair, Chief Officer and Chief
Operating Officer
Enclosure
Mrs C Raybould
Verbal
Miss D Hansen
10.40
1.
Enclosure/
Verbal
.
Patient and Public Involvement
6.
Patient Story – Transforming Care
Quality
7.
To note the Quarterly Quality Narrative Report
Enclosure
Mrs P Palmer
11.00
8.
To note the Quarterly Quality Safeguarding Report
Enclosure
Mrs P Palmer
11.05
Finance and Performance
Lead
9.
To consider the Performance Report 2016/17
Enclosure
Mrs C Raybould
11.10
10.
To receive an update on the Financial and QIPP Report – Month
Seven
Enclosure
Miss J Wright
11.20
11.
To consider and approve the Outcome of the Medicines
Management Consultation
Enclosure
Miss J Wright
11.30
Verbal
Mrs C Raybould
11.40
Enclosure
Miss J Wright
11.45
Strategy and Policy
12.
To note the Award of the Medicines Management Support
Services Contract
Governance
13.
To receive an Information Governance update including revised
policies and Fair Processing Notice
General Issues
14.
To receive an update on Public Health
Lead
Enclosure
Dr K Choudhury
11.50
15.
To note an update on the Sustainability Transformation Plan
Verbal
Minutes and Terms of Reference
Mrs C Raybould
11.55
Lead
16.
To receive the minutes/notes from the Lincolnshire CCG Council
meeting held on 5 October 2016
Enclosure
Dr V Bhandal
17.
To receive the draft minutes from the Health and Wellbeing Board
meeting held on 27 September 2016
Enclosure
Dr V Bhandal
18.
To receive the minutes from the Executive Committee meeting held
on 12 October 2016
Enclosure
Dr D Baker
Verbal
All
12.00
Information
19.
To consider any potential risks identified during the meeting
20.
The next meeting will be held on Wednesday, 21 December 2016
at 10.30 am in the Witham Room, South Kesteven District Council,
St Peters Hill, Grantham, NG31 6PZ
12.05
12.10
close
The items on this agenda are submitted to the Governing Body for discussion, amendment and
approval as appropriate. They should not be regarded, or published, as organisation policy until formally agreed at a Governing Body
meeting at which the press and public are entitled to attend. Papers are available on the NHS South West Lincolnshire website:
www.southwestlincolnshireccg.nhs.uk. In case of difficulty accessing the papers, please contact Jules Ellis-Fenwick, Corporate
Secretary/Manager on 07825 938794 (via e-mail at [email protected])
The Governing Body will be asked to consider the following resolution:
That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the
confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest’ - (Section 1(2) Public
Bodies (Admission to Meetings) Act 1960)
Items in the private part of the meeting are either commercial in
confidence or relate to individual staff and patients.
………………
… ………………
Jules Ellis-Fenwick,
CCG Corporate Secretary/Manager
Subject to approval by the Governing Body at its meeting on 30 November 2016
MINUTES OF THE SOUTH WEST LINCOLNSHIRE CLINICAL COMMISSIONING
GROUP GOVERNING BODY (PUBLIC SESSION) HELD ON WEDNESDAY, 26
OCTOBER 2016 AT 11.30 AM – 1.30 PM IN THE NEW LIFE CONFERENCE
CENTRE, MAREHAM LANE, SLEAFORD NG34 7JP
PRESENT:
Dr Vindi Bhandal
Mr Andrew Burton
Mr Graham Felston
Mr Mike Hill
Mr Allan Kitt
Mrs Pamela Palmer
Mrs Paula Pilkington
Miss Jo Wright
CCG Chair and GP, Sleaford Medical Group, SWLCCG (Chair of meeting)
Lay Member, Patient and Public Involvement, SWLCCG
Lay Member, Governance, SWLCCG (Deputy Chair)
Healthwatch Representative
Chief Officer, SWLCCG
Chief Nurse, SWLCCG
Acting Chief Finance Officer, SWLCCG
Deputy Chief Officer, SWLCCG
IN ATTENDANCE:
Miss Karen Bradford
Dr Kakoli Choudhury
Mr Tony Crowden
Mrs Julie Ellis-Fenwick
Dr Raghu Ramaiah
Mrs Clair Raybould
North Kesteven District Council Representative
Consultant in Public Health, Lincolnshire County Council
Communications Specialist, Optum CSU
CCG Corporate Secretary/Manager, SL/SWLCCG’s
Secondary Care Doctor, Clinical Lay Member, SWLCCG
Chief Commissioning Officer, SWLCCG
APOLOGIES:
Dr Dave Baker
Cllr Sue Woolley
16/922
GP, Vine Street Practice, Grantham and Chair of the Executive Committee,
SWL CCG
Chair of the Health and Wellbeing Board, Lincolnshire County Council
WELCOME AND INTRODUCTIONS
Dr Bhandal welcomed all those present to the meeting. All those present introduced themselves.
Dr Bhandal advised that two GP members were required to be present at the meeting to ensure
compliance with quoracy arrangements as detailed in the CCG Constitution. Dr Baker was not
present at the meeting and Dr Tim Ryder had been unable to attend in his absence. As such the
meeting was not quorate.
16/923
DECLARATIONS OF PECUNIARY AND NON PECUNIARY INTERESTS AND
CONFLICTS OF INTEREST
There were no declarations of interest received. Dr Bhandal declared a conflict in respect of the
update on the Over the Counter Medicines consultation (item nine on the agenda), as a GP
within a dispensing practice.
It was noted that there was no decision to make in relation to this item, as the update was just for
noting. However, Dr Bhandal advised that she would not participate in the update or discussion.
The Governing Body agreed to:
• Note the conflict as declared.
1
Subject to approval by the Governing Body at its meeting on 30 November 2016
16/924
MINUTES OF THE PREVIOUS MEETING
Dr Bhandal presented the minutes of the last meeting held on Wednesday, 28 September 2016
which were considered and the Governing Body agreed to approve the minutes as a true record
subject to the following amendments and approval by Dr Baker as the meeting was not quorate:
•
•
•
16/893 state that the GP members advised that as providers within primary care they had
an interest in Item 13 and 15 on the agenda – Over the Counter Medicines/Products,
although there was no direct conflict. This was incorrect as Dr Bhandal was part of a
dispensing practice and therefore had a conflict, although it was noted that the OTC
proposals would have a negative, albeit minimal, cost impact on a dispensing practice.
Mrs Jeanette Arnold should be listed as present as she had attend the meeting on behalf
of Mrs Palmer.
Page 3 – 16/896 should state that as a result of the closure overnight of Grantham A&E
the CCG, through the lead commissioner, had advised that it wished to pay a revised
tariff.
The Governing Body agreed to:
• Approve the minutes as a true record subject to the amendments listed above.
16/925
MATTERS ARISING FROM THE PREVIOUS MINUTES
Dr Bhandal presented the Action Log as at October 2016. There were five actions identified
which were either complete or on–track to be delivered.
In terms of the dates for the JSNA (Joint Strategic Needs Assessment) it was not certain these
had been received from Public Health. Mrs Raybould advised that the Commissioning Team had
been invited to some meetings, but had received no rationale as to why they had received the
dates. Mrs Raybould requested that the dates be sent to her directly so she could ensure the
information was sent to the appropriate individuals in her team, which was noted by Dr
Choudhury.
Mrs Ellis-Fenwick advised that it had been agreed that a member of Mr Glen Garrod’s team
would attend the December Governing Body meeting to discuss delays in transfer of care.
The Governing Body agreed to:
• Note the action log and verbal report.
16/926
UPDATE FROM THE CCG CHAIR, CHIEF OFFICER, AND CHIEF FINANCE OFFICER
Mr Kitt advised that his Chief Officer update had been included with the papers and outlined the
details for information.
Key highlights included:
•
•
•
•
•
•
CCG staff had been briefed on the Sustainability and Transformation Plan (STP). A
number of CCG’s have also been involved with the development of the STP.
The CCG Annual Public Meeting was held on 28 September 2016, and had received
good attendance, and the market type of event had also been well received.
The newly established System Executive Team (SET), which will oversee the STP,
continue to meet on a weekly basis.
The Lincolnshire Co-ordinating Board (LCB) has been established bringing the Chairs of
all of the NHS organisations together with key elected members from Lincolnshire County
Council to develop Non-Executive oversight of SET and the STP work.
Miss Wright had commenced her secondment as the Joint Chief Finance Officer for both
South West and South Lincolnshire CCG’s on 1 October 2016.
Mr Kitt had announced he would be retiring on 31 March 2016.
2
Subject to approval by the Governing Body at its meeting on 30 November 2016
The Governing Body considered the update. Miss Bradford offered her appreciation to Mr Kitt for
all the hard work he had carried out over the last few years for the CCG, and sought clarification
on whether the recruitment process for his replacement had commenced. Mr Kitt advised that
that recruitment was in hand.
Dr Bhandal supported Miss Bradford’s comments in respect of Mr Kitt.
On a separate issue, Dr Bhandal’s’ three year term as the CCG Chair, was due to end on 30
November 2016. In line with the CCG Constitution the election process for the CCG Chair role
would be carried out by the Local Medical Council during November 2016. Mrs Ellis-Fenwick
would be supporting the process from the CCG aspect.
The Governing Body agreed to:
• Note the Chief Officer’s report and verbal update.
16/927
PERFORMANCE REPORT 2016/17
Mrs Raybould presented the performance report which covered the period from September 2015
- August 2016. It is based on national guidance and covers indicators within the Everyone
Counts Guidance.
Mrs Raybould highlighted the following areas:
•
•
A&E Four hour wait performance at CCG level has improved at 86.3% which is above
trajectory for Lincolnshire but still below target. United Lincolnshire Hospitals NHS Trust
(ULHT) performance is below target for the third consecutive month. Peterborough and
Stamford Hospitals NHS Trust (PSHFT) is above at 89% but Nottingham University
Hospital (NUH) is under performing at just under 70%. NUH have got recovery plans in
place and the first stage had been reached but no improvement had been demonstrated.
This could be as a result of the way in which they are operating, which had impacted on
performance.
On a positive note the CCG could take some assurance that its patients were being seen
and treated much quicker than other places in the country.
Ambulance handovers and East Midlands Ambulance Service (EMAS) were not achieving
against the divisional standards. However, from a CCG point of view there had been an increase
in performance, which is above the national target. This was shown in the performance report.
There is a recovery action plan in place and a considerable amount of work was taking place, led
by Hardwick CCG as the overall lead commissioner and Lincolnshire West CCG as the local
lead to recover the position.
Referral to Treatment (RTT) – the standard was not achieved for the third consecutive month
with performance just short of 91%, which was primarily due to ULHT. Other providers such as
PHSFT and NUH were at 96%.
The CCG had received a letter from NHS England requesting details on its plans for outsourcing.
Outsourcing was about the CCG’s GPs referring to other providers. This would have financial
implications for the CCG in the current year, but the impact would be even greater for next year.
An Action Plan had been submitted to NHS England, who had requested that the inclusion of
further detail.
Mrs Raybould outlined the action being taken by the CCG, including discussions being held with
the Federation about referral management at source. Discussions were also taking place in
terms of getting patients off the backlog waiting list and assessing whether they could have been
referred elsewhere.
3
Subject to approval by the Governing Body at its meeting on 30 November 2016
52 week waits – there were no breaches. The one case reported last year was an error as this
related to South Lincolnshire CCG. This has now been removed from the CCG’s performance
report.
Cancer targets – four of the waiting times were below target but overall performance had
improved.
Two week wait standards remained the main issue, with performance below target, although this
position was reflected up and down the country. The performance report identified there had
been 42 breaches.
Two week breast symptoms – there had been 27 breaches.
31 day waits – there had been one breach which was down to patient choice.
62 day waits – there had been 10 breaches, which Mrs Raybould had reviewed. The review had
identified that these were mainly due to complex pathways.
Mrs Palmer advised that she was aware there had been a suspected breach in respect of
children’s cancer at ULHT. It was agreed that Mrs Palmer would liaise with Mrs Raybould
outside of the meeting regarding this suspected breach.
The Governing Body considered the report. Mr Burton sought clarification on whether breast
referrals could be shifted to another provider. Mrs Raybould advised that two week breast waits
was a national issue due to lack of availability of radiologists. Medium and long term recovery
plans were in place, including recruitment issues, but it was the responsibility of the CCG to try
and recover the position.
IAPT – there was currently an issue in obtaining the relevant data for this target, which was
outside the control of the CCG. As such a predicted standard from Lincolnshire Partnership NHS
Trust (LPFT) had been used and the target was showing as not being met, which was down to
the GP’s. This was being picked up and the CCG had met with LPFT on several occasions. The
GP Five Year Forward View included a clear steer around IAPT, and this was part of the CCG’s
transformation plans.
Early intervention of psychosis, this was a new target and had been achieved by the CCG.
The Governing Body agreed to:
• Note the report and verbal update.
16/928
PROVIDER PERFORMANCE REPORT – MONTH FIVE
Mrs Raybould presented a report that provided an overview to Governing Body of the
performance of providers the CCG contracts with. Page three of the report provided the
summary.
The following items were highlighted
•
•
•
•
•
•
•
As at month five the report showed an under performance against plan on the acute
contract.
Eight of nine providers achieving the RTT target (ULHT performance against this target
was reported under the previous item).
There were issues with some providers around diagnostic targets. Weekly bulletins were
being issued to the CCG GPs in relation to these issues.
There had been two mixed sex accommodation breaches.
Contract notices had been issued to providers in respect of A&E and cancer waits.
The LPFT contract was performing well, with contract notices.
One contract notice had been issued to NUH.
4
Subject to approval by the Governing Body at its meeting on 30 November 2016
•
Millbrook wheelchair contract – there had been contract performance notice but they
have recovered that position.
Discussions had taken place with Optum CSU about the contracts, as the CCG was not seeing
the information it expected to be reported, including information on how they were processing
challenges. Optum were also working with Arden & GEM because Lincolnshire East CCG
(LECCG) was still under them for contract provision, as they were the lead commissioner for the
ULHT contract.
Mrs Raybould advised that other changes were still being made to the format of the report, and
welcomed any further comments from the Governing Body. Miss Wright advised that it would be
helpful to align both the performance and finance reports, but appreciated there were capacity
issues within the finance team currently as key members were heavily involved in the STP
process.
Miss Bradford sought clarification on the number of cases of e-coli, which appeared high, and
whether the CCG costs these types of hospital based infections and where pneumonia was
picked up. Mrs Palmer advised that she would need to check the details with the Infection
Control Lead in terms of the e-coli, which she would action outside of the meeting and report
back to Miss Bradford. Levels of pneumonia were not currently part of a reporting standard.
Action: Mrs Palmer
The Governing Body agreed to:
• Note the report and verbal update.
16/929
FINANCIAL AND QIPP REPORT – MONTH SIX
Miss Wright presented the Finance and QIPP report, which set out the financial position of the
CCG as at month six. The Governing Body were referred to the table set out in the front sheet
which identified that the CCG was no longer forecasting to achieve all of its financial targets at
the end of the year. Delivery of the planned 1% surplus has been rated as an amber risk (not
delivered to date and potential risk for year end with mitigation plans in place) and delivery of
3.5% QIPP savings.
The year to date performance is consistent with the forecast position, with the two indicators
mentioned above flagged as red.
In addition, the CCG has not managed its cash balance to the required level at the end of the
month and is showing a risk to the achievement of financial balance (breakeven).
The recovery plan that has been put in place should bring the CCG back to breakeven by the
end of the year and therefore is flagged as green in the table, but it may not be enough to
achieve a 1% surplus (shown as amber as above).
There have been no additional allocations this month and the CCG has a total of £180.9m with
which to commission services.
Concentrating on the forecast outturn position, Acute services are forecast to overspend by
£404K at the end of the year. This is largely due to overspends on activity carried out in the
private sector to ensure the CCG meets referral to treatment times as well as additional
pathology work. These details and the reasons for the pathology overspend were currently being
investigated.
Mental health services and community health services are both forecasting an underspend
position at year end. Further work is going on to ensure that these positions are robust,
particularly in light of the impending winter period.
5
Subject to approval by the Governing Body at its meeting on 30 November 2016
The prescribing forecast position is showing an overspend of £206K on prescribing budgets, with
a further underachievement of prescribing QIPP of £500k. Underspends on co-commissioning
budgets and other primary care budgets are offsetting these overspends to a position of £96k
overspend over all.
Other programme budgets are forecasting an underspend at year end. The reversal of un-used
year end accruals on the Enhanced Services budgets and the use of contingency reserves to
balance out over spends elsewhere in budgets have been reflected here.
The CCG is continuing to operate within the running cost allowance for 2016/17.
The QIPP position for month six shows that the schemes are slightly over-delivering year to
date, noting that not all information is available to support monitoring of countywide schemes.
The over-delivery of £160K year to date was due to the early delivery of some schemes, ahead
of their profiled delivery, and the over achievement of some items, such as the repatriation of
mental health Out of Area patients.
There are eight schemes that are not on target to deliver the required savings at the end of the
year, resulting in slippage of £670K in achieving the required QIPP. However, it should be noted
that there are additional risks to delivery of some of the remaining QIPP programmes that could
see more slippage than this. The QIPP Programme Management Office (PMO) and Executive
Committee will continue to scrutinise the activity and ensure the achievement of savings and
improvements wherever possible. The additional QIPP mitigation plans as discussed at
previous Governing Body meetings are progressing with the aim of closing the gap that has
opened in delivery.
Miss Wright advised that as the CCG moves through the year the financial risk to the CCG
achieving the required 1% surplus is increasing, due to the requirement to deliver a further 1% of
resources unallocated to support the national NHS position, and due to the previously described
QIPP position. The CCG has reported mitigated risk to NHS England (NHSE) of £2.7M in month
Six, which is the worst case scenario. This situation continues to be closely monitored by the
finance team and overseen by the Risk Management Committee and senior team.
The Governing Body considered the contents of the report and sought clarification on the
overspend in acute services and whether referrals to the private sector to meet constitutional
targets was having an adverse effect.
Miss Wright advised that a considerable amount of the overspend was due to patients requiring
spinal surgery/intervention and there were a lack of providers for this area. Whilst these patients
were taking the CCG over its referral activity levels, the private sector did not cost the CCG
anymore than referral within the public sector.
The Governing Body agreed to:
• Note the month six finance report.
16/930
OVER THE COUNTER (OTC) MEDICINES AND PRODUCTS PUBLIC CONSULTATION
Mr Kitt advised that the OTC consultation had commenced in the middle of October, and was
due to close on 18 November 2016. To date over 700 responses had been received and nearly
3,000 views on social media. The consultation has generated good debate with mixed feedback
received, although the majority of responses have been positive. Some members of the public
have indicated that they felt the proposals did not go far enough and have recommended other
areas for consideration.
6
Subject to approval by the Governing Body at its meeting on 30 November 2016
The Optum CSU and CCG Engagement teams have been very supportive in raising awareness
of the consultation, and a number of events have taken place and support provided in
completion of the survey.
A report would be produced summarising the outcome of the consultation, and this would be
presented to the Governing Body in November for consideration, with a proposed
implementation date of 1 December 2016.
The Governing Body agreed to:
• Note the report verbal update.
16/931
STANDARDS OF BUSINESS CONDUCT AND CONFLICTS OF INTEREST POLICY
(INCLUDING HOSPITALITY, GIFTS AND SPONSORSHIP)
Mrs Ellis-Fenwick advised that the Governing Body was aware that NHS England had published
revised statutory guidance for CCGs on managing conflicts of interest on 28 June 2016. The
guidance has been strengthened as part of a system-wide governance project to improve
conflicts of interest management across the NHS and to increase public confidence in the
propriety of decision-making.
As a result of this updated guidance, it was necessary for the CCG to carry out a review of its
Standards of Business Conduct and Conflicts of Interest Policy. This has been completed and a
number of amendments made, all of which are identified in red in the policy attached to the
paper presented.
The Governing Body considered the contents of the paper and supporting policy presented. Mr
Felston sought clarification on the position in terms of the CCG accepting offers of cash. Mrs
Ellis-Fenwick advised that the policy sets out the position in terms of cash, which should not be
accepted by staff members. Miss Wright advised that in terms of the CCG receiving cash, it did
not have Charitable Fund arrangements in place and therefore cash would not be accepted.
Mrs Raybould referred to the reference on page 18 (item 24) about sponsorship being accepted
by the practices and whether they were aware of this position. Mrs Ellis-Fenwick advised that
this was a new requirement as set out in the NHS England guidance, but the details had not yet
been circulated to the practices as the CCG revised policy had not yet been approved.
Dr Bhandal advised that the type of sponsorship events alluded to in the policy had reduced
considerably in general practice in the last few years, but they would need to understand the
implications set out in the policy. It was suggested that when the policy was issued a
communication was included to the practices emphasising the requirements set out on page 18,
which was noted by Mrs Ellis-Fenwick.
The Governing Body agreed to:
• Approve the revised Standards of Business Conduct and Conflicts of Interest
Policy (subject to confirmation of approval by Dr Dave Baker).
16/932
GOVERNING BODY ASSURANCE FRAMEWORK
Miss Wright presented the latest version of the Governing Body Assurance Framework and Risk
(GBAF), and highlighted the following:
•
•
There have been no new risks added to the GBAF.
There has been one risk for which the scoring has been revised relating to the numbers
of patients for mental health and learning disabilities being sent out of area for treatment,
particularly out of hours.
7
Subject to approval by the Governing Body at its meeting on 30 November 2016
•
There has been one risk removed from the GBAF as it has been managed to a low risk
item, relating to the review of Continuing Healthcare (CHC) patients.
There are two high risk items on the GBAF, both of which relate to the risk of achieving financial
balance, one for the current year and one for the future three years. These have been
discussed in the finance report and continue to be discussed at Governing Body, Executive
Committee and Risk Management Committee on a regular basis.
Miss Wright advised that Section B of the report shows a summary of the Risk Register that has
been considered by the Audit Committee at each of its meetings. It shows the review and
rescoring of risks that happens at the Risk Management Committee and which are ratified by the
Audit Committee. The Risk Management Committee also considers the financial risk and
mitigation plans in detail. There will be a Governing Body Development Session held on risk
management in December.
Miss Wright requested that the Governing Body note the update and the remaining risks
highlighted in the Governing Body Assurance Framework.
The Governing Body considered the contents of the report. Mr Felston advised that he had
considered the report in detail, noting all the changes which seemed appropriate.
The Governing Body agreed to:
• Note the latest version of the Governing Body Assurance Framework.
16/933
UPDATE ON PUBLIC HEALTH
Dr Choudhury advised that the new alcohol and substance misuse service commenced on 1
October 2016 and Public Health were looking to receive feedback from general practice.
The Governing Body discussed this and sought clarification on whether feedback had been
formally requested from general practice rather than raised through the Governing Body, with
only two GP members. Dr Choudhury advised that general practice had not been contacted
directly.
It was proposed and agreed that Dr Choudhury contact Mrs Raybould’s Secretary regarding
distribution of the details to the CCG practices.
Action: Dr Choudhury
Dr Choudhury sought clarification on whether the Governing Body was happy to continue with
verbal updates at the Governing Body meetings or would prefer a written briefing note. The
Governing Body agreed that they would prefer to receive a briefing note for future meetings,
which was noted by Dr Choudhury for action.
Action: Dr Choudhury
The Governing Body agreed to:
• Note the verbal update.
16/934
SUSTAINABILITY AND TRANSFORMATION PLAN
Mr Kitt advised that the final version of the STP had been submitted to NHS England on 21
October 2016. The document would be considered by NHS England over the next few weeks,
after which feedback on the content was expected to be received. Following provision of the
feedback a meeting will then take place with NHS England lead representatives. It was
anticipated this would take place in early December.
8
Subject to approval by the Governing Body at its meeting on 30 November 2016
Mr Kitt advised that a number of Freedom of Information requests had been received seeking a
copy of the STP, which had been declined as the document was still in draft and part of an ongoing piece of work.
The Governing Body agreed to:
• Note the verbal update.
16/935
MINUTES FROM THE LINCOLNSHIRE CCG COUNCIL MEETING
Dr Bhandal presented the minutes from the Lincolnshire CCG Council meeting held on 7
September 2016 and outlined the contents.
The Governing Body agreed to:
• Note the minutes.
16/936
MINUTES FROM THE EXECUTIVE COMMITTEE MEETING
Dr Bhandal presented the minutes from the Executive Committee meeting held on 14 September
2016 and outlined the contents.
The Governing Body agreed to:
• Note the minutes.
16/937
MINUTES FROM THE HEALTH SCRUTINY COMMITTEE
Mr Kitt presented the minutes from the Health Scrutiny Committee meeting held on 21
September 2016 and outlined the contents.
The Governing Body agreed to:
• Note the minutes.
16/938
FREEDOM OF INFORMATION REPORT QUARTER TWO
Mr Kitt presented the Freedom of Information report Quarter two and outlined the contents. It
was noted that there had been some issues with the Freedom of Information service provided by
Optum CSU, but work was taking place with the lead to improve the turnaround with responses.
Mr Felston sought clarification on whether there had been cases of onward reporting of any
breaches by any requesters to the Information Commissioner’s Office. Mr Kitt advised that he
was not aware of any breaches being reported.
The Governing Body agreed to:
• Note the report.
16/939
POTENTIAL RISKS IDENTIFIED DURING THE MEETING
The Governing Body considered whether any new risks had been identified during the meeting,
and agreed that any issues identified were covered through existing risks.
16/940
DATE, TIME AND VENUE OF THE NEXT MEETING
The next meeting will be held on Wednesday, 30 November 2016 at 10.30 am, not 11.00 am as
stated on the agenda. The meeting will take place at the Jubilee Church Conference Centre,
London Road, Grantham.
9
Subject to approval by the Governing Body at its meeting on 30 November 2016
Dr Bhandal advised that she may not be available for the next meeting, in which case Mr Felston
would need to Chair the meeting.
Mr Kitt asked that his apologies for the November meeting be noted, as he is on annual leave.
There being no further business the meeting was closed.
…………………………
GP Chair
……………………….
Date
10
SOUTH WEST LINCOLNSHIRE CCG GOVERNING BODY
PUBLIC SESSION ACTION LOG – NOVEMBER 2016
DELIVERED
MINUTE
NUMBER
MEETING
ITEM
LEAD
ACTION REQUIRED
ON-TRACK TO
DELIVER
SOME ISSUES –
NARRATIVE
DISCLOSURE
TO BE
COMPLETED BY
NOT ON TRACK
TO DELIVER
PROGRESS AS AT
NOVEMBER 2016
STATUS
16/928
October
2016
Performance Report
Mrs Palmer
To check the details of the November 2016
number of cases of E-Coli with
the Infection Control team.
In-progress.
GREEN
16/933
October
2016
Public Health update
Dr
Choudhury
To submit details of the November 2016
request for feedback on the
new alcohol and substance
misuse
service
to
Mrs
Raybould’s
team
for
circulation.
In-progress.
GREEN
16/933
October
2016
Public Health update
Dr
Choudhury
To provide a written report November 2016
from Public Health at future
meeteings.
In-progress.
GREEN
1
MINUTE
NUMBER
MEETING
ITEM
LEAD
ACTION REQUIRED
2
TO BE
COMPLETED BY
PROGRESS AS AT
OCTOBER 2016
STATUS
CHIEF OFFICERS UPDATE NOVEMBER 2016
•
On the 2nd November CCG leaders me to discuss developing a programme of work
to consider options for closer working to support STP implementation. There was
general support for developing the CCG council as a place to “do things once for
Lincolnshire”. There was little support for any structural or organisational change in
the short term as this would distract us all from delivery.
•
On the 2nd of November the Lincolnshire Coordinating Board met; bringing together
the Chairs of all NHS organisations along with elected members; the group continues
to develop and is building much stronger dialogue at non-executive level.
•
On the 4th November I attended a National Briefing led by Simon Stevens and Jim
Mackey on the planning for the next 2 years as we move to implementation of STPs.
Confirmed that the expectation would be for publication in the near future, clear
message that financial position remains challenging and STPs must be realistic
though ambitious.
•
On the 7th of November the CCG senior team met with representatives of Fighting for
Grantham Hospital, the group expressed their concerns about the lack of 24 hour
A&E services and their frustration that Grantham staff had been redeployed away to
other hospitals as a result of their staffing issues rather than a problem at Grantham
itself. It was very clear that there are concerns in the group that plans for integrated
urgent care is being perceived as “down-grading” rather than strengthening what
Grantham already does and future proofing it. We clearly have a great deal of work to
do on communicating the vision for truly joined up 24 hour care for our population.
We have agreed to meet again and continue our dialogue.
•
On the 11th November the Rt. Hon Jeremy Hunt MP, Secretary of State for Health
visited Sleaford and met the Board of LPFT and service users at the CAMHS inpatient service at Ash Villa. The Secretary of State was keen to hear both from
service users, providers and commissioners about how we can continue to improve
services for young people with mental health needs.
•
On 22nd November a first workshop was held with the Joint Commissioning Board to
begin developing the next steps in the integration of Health and Social care, a further
workshop will be held next month.
GOVERNING BODY MEETING
Date of Meeting:
30 November 2016 – public session
Title of Report:
Report Author and Title:
Quarterly Narrative Quality Report
Pamela Palmer, Chief Nurse;
Jeanette Arnold, Deputy Chief Nurse
Agenda item:
7.
Appendices:
1.
Purpose of the Report (including link to objectives)
The purpose of this report is to provide the Governing Body with a narrative summary around a number
of key issues that relate to the oversight of service quality across the health community during Quarter 4
2015/16.
The report provides an overview of information relating to quality reports from provider organisations, the
CCG’s complaints management and further work streams.
2.
Recommendations
The Governing Body is asked to note the contents of the report.
3.
Executive Summary
Quality Schedules form part of the NHS Standard Contract for Acute, Ambulance, Community and
Mental Health and Learning Disability Services. Attainment of key performance indicators is monitored
through Quality Review Meetings as part of the CCG’s Quality Assurance Framework overseen by the
Quality and Patient Experience Committee.
In addition to this the CCGs Nursing and Quality team manage the complaints process for those
complaints received within the CCG that relate to services commissioned by the CCG, the exception to
this is the management of complaints relating to individual GPs or GP practices in the delivery of primary
care services, these are managed through NHS England to avoid ‘conflicts of interest’. Summary
information relating to the conduct of complaints management and thematic information are included.
NHS England only provides basic statistical/ thematic data to the CCG in relation to the primary care /
GP complaints.
The CCG also undertakes quality visits to member practices to offer support and challenge as required
in relation to both performance and quality issues.
The issues identified within this report are managed in detail through either the Quality and Patient
Experience Committee, or the regular contract and quality monitoring processes and as such are
provided to members of the Governing Body for information only.
4.
Management of Conflicts of Interest
Not Applicable within this report.
1
5.
Finance, QIPP and Resource Implications
Not Applicable within this report.
6.
Legal/NHS Constitution Considerations
Statutory duty of Quality.
7.
Analysis of Risk including Assessments
Where required the nursing and quality team will escalate relevant risks to the Risk Committee, with high
risk being reported through the Governing Body Assurance Framework (GBAF).
Please state if the risk is on the CCG Risk Register.
8.
Yes
√
No
Outline engagement – clinical, stakeholder and public/patient
Patient engagement and experience information is utilised to support the review of services; in particular
the triangulation of information is undertaken prior to site visits. Where relevant the providers are
challenged to address key patient concerns through existing complaints/ concern routes. As well as
through the quality review meetings.
9.
Outcome of Impact Assessments
Not Applicable within this report.
10.
Assurance Departments/Organisations who will be affected have been consulted
Insert details of the departments you have worked with or consulted during the process:
Finance
Commissioning
Contracting
Medicines Optimisation
Clinical Leads
Quality
Safeguarding
Other
11.
x
Report previously presented at:
This report provides the latest information and follows previous quality reports.
12. For further information or for any enquiries relating to this report, please contact
Pamela Palmer, Chief Nurse
[email protected] or
Jeanette Arnold, Deputy Chief Nurse
[email protected]
2
GOVERNING BODY MEETING
Quality Report
November 2016
1. Introduction
The purpose of this report is to provide the Governing Body with a narrative summary around a
number of key issues that relate to the oversight of service quality across the health community during
Quarter 1 of the 2016/17 financial year.
The report provides an overview of information relating to quality reports from provider organisations,
the CCG’s complaints management and further work streams.
2. Background
Quality Schedules form part of the NHS Standard Contract for Acute, Ambulance, Community and
Mental Health and Learning Disability Services. Attainment of key performance indicators is
monitored through Quality review Meetings as part of the CCG’s Quality Assurance Framework
overseen by the Quality and Patient Experience Committee. A variety of measures are used to
assess quality such as patient feedback (Friends and Family Test and NHS Choices); complaints and
site visits. These are considered in conjunction with more fixed quantative measures, for example
compliance with timeframes from referral to treatment and two week waits.
3. Complaints
The CCG is committed to ensuring that challenges facing patients raised as concerns or complaints
are captured and that, where appropriate, changes in commissioning strategies are recommended to
improve patient experience. Members of the Governing Body will be aware that from 1st April 2015 the
management of complaints has been undertaken in-house, within the Nursing and Quality team. This
arrangement covers those complaints raised by individuals residing within the CCG boundaries,
irrespective of the service point.
The CCG recognises complaints to be a rich source of information about how services can be
improved and as a tool for risk management. Though not required to, we strive to follow the high
standards of the regulatory and statutory requirements as set out within the Local Authority Social
Services and NHS Complaints (England) Regulations 2009. The CCG is committed to ensuring that
challenges facing patients raised as concerns or complaints are captured and that, where appropriate,
changes in commissioning strategies are recommended to improve patient experience.
Between April and October 2016 the Complaints team received a total of ten complaints.
Number of complaints
Acknowledged within 3 working days
Responded to within 45 working days
Upheld
Partially Upheld
Not Upheld
Not determined due to non-progression e.g. Consent not
received; Patient choice to with withdraw; Existing complaint
already in system elsewhere
Quarter
1
5
4
3
1
2
2
0
Quarter
2
6
4
2
2
2
* Two complaints remain open at the end of Quarter 2 and outcomes are therefore not yet determined
There have been delays in Q1 and Q2 in forwarding full written responses to complainants within our
overarching standard of 45 working days of receipt of the complaint. In most complaints involving a
1
commissioned service the Complaints team did not receive responses within original target
timescales set. It remains a concern that a number of provider complaint reports have been severely
delayed or required to be returned to the provider as the information did not address all aspects of the
complaint raised. The Complaints team continue to monitor timescales and have escalated concerns
accordingly. In addition, a complaints template has been produced detailing identified issues and
concerns, investigation findings and identified learning and actions in order to facilitate timely and
more comprehensive responses.
In the majority of cases the complaints were complex and investigations into the complaint were
required by a number of providers. Chart 2 below details those providers
Out of Area Treatment Access
LPFT
ULHT
CHC Funding
Wheelchair Services
Care Home
NHS 111
Out of Hours
Complex Case team
0
1
2
3
4
5
The Nursing and Quality team continue to challenge and review practice through ongoing quality
review of services linking across the four Lincolnshire CCGs as required. Information from complaints
provides direct data about services we commission and we use this information along with other
sources to drive service improvements and change. In targeted response to the complaints received
during Q1 and Q2 the Quality team has:




Liaised with the SWLCCG Complex Case team with regards to review of processes and
communication standards
Conducted a quality visit of the CCGs’ Wheelchair Services provider, producing an action plan
and requesting the provider conduct a patient experience survey
Conducted LPFT site quality visits
Visited the care home identified within a complaint to review the patient records along with
specific policies and procedures
Complaints received relating to General Practice are passed to NHS England (NHSE), as the
organisation with the management responsibility; this ensures that the complaints are managed with
no conflict of interest. The chart below details the themes of complaints received by NHSE regarding
SWLCCG GP Practices during Q1 and Q2 2016/17
GP Complaints Q1 & Q2
17%
8%
Failure to diagnose
/ delay in diagnosis
Dismissive / lack of
empathy
Clinical
42%
Practice Surgery /
Management
Communications /
Attitude
8%
25%
2
The Nursing and Quality Team is working with Optum CSU to develop and refine a dashboard, which
will include the number and the theme of GP Practice complaints in order to support the ongoing
monitoring and quality of performance in Primary Care.
4. Provider Quality Summary
Each of the core contracted providers is subject to a regular review of quality and patient safety
through existing quality review arrangements; the tables below identify the key themes for each
provider following their most recent quality review. The information is presented to members of the
governing body to aid understanding of the current position. The themes and issues are discussed
within the Quality and Patient Experience Committee (QPEC), with challenge to the providers being
agreed through this route as required.
The following information is provided to give members of the governing body a summary of the key
areas identified through existing quality monitoring systems.
Of particular note is the ongoing high level of vacancy rate within LCHS. Members of QPEC have
challenged the levels and requested further analysis of the data to better understand the pressures
and monitor risks for patients that may be attributable to areas where significant vacancies occur.
3
East Lincolnshire CCG lead on the contract management for United Lincolnshire Hospitals Trust and
have arrangements to review issues and performance on a monthly basis all partner CCGs are invited
to attend and contribute to the meetings. Quality matters are addressed within these meetings and all
CCGs support the quality initiatives across all sites. The SWLCCG nursing team have undertaken site
visits to Grantham A&E twice during the preceding three months, and have challenged the Trust upon
any issues identified. There are agreed processes for the day-to-day management of serious
incidents, through these systematic processes it is of note that challenge has been placed to the
organisation around the timeliness of investigation review and the associated responses. Continued
monitoring of this area has been agreed.
4
The CCG, as lead contract manager for LPFT, continues to maintain oversight of the progress against
the LPFT action plan which relates to the CQC inspection report, and was also invited to the oversight
meeting held by NHS Improvement. The oversight meeting detailed the specific progress against the
key areas of concern, significant progress and improvements were notes, although the challenge of
facilities for inpatient CAMH (Child & Adolescent Mental Health) services was noted. This area of
activity is commissioned by NHS England Specialised Commissioning, and as such does not fall
within the remit of the CCG, we have however requested to be included within further work around
this matter as the potential for continued failure of compliance will be reflected in future CQC
monitoring.
5
South Lincolnshire CCG lead on this contract, as they are the primary user of these facilities, however
some patients from SWLCCG do utilise this service. As with many NHS providers at present
recruitment and retention of staff remains a concern, with increased vacancy reporting during the last
quarter, SLCCG will continue to place scrutiny on the key areas of concern.
Nottingham University Hospitals
The Federated Quality Team does not routinely attend the quality review meetings for Nottingham
University hospitals; the contract lead for this provider is Nottingham CCG; and SWLCCG is invited to
attend. Given the challenges of local commitments attendance at the NUH meeting is targeted to
focus where there are known concerns. All papers are received and reviewed by the quality lead and
deputy chief nurse.
NUH are reporting a decline in A&E performance with patients undergoing protracted waits in A&E for
allocation of beds on assessment units and wards. Quarter 2 16/17 compliance with the 4 hour target
reached 72.10% in July and 69.70% in August 2016. Spikes in daily A&E attendance reaching up to
533 in number with an increase in attendances of 3.3% in Q1 and Q2 compared with the same period
last year are also reported. NUH advise that time to treatment times are also hovering around 70
minutes against the expected 60 minute standard and although this is not within the performance
tolerance, it does demonstrate that patients attending A&E are seen by a decision maker quickly,
despite the enormous pressures encountered.
5.
Primary Care: Practice Visits
During the last quarter there have been 3 practice visits undertaken with routine scheduled visits to
 Swingbridge
 Colsterworth
 Billinghay
6
These were scheduled review visits and no issues of significant concern were noted, although
continued dialogue is occurring in relation to access to medical practitioners if, for any reason
practices close during core hours.
In addition a number of supportive visits have been undertaken to St Johns Medical practice - the aim
of these visits was to both monitor progress against the actions required for CQC compliance and to
support the practice to achieve the required standards.
6.
Provider Quality Visits
The Nursing and Quality team monitor the quality and safety of provider services through a variety of
mechanisms including site visits. Actual observation of the care environment and the patient
experience through such visits is a useful practical and visual method of triangulating evidence and
giving assurance that service providers are meeting standards and are working within a quality
improvement approach.
The team has conducted a number of site visits predominantly to LPFT wards including The Rochford
Unit, Langworth Ward and Brant Ward, all of which provide care for older adults with a mental health
illness, Conolly Ward an acute adult mental health unit and open rehabilitation wards; The Wolds and
Maple Lodge. Initial feedback is given at the time of the visit outlining an overall impression with any
areas of concern escalated accordingly. Following each visit a report is compiled and agreed with the
provider and where required an action plan is produced. During the visits examples of good practice
have been observed including:






Calm and compassionate interaction with patients
Information for patients and visitors detailing access to advocacy, how to complain, carer and
support group networks, focus group details and organisational/ward quality priorities.
Information for patients detailing ‘You said and we did’
A focus upon engagement and support of family members to help to improve the patient
experience.
Use of individual patient ‘memory boxes’ containing highly meaningful items to be used during
activities and for reminiscence therapy.
Excellent examples of individualised care planning, activity planning and implementation.
7
GOVERNING BODY MEETING
Date of Meeting:
30 November 2016 – public session
Title of Report:
Report Author and Title:
Appendices:
Quarterly Quality Safeguarding Report
Jenny Harper, Interim Designate Nurse Safeguarding
Appendix 1- MAPPA Annual Report
1.
Agenda item:
8.
Purpose of the Report (including link to objectives)
The report is presented to provide assurance to members of the Governing Body that the statutory
functions of the CCG that relate to safeguarding are being addressed and completed in accordance with
national requirements.
2.
Recommendations
The Governing Body Members are requested to note the content of the report.
3.
Executive Summary
Across Lincolnshire the four local CCGs are required to ensure that a number of statutorily required
posts are filled, these include the Designated Nurse and Doctor posts for safeguarding children and for
Looked After Children as well as a Named Doctor/ GP for safeguarding. The four local CCGs have
agreed a ‘federated’ service model with one team fulfilling these requirements and working to the needs
of all CCGs.
The primary function of the FST is to gain assurance from provider organisations that they are meeting
their safeguarding duties/responsibilities. In addition the FST provide whole systems leadership and
development in relation to the safeguarding duties of the wider health economy in partnership with the
local safeguarding boards and offer targeted support to the CCGs in their roles in the commissioning
cycle.
GP Training
Level 3 Safeguarding Children training continues to be delivered by the Named GP – Dr Julian
Saggiorato on a monthly basis and Level 3 Safeguarding Adult training is delivered monthly by the
Interim Head of Safeguarding Adults
The uptake of children’s training for South West Lincolnshire CCG in Q2 is shown in table 1.
No CCG staff or associated member practice staff members have attended the adults safeguarding
training during quarter 2.
Attendees
Number
Total
9
GP
3
Nurse Practitioner
3
Practice Nurse
2
CCG Staff
1
Table1.- Children’s Safeguarding
1
Capacity within the Federated Safeguarding Team
Currently filled capacity within the team is:
1 x WTE (Interim) Designate Nurse Safeguarding (commenced 01-09-16).
1 x WTE Head of Safeguarding Adults (commenced 17-10-16)
1 x WTE Safeguarding adult/children Lead
1 x WTE Safeguarding Co-ordinator.
The team are supported by the Chief and Deputy Chief Nurse of South West Lincolnshire CCG as the
service is hosted within this CCG.
Although improving, capacity issues within the Federated Safeguarding team continue to be highlighted
on the organisational risk register.
Recruitment
A Designated Nurse for Safeguarding and LAC was recruited following the retirement of the previous
post-holder, however as previously reported to members of the governing body the successful candidate
withdrew- the post has now been filled for a fixed period with the substantive post-holder in the ‘Head of
Children’s Safeguarding’ undertaking the role in an interim position until the autumn of 2017. There are
plans in place to ensure backfill to the substantive role.
Interim support – FST
•
Specialist support and development of the team is currently being provided by an externally
commissioned safeguarding consultant who has been working with the team since April 2016.
The focus of this work has been primarily around process, innovation and leadership within
safeguarding.
Child Protection – Information Sharing project (CP-IS) update
Work is currently being undertaken with providers and local authority to implement CP-IS within health
and social care.
A strategic meeting with the CP-IS implementation team, LCC and CCG has recently taken place and
the 3 main health providers in Lincolnshire are to be invited to meet as a working group with their
Information Governance and Information Technology representatives to implement the system. A further
health community meeting has been held chaired by the FST to ensure processes are in place to
facilitate the implementation.
CP-IS is mandated to be implemented within Health services by 2018.
Joint Targeted Area inspection (JTAI)
The FST has recently been involved in a Multi-agency thematic inspection around Domestic Abuse
which concluded on Friday 21st October 2016. The Deputy Executive Nurse SWLCCG, Interim
Designate Nurse Safeguarding and Named Doctor safeguarding where interviewed by the Care Quality
Commission (CQC). Interviews with all health service providers and some GPs were undertaken. In
addition evidence was provided by Domestic Abuse support agencies to highlight positive outcome for
survivors of Domestic Abuse. Initial feedback from the CQC has been positive and has recognised that
the new FST team although in its infancy has undertaken new areas of innovative practice and has
shown success with GP training which has consequently improved support for GP practices and timely
referral to MARAC and Social Care.
Multi-Agency Public Protection Arrangements (MAPPA)
There is a legal duty placed on health services, whether commissioners or providers, to co-operate and
support the local MAPPA arrangements, under the Criminal Justice Act (2003).
2
In order to support these duties the CCGs locally fund a proportion of the MAPPA budget in order to
ensure delivery of required strategic and operational planning and delivery. In addition the Chief Nurse
for South West Lincolnshire CCG represents the four local CCGs on the Strategic Management Board
SMB for MAPPA to support the continued multi-agency planning and development of an annual business
plan. The activities of MAPPA locally are required to be presented within an annual report 1- this is
available at the link below for information.
4.
Management of Conflicts of Interest
Not applicable for this report.
5.
Finance, QIPP and Resource Implications
The Team are not currently at capacity. The FST are therefore reviewing their work plan and prioritising
work streams according to risk.
6.
Legal/NHS Constitution Considerations
The statutory standards for safeguarding children are detailed within the Children Act (1989, 2004) and
statutory guidance, Working Together to Safeguard Children (revised 2015) and Promoting the Health
and Wellbeing of Looked After Children (revised 2015)
The statutory standards for safeguarding adults are detailed within the Care Act (2014)
The PREVENT strategy, in accordance with statutory guidance issued under section 29 of the CounterTerrorism and Security Act 2015, details our duty to have due regard to the need to prevent people from
being drawn into terrorism.
In addition the organisational responsibilities are made clear within the Mental Capacity Act (2005) (MCA
2005) and the Deprivation of Liberty Safeguards (2007).
The CQC continue to have oversight of the safeguarding function. The FST works closely with the CQC
and shares intelligence when required in the interest of those using statutory health and health funded
care services in Lincolnshire.
7.
Analysis of Risk including Assessments
Risks identified within this paper include the continued vacancies within the FST which may impact on
the ability to perform all statutory functions. Daily liaison is taking place between the Chief Nurse and
Deputy Chief Nurse to assess risk, prioritise and undertake those duties which ensure the immediate
safeguarding responsibilities are met. This item remains on the CCG Risk register.
Please state if the risk is on the CCG Risk Register.
8.
Yes
x
No
Outline engagement – clinical, stakeholder and public/patient
The report has been compiled though information sharing and partnership working to safeguard across
the NHS economy and social care within Lincolnshire.
1
Appendix 1 - MAPPA Annual Report
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/562766/Lincolnshire.pdf
3
9.
Outcome of Impact Assessments
DUE REGARD TO THE PROACTIVE DUTIES OF THE EQUALITY ACT 2010 HAS BEEN TAKEN IN
DEVELOPMENT OF THIS PAPER AND:
Either: Due Regard is not applicable because this is an update of the progress on the Equality
Objectives. (The Equality Objectives inherently include Due Regard)
Or: Due Regard is applicable and the following work has been undertaken:
NOTE: Policies/decisions may need to be adjusted in line with any Equality Analysis or Due Regard that
is brought back at a future date. Any decision that is finalised without being influenced by appropriate
Due Regard could be deemed unlawful.
Effective safeguarding is underpinned by the reducing health inequalities agenda, recognising that
vulnerable individuals and families require support to gain resilience to effectively safeguard themselves
and live full lives, free from abuse and neglect.
10.
Assurance Departments/Organisations who will be affected have been consulted
Insert details of the departments you have worked with or consulted during the process:
Finance
Commissioning
Contracting
Medicines Optimisation
Clinical Leads
Quality
Safeguarding
Other
11.
x
x
Report previously presented at:
This report provides information on any changes/updates occurring over the past quarter from previous
reports.
12.
For further information or for any enquiries relating to this report, please contact
Please contact:
Mrs J Harper, Designated Nurse - Safeguarding Children, Adults and LAC (Interim) or the Federated
Safeguarding Team Via [email protected]
4
Lincolnshire
Annual Report
1
Intro
Welcome to the 2015/2016 Lincolnshire Multi-Agency
Public Protection Arrangements (MAPPA) Annual
Report.
Peter Wright has, for the period covered by the report,
been chair of the Strategic Management Board and
has had overall responsibility for directing
improvements in the quality of work being undertaken
within MAPPA. Peter brought to MAPPA a breath of
knowledge and level of energy that has been much
appreciated and will be missed both here and across
the wider partnership arena. We wish him all the best
in his new career with Nottingham Health.
Neil Rhodes, Chief Constable, Lincolnshire Police
During the year we have seen consistently high levels
of engagement from a range of agencies in the
management of those who present the highest levels
of risk to the public. Inter-agency working has been
supported by the launch of a series of training events
delivered through the MAPPA office. This has been
reflected in the many positive outcomes which have
been achieved for victims and potential victims of
seriously violent crime.
Peter Adey
Head of Function
National Probation Service
East and West
Lincolnshire
What this report highlights how statutory, private sector
and voluntary agencies work together to manage the
risk presented by sexual and violent offenders who are
due to be released from custody, or who are already
living in the community.
Such offenders, subject to MAPPA, are often
challenging in themselves and present a range of
complex and at times intractable issues which are
necessary to understand and manage to prevent
further victims in our communities. By ensuring
effective identification of MAPPA eligible offenders,
sharing information, assessing and managing risks,
MAPPA serves to minimise the likelihood of reoffending and helps to prevent further victims in our
communities.
Peter Wright, Governor, HMP Lincoln
We would like to thank all the partner agencies and
their staff for the time given to making MAPPA work so
effectively in Lincolnshire. Their dedication is key to
ensuring our local communities remain safe.
Peter Adey
Head of Function
National Probation Service
1
What is MAPPA?
MAPPA background
How MAPPA works
(a) MAPPA (Multi-Agency Public Protection
Arrangements) are a set of arrangements to
manage the risk posed by the most serious sexual
and violent offenders (MAPPA-eligible offenders)
under the provisions of sections 325 to 327B of
the Criminal Justice Act 2003.
 MAPPA-eligible offenders are identified and
information about them is shared by the agencies in
order to inform the risk assessments and risk
management plans of those managing or supervising
them.
 In the majority of cases that is as far as MAPPA
extends but in some cases, it is determined that
active multi-agency management is required. In such
cases there will be regular MAPPA meetings
attended by relevant agency practitioners.
(b) They bring together the Police, Probation and
Prison Services in each of the 42 Areas in
England and Wales into what is known as the
MAPPA Responsible Authority.
 There are 3 categories of MAPPA-eligible offender:
Category 1 - registered sexual offenders; Category
2 – (in the main) violent offenders sentenced to
imprisonment for 12 months or more; and Category
3 – offenders who do not qualify under categories 1
or 2 but who currently pose a risk of serious harm.
(c) A number of other agencies are under a Duty To
Co-operate (DTC) with the Responsible Authority.
These include Social Services, Health Trusts,
Youth Offending Teams, Jobcentre Plus and
Local Housing and Education Authorities.
(d) The Responsible Authority is required to appoint
two Lay Advisers to sit on each MAPPA area
Strategic Management Board (SMB) alongside
senior representatives from each of the
Responsible Authority and duty to co-operate
agencies.
 There are three management levels intended to
ensure that resources are focused upon the cases
where they are most needed; generally those
involving the higher risks of serious harm. Level 1
involves ordinary agency management (i.e. no
MAPPA meetings or resources); Level 2 is where the
active involvement of more than one agency is
required to manage the offender but the risk
management plans do not require the attendance
and commitment of resources at a senior level.
Where senior oversight is required the case would be
managed at Level 3.
(e) Lay Advisers are members of the public with no
links to the business of managing MAPPA
offenders and act as independent, yet informed,
observers; able to pose questions which the
professionals closely involved in the work might
not think of asking. They also bring to the SMB
their understanding and perspective of the local
community (where they must reside and have
strong links).
MAPPA is supported by ViSOR. This is a national IT
system for the management of people who pose a
serious risk of harm to the public. The police have
been using ViSOR since 2005 but, since June 2008,
ViSOR has been fully operational allowing, for the first
time, key staff from the Police, Probation and Prison
Services to work on the same IT system, thus
improving the quality and timeliness of risk
assessments and of interventions to prevent offending.
The combined use of ViSOR increases the ability to
share intelligence across organisations and enable the
safe transfer of key information when these high risk
offenders move, enhancing public protection
measures. All MAPPA reports from England and
Wales are published online at: www.gov.uk
2
MAPPA Statistics
MAPPA-eligible offenders on 31 March 2016
Category 1:
Registered sex
offenders
Category 2:
Violent
offenders
Category 3:
Other dangerous
offenders
Total
Level 1
657
170
-
827
Level 2
4
3
0
7
Level 3
0
0
0
0
661
173
0
834
Total
MAPPA-eligible offenders in Levels 2 and 3 by category (yearly total)
Category 1:
Registered sex
offenders
Category 2:
Violent
offenders
Category 3:
Other dangerous
offenders
Total
Level 2
31
17
25
73
Level 3
12
3
0
15
Total
43
20
25
88
RSOs cautioned or convicted for breach of notification requirements
99
RSOs who have had their life time notification revoked on application
9
Restrictive orders for Category 1 offenders
SHPOs, SHPOs with foreign travel restriction & NOs imposed by the courts
SHPO
17
SHPO with foreign
travel restriction
0
NOs
1
Number of people who became subject to notification requirements following a
breach(es) of a Sexual Risk Order (SRO)
3
0
Level 2 and 3 offenders returned to custody
Category 1:
Registered sex
offenders
Category 2:
Violent
offenders
Category 3:
Other dangerous
offenders
Total
Level 2
4
4
0
8
Level 3
0
1
0
1
Total
4
5
0
9
Level 2
0
-
-
0
Level 3
1
-
-
1
Total
1
-
-
1
Breach of licence
Breach of SOPO
Total number of Registered Sexual Offenders per 100,000 population
101
This figure has been calculated using the Mid-2015 Population Estimates: Single year of age and sex for Police Areas
in England and Wales; estimated resident population, published by the Office for National Statistics on 23 June 2016,
excluding those aged less than ten years of age.
4
Explanation
commentary on
statistical tables
(e) Breach of licence – offenders released into the
community following a period of imprisonment of 12
months or more will be subject to a licence with
conditions (under probation supervision). If these
conditions are not complied with, breach action will be
taken and the offender may be recalled to prison.
MAPPA background
The totals of MAPPA-eligible offenders, broken down
by category, reflect the picture on 31 March 2016 (i.e.
they are a snapshot). The rest of the data covers the
period 1 April 2015 to 31 March 2016.
(f) Sexual Harm Prevention Order (SHPO) –
(replaced Sexual Offence Prevention Orders)
including any additional foreign travel restriction.
(a) MAPPA-eligible offenders – there are a number
of offenders defined in law as eligible for MAPPA
management, because they have committed specified
sexual and violent offences or they currently pose a
risk of serious harm, although the majority (x% this
year) are actually managed under ordinary agency
(Level 1) arrangements rather than via MAPP
meetings.
Sexual Harm Prevention Orders (SHPOs) and interim
SHPOs are intended to protect the public from
offenders convicted of a sexual or violent offence who
pose a risk of sexual harm to the public by placing
restrictions on their behaviour. It requires the offender
to notify their details to the police (as set out in Part 2
of the 2003 Act) for the duration of the order.
(b) Registered Sexual Offenders (RSOs) – those
who are required to notify the police of their name,
address and other personal details and to notify any
changes subsequently (this is known as the
“notification requirement.”) Failure to comply with the
notification requirement is a criminal offence which
carries a maximum penalty of 5 years’ imprisonment.
The court must be satisfied that an order is necessary
to protect the public (or any particular members of the
public) in the UK, or children or vulnerable adults (or
any particular children or vulnerable adults) abroad,
from sexual harm from the offender. In the case of an
order made on a free standing application by a chief
officer or the National Crime Agency (NCA), the chief
officer/NCA must be able to show that the offender has
acted in such a way since their conviction as to make
the order necessary.
(c) Violent Offenders – this category includes violent
offenders sentenced to imprisonment or detention for
12 months or more, or detained under a hospital order.
It also includes a small number of sexual offenders
who do not qualify for registration and offenders
disqualified from working with children.
The minimum duration for a full order is five years. The
lower age limit is 10, which is the age of criminal
responsibility, but where the defendant is under the
age of 18 an application for an order should only be
considered exceptionally.
(d) Other Dangerous Offenders – offenders who do
not qualify under the other two MAPPA-eligible
categories, but who currently pose a risk of serious
harm which requires management via MAPP
meetings.
(g) Notification Order – this requires sexual offenders
who have been convicted overseas to register with the
police, in order to protect the public in the UK from the
risks that they pose. The police may apply to the court
for a notification order in relation to offenders who are
already in the UK or are intending to come to the UK.
5
(h) Sexual Risk Order (incl. any additional foreign
travel restriction)
The Sexual Risk Order (SRO) replaced the Risk of
Sexual Harm Order (RoSHO) and may be made in
relation to a person without a conviction for a sexual or
violent offence (or any other offence), but who poses a
risk of sexual harm.
A breach of a SRO is a criminal offence punishable by
a maximum of five years’ imprisonment. Where an
individual breaches their SRO, they will become
subject to the full notification requirements.
The SRO may be made at the magistrates’ court on
application, by the police or NCA where an individual
has done an act of a sexual nature and the court is
satisfied that the person poses a risk of harm to
the public in the UK or children or vulnerable
adults overseas.
(i) Lifetime notification requirements revoked on
application
Change in legislation on sexual offenders
A legal challenge in 2010 and a corresponding
legislative response means there is now a mechanism
in place which will allow qualifying sex offenders to
apply for a review of their notification
requirements.
Nominals made subject of a SRO are now recorded on
VISOR, as a Potentially Dangerous Person (PDP).
A SRO may prohibit the person from doing anything
described in it – this includes preventing travel
overseas. Any prohibition must be necessary to
protect the public in the UK from sexual harm or, in
relation to foreign travel, protecting children or
vulnerable adults from sexual harm.
Individuals subject to indefinite notification will only
become eligible to seek a review once they have been
subject to the indefinite notification requirements for a
period of at least 15 years for adults and 8 years for
juveniles. This applies from 1 September 2012 for
adult offenders
An individual subject to an SRO is required to notify
the police of their name and home address within three
days of the order being made and also to notify any
changes to this information within three days.
A SRO can last for a minimum of two years and has no
maximum duration, with the exception of any foreign
travel restrictions which, if applicable, last for a
maximum of five years (but may be renewed).
The criminal standard of proof continues to apply, the
person concerned is able to appeal against the making
of the order, and the police or the person concerned
are able to apply for the order to be varied, renewed or
discharged.
On 21 April 2010, in the case of R (on the application of F and Angus Aubrey Thompson) v Secretary of State for the
Home Department [2010] UKSC 17, the Supreme Court upheld an earlier decision of the Court of Appeal and made a
declaration of incompatibility under s. 4 of the Human Rights Act 1998 in respect of notification requirements for an
indefinite period under section 82 of the Sexual Offences Act 2003.
This has been remedied by virtue of the Sexual Offences Act 2003 (Remedial) Order 2012 which has introduced the
opportunity for offenders subject to indefinite notification to seek a review; this was enacted on 30th July 2012.
Persons will not come off the register automatically. Qualifying offenders will be required to submit an application to the
police seeking a review of their indefinite notification requirements. This will only be once they have completed a minimum
period of time subject to the notification requirements (15 years from the point of first notification following release from
custody for the index offence for adults and 8 years for juveniles).
Those who continue to pose a significant risk will remain on the register for life, if necessary. In the event that an offender
is subject to a Sexual Offences Prevention Order (SOPO)/Sexual Harm Prevention Order (SHPO) the order must be
discharged under section 108 of the Sexual Offences Act 2003 prior to an application for a review of their indefinite
notification requirements.
For more information, see the Home Office section of the gov.uk website:
https://www.gov.uk/government/publications/sexual-offences-act-2003-remedial-order-2012
6
Local page
National Probation Service - NE Division
Public Protection – A Priority
Lucia Saiger-Burns
Head of Public Protection
NPS NE Division
2015/2016 has been another year of change for the
NPS. Public Protection has continued to be delivered
through the very strong, positive partnership work
guided by the MAPPA Strategic Management Boards
in all NE areas in the Division.








National developments are coming to fruition
through the dynamic process embedded within
the NPS of E3 - Excellence Efficiency and
Effectiveness. E3 is a national programme of
organisational change to ensure consistent
processes and service delivery throughout
England and Wales and is led by the seven
Deputy Directors in England and Wales and the
Deputy Director responsible for Business
Development.
Changes will include improvements in Approved
premises which will see the introduction of
Psychologically
Informed
Enabling
Environments along with dedicated Key workers
for all residents who will work in partnership with
Probation Officers in the Community.
The MAPPA Website is now fully developed and
in use and used regularly. Practitioners can also
join the MAPPA community to share ideas with
each other to manage some of the most
challenging offenders in society.
Other developments in MAPPA which will
conclude going forward is a revision of MAPPA
Guidance , MAPPA eligibility and a review of
ViSOR which will focus on a consistent business
model for NPS in the future which will maximise
the use of ViSOR wherever possible.
NPS have introduced the Active Risk
Management System in partnership with Police.
NPS NE have provided staff with guidance on
dealing with Child Sexual Exploitation (CSE)
and this is a priority area of work for us all in
identifying perpetrators and victims.
We have also provided more training in Risk
Management and will now focus training on
ways of working with those convicted of sexual
offences who are subject to community
supervision. This will be carried out alongside
the move to a Divisional Sex Offender
Treatment Programme Team who will deliver all
Court Orders for Sex Offender Treatment.
In the next 12 months activity will continue to
build on the E3 organisational model ensuring
Excellence Efficiency and Effectiveness.
7
Achievements 2015/16

Attendance at and engagement with
Lincolnshire MAPPA continues to be very
positive for all agencies at all levels

The MAPPA Re-inspection, undertaken by
HMIC and HMIP, identified a number of
improvements in relation to MAPPA processes
and procedures and there is an Action Plan in
place to implement the recommendations



Key Priorities 2016/17
A rolling multi-agency MAPPA training
continues to be well attended and receive
good feedback
MAPPA Level 1 meetings have been
implemented and are being undertaken on a
regular basis, particularly by Probation
A MAPPA Level 1 database has been devised
and implemented to assist both the MAPPA
Unit and NPS in meeting significant milestones
in the management of cases

A number of VISOR administrators have now
been trained within the NPS and this has
ensured that there is better access to this
system for Offender Managers and a more
robust back up in times of leave or absence for
the VISOR administrator

Lincolnshire MAPPA continues to engage with
other strategic boards such as the Adult
Safeguarding and Child Safeguarding Boards,
as well as the Public Protection Board and the
Prevent Steering Group

NPS staff trained in Lincolnshire have
completed their Active Risk Management
System training; they are now starting to
complete these assessments with Lincolnshire
Police Management of Sexual and Violent
Offenders Officers and this is improving
communication between the two agencies
8

Provide further support and guidance in
relation to the Active Risk Management
System and how this will work between Police
and NPS

Implement and embed the new MAPPA
Guidance, there will be significant updates on
the mental health chapter and it is important
that all agencies, particularly mental health,
have a good understanding of the changes

Develop a process between mental health
providers and MAPPA to ensure everyone is
aware of their responsibilities, including Level
1 reviews

Maintain excellent performance against local
and national targets

Progress the use of Integrated Offender
Management as an intervention for managing
Category 2 offenders at Level 2 and 3
All MAPPA reports from England and Wales are published online at:
www.gov.uk
GOVERNING BODY MEETING
Date of Meeting:
30 November 2016 – public session
Title of Report:
Report Author and Title:
Appendices:
SWLCCG Monthly Governing Body Report
Ramesh Prema – Performance Manager (Optum)
Appendix A – South West Lincolnshire Performance Report
1.
Agenda item:
9.
Purpose of the Report (including link to objectives)
This report provides an overview of performance from April – September 2016. It is based on national
guidance and covers indicators within Everyone Counts Guidance.
2.
Recommendations
The Governing Body members are asked to:
Note current performance. The report provides a dashboard and reports indicators by exception, with
additional detail and improvement narrative provided where performance is below expected levels.
3.
Executive Summary
This month’s report is based on data from September 2016.
Performance Summary
Urgent Care
Targets failed for A&E, EMAS and Ambulance Handovers.
•
A&E: CCG level performance deteriorated in September and remains below the standard.
Performance at ULHT was for the fourth consecutive month, below the submitted trajectory and
performance at Lincoln remains challenging. The Urgent Care Working Group continues to
monitor and action a wide range of strategic actions which support the A&E Improvement Plan.
•
Actions: A CPN (Contract Performance Notice) is in place at ULHT and performance remains
below STP trajectories for 16/17.
•
Significant Concern – target failures for A&E at CCG and provider level, Ambulance
handovers and EMAS
Planned Care
Key targets failed across different areas.
•
•
RTT incompletes failed at CCG level and at ULHT for SWLCCG patients . Action plans are in
place to address performance in General Surgery, Orthopaedics and Cardiology. Neurology;
NUH have served notice on the two visiting consultants, this will have an impact on ULHT
st
capacity. As a result a decision has been made to close the service to new referrals from 1
December 2016 .
One 52 week breach has been reported for September (SWLCCG patient at Grantham A&E update to be provided next month). There were four HCAI’s in September, two more than
projected. Year to date performance is now above the trajectory by two cases.
1
•
•
There was a potential Never Event at Grantham, it is however currently being treated as a
Serious Learning Event following review at the SI/Never Event review panel meeting, an update
is expected next month.
Significant Concern – target failures for : RTT Incompletes, HCAI’s cancelled operations at
ULHT and NUH (Q2).
Cancer Care
Some key standards were not met at CCG or provider level.
•
Three of the nine cancer indicators are below standard for SWLCCG , only three of the standards
were not met at ULHT, a significant improvement on the previous month when five of the
standards were not met . Overall, performance in September improved at CCG level from
August’s. The two week wait for breast symptoms achieved 88.80% at ULHT, having achieved
only 26.30% in August.
•
Actions: A CPN is in place at ULHT and NUH for Cancer.
•
Concern remain as performance is below the standard in September for some of the
indicators at CCG level and at ULHT, sustainability is also an on -going issue.
Mental Health
4.
•
Based on the latest NHS Digital published data (up to April 2016), standards for IAPT were
met, (LPFT have provided predicted data for May- Sept).
•
Based on the latest predicted data the IAPT standard for Access is predicted to achieve for the
first time since April 2016.
•
Dementia remains a challenge with performance significantly below the performance standard.
•
Actions: A range of plans are in place to address both IAPT and dementia performance.
•
Dementia remains a concern as performance has shown no real sign of improvement, the
trajectory for achievement is now March 2017.
Management of Conflicts of Interest
Not applicable.
5.
Finance, QIPP and Resource Implications
Not applicable.
6.
Legal/NHS Constitution Considerations
Not applicable.
7.
Analysis of Risk including Assessments
This section should identify known or potential risks and how these are being mitigated, including
conflicts of interest.
Please state if the risk is on the CCG Risk Register.
Yes
2
√
No
8.
Outline engagement – clinical, stakeholder and public/patient
Not applicable.
9.
Outcome of Impact Assessments
Not applicable.
10.
Assurance Departments/Organisations who will be affected have been consulted
Insert details of the departments you have worked with or consulted during the process:
Finance
Commissioning
Contracting
Medicines Optimisation
Clinical Leads
Quality
Safeguarding
Other
x
11. Report previously presented at:
The performance report is presented to the Governing Body at each meeting.
12. For further information or for any enquiries relating to this report, please contact
Ramesh Prema – Performance Manager (Optum)
[email protected] Tel 01476 406187
3
South West Lincolnshire – Monthly Governing Body Report - November 2016 (September 2016 data)
1
Contents
• Introduction
3
• Executive Summary
4
• Urgent Care
5
• Planned Care
10
• Cancer Care
14
• Mental Health
18
2
Introduction
The Governing Body Report provides assurance to the CCG on the
achievement of its constitutional and governance standards. This report focuses
on achievement of the monthly reported standards.
The quarterly Governing Body Report contains more detailed information on the
frameworks listed below, which are also referenced against specific measures in
this report.
• NHS Constitution - Updated monthly
• Quality Premium - Updated quarterly
• Better Care Fund - Updated quarterly
• NHS Outcomes Framework - Updated quarterly
• Everyone Counts (Outcomes Measures ) - Updated quarterly
This report organises the standards into healthcare system groupings i.e. Urgent
Care, Planned Care, Cancer Care and Mental Health in order to enable ease of
commentary, oversight and assurance on system problems.
3
Executive Summary
Significant concern
Moderate concern
No concern
Targets failed for A&E, EMAS and Ambulance Handovers.
Urgent Care
• A&E: CCG level performance deteriorated in September and remains below the standard. Performance at ULHT was for the fourth
consecutive month, below the submitted trajectory and performance at Lincoln remains challenging. The Urgent Care Working Group
continues to monitor and action a wide range of strategic actions which support the A&E Improvement Plan.
• Actions: A CPN (Contract Performance Notice) is in place at ULHT and performance remains below STP trajectories for 16/17.
• Significant Concern – target failures for A&E at CCG and provider level, Ambulance handovers and EMAS.
Key targets failed across different areas.
• RTT incompletes failed at CCG level and at ULHT for SWLCCG patients . Action plans are in place to address performance in General Surgery,
Orthopaedics and Cardiology. Neurology; NUH have served notice on the two visiting consultants, this will have an impact on ULHT capacity.
As a result a decision has been made to close the service to new referrals from 1 st December 2016 .
Planned Care
• One 52 week breach has been reported for September (SWLCCG patient at Grantham - update to be provided next month). There were four
HCAI’s in September two more than projected. Year to date performance is now above the trajectory by two cases.
• There was a potential Never Event at Grantham, it is however currently being treated as a Serious Learning Event following review at the
SI/Never Event review panel meeting, an update is expected next month.
• Significant Concern – target failures for : RTT Incompletes, HCAI’s cancelled operations at ULHT and NUH (Q2).
Some key standards were not met at CCG or provider level.
Cancer Care
• Three of the nine cancer indicators are below standard for SWLCCG , only three of the standards were not met at ULHT, a significant
improvement on the previous month when five of the standards were not met . Overall, performance in September improved at CCG level
from August’s. The two week wait for breast symptoms achieved 88.80% at ULHT, having achieved only 26.30% in August.
• Actions: A CPN is in place at ULHT and NUH for Cancer.
• Concern remain as performance is below the standard in September for some of the indicators at CCG level and at ULHT,
sustainability is also an on -going issue.
Based on the latest NHS Digital published data (up to April 2016), standards for IAPT were met, (LPFT have provided predicted data
for May- Sept).
• Based on the latest predicted data the IAPT standard for Access is predicted to achieve for the first time since April 2016.
Mental Health
• Dementia remains a challenge with performance significantly below the performance standard.
• Actions: A range of plans are in place to address both IAPT and dementia performance.
• Dementia remains a concern as performance has shown no real sign of improvement, the trajectory for achievement is now March
2017.
4
Urgent Care – Overview
ULHT A&E
• A&E four hour wait performance at CCG level deteriorated
in September (85.23%) from August (86.83%) ,
performance remains below the 95% standard. A&E
performance improved at ULHT in September (78.40% ),
August (77.80%), but remains below the submitted
trajectory (85%) for September.
• There has been continued demand pressures with the
subsequent impact on the reliance on escalation beds and
cancelled operations.
EMAS
• At a regional level, performance for all three standards
continues to be below the national standards and below
the revised stretched trajectories. The CPN remains in
place. September performance deteriorated for all three
measures.
• As a Division, Lincolnshire is not achieving national
standards for the month or the year to date. Lincolnshire
did not achieve the divisional minimum performance
trajectories for all three standards in September.
• Performance at Lincoln remains poor at 74.75% against a
trajectory of 88.70%. Reliance on locum staffing,
particularly for night shifts has seen increased numbers of
breaches throughout the night continuing.
-
• Grantham performance improved to 97.14% (4.84% over
trajectory).
• There was a significant deterioration in performance at
South West Lincolnshire; Red 1, 61.30% (down 16%).
Red 2, 53.40% (down 6.8%) and A19, 62.80% (down
8.4%).
• The internal improvements and improvements in flow
should return performance to the April/May levels of 8085%. This improvement could be offset if ULHT fail to
recruit.
• The A&E department has a major improvement plan in
progress to secure the necessary changes to improve
performance and quality. The programme has two facets
(a) Access and (b) Flow. The programme of work has a
strict governance and accountability framework for actions
and reports through the Chief Operating Officer to the
Trust’s Chief Executive.
-
NHS111
• Calls answered within 60 seconds did not
meet the target in September (94.21%)
against the 95% standard, year to date
performance is still red (93.18%).
• Abandoned calls after 30 seconds met the
target in September (1.25%) for the fifth
consecutive month.
Red 1 Performance for September saw an improvement
but is still below the same period last year.
Red 2 and Red A19 performance is lower than
September and the same period last year.
• There are a number of factors that have been reported by
EMAS as having a negative impact on performance in
September including the closure of A&E at Grantham.
• EMAS have reported that ambulances have a much
longer travelling time now to Lincoln, Pilgrim or indeed
Peterborough and Nottingham. They have also reported
that an increasing number of patients are refusing to go to
Lincoln/Pilgrim and choosing to go to
Peterborough/Nottingham which is adding even more
travel time.
• No trolley waits were reported in September for SWLCCG
patients.
• Handovers: The number of handover delays of greater
than 30 and 60 minutes fell in September at Grantham
(the lowest levels seen this year).
5
Urgent Care – A&E performance (including NHS Constitution)
CCG A&E
Description
Target
A&E Waiting Time - % of people w ho spend 4 hours or
less in A&E (SUS - CCG)
Oct 15
Nov 15 Dec 15 Jan 16
Feb 16 Mar 16 Apr 16 May 16 Jun 16
Jul 16
Aug 16 Sep 16
YTD
95% 92.04% 90.65% 85.46% 85.79% 84.78% 84.11% 85.37% 85.31% 83.42% 84.92% 86.83% 85.23% 85.18%
ULHT A&E – Trust Position
Description
Target
Submitted Trajectory 16/17 - A&E Waiting Time
A&E Waiting Time - % of people w ho spend 4 hours or
less in A&E (ULHT)
Oct 15
Nov 15 Dec 15 Jan 16
Feb 16 Mar 16 Apr 16 May 16 Jun 16
89.0%
Jul 16
Aug 16 Sep 16
YTD
76.60% 82.00% 82.00% 84.00% 84.00% 85.00% 81.72%
95% 86.41% 86.52% 84.88% 82.73% 81.07% 80.32% 80.54% 83.52% 81.18% 78.56% 77.80% 78.40% 80.00%
PSHFT / NUH A&E – Trust Position
Description
Target
Dec 15 Jan 16
Feb 16 Mar 16 Apr 16 May 16 Jun 16
Jul 16
Aug 16 Sep 16
YTD
Submitted Trajectory 16/17 - A&E Waiting Time
96.00%
A&E Waiting Time - % of people w ho spend 4 hours or less in A&E
(PSHFT)
95.00% 91.63% 87.24% 81.11% 75.38% 76.11% 79.15% 83.46% 74.90% 89.07% 86.13% 81.47%
A&E Waiting Time - % of people w ho spend 4 hours or less in A&E
(NUH)
95.00% 80.49% 76.22% 74.45% 76.33% 78.16% 75.00% 71.01% 72.16% 69.70% 81.25% 74.55%
74.00% 74.00% 77.00% 80.00% 83.00% 86.00% 79.00%
Ambulance Handovers
Description
Ambulance handover time - Number of handover delays of >30 minutes
(Grantham)
Ambulance handover time - Number of handover delays of >1 hour
(Grantham)
Target
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
YTD
0
84
73
121
125
129
135
87
134
114
98
66
31
530
0
18
13
30
33
24
39
20
36
21
16
12
2
107
Trolley Waits – Trust Position
Description
Trolley waits in A&E - Number of patients who have waited over
12 hours in A&E from decis ion to admit to admis s ion (ULHT)
Trolley waits in A&E - Number of patients who have waited over
12 hours in A&E from decis ion to admit to admis s ion (PSHFT)
Trolley waits in A&E - Number of patients who have waited over
12 hours in A&E from decis ion to admit to admis s ion (NUH)
Target
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16 Sep 16
YTD
0
0
0
0
0
0
0
1
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
2
2
1
0
1
0
2
0
0
3
6
Urgent Care – Constitution Indicators
Description
National Standard
End of
Year
Target Apr-16 May-16 Jun-16
75%
Lincolnshire Trajectory 16/17 -Category A
(Red 1) 8 minute response time
Lincolnshire 16/17 actual
81.60%
Category A (Red 1 ) (CCG)
National Standard
71.80%
Category A (Red 2) (CCG)
National Standard
Lincolnshire Trajectory 16/17 -Category A
19 minute response time
Lincolnshire 16/17 actual
Category A 19 (CCG)
75%
75%
Jul-16 Aug-16 Sep-16
75%
75%
75%
YTD
75%
67.40% 71.90% 75.40% 74.80% 74.40% 74.80% 73.12%
72.60% 68.00% 72.80% 71.70% 68.40% 70.40% 70.65%
61.50% 52.80% 57.60% 73.10% 77.30% 61.30% 63.93%
75%
Lincolnshire Trajectory 16/17 -Category A
(Red 2) 8 minute response time
Lincolnshire 16/17 actual
75%
75%
75%
75%
75%
75%
75%
75%
52.90% 64.40% 70.80% 70.60% 68.60% 70.60% 66.32%
62.90% 66.40% 56.70% 56.40% 62.10% 60.00% 60.75%
59.20% 60.30% 49.00% 50.10% 55.60% 53.40% 54.60%
95%
95%
95%
95%
95%
95%
95%
95%
89.00% 82.90% 81.20% 81.20% 79.10% 81.20% 82.43%
84.60%
82.90% 84.10% 76.00% 73.10% 79.50% 76.70% 78.72%
74.20% 76.60% 65.00% 64.40% 71.20% 62.80% 69.03%
NHS 111
Description
Target
Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun-16 May 18 Jul-16 Aug-16 Sep-16
YTD
NHS 111 - % Abandoned Calls after 30 seconds (Lincolnshire)
<5% 1.00% 0.51% 2.55% 0.78% 1.38% 5.17% 2.22% 1.13% 1.07% 1.89% 1.89% 0.84% 1.25% 1.38%
NHS 111 - % Calls answered within 60 seconds (Lincolnshire) 95.00% 93.15% 95.53% 95.05% 94.25% 90.58% 77.58% 88.73% 93.97% 95.20% 91.68% 91.68% 95.31% 94.21% 93.18%
7
Urgent Care – Provider A&E Activity
•
A&E activity peaked in March and May 2016 at ULHT and in July at PSHFT and August at NUH. A&E attendances
fell at ULHT in August by 8% after a busy July.
8
Urgent Care – Issues and Actions
ULHT – A&E
•
The Trust is focusing its efforts on three key areas –
SAFER, meeting ward discharge volumes and stabilisation
of the minors stream and performance. Furthermore, the
Trust has brought in temporary dedicated “turnaround”
expertise to Pilgrim and Lincoln sites to help improve
performance and safety. Externally, the demand into the
Trust continues to restrict delivery, therefore, this is being
addressed with commissioners through the contracting
route.
EMAS
• Protocols for Grantham Hospital have been drafted
with patients with MEWS (Modified Early Warning
Scores) scores of five or above not being taken to
Grantham. The Urgent Care Board is to confirm
drafts have been agreed.
• An audit of inter-facility transfers has been agreed at
Grantham Hospital, which will take place in Q2
2016/17. Grantham A&E is now closed overnight.
•
At Lincoln, some success with recent adverts to fill middle
grade roles will mean a more sustainable rota and the
trajectory presented as part of the STP – based mainly on
improving flow – will be back in place. With current
improvements, the performance should be sustained and a
return to the STP trajectory is achievable for November.
• There were joint plans in place between EMAS and
ULHT to address the handover problems with the
aim of no one-hour breaches by the end of October.
This deadline was not hit and the A&E Recovery
Board is working with ULHT and EMAS on an
update.
•
Improvement in quality of consultant locum staffing allowed
an option of moving two associate specialists who were
acting up, back to middle grade rota to support. Grantham
middle grades are now also supporting the rota. Additional
middle grade is being put on for evenings / nights on busy
days (Friday – Tuesday) where possible. A&E Risk tool is
now live and the Operations Centre are monitoring and
sourcing additional doctors from wards to support A&E
when required. MEAU consultants reviewing medical
patients are remaining in A&E first thing in the mornings.
• The current EPRF (Electronic Patient Report Form)
system is centrally funded by the Department of
Health and should have ended on the 7th July 2016,
however CCGs provided interim funding. EMAS
have asked the CCG’s to fund £30k/month as the
region (£5k/month per CCG) from October to
December with the possibility of supporting it until
March 2017. Negotiations are on-going.
•
Grantham performance improved due to changes in
working practices. Team working now fully embedded,
triage within 15 minutes improving and first assessment
due to creation of dedicated see and treat room next to
triage room. Weekly team meeting to review performance
and progress of actions improving team leadership and
responsibility.
NHS111
• Care UK, was unsuccessful in the East
Midlands procurement for this service. The new
provider will be Derbyshire Health United
(DHU).
• DHU took over delivery of the service on 1st
October 2016.
• Lincoln – A non-clinical co-ordinator is now in post and
changes in working patterns continue to be implemented.
9
Planned Care – Overview, Issues and Actions
ULHT - Overview
• RTT Incompletes: the standard has not been
achieved (90.59% in September) at CCG level
since May 2016.
• For SWLCCG patients at ULHT the RTT standard
was not achieved for the seventh consecutive
month in September (88.30%). Ten specialties
failed the standard: Cardiology (80.12%),
Dermatology (78.19%), ENT (89.46%), General
Medicine (87.88%), Gynaecology (91.35%),
Neurology (71.84%), Rheumatology
(91.43%),Thoracic Medicine (89.62%) , Trauma and
Orthopaedics (88.93%) and other (87.84%). ULHT
as a Trust also did not achieve the standard
(88.64%).
• Cancelled Operations: operations rescheduled
within 28 days whilst above the zero tolerance
(8.38%), has improved significantly this financial
year.
ULHT - Issues
ULHT - Actions
• RTT performance remains under the
standard. The Trust is focusing recovery
against six specialties – ENT, General
Surgery, Trauma & Orthopaedics, Cardiology,
Gastroenterology and Neurology. Specialties
have been required to submit a remedial
action plan.
• The following 8 specialities have each produced recovery
action plans which set out short term actions to improve
speciality level performance – General Surgery,
Orthopaedics, ENT, Gastro, Respiratory, Dermatology,
Cardiology, Neurology.
• Neurology - NUH have served notice on the
two visiting consultants, this will have an
impact on ULHT capacity. As a result a
decision has been made to close the service
to new referrals from 1st December 2016 .
• At a speciality level General Surgery,
Neurology and Orthopaedics continue to be
particularly challenged. In recent months
performance within Cardiology, ENT and
Gastroenterology have all deteriorated as a
result of consultant vacancies, which adds
increased risk to the overall Trust position.
• MSA: No MSA breaches have been reported in
September or year to date.
• Diagnostics: the standard was achieved at CCG
level (99.11%), YTD performance remains within the
standard (99.07%). The standard was also met at
ULHT (99.14%) for SWLCCG patients but not at
PSHFT (98.67%).
• HCAI: The number of HCAI’s (C-diff) exceeded the
trajectory (2) for the month (4). The CCG is now two
cases above trajectory YTD. Three were attributed
to an acute trust and one to a non acute trust.
• Diagnostics: the Trust didn’t achieve the six
week diagnostic standard in September for
the third consecutive month. The
performance level was 98.56%. Plans are in
place to address breaches in TOEs and
Neurophysiology to ensure diagnostic
performance in October improves from its
September position.
• Key actions contained within these plans include
increasing internal capacity through additional outpatient
and theatre sessions from their existing workforce and
utilisation of additional locum capacity.
• The Business Units are all also exploring the opportunities
to extend sub-contracting relationships with independent
sector providers.
•
ULHT have asked the CCGs to outsource, at point of
referral, the following volumes:
• ENT – 200 patients
• Cardiology – 150 patients
• Dermatology – 150 patients
• Orthopaedics – 100 patients
• Neurology – All routine referrals between 1 December
2016 and 31 March 2017.
• Where activity levels are significantly above the contract
level, the CCGs are being asked to initiate actions to
support the Trust by controlling referral rates into these
specialities.
• Additional validation resource commenced within the Trust
on 26th September for a six week period.
• The Lincoln Medicine Business Unit have refreshed the
Echo recovery plan. Additional sessions for TOEs
(Transoesophagael echo) and Stress Echo's have been
scheduled for October and November. If all of the
scheduled additional sessions are completed, it is
expected that the Echo performance will improve in
October and be within 1% by the end of November.
10
Planned Care – CCG performance (NHS Constitution)
CCG – RTT Incompletes
Description
Oct 15
Nov 15
Dec 15
Mar 16 Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
RTT - Incomplete Pathw ays (CCG)
Target
92% 93.96%
93.00%
93.31% 93.32% 93.85% 92.61% 92.49%
Jan 16
Feb 16
92.29%
91.93%
91.83%
90.80%
90.59% 91.66%
YTD
RTT - Incomplete Pathw ays (CCG for ULHT)
92% 92.98%
91.93%
92.37% 92.66% 93.23% 91.69% 91.26%
90.98%
90.65%
90.59%
89.07%
88.30% 90.14%
RTT - Incomplete Pathw ays (CCG for PSHFT)
92% 96.47%
94.17%
94.17% 93.56% 95.34% 94.71% 95.20%
97.32%
94.59%
96.14%
95.01%
96.15% 95.74%
RTT - Incomplete Pathw ays (CCG for NUH)
92% 97.80%
96.88%
97.62% 97.92% 97.54% 96.72% 95.86%
96.23%
95.41%
95.27%
95.50%
95.13% 95.57%
Oct 15
Nov 15
Dec 15
Mar 16 Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
92% 92.44%
92.29%
92.40% 92.48% 93.14% 92.24% 92.11%
92.45%
92.03%
91.34%
90.79%
88.64% 91.23%
ULHT – Incompletes – All CCG’s
Description
Target
RTT - Incomplete Pathw ays (ULHT)
Jan 16
Feb 16
YTD
52 week breaches
Description
RTT - No. Over 52 Weeks Within Incomplete
Pathw ays (CCG)
Target
0
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
0
0
0
0
0
0
0
0
0
0
0
Aug-16 Sep-16
0
YTD
1
1
HCAI
Description
Target
Healthcare acquired infection (HCAI) measure (MRSA)
(CCG)
Healthcare acquired infection (HCAI) measure
(Clostridium difficile infections) (CCG)
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
YTD
0
0
0
0
0
0
0
0
0
0
0
0
0
0
25
4
3
4
2
3
4
1
4
1
2
2
4
14
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
2
0
2
1
1
MSA
Description
Mixed Sex Accommodation (MSA) Breaches - CCG
Target
0
Mar 16 Apr 16
0
0
May 16
Jun 16
Jul 16
Aug 16
Sep 16
YTD
0
0
0
0
0
0
11
Planned Care – CCG performance (NHS Constitution)
Diagnostic Waiting Time
Description
Oct 15
Nov 15
Dec 15
Mar 16 Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
Diagnostic Test Waiting Time <6 w ks (CCG)
Target
99% 99.51%
99.21%
98.82% 98.93% 99.54% 98.84% 98.17%
99.50%
99.33%
99.36%
98.94%
99.11% 99.07%
Diagnostic Test Waiting Time <6 w ks (CCG for ULHT)
99% 99.81%
99.24%
99.03% 99.09% 99.58% 98.83% 98.12%
99.53%
99.54%
99.50%
99.11%
99.14% 99.16%
Diagnostic Test Waiting Time <6 w ks (CCG for PSHFT)
99% 100.00% 100.00% 98.90% 97.25% 100.00% 98.06% 100.00% 100.00% 96.39% 100.00% 97.70%
98.67% 98.79%
Diagnostic Test Waiting Time <6 w ks (CCG for NUH)
99% 100.00% 100.00% 100.00% 98.91% 100.00% 99.10% 98.65%
Description
Target
Jan 16
Jan 16
Feb 16
Feb 16
YTD
99.07% 100.00% 100.00% 100.00% 100.00% 99.62%
Oct 15
Nov 15
Dec 15
Mar 16 Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
YTD
Diagnostic Test Waiting Time <6 w ks (ULHT)
99% 99.62%
99.43%
99.20% 99.15% 99.32% 99.08% 99.10%
99.05%
99.07%
98.92%
98.66%
98.56% 98.89%
Diagnostic Test Waiting Time <6 w ks (PSHFT)
99% 99.65%
99.74%
98.06% 97.47% 99.80% 99.67% 99.39%
99.70%
98.99%
99.46%
99.20%
98.87% 99.27%
Diagnostic Test Waiting Time <6 w ks (NUH)
99% 99.47%
99.09%
98.93% 98.87% 99.21% 99.13% 99.16%
99.61%
99.77%
99.76%
99.82%
99.78% 99.66%
Cancelled Operations
Description
Target
Q4_1516
Q1_1617
Q2_1617
YTD
Cancelled Operations - % of patients cancelled for nonclinical reasons not re-admitted w ithin 28 day (ULHT)
0%
15.43%
8.59%
8.38%
8.48%
Cancelled Operations - % of patients cancelled for nonclinical reasons not re-admitted w ithin 28 day (PSHFT)
0%
8.33%
9.26%
7.87%
8.56%
Cancelled Operations - % of patients cancelled for nonclinical reasons not re-admitted w ithin 28 day (NUH)
0%
3.18%
2.34%
3.57%
2.95%
Never Events
Description
Never Events (CCG)
Standard
0
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
0
0
0
0
0
Mar 16 Apr 16
0
0
May 16
Jun 16
Jul 16
Aug 16
Sep 16
YTD
0
0
0
0
0
0
12
Planned Care – Provider Elective Activity
•
Elective activity peaked in February 2016 at ULHT, in October at NUH and August at PSHFT
13
Cancer Care – Overview
SWLCCG
• Three of the nine cancer waiting time indicators are
below the standard in September:
ULHT
• Three of the nine indicators are below the standard:
• Two week breast symptoms
• 31 day waits - surgery
• 62 day wait - GP Referral
• Two week breast symptoms (76.50%)
• Cancer 31 Day waits (93.90%)
• 62 day standard (65.60%)
Performance improved in six standards:
Performance deteriorated in three standards:
• Cancer 31 Day waits (failed) 93.90%
• 62 day standard GP referral (failed) – 65.60%
• 62 day consultant upgrade – 75% (no standard)
Two standards have improved:
• Two week wait standard (achieved) – 97.60%
• Two week wait breast (failed) – 76.50%
For three standards performance has been
maintained at 100%:
• 31 day subsequent treatment surgery (achieved) –
100%
• 31 day subsequent treatment drugs -(achieved) –
100%
• Cancer 62 Day Waits - treatment from Screening
referral - (achieved) – 100%
•
•
•
•
Two week wait standard (achieved) – 94.60%
Two week breast symptoms (failed) – 88.80%
31 day standard (achieved) – 98.00%
31 day subsequent treatment radiotherapy
(achieved) – 94.30%
• 62 day screening service referral (achieved) –
92.90%
• 62 day consultant upgrade (achieved) – 90.50%
ULHT
• As part of the planning round for 2016/17, local
trajectories were agreed between ULHT and
NHS England for five of the nine cancer
standards. Of those local trajectories for
September, only two were met. Local trajectories
have been agreed for:
• 2 week wait breast (93% September, actual
88.8% - failed).
• 31 day surgery (94% September, actual
91.2% - failed).
• 31 day radiotherapy (94% September, actual
94.3% - achieved).
• 62 day standard (85% September, actual
72.7% - failed).
• 62 day screening (90% September, actual
92.9% - achieved).
Performance deteriorated in three standards:
• 31 day subsequent treatment surgery (failed) –
91.20%
• 31 day subsequent treatment drugs -(achieved) –
98.40%
• 62 day standard – (failed) – 71.90%
14
Cancer Care – CCG performance All Providers (NHS Constitution)
Cancer Care – SWLCCG performance
Standard/
Target
Oct-15
Nov-15
Dec-15
Jan-16 Feb-16
Mar-16 Apr-16 May-16
Jun-16
2 Week Waits - suspected cancer referrals
93%
90.30%
94.90%
95.00% 91.70% 96.60%
95.20% 91.70% 93.70%
89.20% 88.17% 88.70%
97.60%
90.29%
2 Week Wait- breast symptomatic referrals
93%
82.50%
93.00%
93.10% 89.70% 93.80%
94.30% 92.90% 93.80% 100.00% 50.00% 42.90%
76.50%
75.92%
Cancer 31 Day Waits - first definitive treatment
96%
97.10%
92.10% 100.00% 93.10% 96.50%
91.50% 94.40% 94.60%
93.90%
95.50%
Cancer 31 Day Waits - subsequent treatment,
surgery
94%
100.00% 75.00% 100.00% 93.80% 100.00% 100.00% 81.80% 88.30% 100.00% 81.25% 100.00% 100.00%
90.27%
98%
100.00% 100.00% 95.70% 90.30% 94.10%
94.10% 88.30% 95.70% 100.00% 95.83% 100.00% 100.00%
95.97%
94%
92.90% 100.00% 100.00% 75.00% 79.30%
88.60% 76.90% 95.00% 100.00% 93.33% 90.00%
94.10%
91.05%
85%
84.40%
85.70%
92.90% 69.70% 63.60%
80.00% 73.10% 78.10%
65.60%
74.41%
90%
No national
standard
88.90%
88.90%
80.00% 86.70% 66.70%
60.00% 16.70% n/p
100.00% 100.00%
58.35%
Description
Cancer 31 Day Waits
chemotherapy
Cancer 31 Day Waits
Radiotherapy
Cancer 62 Day Waits
GP referral
Cancer 62 Day Waits
Screening referral
Cancer 62 Day Waits
Consultant upgrade
Jul-16
Aug-16
98.40% 93.62% 96.50%
Sep-16 YTD 16/17
-subsequent treatment,
- subsequent treatment,
- first definitive treatment,
67.50% 82.76% 70.60%
- treatment from
- treatment from
80.00%
86.00%
75.00% 83.00%
60.00%
67.00% 75.00% 100.00%
n/p
n/p
50.00% 33.30% 100.00%
75.00%
71.70%
** N/P No Patients
Provider ULHT– Cancer performance
Standard/
Target
Oct-15
Nov-15
Dec-15
Feb-16
Mar-16 Apr-16 May-16
Jun-16
2 Week Waits - suspected cancer referrals
93%
91.80%
95.70%
95.50% 93.20% 94.90%
92.50% 87.80% 92.60%
92.10% 82.70% 81.10%
94.60%
87.26%
2 Week Wait- breast symptomatic referrals
93%
87.80%
93.80%
94.30% 93.80% 95.90%
90.60% 94.60% 96.60%
93.00% 24.80% 26.30%
88.80%
67.06%
Cancer 31 Day Waits
Cancer 31 Day Waits
surgery
Cancer 31 Day Waits
chemotherapy
Cancer 31 Day Waits
Radiotherapy
Cancer 62 Day Waits
GP referral
Cancer 62 Day Waits
Screening referral
Cancer 62 Day Waits
Consultant upgrade
96%
99.10%
99.00%
98.10% 96.10% 97.20%
96.70% 95.80% 95.00%
98.70% 97.60% 96.60%
98.00%
96.80%
94%
97.10%
94.40%
97.10% 87.80% 92.20%
92.10% 80.40% 90.90%
95.00% 95.80% 97.80%
91.20%
91.98%
98%
100.00% 98.80%
94.00% 83.30% 98.90%
91.60% 84.60% 97.60% 100.00% 98.00% 98.80%
98.40%
95.80%
94%
94.90%
98.00%
97.40% 73.50% 88.90%
90.70% 84.00% 94.00%
92.80% 89.90% 84.60%
94.30%
89.06%
85%
74.10%
82.60%
84.80% 72.80% 71.80%
75.60% 74.70% 70.00%
68.90% 75.60% 74.00%
71.90%
72.64%
90%
87.50%
85% (ULHT
set target) 96.40%
92.50%
81.20% 84.80% 88.90%
92.10% 80.60% 86.20%
96.20% 90.90% 78.90%
92.90%
86.56%
87.90%
85.20% 90.50% 68.40%
69.20% 85.00% 87.80%
73.90% 73.50% 90.00%
90.50%
81.70%
Description
- first definitive treatment
- subsequent treatment,
Jan-16
Jul-16
Aug-16
Sep-16 YTD 16/17
-subsequent treatment,
- subsequent treatment,
- first definitive treatment,
- treatment from
- treatment from
There is no national standard for Cancer 62 day waits, however locally a standard of 85% has been agreed.
15
Cancer Care – Breaches (All Providers)
Cancer Wait
Indicators - Sep 2016
Cancer 2WW
Cancer 2WW Breast
Symptoms
Cancer 31 Day
Cancer 31 Day Surgery
Cancer 31 Day Drugs
Cancer 31 Day Radiotherapy
Cancer 62 Day
Cancer 62 Day Screening
Cancer 62 Day Upgrade
Target
Patients
Seen
Patients
seen within
target
Breaches
% achieved
93%
375
366
9
97.60%
34
26
8
76.50%
66
62
4
93.90%
10
10
0
100.00%
15
15
0
100.00%
17
16
1
94.10%
32
21
11
65.60%
2
2
0
100.00%
4
3
1
93%
96%
94%
98%
94%
85%
90%
n/a
n/a - no national standard
75.00%
Cancer 2 Week waits: nine breaches, ULHT (6), NUH (2), University College London (1). Of the six breaches,
five were due to patient choice and one was due to a clinical cancellation. Breaches at NUH and UCL were due
to patient choice.
Cancer 2 Week waits: (Breast Symptoms): eight breaches at ULHT, seven were due to patient choice and
one was due to an administrative error. Achievement against the standard is expected in October, with the
current forecast at 94%, but long-term sustainability is more risky due to resource issues.
Cancer 31 day waits: four breaches all at ULHT, due to capacity (1), patient choice (1), patient requiring
further investigations (2).
Cancer 62 Day waits: eleven breaches, ten at ULHT and one at Nottingham University Hospital Trust, due to
complex cases, capacity and patient choice (see table on next page).
Recovery is not likely this financial year. Ongoing actions include demand and capacity modeling, radiology
reporting, and the lower GI pilot (which so far has had positive success at Lincoln, but requires further
enhancement before being rolled out). The full impact of recently implemented actions has not yet been seen.
ULHT continues to meet with NHSE and NHSI to discuss their plans for system recovery. The single biggest
challenge for ULHT remains diagnostic capacity and process. ULHT were successful in their bid to the
diagnostic capacity fund, £418k was secured, however this will only impact on CT. MRI continues to be a
constraint.
Cancer 62 Day waits – Consultant Upgrade: one breach at ULHT , CT request rejected as up to date GFR
(Glomerular Filtration Rate) test needed.
ULHT - United Lincoln Hospital Trust
NUH - Nottingham University Hospital Trust
UCL - University College London
16
Cancer – 62 Day Waits
Cancer 62 day – 12 SWLCCG patients breached the 62 day standard: the table below summarises all breached 62 day wait patient pathways at SWLCCG:
First
Days’ Tum our Type
treatm ent w ait
provider
ULHT
65 Head & Neck
Treatm ent
group
Notes
Adm itted or nonadm itted
11915173 GP Referral
First
seen
provider
ULHT
Drug
Treatments
Teeth extraction delay
Admitted
11835218 GP Referral
ULHT
ULHT
105 Low er
Gastrointestinal
Drug
Treatments
Complex diagnosis involving UGI MDT & SLIM
Admitted
11631239 GP Referral
PSHFT
PSHFT
Drug
Treatments
Delay in OPA follow ing MDT. Pt delayed treatment until after holiday.
Admitted
8077463 GP Referral
ULHT
ULHT
Drug
Treatments
Delay getting MRI reported
Non-admitted
11915269 GP Referral
ULHT
ULHT
Drug
Treatments
patient hadnt made up mind on what treatment option he wanted to take
Non-admitted
12191268
ULHT
ULHT
105 Urological
(Excluding
Testicular)
71 Urological
(Excluding
Testicular)
67 Urological
(Excluding
Testicular)
94 Upper
Gastrointestinal
CT req rejected as up to date GFR needed
Admitted
11914524 GP Referral
ULHT
ULHT
Drug
Treatments
Palliative
Delay getting patient discussed at Myeloma MDT to confirm treatment plan.
Non-admitted
11914691 GP Referral
ULHT
ULHT
11834722 GP Referral
ULHT
ULHT
11598837 GP Referral
ULHT
ULHT
11915335 GP Referral
ULHT
ULHT
11914815 GP Referral
ULHT
ULHT
Patient
CWT ref
Referral
Type
82 Haematological
(Excluding Acute
Leukaemia)
65 Haematological
(Excluding Acute
Leukaemia)
103 Lower
Gastrointestinal
130 Low er
Gastrointestinal
77 Low er
Gastrointestinal
85 Urological
(Excluding
Testicular)
Radiotherapy Patient initially referred to head and neck. Patient cancelled biopsy, delayed by a
w eek. Once diagnosed had to be referred to haematology.
Admitted
Radiotherapy significant deley in MRI report which delayed treatment planning
Non-admitted
Surgery
Admitted
Surgery
Ref to Lung, then Upper GIPt offered surgery either 14/07 or 21/07 pending an
opinion from the UGI MDT but the pt refused to have any surgery till Aug due to
personal commitments
Lack of capacity and delays w ithin Radiology
Surgery
Lack of combined clinic capacity
Admitted
Admitted
17
Mental Health – Overview and Issues
EIP
Early Intervention in Psychosis
• There were four patients on the
pathway in September; all were
seen within two weeks.
IAPT
• May - September data is not available
(see update below). LPFT are however
predicting the Access standard will be met
in September for the first time since May.
The recovery standard is also predicted to
achieve in September.
CPA
Care Programme Approach
• 94.47% achievement in quarter 2 is just
below the 95% standard.
• During quarter two, there were 19
patients on the CPA. 18 were followed
up within 7 days.
Dementia
• Estimated diagnosis rate for dementia –
Performance in September was 55.7%.
Performance remains below the standard
(67%) and the trajectory for achievement is
now March 2017.
Reasons for underperformance:
• IAPT Data - the required agreements are
not in place yet for IAPT data to flow to
any CCGs or Optum. This is in the hands
of NHS Digital and outside of the CCG’s
control.
• Due to recruitment issues, the access
target has proved challenging in recent
months. The standard however is
predicted to achieve for the first time since
April 2016.
• Audit of SWLCCG care homes found
that the number of people in care homes
with a diagnosis/potential diagnosis of
dementia was lower than expected, with
many people already on the dementia
register.
• GP Practice referrals are low - GP's are
concerned regarding the post-diagnosis
support available for people with
dementia.
• South West Lincolnshire CCG have seen
a significant increase in access.
18
Mental Health – CCG Performance
EIP
Description
Early Intervention in Psychosis - Patients treated
w ithin 2 w eeks (CCG)
Early Intervention in Psychosis - Patients treated
w ithin 2 w eeks (LPFT)
Target
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
50%
N/a
N/a
N/a
N/a
N/a
100.00%
0.00%
100.00%
N/P
50%
N/a
N/a
N/a
N/a
N/a
57.14%
54.55%
80.00%
100.00%
94.12%
87.50%
95.00%
83.23%
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
YTD
1.80%
1.50%
1.10%
1.51%
1.40%
1.65%
1.45%
1.23%
1.15%
1.09%
1.23%
1.57%
1.29%
IAPT Recovery Rate (CCG)
50% 43.90%
54.60%
56.50%
64.20%
56.80%
55.60%
61.90%
66.70%
59.60%
52.90%
64.80%
57.40%
60.55%
IAPT 6 Weeks Waiting (CCG)
75% 100.00% 100.00% 100.00% 98.25%
91.47%
92.73%
95.20%
94.10%
89.90%
95.30%
93.20%
91.10%
93.13%
IAPT 18 Weeks Waiting (CCG)
95% 100.00% 100.00% 100.00% 100.00% 100.00% 99.39% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100.00% 100.00% 100.00%
YTD
75.00%
n/p = no patients
IAPT
Description
Target
IAPT Roll Out (CCG) - (Annual Target 16/17 15%)
Description
1.25%
Target
IAPT Roll Out ( LPFT) - (Annual Target 16/17 15%)
Oct 15
1.25%
IAPT Recovery Rate (LPFT)
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
YTD
1.60%
1.70%
1.10%
1.20%
1.40%
1.40%
1.60%
1.30%
1.28%
1.15%
1.30%
1.30%
1.32%
50% 48.10%
52.60%
51.40%
52.80%
56.80%
55.40%
56.80%
55.70%
54.80%
56.70%
55.20%
55.20%
55.73%
CPA
Description
Target
% of patients under adult mental illness on CPA
w ho w ere follow ed up w ithin 7 days of discharge
from psychiatric in-patient care (CCG)
95%
% of patients under adult mental illness on CPA
w ho w ere follow ed up w ithin 7 days of discharge
from psychiatric in-patient care (LPFT)
95%
% of patients under adult mental illness on CPA
w ho w ere follow ed up w ithin 7 days of discharge
from psychiatric in-patient care (CPFT)
95%
Q1_1516
Q2_1516
Q3_1516
Q4_1516
Q1_1617
Q2_1617
YTD
100.00%
100.00%
100.00%
100.00%
100.00%
94.47%
97.24%
97.28%
96.33%
92.25%
98.45%
97.83%
96.75%
97.29%
96.82%
96.87%
95.54%
96.08%
95.54%
95.05%
95.30%
DEMENTIA
Description
Estimated diagnosis rate for people w ith dementia
Target**
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
YTD
67% 58.00%
57.20%
58.00%
58.70%
58.70%
57.80%
57.30%
56.70%
56.70%
56.60%
56.80%
55.70%
55.70%
**Annual


IAPT data from May 16 is based on predicted data provided by LPFT.
IAPT Roll Out Monthly stretch target for 15/16 was 1.5%, the 16/17 monthly target is 1.25%
19
Mental Health – Actions
EIP
Early Intervention in Psychosis
• 100% achievement in
September.
IAPT
• Trainees - Trainee PWPs (Psychological
Wellbeing Practitioners). Three of the trainees
have now qualified. The service now has 12
trainees, five of whom have only recently
started.
CPA
Care Programme Approach
• Achievement is just below the 95%
standard 94.47%.
Dementia
• SWLCCG are on the regional performance list
as requiring improvement and have agreed to
meet with the Clinical Network to agree a
package of support to improve performance.
The first meeting is in November.
• Recruitment - Following recruitment LPFT has
trainees at CBT level as well as PWP. This
means that capacity is inevitably reduced.
• NHSE and the Clinical Network have provided
a draft analysis of each practice’s performance
to assist SWLCCG in identifying best and
worst performers.
• Referrals – LPFT have identified the surgeries
that are low referrers to the service and will be
contacting them to raise their profile and
establish any barriers working closely with
support from the CCG’s on this.
• The CCG have commissioned a review from
Optum to look at the expected numbers of
people with dementia by GP practice to inform
them of where to direct their focus. This will
include the development of a dementia
dashboard to include population profiles,
emergency admissions and location of
residential institutes. The dashboard is now
available.
• The CCG is in regular contact with practices
about improving its dementia diagnosis
rate. Additionally, practices are kept informed
of mechanisms to provide support to patients,
carers, and families in the event of diagnosis
e.g. the Dementia Family Support Service.
20
GOVERNING BODY MEETING
Date of Meeting:
30 November 2016 – public session
Title of Report:
Report Author and Title:
Appendices:
Month 7 (October) Financial Monitoring Report & QIPP Report
Victoria Hundleby, Deputy Chief Finance Officer
Appendix A – Month 7 Finance Report
Appendix B – Month 7 QIPP
1.
Agenda item:
10.
Purpose of the Report (including link to objectives)
The Finance and QIPP Update report provides the latest information on the financial position of South
West Lincolnshire CCG to the end of October 2016.
2.
Recommendations
The Governing Body is requested to receive the Finance and QIPP update report and to discuss the
issues raised in the report.
3.
Executive Summary
The CCG plans to deliver its core financial targets including the planned surplus of 1% (£1,639k) of its
Resource Limit Allocation by year-end. The details are provided in Section 4 below and within the
attached Appendix A Finance Report.
The table below outlines the delivery position against core financial targets including the forecast at the
end of the year and the position to date. This is based on information currently available.
On-target / achieved
Not delivered to-date and potential risk for year end with
mitigation plans in place.
Major risk with recovery plan
Contain revenue expenditure within the CCG’s Revenue
Resource Limit (financial balance)
Delivery of Planned Surplus of £1,639k (1%) by year-end
Contain capital expenditure within the CCG’s Capital
Resource Limit of zero (awaiting confirmation).
Contain cash payments within the CCG’s Cash Resource Limit
Comply with the Better Payment Practice Code.
Delivery of 3.5% QIPP financial savings
Month end cash balance within 1.25% of drawdown value
Retain 1% of resources uncommitted at the end of the year
over and above the planned surplus
a.
Year-end
Forecast
Position
Month 7
Cumulative
Position
Month 7
Green
Green
Green
Amber
Red
Green
Green
Green
Green
Green
Green
Red
Green
Green
Green
Amber
Red
Green
Green
Green
Green
Green
Green
Green
Key Budget Movements and Allocation Adjustments
The table below confirms the allocation received by the CCG as at Month 7 reporting. The change inmonth relates to a non-recurrent allocation of £27k for Children Young People mental health.
1
CCG Allocation
Total
£'000
Programme
Allocation as at M6 reporting
180,851
CYP Local Transformation Mental
Health
27
180,878
Allocation as at M7 reporting
b.
Financial Performance Report - Appendix A Table 1
Appendix A provides detailed information of expenditure to date against the resources available. The
table below shows the summarised version of expenditure by Programme. In line with the submitted
financial plan, the Month 7 budget reflects the profiled budget taking into account anticipated dates of
realising QIPP savings and spending profiles. The transformational QIPP schemes are profiled later in
the year.
Programme (£'000)
Annual
Budget
Forecast
Outturn
Variance
(Over)/Under
Budget to
Date
Expenditure
Variance
to Date
(Over)/Under
Acute
Mental Health
Community Health
Continuing Care
Primary Care
Other
Headroom 1%
Uncommitted
86,575
16,781
13,583
10,512
43,354
3,865
87,039
16,439
13,040
11,828
43,092
3,254
(463)
343
543
(1,316)
262
611
50,953
9,789
7,923
6,298
25,290
2,254
50,956
9,449
7,516
7,069
25,895
2,038
(4)
340
407
(771)
(606)
217
1,758
1,758
0
0
0
0
Total Programme
176,428
176,451
(22)
102,507
102,923
(416)
2,811
1,639
2,789
0
22
1,639
1,640
650
1,642
0
(3)
650
180,878
179,240
1,638
104,796
104,565
231
Corporate
Planned Surplus
Total Expenditure
The Month 7 position presents an under achievement of the planned surplus by £419k.
The forecast outturn position for year-end continues to forecast delivery within the CCG allocation and
achievement of the business rules required. The Governing Body are requested to note the financial risk
included in the Governing Body Assurance Framework which is reported to Governing Body on a
quarterly basis.
c.
Running Costs (administration) Financial Performance Report – Appendix A Table 2
The CCG is operating within its running cost allocation.
Table 2 in Appendix A illustrates the CCG staffing numbers for October as 28.8 WTE (whole time
equivalent). This figure relates to the WTE people employed by the CCG which is adjusted for the CCG
proportional share for posts which it hosts i.e. posts which have a county wide remit for which we
recharge other CCGs for their share.
d.
Cash Book Statement – Appendix A Table 3
The cash book closing balance position of £519k at the end of Month 7 was not within the 1.25% month
end closing balance target and was a deterioration compared to Month 6. This partly relates to the
rebate from HMRC for the wheelchair contract which was not planned to be received in October.
2
The CCG continues to work closely with Optum colleagues to improve the cash forecasting process.
e.
Better Payment Practice Code (BPPC) – Appendix A Table 4
The target is to pay at least 95% of all NHS and non-NHS trade creditors within 30 calendar days of
receipt of goods or a valid invoice (whichever is later) unless other payment terms have been agreed.
The CCG has achieved the target for Month 7. The cumulative position will be reported in the Annual
Accounts for 2016-17.
f.
Payables and Receivables – Appendix A Table 5 and 6
Table 5 ( Payables 30 days and over)
The credit balance is due to a credit note from a care home provider.
Table 6 (Receivables 30 days and over)
The CCG continues to work with Optum and the local providers (Lincolnshire County Council and
Lincolnshire CCGs) to decrease the value of Receivables. All Receivables are expected to be resolved.
g.
Statement of Finance Position
The statement of financial position is shown as at the end of October.
h.
QIPP Update
The Project Management Group for QIPP which is supporting the Executive continues to meet on a
regular basis.
QIPP schemes are reported in Appendix B. QIPP is slightly over delivering at Month 7 noting that not all
scheme monitoring information is available particularly for embedded county wide schemes. The
forecast position is predicting current QIPP schemes may not all deliver by the year end with an
identified risk of £670k. The senior team has undertaken a review to affirm financial risk mitigation plans
for the CCG and these are currently being clinically assessed by the clinical Executive Committee.
There are also countywide financial risk mitigation plans currently being considered which are targeting
prescribing and procedures of low clinical value.
Overall, the mitigation plans are expected to address the risk highlighted in the QIPP forecast position.
The monthly plans have been profiled over the year and transformational QIPP schemes, in particular,
Right Care and repatriation of activity into the community are planned to start later in the year, both of
these transformational projects have been amber rated to align with the risk log. The RAG rating is
being continuously reviewed by the QIPP Project Group and Executive.
i.
Financial Risk
The Governing Body have been well briefed on the financial challenges for 2016/17 and beyond. This is
being addressed via the QIPP programme and the collaborative working across Lincolnshire NHS and
Social Care organisations via LHAC to support sustainable affordable health care for our population.
Specifically for 2016/17 the delivery of the QIPP programme and delivering the target 1% of resources
unallocated at the end of the year presents a financial risk which is addressed in the risk log. As noted in
the QIPP section above, the Executive Committee are planning for further QIPP schemes local to the
CCG and countywide mitigation plans to support delivery of the year-end financial position within the
business rules. The reported mitigation risk as noted in our return to NHSE is £2.3m which represents
the potential worst case of the CCG not meeting the required business rules. This is being closely
scrutinised by the Risk Management Committee and the Senior Team.
3
4.
Management of Conflicts of Interest
None.
5.
Finance, QIPP and Resource Implications
See Appendices.
6.
Legal/NHS Constitution Considerations
None.
7.
Analysis of Risk including Assessments
This section should identify known or potential risks and how these are being mitigated, including
conflicts of interest.
Please state if the risk is on the CCG Risk Register.
Yes
X
No
8.
Outline engagement – clinical, stakeholder and public/patient
None.
9.
Outcome of Impact Assessments
Not applicable.
10.
Assurance Departments/Organisations who will be affected have been consulted
Insert details of the departments you have worked with or consulted during the process:
Finance
Commissioning
Contracting
Medicines Optimisation
Clinical Leads
Quality
Safeguarding
Other
X
X
X
X
X
X
X
11. Report previously presented at:
Not applicable.
12. For further information or for any enquiries relating to this report, please contact
Contact Name: Victoria Hundleby
Email: [email protected]
Tel: (01476) 406596
4
South West Lincolnshire CCG:
Appendix A Financial Monitoring Report
Month 7
Table 1:
South West Lincolnshire CCG
Acute NHS
United Lincolnshire Hospitals NHS Trust
United Lincolnshire Hospitals NHS Trust - Out of Contract
East Midlands Ambulance Service NHS Trust
Nottingham University Hospitals NHS Trust
Peterborough and Stamford Hospitals NHS Foundation Trust
Northern Lincolnshire & Goole Hospitals NHS Foundation Trust
Acute QIPP
Acute NHS
Acute - NHS
Annual
Budget
Forecast
Outturn
£'000
£'000
Forecast
Variance
(Over) /
Under
£'000
Budget to
Date
Expenditure
to Date
Expenditure
(Over) /
Under
£'000
£'000
£'000
57,995
2,045
4,250
6,914
3,452
2,507
(1,857)
4,411
79,717
58,278
1,919
4,233
6,598
3,663
2,677
(1,857)
3,727
79,238
(283)
126
17
316
(211)
(170)
0
684
480
33,662
1,193
2,479
4,033
2,014
1,462
(464)
2,573
46,952
33,772
992
2,483
3,768
2,121
1,562
(464)
2,153
46,386
(109)
201
(4)
266
(107)
(100)
0
420
566
5,254
1,604
6,011
1,790
(757)
(186)
3,065
936
3,526
1,044
(461)
(109)
Acute Total
86,575
87,039
(463)
50,953
50,956
(4)
Mental Health
Lincolnshire Partnership Foundation Trust
Section 75 - Learning Disabilities
Section 75 - CAMHS
Mental Health
Mental Health Total
11,149
3,020
1,147
1,465
16,781
11,023
2,943
953
1,520
16,439
126
77
194
(54)
343
6,504
1,762
669
855
9,789
6,310
1,717
556
867
9,449
194
45
113
(12)
340
Community Health Services
Lincolnshire Community Health Services
Section 75 - Proactive Care
Section 75 - ICES
St Barnabas
Community
Community Health Services Total
8,375
1,130
488
1,446
2,144
13,583
8,433
1,497
511
1,130
1,470
13,040
(58)
(367)
(23)
316
674
543
4,885
659
285
844
1,251
7,923
4,919
873
298
667
759
7,516
(34)
(214)
(13)
177
492
407
Continuing Healthcare Total
10,512
11,828
(1,316)
6,298
7,069
(771)
Primary Care
Prescribing
Prescribing QIPP
Co-Commissioning
Local Enhanced Services
Primary Care
Primary Care Total
21,824
0
18,782
1,013
1,735
43,354
22,160
0
18,393
1,077
1,462
43,092
(336)
0
389
(64)
273
262
12,731
0
11,082
591
886
25,290
13,709
0
10,708
628
850
25,895
(979)
0
374
(37)
36
(606)
1,117
1,571
902
1,758
(303)
578
5,623
1,035
1,323
902
1,758
(303)
298
5,012
82
248
0
0
0
280
611
652
916
515
0
(177)
348
2,254
633
772
294
0
(101)
440
2,038
19
145
221
0
(76)
(92)
228
176,428
176,451
(22)
102,507
102,923
(416)
2,811
2,789
22
1,640
1,642
(3)
179,239
179,240
(0)
104,146
104,565
(419)
1,639
0
1,639
650
0
650
180,878
179,240
1,638
104,796
104,565
231
Resource Limits
Confirmed
Anticipated
Potential
(162,096)
0
(18,782)
0
0
0
(162,096)
0
(18,782)
(93,840)
0
(10,956)
0
0
0
(93,840)
0
(10,956)
Total Resource Limit
(180,878)
0
(180,878)
(104,796)
0
(104,796)
Acute - Non NHS
Acute - Non Contract Activity
Other Programme Services
Non Emergency Patient Transport Services
AQP
Contingency 0.5%
Headroom 1% Uncommitted
Other QIPP
Other
Other Programme Services Total
Programme Costs Total
Running Costs Total
Total Expenditure
Planned Surplus
Total Budgets
Q:\South West CCG\2016-17\Finance\Governing Body\M08. November 2016\Appendix A - Month 7 2016.17 Tables 1
South West Lincolnshire CCG: Finance Monitoring Report
Appendix A - Month 7 October 2016
Table 2 - Staff Numbers
WTE adjusted for CCG proportional
share for SWLCCG hosted posts.
Head count employed by CCG*
Budget
WTE
27.3
46.0
Apr-16
WTE
27.3
46.0
May-16
WTE
27.3
46.0
Jun-16
WTE
26.2
45.0
Jul-16
WTE
27.4
47.0
Aug-16
WTE
26.2
44.0
Sep-16
WTE
26.5
46.0
Oct-16
WTE
28.8
52.0
Nov-16
WTE
Dec-16
WTE
Jan-17
WTE
Feb-17
WTE
Mar-17
WTE
Cumulative
£'000
£98
£96,227
-£95,806
£519
Apr-16
£'000
£98
£13,800
-£13,266
£632
£173
No
May-16
£'000
£632
£14,200
-£13,329
£1,503
£178
No
Jun-16
£'000
£1,503
£14,227
-£15,577
£153
£178
Yes
Jul-16
£'000
£153
£14,000
-£13,411
£742
£175
No
Aug-16
£'000
742
Sep-16
£'000
889
Oct-16
£'000
471
Nov-16
£'000
Dec-16
£'000
Jan-17
£'000
Feb-17
£'000
Mar-17
£'000
* ( excludes GPs and Lay members)
Table 3 - Cash Book Statement
Opening Cash Balance
Cash Drawdown
Payments
Closing Balance
Target 1.25% of Drawdown
Target Achieved?
Table 4 - Better Payment Practice Code (BPPC)
Report
Invoices Paid Within 30 Days
Invoices Paid Over 30 Days
Invoices Paid Within 30 Days
Invoices Paid Over 30 Days
% of invoices paid within 30 days (Number)
% of invoices paid within 30 days (£)
Month 7 (October 2016 in Month)
TOTAL
NHS
Non-NHS
Number
Number
Number
1,047
201
846
17
2
15
£'000
£'000
£'000
£14,099
£8,921
£5,179
£20
£4
£16
%
%
%
98%
99%
98%
100%
100%
100%
If total value of invoice paid is less than invoices
paid within 30 days is due to credit notes.
Table 5 - Payables > 30 days
Total
31-60 days 61-90 days
£'000
£'000
-9
30
13,500
13,500
13,000
-£13,353
£889
£169
No
-£13,918
£471
£169
No
-£12,952
£519
£163
No
£0
£0
Cumulative position (year to date)
TOTAL
NHS
Non-NHS
Number
Number
Number
6,325
1,405
4,920
132
26
106
£'000
£'000
£'000
£97,183
£62,485
£34,699
£485
£197
£289
%
%
%
98%
98%
98%
100%
100%
99%
If total value of invoice paid is less than invoices
paid within 30 days is due to credit notes.
90+ days
£'000
128
A high volume of the invoices for 30-90 days and 90+ days includes balances with other NHS
organisations for over or under-performance and some invoices from non-NHS organisations for NCA's.
Q:\South West CCG\2016-17\Finance\Governing Body\M08. November 2016\Appendix A - Month 7 2016.17 Tables 2-7
£0
£0
£0
£0
£0
£0
£0
£0
South West Lincolnshire CCG: Finance Monitoring Report
Appendix A - Month 7 October 2016
Table 6 - Receivables > 30 days
Total
31-60 days 61-90 days
£'000
£'000
28
2
91+ days
£'000
131
The balances are expected to be paid to the CCG. The over 90 day includes £93k inter CCG recharges
and £31k invoice with NHS England.
Table 7 - Statement of Financial Position
Other Non-Current Assets
Non-Current Assets
Cash
Accounts Receivable
Other Current Assets
Current Assets
Total Assets
Accounts Payable
Accrued Liabilities
Other Liabilities
Current Liabilities
Total Assets Less Current Liabilities
Total Assets Employed
Non-Current Payables
Non-Current Borrowing
Other Liabilities
Long Term Liabilities
General Fund
Total Taxpayers Equity
Sep-16
£'000
Oct-16
£'000
Variance
£'000
0
0
0
0
0
0
471
1,908
0
2,379
2,379
11,806
61
0
11,867
(9,488)
(9,488)
0
0
0
0
(9,488)
(9,488)
519
1,684
0
2,203
2,203
11,920
74
0
11,994
(9,791)
(9,791)
0
0
0
0
(9,791)
(9,791)
(48)
224
0
176
176
(114)
(13)
0
(127)
303
303
0
0
0
0
303
303
Q:\South West CCG\2016-17\Finance\Governing Body\M08. November 2016\Appendix A - Month 7 2016.17 Tables 2-7
Appendix B
QIPP Monitoring - 2016/17
Month
7
Cost (£)
Scheme No
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Scheme Name
AHL / Audiology
BADs/BADs +
Clinical Assessment Service (CAS) - including closure of escalation beds
Continuing Care and Individual Funding Requests
Repatriation of Mental Health OATS patients/risk share
Personal Health Budgets
Prescribing Review – Pharmacist Support to Practices
Right Care - CVD
Right Care - Diagnostics
Right Care - Follow ups
Right Care - MSK
Right Care - Respiratory
Repatriation of Identified Specialties to the Community
Transitional Care
VFM - challenge to the payment process.
Reduction to CCG administration
Reduced support to Adult Social Care
Prior Year / Winter resilience
PCCC. Practice moving from PMS to GMS
LCHS Reduced spend (MOT)
Total
YTD QIPP Plan
YTD Actuals
88,667
60,000
174,500
110,000
65,000
80,000
716,000
200,000
0
0
0
0
100,000
54,000
100,000
59,500
372,000
170,000
15,500
81,500
39,864
60,910
0
0
536,500
26,667
308,752
393,107
2,480,667
Cost (£)
YTD Variance
FY QIPP Plan
FOT Actuals
FOT Variance
266,000
120,000
349,000
220,000
130,000
160,000
1,296,000
1,150,000
0
0
0
0
700,000
108,000
200,000
119,000
744,000
340,000
31,000
163,000
95,673
146,183
87,250
110,000
1,073,000
160,000
981,005
943,456
0
0
29,813
59,500
372,000
170,000
0
81,500
48,803
-910
174,500
110,000
-471,500
53,333
407,248
-193,107
0
0
0
0
100,000
54,000
70,187
0
0
0
15,500
0
350,000
54,000
59,625
119,000
744,000
340,000
0
163,000
170,327
-26,183
261,750
110,000
-943,000
0
314,995
206,544
0
0
0
0
350,000
54,000
140,375
0
0
0
31,000
0
2,112,612
368,055
6,300,000
5,630,192
669,808
FYE RAG
£'000
96
146
87
110
1,073
160
981
943
0
0
0
0
350
54
60
119
744
340
0
163
GOVERNING BODY MEETING
Date of Meeting:
30 November 2016 – public session
Title of Report:
Report Author and Title:
Appendices:
Outcome of the Medicines Management Consultation
Steph King, Engagement Lead Optum International
Appendix A – Medicines Management Consultation results and appendices
1.
Agenda item:
11.
Purpose of the Report (including link to objectives)
The purpose of this report is to present the outcomes of the Medicines Management consultation in
Lincolnshire to the four CCG Governing Bodies to support the CCG decision on the proposed approach
to prescribing in Lincolnshire. The feedback will help shape the way we prescribe moving forward.
2.
Recommendations
The CCG’s Governing Body are asked to review the consultation results and agree the following
recommendations:
1. To restrict prescribing over the counter / minor ailment medicines for short term selflimiting conditions
2. To limit prescribing to bread, flour and bread mixes only within Coeliac UK recommended
quantities
3. To restrict the prescribing of baby milk including specialist infant formula
4. To restrict the prescribing of oral nutritional supplements in line with ACBS guidance
Agree the implementation date for restricting prescriptions for over the counter medications or the option
to implement retrospectively.
3.
Executive Summary
The Clinical Commissioning Groups in Lincolnshire (Lincolnshire East Clinical Commissioning Group,
Lincolnshire West Clinical Commissioning Group, South Lincolnshire Clinical Commissioning Group and
South West Lincolnshire Clinical Commissioning Group) undertook a consultation from Tuesday 4th
October until Friday 18th November 2016 on proposals on what is prescribed in Lincolnshire. This
consultation proposed:
1.
2.
3.
4.
To restrict prescribing over the counter / minor ailment medicines for short term self-limiting
conditions
To restrict or stop the prescription of gluten-free foods
To restrict the prescribing of baby milk including specialist infant formula
To restrict the prescribing of oral nutritional supplements in line with ACBS guidance
The consultation provided an overview of the proposed service changes to ensure the health budget for
Lincolnshire is spent as effectively as possible, whilst minimising waste and promoting self-care to its
population. The consultation document reiterated that these items will still be available for some patients
on clinical assessment.
This report provides results of the consultation for the Governing Body to review alongside the Equality
Impact Assessment and feedback from the events to make a decision on the recommendations.
1
1,448 responses were received (1,309 via the online survey and 139 hard copy returns) with a social
media reach of over 22,500, demonstrating a wide reaching, robust consultation process.
Proposal 1: to restrict prescribing over the counter medicines for short term, selflimiting conditions
Proposal 2: to limit prescribing to bread, flour and bread mixes only within Coeliac
UK recommended quantities
Proposal 3: to restrict prescribing specialist baby milks and infant formulae
Proposal 4: to restrict prescribing of nutritional supplements
85% agreed
53% agreed
64% agreed
72% agreed
4.
Management of Conflicts of Interest
Not applicable.
5.
Finance, QIPP and Resource Implications
As part of QIPP, the four Lincolnshire CCGs undertook the consultation to shape the way we prescribe
moving forward to meet the challenging financial targets.
6.
Legal/NHS Constitution Considerations
The CCG has a statutory duty to engage with patients and the public in the planning of services and also
a duty to secure the continuous improvement of services. The paper supports all the patient rights in the
NHS Constitution.
7.
Analysis of Risk including Assessments
Not applicable
Please state if the risk is on the CCG Risk Register.
Yes
No
X
8.
Outline engagement – clinical, stakeholder and public/patient
The consultation was robust and wide reaching, receiving feedback from patients, the public,
stakeholders and partner organisations to inform CCG decision making.
9.
Outcome of Impact Assessments
A Quality Impact Assessment (QIA) and Equality Impact Assessment (EIA) have been completed and
attached as appendices to this report
10.
Assurance Departments/Organisations who will be affected have been consulted
Insert details of the departments you have worked with or consulted during the process:
Finance
Commissioning
Contracting
Medicines Optimisation
Clinical Leads
Quality
Safeguarding
Other
X
X
X
X
X
X
X
2
11. Report previously presented at:
Not applicable
12. For further information or for any enquiries relating to this report, please contact
Steph King, Engagement Lead, Optum
[email protected]
3
Medicines Management Consultation
Results: views on what we prescribe in
Lincolnshire
23 November 2016
Contents
Page
2
Executive Summary
3
Purpose of report
3
Introduction to the consultation
4
Equality Impact Assessment
4
Consultation process
7
Responses
10
Results
10
•
Background feedback
12
•
Proposal 1: Over the counter medication
15
•
Proposal 2: Gluten free food
21
•
Proposal 3: Specialist baby milks and infant formulae
23
•
Proposal 4: Oral nutritional supplements
26
•
Formal responses to the consultation
29
•
Themes from events and meetings
31
•
Themes from calls, letters and emails
33
Recommendations
Appendix 1: Equality Impact Assessment
Appendix 2: Full Health Scrutiny Committee Lincolnshire response
Appendix 3: Healthwatch Lincolnshire feedback
Appendix 4: Department of Nutrition & Dietetics United Lincolnshire Hospitals NHS
Trust
Appendix 5: Coeliac UK
Appendix 6: British Society of Gastroenterology
Appendix 7: British Specialist Nutrition Association
Appendix 8: Lincolnshire Local Pharmaceutical Committee
Appendix 9: Consultation document and Survey
Appendix 10: Quality Impact Assessment
1
Executive Summary
Proposal
The Clinical Commissioning Groups in Lincolnshire (Lincolnshire East Clinical Commissioning Group,
Lincolnshire West Clinical Commissioning Group, South Lincolnshire Clinical Commissioning Group
and South West Lincolnshire Clinical Commissioning Group) undertook a consultation from Tuesday
4th October until Friday 18th November 2016. This consultation proposed:
1. To restrict prescribing over the counter / minor ailment medicines for short term self-limiting
conditions
2. To restrict or stop the prescription of gluten-free foods
3. To restrict the prescribing of baby milk including specialist infant formula
4. To restrict the prescribing of oral nutritional supplements in line with ACBS guidance
Engagement Activities
A comprehensive programme of communications and engagement was undertaken across
Lincolnshire to enable as many people as possible to get involved in the consultation. The online
survey was supported by paper copies sent to those who requested them, a social media campaign
to promote the consultation and encourage involvement, attendance at community groups and
arrangement of drop in sessions across the county. Links to the survey were also sent to a large
number of key stakeholders and public databases. The EIA (Equality Impact Assessment) supported
identification of targeted engagement.
Response
1,448 responses were received (1,309 via the online survey and 139 hard copy returns) with a social
media reach of over 22,500, demonstrating a wide reaching, robust consultation process.
Proposal 1: to restrict prescribing over the counter medicines for short term, selflimiting conditions
Proposal 2: to limit prescribing to bread, flour and bread mixes only within Coeliac
UK recommended quantities
Proposal 3: to restrict prescribing specialist baby milks and infant formulae
Proposal 4: to restrict prescribing of nutritional supplements
85% agreed
53% agreed
64% agreed
72% agreed
Recommendations
1. Implement the proposals agreed above, subject to formal endorsement at the 4 CCG
Governing Body meetings on 30th November and 1st December 2016
2. Agree implementation for future restricting of prescriptions for over the counter medications or
option to implement retrospectively
3. Agree implementation date of all proposals as 5th December 2016
4. Consider the outcomes of the Equality Impact Assessment (appendix 1) alongside these
consultation findings
2
Purpose of report
The purpose of this report is to present the outcomes of the Medicines Management consultation in
Lincolnshire to the four CCG Governing Bodies to support their decision making on the proposed
approach to prescribing in Lincolnshire. The feedback will help shape the way we prescribe moving
forward.
Introduction to the consultation
The Clinical Commissioning Groups in Lincolnshire (Lincolnshire East Clinical Commissioning Group,
Lincolnshire West Clinical Commissioning Group, South Lincolnshire Clinical Commissioning Group
and South West Lincolnshire Clinical Commissioning Group) undertook a consultation from Tuesday
4th October until Friday 18th November 2016 on proposals on what is prescribed in Lincolnshire.
The challenge faced by all organisations across the NHS is how to spend the available budget in
ways that most benefit the health of the whole population and delivers good value for money. The
CCGs evaluate all services to ensure that each service offers good quality, the best possible
outcomes for patients and good value for money. Resources must be allocated in an effective and
equitable way for the benefit of the whole population to achieve the best possible outcomes for the
most number of patients. A number of planned savings will come from the transformation of services
to reduce complexity, waste and duplication, but in order to meet the challenging financial targets the
CCGs have also had to look at reprioritising services.
This consultation proposed:
1. To restrict prescribing over the counter / minor ailment medicines for short term self-limiting
conditions
2. To restrict or stop the prescription of gluten-free foods
3. To restrict the prescribing of baby milk including specialist infant formula
4. To restrict the prescribing of oral nutritional supplements in line with ACBS guidance
The consultation provided an overview of the proposed service changes to ensure the health budget
for Lincolnshire is spent as effectively as possible, whilst minimising waste and promoting self-care to
its population. The consultation document reiterated that these items will still be available for some
patients on clinical assessment.
3
Equality Impact Assessment
An Equality Impact Assessment was undertaken to assess the potential impact on the nine protected
characteristics covered under the Equality Act 2010. From this assessment activity we undertook
focused engagement with these groups, as well as the population as a whole. The full EIA is available
as Appendix 1.
Consultation process
The CCGs undertook a wide reaching and robust consultation process, implementing a number of
different communication and engagement methods to ensure involvement from as many people and a
wide variety of stakeholders as possible. As part of the consultation, the following was produced:
•
Full consultation document with survey with options to request the document in other
languages and formats
•
Online survey with supporting information from the consultation document
•
Poster promoting the consultation
•
Briefing for staff and organisations
This was distributed to the following stakeholders:
•
Lincolnshire Health Scrutiny Committee
•
Lincolnshire Health and Wellbeing Board
•
Healthwatch Lincolnshire
•
Lincolnshire County Council Adult and Children’s Services
•
MPs
•
NHS England
•
GPs and Lincolnshire Local Medical Committee
•
Pharmacies and Lincolnshire Local Pharmaceutical Committee
•
Lincolnshire and neighbouring NHS Provider organisations requesting circulation to relevant
clinics and services
•
Public Health
•
District Councils
•
East Midlands Ambulance Service
4
•
Coeliac UK
•
Dieticians
•
Membership / patient panels for ULHT, LCHS (590 members), LPFT
•
Staff in NHS Provider Organisations, CCGs
•
Patient Participation Group representatives
•
Children’s Centres
•
Care Homes
•
Community groups such as Age UK, Carers Support Groups, homeless organisations,
disability groups, St Barnabas, Mental Health Forum, Age Concern, British Red Cross, LCVS,
Citizens Advice Bureau, Job Centres, Colleges, Social Exclusion Group, Pre – schools and
many more.
Drop in sessions and events were held in:
Date
1 November 2016
2 November 2016
3 November 2016
10 November 2016
17 November 2016
Time
Location
2pm-4pm
2pm – 4pm
10 am – 12pm
2pm - 4pm
10 am – 12 pm
St Swithin’s Community Centre
John Coupland Hospital
Skegness Hospital | Main Reception
County Hospital Louth
Parkside Medical Centre
Attendance at events
•
•
•
•
•
•
•
•
•
•
•
•
•
Spalding COPD Group
PPG cluster Group
Evergreen Support Group (Stamford, Bourne and Deepings)
South Holland Health and Wellbeing Network Meeting
Munro PPG meeting
Little Explorers
Let’s Get Active
Family Fun
Learning together tweenies
Learning together babies
Baby & Child Clinic - Antenatal clinic
Learning Together Toddlers
LPFT involvement strategy event, Skegness
5
This was promoted using the following methods:
•
On each of the four CCG websites with adverts pinned to the front page
•
Facebook pages
•
Twitter accounts
•
Press releases
•
Radio interview
The total social media reach across the consultation period is outlined below:
Lincolnshire East
South Lincolnshire
South West Lincolnshire
Lincolnshire West
Total
4,119
3,321
2,796
12,311
22,547
Responses
6
In total 1,448 surveys were completed, 1,309 via the online survey and 139 hard copy returns.
The map below shows the spread of responses received across Lincolnshire.
Of the 1448 responses, 1408 indicated in what context they were responding as, as shown in the
table below:
Respondent
Number
A member of the public
%
1,142
81%
A GP
48
3%
Another healthcare professional
131
9%
A pharmacist
20
1%
A representative of a group or organization
67
5%
with an interest in these proposals
7
Some respondents provided additional information to express that they were patients with conditions
affected by the consultation, clinical staff, a councillor, PPG member, staff from nursing homes and
other professions.
Age
Gender
Sexual orientation
<17
0%
Male
33%
Heterosexual / straight
88%
18-20
1%
Female
65%
Bisexual
1%
21-29
7%
Prefer not to say
3%
Gay man
<1%
30-39
13%
Gay woman
1%
40-49
17%
Prefer not to say
9%
Same gender as
assigned at birth
50-64
35%
Yes
95%
65-74
21%
No
<1%
75-84
7%
Prefer not to say
4%
85+
0%
Are you a carer?
Yes
14%
No
86%
Do you consider yourself to
Do you consider
have a disability?
yourself to have a long
Employment status
term condition?
Yes
18%
Yes
50%
Employee in full time
39%
work
No
78%
No
47%
Employee in part time
14%
work
Prefer not to say
4%
Prefer not to say
3%
Retired
32%
Permanently sick /
3%
disabled
Nature of disability
Nature of condition
Full time carer
1%
Learning disability
3%
Heart condition
17%
Unemployed
1%
Long term mental
15%
Diabetes
17%
Self employed
7%
63%
COPD
5%
Looking after home
2%
health
Physical impairment
8
Blind / sight impairment
5%
Chronic kidney
2%
Full time education
1%
Cancer
5%
Part time student
<1%
Coeliac Disease
55%
Government supported 0%
condition
Deaf / hearing
14%
impairment
Learning disability
3%
training
Ethnicity
Asian or Asian British - Bangladeshi
<1%
White – British
89%
Asian or Asian British – Indian
<1%
White – Irish
1%
Asian or Asian British – Pakistani
<1%
White – Polish
<1%
Other Asian background
<1%
White –
<1%
Gypsy/Traveller/Roma
Black or Black British - African
<1%
Other white background
2%
Black or Black British - Caribbean
0%
Chinese
<1%
Mixed Heritage – White & Asian
<1%
Prefer not to say
5%
Mixed Heritage- White & Black African
0%
Mixed Heritage- White & Black Caribbean
<1%
Other mixed background
<1%
9
Results
Background feedback
By far the majority of respondents (84%) understood why these proposed changes need to be made.
Of the 156 respondents who answered ‘no’ to this question, more than the average of all respondents
paid for their prescriptions and have either themselves or a member of their family have been
prescribed gluten free food.
10
The majority of respondents (71%) agreed that money being spent on over the counter items could
be better spent. 15% disagreed and 13% were undecided.
Q3: Please tell us what you would most prefer to spend your money on
(where 1 is the most preferred to spend money on and 6 the least preferred).
Answered: 1,381
11
Skipped: 67
As the previous table shows, respondents ranked each service depending on which they would prefer
to spend money on.
Most prefer to spend money on
Least prefer to spend money on
Access to physiotherapy services
Non urgent referrals to orthopedics for 3 months
Prescription of baby milk and specialist infant formula
Prescription of gluten free food
Prescription of over the counter drugs
Prescription of oral nutritional supplements
Proposal 1: Over the counter medications
12
By far the majority of respondents strongly agreed or agreed (85%) with the proposal to restrict
prescribing over the counter medicines for short term, self-limiting conditions. 52% of those agreeing
with the proposal do not currently pay for their prescriptions whereas 48% do.
Of the 12% (180) who disagreed with this proposal, 60% still understood why the CCGs needed to
make the changes proposed. 51% pay for prescriptions and 49% don’t.
Comments made on this are again supportive of the proposals as they are widely available over the
counter and at a much reduced price. However, the consensus was that for those with severe, life
limiting illnesses, these medications should continue to be prescribed and consideration given to
patient’s circumstances (e.g. financial) and for children and the elderly before decisions are made
using means testing and not a ‘one size fits all’ approach.
A slightly higher proportion of respondents do not pay for their prescriptions (52%) than those who do
(48%). Of those who did pay for their prescriptions, 84% understood why the CCGs need to make the
changes proposed and 71% agreed that the money spent on over the counter medications could be
13
better spent on maintaining and protecting other treatments and services with similar answers of 83%
and 72% respectively for those who do not pay for prescriptions.
There is little difference in agreement or not to the proposals based on whether respondents pay for
prescriptions or not as the table below shows although the difference in the options for gluten free
food is larger than any other proposal:
(% agree or strongly agree to the proposals):
Proposal
Pay for
Do not pay for
prescriptions
prescriptions
Over the counter medication
84%
86%
Stop all gluten free food
41%
31%
Limit gluten free food
48%
56%
Baby milk and formula
62%
66%
Nutritional supplements
73%
73%
14
Proposal 2: Gluten free food
Slightly more than half of respondents’ (53%) preferred option is to limit prescribing to bread, flour
and bread mixes only within Coeliac UK recommended quantities and over a third (36%) preferred to
stop ALL prescribing of gluten-free foods with no replacement system. Of those who are prescribed,
or a member of their family are prescribed gluten free food, 16% prefer the option to stop all
prescribing and 73% prefer the option to limit prescribing.
15
Q7: Comments on the proposal for gluten free prescriptions
1,229 comments were received to this question and have been themed and summarized in order of
reference below.
Those who preferred the option to limit prescribing commented (747):
Most
Theme
Summarised comments
mentioned
1
Expense
•
Gluten free foods are not available at "competitive prices" and cost
considerably more than the gluten containing equivalents.
•
Not everyone will have the resources to buy gluten free food, which
usually costs a lot more and is harder to find
•
“Our current shopping bill is large enough with the addition of
gluten free products and I feel that if we had to buy bread as
well, this would be difficult as we are a one income family”
•
Gluten free food can be expensive particularly in a poor household so
I would be in favour of limiting the future prescription to those that
really need it
•
Gluten-free prescriptions should be equated with medicine that a
sufferer of another condition has
•
Patients should buy treats (cakes and biscuits), but bread rolls and
mixes are not affordable and the mixes are NOT available in the
shops- the only place you can get these is on prescription.
2
Access
•
Elderly, frail, vulnerable, bed bound and disabled people do not have
the same access to broad supermarket shopping
•
Lincolnshire is a rural county and the patient may not have access to
larger supermarkets who supply gluten free products
•
“To shop is minimum 3hr round trip for me to get gluten free
bread”
•
Some low income families can’t afford to buy these products
•
Children and those on benefit should be catered for by NHS
•
To stop prescribing of gluten-free foods with no replacement system
16
is wrong as it will have a huge impact on children from low income
families.
3
Availability
•
Gluten free foods are more widely available in supermarkets
•
It should be prioritized- gluten free food, like over the counter
medicines can be bought at supermarkets etc
•
“Personally I am gluten free and manage to obtain everything
from supermarkets”
•
There is more readily available gluten-free foods that are much
cheaper than the cost of a prescription.
•
Basics should be provided but the choice in shops has improved
dramatically over recent years
4
Nature of
•
Coeliac disease can lead to serious health implications and a gluten
the
free diet is the only treatment. Prescription items such as gluten-free
disease
bread are fortified with important vitamins and nutrients not always
found in shop-based items. In addition, many shop-bought gluten-free
items are high in fat and sugar.
•
“Prevention is better than cure. If you restrict all gluten free food
people will take short cuts in their diets and will eat badly and
cause themselves problems.”
•
Coeliac disease needs to be treated properly in order to prevent other
complications for example bowel cancer and costing the NHS even
more in treatment costs
•
Not getting the right stuff for some people with gluten-related
disorders can be fatal, it is important that they have the security of
knowing they will always be able to access gluten-free food cheaply.
•
It is too easy now for the newly diagnosed to buy poor quality 'glutenfree food, if they can afford it and then suffer in the years to come
17
Those who preferred the option to stop prescribing commented (507):
Most
Theme
Summarised comments
mentioned
1
Availability
•
Gluten-free foods are widely available in supermarkets
•
Gluten free food is readily available in all major supermarkets.
Everyone else is responsible for buying their own food. It should not
be the NHS responsibility to feed people. This food is available at a
reasonable cost and therefore should be purchased if required.
•
Gluten free products are now a routine product which may be
purchased in our local supermarket at a similar cost to non-gluten. £6
spent on a prescription for gluten free spaghetti when the same
product in Aldi is 99p.
•
“Gluten food should be paid for like every other food. It is
readily available in all big supermarkets. The days have gone
where it was hard to find”
•
Gluten free food products are widely available and should be part of
normal housekeeping. It is not right that people can get them on the
NHS
2
Inequality
•
This removes the inequity described in the papers. Affordable healthy
options are widely available. Advice is also widely available.
•
Other conditions don't have access to prescribed special foods and
plenty availability of GF foods now
•
“Diabetics, renal patients and others with food allergies and
intolerances don't get food prescribed- why should coeliacs be
any different?”
•
There are not the same provisions for other allergies/intolerances.
People could just avoid those foods if they can't afford to pay for the
products in a supermarket.
•
Other conditions don't have access to prescribed special foods.
There is plenty of availability for gluten intolerant patients to buy food
that will accommodate their condition
•
Reactions to certain foods is not confined to Coeliacs - we all have to
18
purchase food according to what suits us.
•
I have asthma and need daily medication to live which I am forced to
pay for, whereas if you are allergic to gluten, as limiting as it is you
can simply not ingest it. I don't have the option of choosing not to
breathe.
3
Nutrition
•
“Diet does not need to include specialist gluten-free food, in the
past people avoided things and ate alternatives so why do we
need a substitute? The consultation says that "Gluten free foods
will still be prescribed in specific circumstances where a
dependent patient could be at risk of dietary neglect." so some
people will still be protected which is fair but the vast majority
should be purchasing their own food”.
•
There are plenty of alternatives to foods containing gluten. It is a
question of educating people as to what those alternatives are.
Suggestions from all of these comments included:
 Immediate withdrawal of these foods for some dependent on them may cause initial problems
for those unable to regulate their own diet. Therefore, a fallback position in the form of these
staple ingredients together with GOOD nutritional advice should lessen this potential problem
before an eventual stop to all prescribing of such foods is introduced.
 Provide vouchers to coeliac patients who have to eat gluten free food
 Reviewing the current gluten free prescription list to consider supporting the healthy food
choices of wholemeal / whole grain / seeded and high fibre products rather than the processed
white flour and high sugar items allowed onto that list at present
 Stop prescribing but allow patients to access coeliac society approved quantities via a coeliac
society outlet, i.e. the coeliac society acts for and helps support its members to behave
responsibly in accessing appropriate levels of gluten free products.
 Phased approach to eventual withdrawal would be more appropriate
 Benefits agency to provide the extra money to finance gluten free food
 Commission pharmacies to operate a token service- cut out the GP on-costs plus Pharmacies
are VAT exempt so service delivery costs and supply costs are outside of the scope of VAT
 A limited service, or means-tested service might work better
19
 There will, of course, be cries of hardship, but mainly from people who do not want to prepare
food and expect everything to be delivered ready to eat. The NHS cannot afford to provide this
service. Quantities will need to be assessed so that people can prepare other foods.
 Campaign nationally and locally to negotiate reduced prices with the suppliers
 My prescription of 8 loaves every time is too much and some is wasted
A small number of comments were made relating to the survey itself regarding frustration that an
option wasn’t provided to continue prescribing gluten free products in the current way using the points
based system.
70% of respondents or a member of their family have not been prescribed gluten free food whereas
30% have. Of the 30% who have themselves or a member of their family been prescribed gluten free
food, 29% didn’t agree that the money being spent on over the counter items would be better spent
on maintaining and protecting other treatments and services which is nearly twice the proportion of
the rest of the respondents.
20
Those who receive gluten free products also ranked the prescription of gluten free food higher on
what they prefer to spend money on:
Most prefer to spend money on
Least prefer to spend money on
Access to physiotherapy services
Prescription of gluten free food
Non urgent referrals to orthopedics for 3 months
Prescription of baby milk and specialist infant formula
Prescription of over the counter drugs
Prescription of oral nutritional supplements
Proposal 3: Specialist baby milks and infant formulae
21
64% of respondents agreed or strongly agreed with the proposal to restrict prescribing specialist baby
milks and infant formulae. This proposal received the largest level of disagreement with 28% either
disagreeing or strongly disagreeing with the proposal. Of the 12% whose child or family member have
been prescribed these 59% agree with the proposal and 38% disagree.
Comments received largely supported the proposal to restrict this prescribing, citing that these
formulas are widely available in the supermarkets and pharmacists. “Baby milk is available from all
stores now but they don't want to pay for it the list is endless of the abuse of prescriptions”.
However, further comments clarified that specialist milks for certain conditions are only available on
prescription and in the case of premature babies, this is an essential requirement on prescription for
their growth and development. “The section on baby milks and specialist formulae is a great
concern. I totally agree that thickened formulae and lactose free formulae, for the treatment of
a primary or secondary lactose intolerance should be purchased by parents as these are a
similar price to a normal baby formula. However the proposal doesn't stop there. Are we
suggesting that babies and infants with serious medical conditions requiring a specialist baby
milk or formula are only to get these if parents can afford £80 per week to buy them? If
specialist formulae are made available over the counter how will the use of these formulae be
regulated?”
22
By far the majority of respondents have not been prescribed these products. However, as the
feedback to question 3 demonstrates, the provision of specialist baby milks and infant formulae is the
third most preferred choice to spend money on after physiotherapy and orthopedic appointments.
Proposal 4: Nutritional supplements
72% of respondents agree with the proposal to restrict prescribing of nutritional supplements and
21% disagree. Of the 20% who themselves or a family member has been prescribed oral nutritional
supplements, 73% agree with the proposal and 24% disagree.
23
Just over a quarter of respondents have themselves or a member of their family, been prescribed oral
nutritional supplements.
Q13 comments
Many of the 836 comments in this final comments box of the survey reiterated the feedback regarding
the specific proposals which have been summarized and captured within the rest of this report.
A number of these comments focused on the prescription of oral nutritional supplements which was
considered on one hand to be essential, particularly for the elderly and infirm, if no other alternative
was available and if they had received an appropriate assessment. “My father was prescribed
these following a long period of hospitalisation with Crohn's. He weighed 6st and would have
died without these supplements. There are very hard to source, the pharmacy ordered them in
especially each week”.
However, it was also considered to be an easy solution and often abused. “There are ways to add
nutritional value to foods without resorting to supplements. Supplements are just care homes
24
taking the easy way out, so these should not be prescribed unless food cannot be taken at
all”.
General comments
Comments on all of the proposals suggested that there was a need for adequate assessment and
means testing to ensure those who require prescriptions receive them and that it is a clinically based
decision. With regards to oral nutritional supplements, it was felt that care homes give this out too
easily and if they do they should be made to pay for it including education of care homes. Abuse of
the current system was also mentioned, citing that people get simple painkillers on prescription
‘because they can’ and they know of people who use prescribed gluten free food for the whole family
when it is not required. Self-funding and self-care was raised as a practical solution to reduce the
instances of prescribing unnecessarily supported by education and information on what is medication
and food products are suitable and available. Differing views on the survey itself were also fed back
with some feeling it needed more objective information and context for someone to have strong
opinions in areas where they have no personal knowledge and questions were biased while others
agreed with the proposals and felt it was balanced and fair.
25
Formal responses to the consultation
In addition to the completed surveys, formal responses were received from the following
organisations with their summarized feedback. Full responses with additional information are
attached as appendices 1-7:
The Health Scrutiny Committee for Lincolnshire
Proposal 1: To restrict providing over the counter / minor ailment medicines for short term, selflimiting conditions
The Committee supports the principle of self-care for very minor ailments and notes that some
medicines are cheap and widely available whereas others are more expensive and not as widely
available and are therefore concerned of the impact on low income families.
Proposal 2: To restrict the prescription of gluten-free foods.
The Committee supports the proposal to limit prescription of gluten free foods to bread, bread flour
and bread mixes although GPs should be allowed discretion to take into account the wider impact of
these proposals with support from the CCGs.
Proposal 3 - To restrict prescribing of baby milks and specialist infant formula
The Committee notes that specialist baby milks and infant formulas can be expensive and is
concerned about the potential impact on low income families and believes that GPs should be
allowed the discretion to take account of exceptional circumstances, including any serious financial
impacts on families with support from the CCGs.
Proposal 4 – To restrict prescribing oral nutritional supplements
The Committee strongly supports the "food first" approach and are concerned that some care homes
rely too heavily on nutritional supplements although GPs should be allowed discretion.
General Comments
The Committee are reassured that discretion will be applied by GPs to take into account individual
circumstances. The Committee are concerned the six week period of consultation is too short
although acknowledge the pressure on the CCGs with regards to the timescales, and that the
consultation document has not been widely circulated as some GPs have decided not to make the
consultation document available although they acknowledge the efforts to promote this consultation.
26
Healthwatch Lincolnshire
Healthwatch Lincolnshire believes it is right to give people living in our county the opportunity to
comment on any proposed changes that will affect the medication they are prescribed. The
consultation period of 6 weeks is noted and ask that future consultations are open for a minimum of
12 weeks. If it decided to proceed with the recommendations robust support should be given to
prescribers and patients regarding discretion. We have concerns about how reduction of over the
counter prescribed medication might affect low income patients and families. There perhaps needs to
be some national requirement to raise the exemption age limit for those eligible to receive free
prescribed medications.
Department of Nutrition & Dietetics United Lincolnshire Hospitals NHS Trust
Proposal 2: To restrict or limit the prescribing of gluten free foods
We would support the continuation of the availability of staple gluten free foods on prescription for
patients with Coeliac Disease and Dermatitis Herpetiformis as recommended by Coeliac UK.
Proposal 3: To Restrict prescribing baby milks and specialist Infant Formula.
A clear guide of when to direct patients to their local pharmacy and when a prescription for a baby
milk or specialist formula is appropriate to consider would be more helpful. Age ranges that a
prescription would be expected to be required and timely re-introduction programmes would all help
to reduce unnecessary and costly prescribing. If a recommendation is made by a Paediatrician or
Paediatric Dietician for a specialised infant formula then this should be prescribed.
Proposal 4: To restrict prescribing of nutritional supplements (ONS)
A very clear pathway for managing nutrition in the community is required. Previously a PACE Bulletin
(Guidance on the Prescribing of Oral Nutritional Supplements Vol 8 No. 8 May 2014) has been
produced which describes the process for nutritional assessment and intervention. We would
reinforce this process. Nutritional screening should be undertaken using a validated nutritional
screening tool e.g. Malnutrition Universal Screening Tool (MUST). For those identified to be at
Medium or High Risk on MUST then food first interventions should be used to help increase dietary
intake e.g. snacks and food fortification advice. On re-assessment, after all dietary interventions have
been implemented, if the patient remains as Medium or High Risk and there is no improvement then
27
ONS should be considered. Goals should be set to assess the effectiveness of the intervention.
Regular re-assessment should take place. Where ONS has been requested by a Dietician following
individual patient assessment this should be prescribed.
Coeliac UK
Proposal 2: To restrict the prescription of gluten-free foods.
We are concerned that you are considering removing access to gluten-free food on prescription and
our concerns are shared by the British Society of Gastroenterology. We are concerned that the
consultation does not provide an option for continuing with the current policy for gluten-free
prescribing and does not reference coeliac disease and only refers to gluten free food. Research
shows gluten free foods are not readily available to purchase in budget supermarkets and
convenience stores and are expensive, therefore gluten free food on prescription is especially vital for
the elderly or those with limited transport.
British Society of Gastroenterology
Proposal 2: To restrict the prescription of gluten-free foods.
The proposed removal by CCGs of prescriptions for Gluten Free Diets poses a direct impact on the
care of patients with coeliac disease, as well as wider cost implications for the health economy and
we would like to put on record our support for Coeliac UK on this issue. As part of your review the
BSG would urge that due regard is paid to the impact of any withdrawal of gluten free diets
prescriptions on patients and wider healthcare costs. We are concerned that the consultation
document lacks direct reference to coeliac disease but instead states that gluten-free foods are
prescribed for people with ‘particular dietary requirements’.
British Specialist Nutrition Association Ltd
Proposal 3: To Restrict prescribing baby milks and specialist Infant Formula.
We support the ambition to explore ways to make our health services more sustainable, to help
patients to take responsibility for their own health and to reduce the need for unnecessary
prescriptions. However, it is necessary to highlight the importance of ‘specialist infant formulae’ to
28
avoid any confusion with baby milks in general. It is vitally important that these products remain
available on prescription as they must be used under the supervision of a healthcare professional.
We believe it is important to retain the option for the doctor to prescribe such formulas when the
diagnosis is made. This is necessary to ensure the baby receives the correct formula via a
prescription dispensed by a pharmacist.
Lincolnshire Local Pharmaceutical Committee
As the committee representing NHS pharmacy contractors we are acutely aware of the needs of the
NHS to find efficiencies. However, we believe the consultation is flawed, in particular with regard to
the desire to restrict prescribing of non-prescription-only-medicine for those suffering from short term
or self-limiting conditions. Community pharmacy is the most accessible NHS primary care provider
and can do more to take the burden away from general practice, out of hours providers and
emergency departments. We would like to see commissioners and stakeholders work with
community pharmacy to develop services locally that can play a real and significant part in reducing
the demand on primary and urgent care services.
With regard to the other elements of the consultation, the committee would wish to make the
observation that Lincolnshire is a large, rural and to make the generalised assumption that patients
have easy access to large retailers selling specialised foods and infant formula at prices comparable
to normal groceries is a flawed one and provision must be made to support those patients.
Themes from events and meetings
In addition to the wide circulation of the consultation document, drop in events and public meetings
were held in some CCG areas and others attended existing community meetings to promote the
opportunities for involvement. These events were targeted to areas identified in the Equality Impact
Assessment as likely to be most affected by the proposals. The drop in events were hosted by CCG
Clinical Leads and offered people the opportunity to ask questions and provide feedback on the
consultation proposals. Drop in sessions targeted children from low income families. Overall, over
100 people were engaged at these events and the feedback from all has been themed and
summarised below:
•
Surprise was expressed that prescribers can't refuse to prescribe over the counter medicines
and that this agenda isn't a national one with statutory directives.
29
•
It was recognised that CCGs are under considerable financial pressure and have to make
difficult decisions
•
It was questioned how GPs could enforce much of the above without legislative support and
back up
• “Some felt outraged that this hadn’t been introduced sooner and they were
shocked at the amount of money being wasted”
•
Some felt that waste medication via repeat prescribing felt like a much bigger issue and much
more important to tackle as there were safety concerns as well as costs.
Over the counter medications:
•
General agreement that proposals were sensible and patients should attend a pharmacy in the
first instance other than for those medications which also have a public health implication
•
Concerns that stopping prescribing medicines for long term use could have significant knock
on effects
•
Agreed thrush treatment should be restricted as although expensive it is usually required
infrequently. However, some more expensive medications could prevent patients from getting
treatment
•
Concerns raised relating to Non-steroidal anti-inflammatory drugs (NSAIDs) that will bought
over the counter and how GPs will be able to monitor the use of all medicines if patients
purchase them themselves and how they interact with other medicines
•
Nicotine Replacement Therapy was felt should not be available on prescription
•
Self-care needs promotion and community support
•
Education on this should be introduced at school age level
Gluten free products:
•
Costings of gluten free foods were questioned as still felt to be more expensive than standard
products and that NHS purchase price might be over inflated. Concerns for impact of
proposals on low income families
•
It was felt a ‘no change’ option should be available but general agreement to limit the supply of
gluten free products as a fair compromise to prescribe only staple foods
•
More support required for low income families to enable making gluten free food from scratch
30
Baby milk:
•
General discussion supported restriction of prescriptions
•
Expectant mums should be made aware if they plan to buy formula rather than breastfeed
especially as some can be costly and provided with a list of products available from chemists
Oral nutritional supplements:
•
General discussion supported restriction of prescriptions unless recovering from major or
terminal illnesses
•
Consideration should be given to elderly patients in rural areas whose prescribed medicines
are delivered to their door
•
Care homes should do more to encourage residents to eat normal food with support for staff to
implement this
Themes from telephone calls, letters and emails received from PPGs and
members of the public (40)
A number of telephone calls and emails were received during the consultation process, the main
points of which are outlined below.
Over the counter medications:
•
Over the counter medications are restricted to buy in large quantities and more convenient to
receive as one single prescribed pack than multiple purchases
•
Frustration (some were outraged) that this hadn’t been introduced sooner and were shocked at
the amount of money being wasted. All proposals agreed with and felt it needed to be rolled
out nationally with governmental influence and prevent a ‘post code lottery’.
•
If particular drugs are recommended they should still be prescribed for those who don’t pay.
“For those who do pay, they should be told the price of both options and
given the opportunity to purchase it themselves over the counter”
•
Suggestion that education around this should be introduced at school age
31
Gluten free products:
•
It is a challenge to buy gluten free products in supermarkets and when they are available they
are expensive
•
Pensioners, particularly those in rural areas, with no transport and no local shops who sell
gluten free food will particularly struggle if they did not receive this on prescription
•
Offers made to meet with local interest groups to discuss the proposals and suggested ways of
working moving forward
• “The availability of these foods is a lifeline to me as I would find it very
difficult to afford the basic bread, flour etc. I do not expect to have the
luxury items”
•
Those with multiple dietary allergies would not know where to buy the foods they get on
prescription and it isn’t available in supermarkets
•
Suggestion for pharmacists to see ‘medical diet foods’ at cost price
•
Suggestion to convince the Government that action should be taken to persuade
manufacturers to reduce the costs of gluten free food
•
Suggestion that the NHS should negotiate and not pay more than prices in local shops
Baby milk:
•
Request specifically to continue to prescribe Nutriprem which is for most vulnerable, premature
babies and very expensive compared to normal milk. Without this, it could result in an
expensive readmission to hospital. Multivitamins, especially Sytron, is also essential and not
available at supermarkets
General comments
•
Greater savings could be made by reforming the structure of the NHS and removing layers of
bureaucracy rather than service changes which impact on patients.
•
Self-care should be promoted and supported– all patients should follow this course of action
before consulting a GP
•
Times have changed and the proposals reflect that with the availability of all of these products
more widely available
32
Some comments and concerns have been received throughout the process regarding the
consultation process itself:
•
Who will make the decisions on who is prescribed medications and will it take into account
financial and other health considerations?
•
To change the working practice of prescribing for the whole of Lincolnshire can lead to a lot of
extra work
•
Consultation process considered to be too short
•
Lack of specific targeting of consultation to patients
•
Dissatisfaction with survey wording and no option to continue prescribing gluten free food as it
is currently
Recommendations
1. Implement the proposals, subject to formal endorsement at the 4 CCG Governing Body
meetings on 30th November and 1st December 2016
2. Agree implementation for future restricting of prescriptions for over the counter medications or
option to implement retrospectively
3. Agree implementation date of all proposals as 5th December 2016
4. Consider the outcomes of the Equality Impact Assessment alongside this consultation
5. Produce and implement a comprehensive marketing and communications plan to provide
feedback on the outcome to the public and other key stakeholders ‘You Said – We Did’.
6. Work with key stakeholders including GPs, practice staff, community pharmacists, providers,
nurseries, schools and care homes to gain support for implementation of the proposals.
33
Due Regard (Equality Analysis) for OTC prescribing
Introduction
The general Public Sector Equality Duty as set out in the Equality Act 2010 requires public authorities, in the exercise of
their functions, to have due regard to the need to:
•
•
•
Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act.
Advance equality of opportunity between people who share a protected characteristic and those who do not.
Foster good relations between people who share a protected characteristic and those who do not.
The general equality duty does not specify how public authorities should analyse the effect of their existing and new
policies and practices on equality, but doing so is an important part of complying with the general equality duty. It is up to
each organisation to choose the most effective approach for them. This standard template is designed to help staff
members to comply with the general duty.
Further, one of the specific Public Sector Equality Duties, with which the CCG must comply, requires that information
evidencing compliance with the Public Sector Equality Duty is published.
Karen Duncombe – Assurance Manager, Optum CSS
Last Updated: 25/04/16
Due Regard (Equality Analysis) is an on-going proactive process which requires the use of information about the effect
our decisions are likely to have on local communities, service users and employees, particularly those who are most
vulnerable or at risk of disadvantage.
This template has been designed to assist in collating the information and evidence necessary to support the Due Regard
process in the making and implementation of our decisions when considering changes to services or functions, this
includes service re-design/reconfiguration.
Organisation
Service area
Lead Officer Responsible for Due Regard
Project Subject/Title
Lincolnshire Clinical Commissioning Groups
Prescribing
Karen Duncombe
Over the Counter Prescribing
Aims of the Due Regard (Equality Analysis)
Scope of the Due Regard, i.e. service
change/service re-design, reconfiguration:
Summary of findings
Options/mitigations
Karen Duncombe – Assurance Manager, Optum CSS
Service change
The equality analysis has found that restricting over-the-counter
medicines potentially has a detrimental impact on older adults and
children, particularly of low income families. This could be challenged
under the Equality Act 2010
In order to mitigate, it is recommended that GPs use their discretion in
prescribing for these groups of people, with a tendency to prescribe
rather than not in cases where older people or children may be at risk
Last Updated: 25/04/16
Phase 1: Gathering information
Type of information
Data on user trends
(i.e. patient/service user/population)
Karen Duncombe – Assurance Manager, Optum CSS
Findings
Empowering people with the confidence and information to look after
themselves gives people greater control of their health and encourages
behaviour that will help to prevent ill health in the longer-term. In many cases,
people can take care of their minor conditions if they are provided with the right
information, enabling health care professionals to focus on patients with more
serious health problems.
The majority of people feel comfortable managing everyday minor conditions,
particularly when they can recognize symptoms and have successfully treated
themselves with over-the-counter (OTC) medicines in the past. Many people will
hold stocks of a wide range of OTC remedies at home in order to manage minor
health problems in their family as they arise. A well-stocked family medicine
cabinet is likely to hold: paracetamol tablets 500mg, paracetamol 120mg in 5ml
or 250mg in 5ml (depending on the age of the children), an antacid for
dyspepsia or heartburn, an emollient for dry skin, antifungal cream for vaginal
thrush or athlete’s foot, ibuprofen 200mg tablets, an antihistamine for hayfever
in the summer, cough and cold remedies etc. This policy seeks to encourage all
households to proactively manage minor conditions with OTC medicines in the
same way without unnecessary recourse to primary care medical services
whenever a minor healthcare problem arises.
Despite people’s willingness to self-treat, there are still 57 million GP
consultations nationally a year for minor conditions at a total cost to the NHS of
£2 billion. These appointments take up an average of one hour a day for every
GP. Research shows that people often abandon self-care earlier than they need
to, typically seeking the advice of a GP within four to seven days. The main
reasons for this are:
•
lack of confidence in understanding the normal progress of symptoms
(e.g. a cold can last up to 14 days; a cough for 3 weeks or more).
Last Updated: 25/04/16
•
misperception of the severity and duration of symptoms.
•
the need to seek reassurance that nothing more serious is wrong.
•
seeking a prescription for a medicine, even though the same medicine is
available to buy.
•
seeking treatment for a condition that will get better on its own.
Research suggests that health-seeking behaviour is repetitive with 62% of
patients choosing to visit a GP if a prescription was issued on the previous
occasion. Conversely, experience with self-care builds confidence with 84% of
patients choosing self-care for subsequent episodes following a successful foray
into self-care in the past.
Providing an environment that supports self-care has been shown to:
•
improve the health and wellbeing of local communities.
•
raise awareness of and increase access to suitable providers of
healthcare advice and support.
•
reduce avoidable appointments in general practice, thus helping to
safeguard appointment time for patients with more serious health problems.
•
reduce avoidable visits to the local emergency departments and
appointments with out-of-hours GP services.
•
reduce NHS expenditure on medicines that can be bought in the
community without prescription, thus helping safeguard local NHS resources for
medicines that are only available on prescription, as well as other services.
It is estimated that by implementing this policy:
•
every GP in Lincolnshire will have up to one hour a day freed up to see
patients with more serious conditions
•
up to £47,000 a month in local NHS expenditure on prescription costs
can be saved
•
there will be a reduction in medicines waste and costs associated with
medicines waste
•
patients and carers will be better informed about how to manage minor
Karen Duncombe – Assurance Manager, Optum CSS
Last Updated: 25/04/16
Benchmarking
conditions.
Warrington CCG undertook a public consultation and ceased prescribing OTC
medications in January 2016; however, they did not amend access to glutenfree prescribing.
St Helens have also ceased prescribing OTC medications, apart from the
prescribing of gluten free foods “unless there are specific circumstances
whereby a dependent patient could be at risk of dietary neglect”.
West Cheshire has ceased prescribing OTC medications and gluten free
products but is continuing to prescribe baby formula.
Cambridgeshire and Peterborough CCG has also ceased to prescribe all OTC
medications.
Results of consultation (highlighting
which stakeholders groups were
involved in context of protected
characteristic/equality groups)
Karen Duncombe – Assurance Manager, Optum CSS
None of the above organisations have published an Equality Analysis as part of
the decision-making process.
See report of which this document forms an appendix
Last Updated: 25/04/16
Phase 2 Impacts
As part of the Phase 1 exercise, the following impacts have been identified around gluten free prescribing and the
prescribing of infant formula and paracetamol.
Age: Where a person is at risk of unfair treatment because of their age group
Issue/option
Positive Impact or benefits
Negative impact or risks
Action Required
Proposed
cessation of gluten
free prescribing for
children
None
Because children are not in charge of
their own decisions around eating,
changes in prescribing may put
children at nutritional risk.
Consultation to
consider the impact
on children around
changes to
prescribing glutenfree foods.
Consideration to be
given to continuation
of prescribing
gluten-free foods for
children.
Proposed
cessation of
paracetamol
prescribing for
children
None
If a family cannot afford paracetamol
for a child, there is a risk of the child
having febrile convulsions and being
admitted to hospital.
Consultation to
consider the impact
on children around
changes to
prescribing
paracetamol for
children.
Consideration to be
given to continuation
of prescribing
paracetamol to
Karen Duncombe – Assurance Manager, Optum CSS
Last Updated: 25/04/16
children.
Disability and health and wellbeing: All forms of disability recognised under the Equality Act 2010 including sensory
impairment, mental health, learning disabilities, mobility related conditions, conditions such as heart disease, diabetes,
asthma. This also covers any impact on health and well being
Issue/option
Positive Impact or benefits
Proposed
None
cessation of gluten
free prescribing for
people with coeliac
disease
Negative impact or risks
Action Required
Coeliac disease is considered a
disability under the Equality Act 2010
and people who do not follow a
gluten-free regime can experience
severe symptoms as a result.
However, there are a range of gluten
free items available in most
supermarkets.
Consultation to
consider the impact
of changes to
gluten-free
prescribing on
people with Coeliac
disease, including
consultation with
Coeliac UK.
Pregnancy and Maternity: relates to women who are pregnant or within their allocated maternity period; up to 26 weeks
after birth.
Issue/option
Positive Impact or benefits
Negative impact or risks
Action Required
Proposed
cessation of the
prescription of
infant formula
None
If non-dairy formula is more
expensive than ordinary formula, or
where breast feeding is not an option
because of a medical issue with the
mother, the infant may be at
nutritional risk.
Consultation to
consider the impact
of cessation of
prescriptions of
infant formula.
Karen Duncombe – Assurance Manager, Optum CSS
Last Updated: 25/04/16
Socio-Economic Status: This can include people on low incomes, as well as issues around rural and urban deprivation –
You may wish to include this, although it is beyond the scope of the Equality Act 2010.
Issue/option
Positive Impact or benefits
Negative impact or risks
Action Required
Where certain
products are not
locally available or
are more
expensive than
their counterparts
(e.g. gluten free
foods)
None
There is potential for people to fail to
eat correctly for their condition,
should suitable foods be hard to
acquire due to rural isolation, or more
expensive – this could put some
people at risk.
Consultation to
consider the impact
of changes to
prescribing glutenfree foods to people
who might be at
nutritional risk
otherwise.
Good Relations: This is where a decision or a change to services may risk creating tensions between community groups
in a local area, or has the potential to improve relations between groups.
Issue/option
Positive Impact or benefits
Negative impact or risks
Action Required
Perceived
prescribing
inequalities have
the potential to
cause some poor
relations between,
for example,
people who need
gluten free foods
and people who
need lactose free
foods and have to
Changed to prescribing of gluten free
foods would potentially improve
relations due to the perceived
inequalities in current prescribing
arrangements.
None
Consultation to
consider views of
people with other
dietary needs which
are not available on
prescription.
Karen Duncombe – Assurance Manager, Optum CSS
Last Updated: 25/04/16
purchase their
own.
Karen Duncombe – Assurance Manager, Optum CSS
Last Updated: 25/04/16
Phase 3: Action Planning
Based on actions raised in the action required box above
Area for further
action
Consultation to be
undertaken
October 2016
Actions
proposed
Findings of
consultation to
inform the final
Equality Analysis
and actions
therefrom.
Lead officer
Recommendations
from this
document and the
consultation report
to be taken into
consideration in
making a final
decision
Recommendation
for GP discretion
to be used in
prescribing
Karen
Duncombe
Karen Duncombe – Assurance Manager, Optum CSS
When
Karen
November
Duncombe/Steph 2016
King
December
2016
Resource
Outcome
implications
Staff time
The
consultation
indicated that
restrictions in
prescribing
should be
recommended
but with GP
discretion
recommended
Savings on
TBA
prescribing
will reduce
but not by
the full
amount
Last Updated: 25/04/16
THE HEALTH SCRUTINY
COMMITTEE FOR LINCOLNSHIRE
Boston Borough
Council
East Lindsey
District Council
City of Lincoln
Council
Lincolnshire
County Council
North Kesteven
District Council
South Holland
District Council
South Kesteven
District Council
West Lindsey
District Council
RESPONSE OF THE HEALTH SCRUTINY COMMITTEE FOR LINCOLNSHIRE TO
THE MEDICINES MANAGEMENT CONSULTATION
This is the response of the Health Scrutiny Committee for Lincolnshire to the
Medicines Management Consultation, undertaken by the four Lincolnshire Clinical
Commissioning Groups between 4 October and 18 November 2016.
Proposal 1: To restrict providing over the counter / minor ailment medicines for short
term, self limiting conditions
The Committee supports the principle of self-care for very minor ailments. The
Committee notes that some medicines such as paracetamol or ibuprofen are cheap
and widely available in supermarkets or local convenience stores. However, some
over the counter medicines, such as cough syrups, thrush creams or ointments, or
child paracetamol are not as cheap, nor as readily available. For this reason, the
Committee records its concern that this proposal may have an impact on low income
families, as some more expensive over the counter medicines may no longer be
affordable to these families.
The Committee accepts that in addition to the financial saving from this proposal,
there would be a benefit of more GP appointments becoming available. While
pharmacists have the skills to offer advice and provide medicines in most instances,
there may be a small number of instances where pharmacists should recommend a
GP appointment, so that patients can receive the required medical advice, and
potentially a prescribed medicine.
Proposal 2: To restrict the prescription of gluten-free foods.
The Committee supports the proposal to limit prescribing of gluten-free foods to
loaves of bread, bread-flour and bread mixes (in accordance with Coeliac UK's
recommended quantities). However, GPs should be advised always to take account
of the impact of these arrangements on particular individuals, and allowed the
discretion in exceptional circumstances to prescribe other products.
If this proposal is implemented all GPs should receive guidance from the clinical
commissioning groups, in terms of what should be prescribed and in what quantities,
and also advised that they should take account of exceptional circumstances.
Page 1
Proposal 3 - To restrict prescribing of baby milks and specialist infant formula
The Committee notes that specialist baby milks and infant formulas may cost four
times as much as standard milk and formulas. The Committee is concerned about
the potential impact on low income families and believes that GPs should be allowed
the discretion to take account of exceptional circumstances, including any serious
financial impacts on families. GPs should be provided with the guidance to enable
them to exercise their discretion on this.
Proposal 4 – To restrict prescribing oral nutritional supplements
The Committee strongly supports the "food first" approach for those with low appetite
or a degree of malnourishment. There is a concern that some care homes rely too
much on nutritional supplements, when they should be encouraging their residents to
eat food.
However, the Committee is mindful that there may be exceptional circumstances,
and GPs should be advised of the need to take account of the impact on low income
families.
General Comments
The Committee notes that each proposal includes the word "restrict", rather than
"discontinue". This provides an element of reassurance that discretion will be
applied by GPs, who can take account of individual and exceptional circumstances,
in particular impacts on low income families.
The Committee is concerned that the six week period of consultation has been too
short, although the Committee acknowledges the pressures on the four clinical
commissioning groups to reduce expenditure during the remainder of the 2016/17
financial year. The Committee is also concerned that the consultation document has
not been widely circulated, as some GP practices have decided not make the
consultation document available in their waiting rooms. Efforts to promote the
consultation are acknowledged.
In view of this, the Committee will be seeking feedback from the clinical
commissioning groups on the numbers of responses received; and an analysis of the
types of patient and their geographical location.
Whatever is determined by the clinical commissioning groups on this proposal, the
Committee would like to emphasise the importance of publicising the new
arrangements, to ensure patients are aware of the new arrangements and the
reasons for their introduction.
Page 2
Response re Medicines Management Consultation from Department of Nutrition &
Dietetics United Lincolnshire Hospitals NHS Trust
Proposal 2: To restrict or limit the prescribing of gluten free foods
A gluten free diet is the sole treatment for Coeliac disease (CD) and Dermatitis
Herpetiformis (DH) enabling the patient to meet their nutritional needs and avoid the
complications of untreated disease. This is diet is essential to enable good health for all
people with either condition.
Compliance can be challenging and the availability of gluten free foods is essential to enable
people with both CD and DH to achieve lifelong strict adherence to a gluten free diet.
Although many GF options are available in large supermarkets they are at least three times
the cost of similar items containing gluten.(25.10.16 Tesco cost for 13 units = Coeliac UK
recommended units for a child 7-10yrs = £20.70 Gluten containing equivalents £7.31). If GF
products are not available on prescription this will pose a significant burden for people on
low incomes or with limited mobility.
Smaller supermarkets and local shops do not provide GF options causing inequity in
availability especially in rural areas.
Availability combined with the cost is likely to result in non-adherence to the diet and
consequently malabsorption and risk of malignancy. NICE quality standard (QS134)
published in October 2016 recognises these risks and recommends that patients need to be
supported by healthcare professionals to find suitable gluten-free food products on
prescription to enable them to maintain a gluten-free diet.
Recommendation
We would support the continuation of the availability of staple gluten free foods on
prescription for patients with Coeliac Disease and Dermatitis Herpetiformis as
recommended by Coeliac UK.
References: NICE Quality Standard 134 :Coeliac Disease Oct 2016
Proposal 3: To Restrict prescribing baby milks and specialist Infant Formula.
This section is very unclear as to what is proposed to be restricted, for which conditions and
what age group of child is being targeted. It contains some clinical errors.
It is correct that thickened formula and lactose free formula can be purchased at a roughly
equivalent price to a normal baby formula and do not need to be available on prescription.
However Soya based formulae are not recommended for children under 6 months of age
unless they have a diagnosis of Galactosaemia in which case this is the only suitable formula
to treat this condition. Soya formula is not suitable for all children who need to avoid
normal cow’s milk based formulae.
The Lincolnshire CCGs annual spend of £740,000 on infant formulae includes more than the
cost of prescribing soya, thickened formula and formulae for lactose intolerance. It includes
formula required for diagnosed medical conditions, the treatment for which is an essential
and long lasting change in infant formula. The formulae used to treat cow’s milk protein
allergy and faltering growth are not mentioned in either the “What is included?” section or
in the “What is not included section?”.
Cows Milk Protein Allergy
The cost of formulae to treat Cow’s milk protein allergy in infants is not similar to a normal
formula milk, nor are they readily available to purchase. An extensively hydrolysed formula
(which should be the most common formula used and in the majority of cases first line) ,
costs around three times the cost of a normal formula when bought over the counter. An
Amino Acid based formula, essential for some 10% of children with a cow’s milk protein
allergy, costs 7 times more than a normal formula. This essential treatment for their baby
will not be affordable for the majority of parents. Soya formula is not suitable for babies
with a cow’s milk protein allergy as they may also react adversely to Soya. It should not be
given to babies under 6 months of age. Through examination of IMS prescribing data, it
would appear that there is an over-prescribing of the more expensive amino-acid based
formulae for cow’s milk protein allergy. Extensively hydrolysed formulae should be tolerated
by 90% of children (NICE June 2015) .Tackling inappropriate formula choice and ensuring
that children move on from specialist formula milks at an appropriate time, would be likely
to result in substantial cost savings.
The statement in the document that alternatives to cow’s milk are widely available would
be directed at children who are no longer requiring a Formula milk in which case a
prescription should never have been contemplated. The milks mentioned are not
nutritionally equivalent to cow’s milk and their necessity and suitability in children under 18
– 24 months of age should be assessed by a dietitian. Most children outgrow the allergy to
cow’s milk between the ages of 12 and 24 months and can then consume cow’s milk. Goats
milk is not suitable in Lactose intolerance or cow’s milk protein allergy, or any other clinical
condition and should therefore not be mentioned as an alternative.
The document produced jointly by ULHT dietitians and GEM on Lactose Intolerance and
Cow’s Milk Protein Allergy, the updated version of which is currently going through the CESC
process, has always recommended that Lactose Free formulae be purchased by parents. It
gives further guidance on how to manage both Lactose intolerance and Cow’s Milk Protein
Allergy. The advice of a dietitian should be sought when a cow’s milk protein allergy is
suspected. (NICE June 2015)
Faltering Growth
Children experiencing faltering growth in infancy often require a change in formula milk for
a period of time. For some this may involve, under the close supervision of a dietitian, a
concentration of a normal formula milk. When this is not a suitable option specialist high
energy and protein formulae are used. The specialist Formula milks are not readily available
to purchase and would cost considerably more to purchase than normal formula milks.
Some babies with absorption and gut motility issues may require a hydrolysed high calorie
formula which has even greater cost implications. Other conditions may require an altered
fat type for a period of time or the omission of a particular amino acid for life. None of these
is mentioned as included or excluded in the consultation document. The choice of formula
for a baby should be made on clinical need and not on what parents can afford. Encouraging
parents to seek out alternative milks and specialist formulae themselves, may lead to erro rs
in their choice of formula. For example parents may choose the cheaper lactose free
formula which would harm a child who should be receiving a cow’s milk protein free milk. It
may also lead to parents self-diagnosing their children and imposing unnecessarily dietary
changes on them as the milks become more widely available without guidance from a
clinician.
Recommendation
A clear guide of when to direct patients to their local pharmacy and when a prescription for
a baby milk or specialist formula is appropriate to consider would be more helpful. Age
ranges that a prescription would be expected to be required and timely re -introduction
programmes would all help to reduce unnecessary and costly prescribing.
If a recommendation is made by a Paediatrician or Paediatric Dietitian for a specialised
infant formula then this should be prescribed.
References
1. NICE Cow’s Milk Protein Allergy in Children June 2015
Proposal 4: To restrict prescribing of nutritional supplements (ONS)
Commissioners have a responsibility to include Nutrition & Hydration in their commissioning
priorities (NHS England Guidance- Commissioning Excellent Nutrition and Hydration 2015 2018).
Malnutrition is common in the UK affecting more than 3 million peopl e at any one time.
Malnutrition is estimated to be associated with costs to the UK health economy of more
than £19 billion per annum (BAPEN 2015)
Improving the identification and treatment of malnutrition is estimated to have the third
highest potential to deliver cost savings to the NHS (NICE 2011).
No assessment has ever been undertaken in Lincolnshire to quantify how many patients do
not require ONS and thus the potential savings. Schemes implemented in other parts of the
country to assess patients nutritional status and ensure appropriate prescription have
shown savings of between 30 and 47%.
It is agreed that ‘Food First’ should always be used.
There are only a limited number of OTC supplements available e.g. Complan and Meritene
(please note consultation document states Build-Up which is no longer produced).
Dietetic Assessment and Advice
There are a significant number of out-patients who are under of the care of the Dietitians
who have been referred for nutritional support and advice. This would in clude patients with
a range of medical conditions e.g. cancer, renal failure, IBD, stroke, dysphagia, COPD, etc. It
is important that these patients still qualify for prescription of ONS as they will have been
individually assessed and dietary advice and ONS recommended as part of their care plan.
Adequate nutrition is vital to maintain health and poor nutritional status contributes to
hospital admissions and poor outcomes.
When request is made for ONS following an in-patient stay this should be for a period of no
more than 4 weeks and a repeat prescription should not be instigated unless this is clearly
stated in the discharge letter.
The Dietetic service is a limited resource and cannot assess every adult patient from whom
ONS may be beneficial.
However children should only be prescribed nutritional supplements on the advice of a
Dietitian or Paediatrician.
Recommendation
A very clear pathway for managing nutrition in the community is required. Previously a PACE
Bulletin (Guidance on the Prescribing of Oral Nutritional Supplements Vol 8 No. 8 May 2014)
has been produced which describes the process for nutritional assessment and
intervention.
We would reinforce this process.
Nutritional screening should be undertaken using a validated nutritional screening tool e.g.
Malnutrition Universal Screening Tool (MUST).
For those identified to be at Medium or High Risk on MUST then food first interventions
should be used to help increase dietary intake e.g. snacks and food fortification advice.
On re-assessment, after all dietary interventions have been implemented, if the patient
remains as Medium or High Risk and there is no improvement then ONS should be
considered.
Goals should be set to assess the effectiveness of the intervention.
Regular re-assessment should take place.
Where ONS has been requested by a Dietitian following individual patient assessment this
should be prescribed.
References:
1. NHS England Guidance Commissioning Excellent Nutrition and Hydration 2015-2018.
Oct 2015
2. Managing Adult Malnutrition in the Community – multi-professional consensus panel
May 2012
3. GEMCSU Lincolnshire Prescribing and Clinical Effectiveness Bulletin Vol 8, No.8 May
2014
Katherine Green Trust Lead Dietitian
Kathryn Kelly Site Lead Dietitian Grantham and Pilgrim Hospital Boston
Katy McMillan Home Enteral Nutrition & Paediatric Team Lead Dietitian
Dr Peter Holmes
Lincolnshire East CCG
Cross O’Cliff Court
Bracebridge Heath
Lincoln
LN4 2HN
6 October 2016
Dear Dr Holmes,
We have been made aware of the review of gluten-free prescribing by four clinical commissioning groups
(CCGs) in Lincolnshire. As the largest patient organisation representing over 60,000 Members we would
like to submit this letter as a formal response to the consultation. We would also like to raise some
significant concerns about the consultation which we will also be escalating to Healthwatch.
We are concerned that you are considering removing access to gluten-free food on prescription, a service
providing essential NHS support and a safety net for the most vulnerable in light of the higher cost and
limited availability of gluten-free staple foods in supermarkets. As you will see from the enclosed
statement, our concerns are shared by the British Society of Gastroenterology.
The significance of the gluten-free diet
Coeliac disease is an autoimmune disease caused by a reaction to gluten, found in wheat, barley and rye.
Adherence to the gluten-free diet remains the complete medical treatment and having coeliac disease
therefore requires significant dietary modification. The use of gluten-free substitute staple foods facilitates
the necessary dietary adaptation. Rates for adherence to the gluten-free diet can vary between 42-91% [1]
and access to gluten-free staples on prescription can be related to adherence [2].
Non adherence to the gluten-free diet is associated with an increased risk of long term complications,
including osteoporosis, ulcerative jejunitis, intestinal malignancy, functional hyposplenism, vitamin D
deficiency and iron deficiency [3]. These long term complications will impact upon quality of life for the
patient and treating these complications will result in financial implications for the NHS.
You have stated that rice and potatoes can be used to replace gluten containing foods. This would have a
significant effect on the nutrient content of the diet. In the UK, bread is an important source of energy,
dietary fibre, vitamins and minerals. It provides more than 10% of our intake of protein, B vitamins and
iron, and one fifth of our dietary fibre and calcium [4]. For example, replacing the average amount of bread
consumed daily in the UK (72g) [4] with an isocaloric portion of rice would reduce the iron content by 90%
and the calcium content by 82%. People with coeliac disease have higher calcium requirements (1000mg)
than the general population (700mg) [5], therefore including good sources of calcium in the diet is
particularly important for people with coeliac disease.
Concerns with the consultation
We are concerned that the questionnaire does not provide an option for continuing with the current policy
for gluten-free prescribing. This demonstrates that the decision to withdraw or restrict access to
gluten-free food on prescription has already been made before the consultation has been carried out. In
addition, the questions about other proposals put forward ask respondents to provide their level of
agreement with the proposal, allowing respondents to voice their disagreement with a proposal. Why has
a different approach been taken for gluten-free prescribing?
The consultation document states “last year Lincolnshire CCGs spent £472,000 on gluten-free food which is
roughly equivalent to 30 treatments for breast cancer. If this service was restricted then this money could
alternatively be used to maintain and protect other clinical services.” It is highly inappropriate to imply that
patients with breast cancer would not receive treatment due to the prescribing of gluten-free foods.
Further, the consultation document states that the CCG is spending £38m over the budget, any savings
would therefore be addressing the deficit rather than being available to fund treatments.
You have stated that gluten-free foods are widely available, we would dispute this statement which is not
in line with the latest research on this topic. Gluten-free staple foods are not readily available to purchase
in budget supermarkets and convenience stores shops [6, 7]. Therefore, it cannot be assumed that all
people with coeliac disease will be able to purchase gluten-free foods in their local shop. Access to glutenfree food on prescription is especially vital for the most vulnerable such as the elderly or those with limited
transport options.
You have also stated that gluten-free foods are available at competitive prices. Research shows that
gluten-free staple foods are 3-4 times more expensive than gluten containing equivalents [6, 7]. An
example of the increased cost of gluten-free staple foods is gluten-free bread, recent data shows glutenfree white bread is still on average 6 times the cost of gluten- containing by volume, and has not reduced
since 2008 (see Annex 1). Gluten-free staple foods on prescription therefore help to address the financial
burden for patients and are essential for people on fixed or low incomes.
The consultation compares the price in supermarkets to the price charged to the NHS. While the cost to
the NHS may be higher than in the supermarket, patients should not be penalised on the basis of poor
procurement by the NHS.
You then say “removing or limiting gluten-free foods from prescription will also remove the potential for
inequity, as foodstuffs for patients with other conditions where dietary interventions are recommended are
not prescribed.” This statement is misleading as the NHS does prescribe other foods in addition to glutenfree staples. An example of a condition where the only treatment is a life-long strict diet is the
management of phenylketonuria, where the NHS does support people by prescribing specialist low protein
substitute foods. This may be a more appropriate comparison.
We are concerned that the consultation document does not once reference coeliac disease and simply
refers to gluten-free food. This does not provide reasonable context to those completing the survey who
many not be aware of the issues surrounding managing the gluten-free diet – indeed it could be said to be
entirely misleading without this context. Gluten-free foods on prescription are only approved by the
Advisory Committee on Borderline Substances (ACBS) for patients with a medical diagnosis of coeliac
disease.
Based on the inaccuracies and misleading statements that we have highlighted above, do you have any
plans to review the consultation document?
Equality Impact Assessment
We are concerned that the proposal to withdraw gluten-free food on prescription is not equitable and will
have a disproportionate impact on the most vulnerable patients. As part of the policy development, has an
equality impact assessment been completed? Our concerns are reflected in the draft National Institute of
Health and Care Excellence (NICE) coeliac disease Quality Standard equality impact assessment. The
assessment recognises that access to gluten-free food is more difficult for people on low incomes and that
these people should be given additional support with regard to gluten-free food on prescription to support
adherence to the diet.
When conducting the equality impact assessment, consideration should be given to patients who may find
gluten-free staple foods unaffordable, patients who are unable to access gluten-free staple foods and
patients who have barriers to reading and understanding food labels. Examples are provided in Annex 2,
please note that this list is not exhaustive.
We look forward to hearing from you and would welcome the opportunity to discuss this further.
Kind Regards
Sarah Sleet,
Chief Executive, Coeliac UK
cc. Dr Sunil Hindocha (Clinical Chief Officer, Lincolnshire West CCG), Dr Kevin Hill, (Chair, South Lincolnshire
CCG), Dr Vindi Bhandal, (GP Chair South West Lincolnshire CCG)
[1] Hall, N.J. Rubin, G. & Charnock, A. (2009). Systematic review: adherence to a gluten-free diet in adult patients with coeliac disease. Alimentary
Pharmacology & Therapeutics, 30, 315-330.
[2] Hall, N. et al. (2013). Intentional and inadvertent non-adherence in adult coeliac disease. A cross-sectional survey. Appetite 68 56-62
[3] National Institute for Health and Clinical Excellence (2015) Coeliac disease: recognition, assessment and management 2015
[4] O’Connor A (2012) An overview of the role of bread in the UK diet. British Nutrition Foundation. Vol. 37, Issue 3, 193-212, Article first published
online: 8 Sep, 2012
[5] Ludvigsson JF, Bai JC, Biagi F et al (2014) Diagnosis and management of adult coeliac disease: guidelines from the British Society of
Gastroenterology Gut 2014;63:1210-1228 doi:10.1136/gutjnl-2013-306578
[6] Singh, J. & Whelan, K. (2011). Limited availability and higher cost of gluten-free foods. Journal of Human Nutrition and Dietetics, 24, 479-486.
[7] Burden, M., et al., (2015) Cost and availability of gluten-free food in the UK: in store and online. Postgraduate Medical Journal, 2015: p.
postgradmedj-2015-133395
Annex 1 - Historical price data – White bread gluten-free and gluten-containing comparison
May 2016




Price data for gluten-free and gluten-containing products gathered through Brand View
Average of 30 gluten-free white breads, 38 gluten-containing white breads (sample of budget, own
label and branded products)
Between July 2008 and May 2016 gluten-free white bread is consistently on average 6 times the
cost of gluten-containing white bread (worked out on volume price per 100g for comparison)
Gluten-free white bread prices have not come down significantly over the last 8 years.
White bread - volume price
8
7
6
5
4
3
2
1
Gluten-free
01-03-2016
01-11-2015
01-07-2015
01-03-2015
01-11-2014
01-07-2014
01-03-2014
01-11-2013
01-07-2013
01-03-2013
01-11-2012
01-07-2012
01-03-2012
01-11-2011
01-07-2011
01-03-2011
01-11-2010
01-07-2010
01-03-2010
01-11-2009
01-07-2009
01-03-2009
01-11-2008
01-07-2008
0
Standard
Annex 2, Example characteristics which should be considered when assessing criteria for
vulnerable patients
Patients who may find gluten-free
staple foods unaffordable
Patients exempt from prescription
charges in receipt of an incomerelated benefit or tax credit, a long
term medical condition or long
term physical or mental disability
which requires a carer
Students in full time education
Families with more than one
person with coeliac disease in the
household
Patients with increased energy
requirements e.g. children,
breastfeeding mothers
Patients with conditions which
prevent them from managing their
own financial affairs
Patients accessing food banks
Patients who are unable to
access gluten-free staple
foods
Patients who are housebound
Patients who have barriers to
reading and understanding food
labels
Patients who have difficulty
understanding written English or
literacy issues
Patients living in
geographically isolated areas
Patients with mobility issues
with no access to transport
Patients with learning disabilities
such as Downs Syndrome
British Society of Gastroenterology statement on the proposed removal of prescriptions for GFD
The proposed removal by CCGs of prescriptions for Gluten Free Diets (GFD) is an important issue for the British
Society of Gastroenterology (BSG) as it poses a direct impact on the care of patients with coeliac disease, as
well as wider cost implications for the health economy.
The BSG’s membership includes most of the consultants and specialists in gastroenterology in the UK that
treat patients with coeliac disease and we would like to put on record our support for Coeliac UK on this issue.
Adherence to the gluten-free diet remains the complete medical treatment and having coeliac disease
therefore requires significant dietary modification. The use of gluten-free substitute staple foods facilitates
the necessary dietary adaptation. Rates for adherence to the gluten-free diet can vary between 42-91% [1]
and gluten-free staples on prescription have been related to adherence [2].
Non adherence to the gluten-free diet is associated with an increased risk of long term complications, including
osteoporosis, vitamin D deficiency and iron deficiency [3]. These long-term complications will impact upon
quality of life for the patient and treating these complications are likely to result in financial implications for
the NHS through other treatment costs or bed days.
In addition to facilitating dietary adaption, gluten-free staple foods contribute important nutrients to the diet.
In the UK bread is an important source of energy, dietary fibre, vitamins and minerals. It provides more than
10% of our intake of protein, B vitamins and iron, and one fifth of our dietary fibre and calcium. Removing
important staples from the diet may therefore have a significant effect on the nutrient content of the diet [4].
The National Institute of Health and Care Excellence (NICE) quality standard on coeliac disease is currently
under development and highlights that access to gluten-free food may be more difficult for people on low
incomes and that these people may need more support. As part of your review the BSG would urge that due
regard is paid to the impact of any withdrawal of GFD prescriptions on patients and wider healthcare costs.
Certainly the published evidence is that high street purchase of GFD products are three to four times the cost
of equivalent gluten containing food [5,6]. Furthermore access to GFD remains in large supermarkets and not
corner shops which will clearly make purchase difficult for the old and infirm. [5,6].
We are concerned that the consultation document lacks direct reference to coeliac disease but instead states
that gluten-free foods are prescribed for people with ‘particular dietary requirements’. We do not feel that
this provides enough detail for people completing the survey who do not have coeliac disease themselves.
Gluten-free foods on prescription are only approved by the Advisory Committee on Borderline Substances
(ACBS) for patients with a medical diagnosis of coeliac disease. This misperception of the GFD is leading to an
inequity in health care for patients with coeliac disease. Unlike other autoimmune diseases (such as Type 1
Diabetes or Autoimmune Thyroid Disease) where prescriptions are free, the selection of GFD prescriptions as
an option for budgetary savings will have a significant impact on patients health and this in turn will generate
long-term costs to the NHS which will be greater than the short term savings.
We would urge CCGs to consider these facts in their decision making process and we would recommend a
formal consultation process which will allow necessary access to GFD products for patients that require
them and examine alternative potentially cost-effective models such as pharmacy led services to be
considered.
[1] Hall, N.J. Rubin, G. & Charnock, A. (2009). Systematic review: adherence to a gluten-free diet in adult patients with coeliac disease. Alimentary
Pharmacology & Therapeutics, 30, 315-330.
[2] Hall, N. et al. (2013). Intentional and inadvertent non-adherence in adult coeliac disease. A cross-sectional survey. Appetite 68 56-62
[3] National Institute for Health and Clinical Excellence (2015) Coeliac disease: recognition, assessment and management 2015
[4] O’Connor A (2012) An overview of the role of bread in the UK diet. British Nutrition Foundation. Vol. 37, Issue 3, 193-212, Article first published
online: 8 Sep, 2012
[5] Singh, J. & Whelan, K. (2011). Limited availability and higher cost of gluten-free foods. Journal of Human Nutrition and Dietetics, 24, 479-486.
[6] Burden, M., et al., Cost and availability of gluten-free food in the UK: in store and online. Postgraduate Medical Journal, 2015:91;622-6.
11 November 2016
Dr. Peter Holmes
Clinical Commissioning Group Chair
NHS Lincolnshire East CCG
Cross O' Cliff, Bracebridge Heath
Lincoln, LN4 2HN
Also by e-mail to: [email protected]
Dear Dr. Holmes,
‘Proposal 3: To restrict prescribing baby milks and specialist infant formula’.
We take the opportunity to contact you as part of the Lincolnshire CCG’s ‘Medicines Management
Consultation Your views on what we prescribe in Lincolnshire’ especially concerning ‘Proposal 3: To
restrict prescribing baby milks and specialist infant formula’.
The British Specialist Nutrition Association (BSNA) is the trade association representing
manufacturers of products designed to meet specialist nutritional needs. Our members include
manufacturers1 of formulas for infants and young children, including those designed to help manage
special medical conditions which have been assessed by the Advisory Committee on Borderline
Substances (ACBS) and which are made available on prescription.
BSNA appreciates the opportunity to comment on the proposed future model for prescribing in
Lincolnshire. We support the ambition to explore ways to make our health services more
sustainable, to help patients to take responsibility for their own health and to reduce the need for
unnecessary prescriptions. However, we feel it is necessary to highlight the importance of ‘specialist
infant formulae’ to avoid any confusion with baby milks in general. As you indicate, major
supermarkets have infant formulae on their shelves as standard, with even more options available
on the internet; and there are alternatives to cow’s milk available. All of this could imply that there
are many suitable formulae available to parents to feed their child, without the need to see a
healthcare professional (HCP) when their child is unwell but the role of the HCP should not be
underestimated.
Foods for Special Medical Purposes (FSMPs) are one solution available when offering nutritional care;
specialised infant formulae and feeds are infant FSMPs (iFSMPs) designed to support the dietary
management of specific conditions including infant feeding problems. iFSMPs, by definition, are
individually formulated to deliver adequate nutrition to enable normal growth and development, as
well as containing functional ingredients intended for the dietary management (under medical
supervision) of infants who suffer from certain conditions. They can help to manage a range of
1
Abbott, Danone, NANNYcare, Nestle, Mead Johnson
British Specialist Nutrition Association Ltd (BSNA Ltd) | 6 Catherine Street | London | WC2B 5J J
problems, from severe clinical conditions to functional disorders that are less severe but still require
appropriate management in the community. It is vitally important that these products remain
available on prescription as they must be used under the supervision of a healthcare professional.
There are a range of iFSMPs available to manage specific clinical conditions. In addition to those
highlighted in the consultation i.e. renal disease, liver disease, those receiving cancer treatment,
other examples include hypoallergenic feeds (extensively hydrolysed formulae or amino-acid based
formulae) for infants and children with cow’s milk allergy, formulae for inherited metabolic disorders,
or preterm formulae which are tailored to meet the specific requirements of a preterm infant. It is
important that these cases are closely managed, treated and followed up by relevant HCPs, therefore
these iFSMPs should be available on prescription.
The cost and efficacy of formulas to meet specific nutritional or medical requirements, and which are
available on prescription, have been assessed by the ACBS. These include a wide range of formulas
such as thickened formulas for babies suffering from gastro-oesophageal reflux, lactose-free
formulas for babies with lactose intolerance and others for the dietary management of food allergy.
Conditions such as these can be significantly distressing to the parents of children suffering from such
conditions, and the governance of the ACBS ensures an important level of cost benefit to the NHS. To
ensure best patient care, we believe it is important that all iFSMPs maintain their status, no matter
the severity of the condition, or whether the iFSMP is available on prescription or to purchase
through pharmacies.
We believe it is important to retain the option for the doctor to prescribe such formulas when the
diagnosis is made. This is necessary to ensure the baby receives the correct formula via a
prescription dispensed by a pharmacist. This eliminates the risk that a stressed parent and/or one
who may not be clear about the differences between various formulas, may inadvertently purchase
an incorrect formula thus putting the health of the baby at risk. GPs and clinicians are best placed to
assess the needs of each individual patient and should be able to continue to prescribe any
medications and supplements if they are considered necessary, as they always have done.
We look forward to hearing from you at your earliest convenience concerning whether HCPs will still
be able to prescribe all specialist infant milks? If you would prefer to discuss this in person, we would
be happy to do so.
Thank you for your consideration of our letter.
Yours sincerely
Declan O’ Brien
Director General
Copy to: Mr. Gary James, Accountable Officer
2
Received via email 18th November 2016
Dear Adam / Kevin,
Lincolnshire Local Pharmaceutical Committee has discussed the contents of your
consultation and would like to make the following general comments alongside the
online survey which we have also completed.
As committee representing NHS pharmacy contractors we are acutely aware of the
needs of the NHS to find efficiencies. However, we believe the consultation is flawed, in
particular with regard to the desire to restrict prescribing of non-prescription-onlymedicine for those suffering from short term or self-limiting conditions.
We do not believe that asking patients what they would rather have the NHS spend
money on by comparing A with B, without including enough information about the
impact of the disease states that patients affected by A or B is fundamentally
unsound. Furthermore, it risks making patients affected by those conditions feel
isolated or that the NHS is not for them.
We have deliberately left the question that asks us to rank priorities of care blank.
We also do not believe that implying savings achieved as a result of any decisions
taken as a result of this consultation will be reinvested in other services is wrong. This
consultation is purely about saving CCG costs, not reinvesting in other services and
patients should be made aware of this.
Community pharmacy is the most accessible NHS primary care provider, with a highly
skilled pharmacist led team available without appointment in the heart of communities,
often open extended hours. Pharmacists have the right skills to effectively triage
patients and prevent them accessing more costly, inappropriate care pathways and it is
absolutely right that in any health economy community pharmacy should be the first port
of call for patients seeking episodic healthcare.
Community pharmacy as a sector, and us as a local representatives of the profession,
recognise that community pharmacy can do more to take the burden away from general
practice, out of hours providers and emergency departments. We would like to see
commissioners and stakeholders work with community pharmacy to develop services
locally that can play a real and significant part in reducing the demand on primary and
urgent care services.
However, this can only be achieved with collaborative working across primary
care. Attempting to decommission the self-limiting conditions from primary care in
isolation of placing community pharmacy as the first port of call in local service
pathways will cause patient confusion, frustration and distress.
The committee also notes the requirements of Regulation 15 in the General Medical
Services contract. It is unfair on our colleagues in general practice to implement a
policy which runs counter to the requirements in their terms of service.
With regard to the other elements of the consultation, the committee would wish to
make the observation that Lincolnshire is a large, rural county with few large
conurbations and limited transport links. To make the generalised assumption that
patients have easy access to large retailers selling specialised foods at infant formula at
prices comparable to normal groceries is a flawed one and provision must be made to
support those patients.
Kind regards,
Steve Mosley
Chief Officer
Lincolnshire Local Pharmaceutical Committee
Medicines Management Consultation
Your views on what we prescribe in
Lincolnshire
4 October – 18 November 2016
Get Involved
You can give us your views in a number of ways:
• Fill in the survey found on any of our websites www.lincolnshireeastccg.nhs.uk ;
www.lincolnshirewestccg.nhs.uk ; www.southwestlincolnshireccg.nhs.uk ;
www.southlincolnshireccg.nhs.uk
• Fill in the paper copy of the survey found at the back of this consultation document and send it to
Adam Marshall, Optum, South Kesteven District Council Offices, St Peters Hill, Grantham, NG31
6PZ
• Contact the Engagement Team on 01476 406167 or [email protected]
• If you belong to a group or organisation, you can invite us along to one of your meetings by
contacting us on the details above
This document is available in other languages and formats on request. To request alternative formats,
or if you require the services of an interpreter, please contact us.
This consultation document has been drawn up in accordance with the legal requirements and
guidance from Section 242 and Section 14Z2 Health and Social Care Act 2012 and the Cabinet
Office Consultation Principles.
Who are we?
Lincolnshire East Clinical Commissioning Group, Lincolnshire West Clinical Commissioning Group,
South Lincolnshire Clinical Commissioning Group and South West Lincolnshire Clinical
Commissioning Group are the local NHS organisations responsible for planning, organising and
buying NHS funded healthcare for the 731,500 people in Lincolnshire. This includes: hospital
services, community health services, the delegated commissioning of general practice and mental
health services. NHS England has responsibility for buying dentist, pharmacist and optical primary
care services and specialist services– such as heart transplants and secure mental health services,
whilst local authorities commission public health services like health visiting and sexual health.
The four Lincolnshire CCGs are membership organisations which includes the 101 GP practices
across the county. Together we work in partnership, with the local authorities, including public health,
health and voluntary services to transform the health and social care system to meet the challenges
of the future.
The challenge faced by all organisations across the NHS, is how to spend the available budget in
ways that most benefit the health of the whole population and delivers good value for money. We
have to evaluate every service we commission to ensure that each service offers good quality, the
best possible outcomes for patients and good value for money. We also need to ensure that we
allocate our resources in an effective and equitable way for the benefit of the whole population to
achieve the best possible outcomes for the most number of patients.
What are we asking for your views on?
The four CCGs have a big financial challenge to meet in the short term. Whilst the NHS budget has
increased, demand for health care has increased faster. Currently we are spending £38m more than
our existing budget. We think the money we spend on items that are readily available over the
counter might be better spent on treatments, staff and essential services that patients cannot get in
any other way for the greatest benefit of patients.
A number of planned savings will come from the transformation of services to reduce complexity,
waste and duplication, but in order to meet our challenging financial targets we have also had to look
at reprioritising our services.
Key financial pressure areas include continuing healthcare and complex care packages and
prescribing. This is significantly affecting the CCGs’ ability to meet its statutory financial duties in
2016/17. The CCGs are looking to secure more efficient, effective ways of working across all of these
areas.
This consultation document provides an overview of our proposed service changes to ensure the
health budget for Lincolnshire is spent as effectively as possible, whilst minimising waste and
promoting self-care to its population.
In line with our responsibilities we have reviewed the money we spend on prescribing certain
medicines, treatments, products and food items. The items reviewed are either:
Widely available over the counter (in pharmacies or shops) at a retail price that is lower than the
NHS prescription charge (currently £8.40 per item)
Prescribed for conditions that have no clinical need of treatment
Supported by insufficient evidence of clinical benefit or cost effectiveness
From this review we have identified a range of items currently available over the counter to buy either
from the general retailers or community pharmacies that we are proposing to restrict the prescribing
of in Lincolnshire. Our proposals are:
Proposals:
1. To restrict prescribing over the counter / minor ailment medicines for conditions other than those
where the clinical need can only be met by a prescription
2. To restrict or stop the prescription of gluten-free foods
3. To restrict the prescribing of baby milk including specialist infant formula
4. To restrict the prescribing of oral nutritional supplements in line with ACBS guidance
These will still be available for some patients on clinical assessment.
Proposal 1: To restrict providing over the counter / minor ailment medicines for short term,
self-limiting conditions.
Why are we proposing to restrict the prescribing of these medicines for short-term, selflimiting conditions?


The four Lincolnshire CCGs spend approximately £13.5 million per year on the medicines that
are available to buy over the counter. Many of these prescriptions are for the short term relief
of minor ailments. A significant proportion of this money can be better spent meeting the
healthcare needs of those requiring significant treatment for much more serious health
problems.
Prescribing of over the counter / minor aliment medicines for short term, self-limiting conditions
is not considered to be efficient or economical use of the CCGs’ limited resources. When
prescribing for minor ailments the NHS pays both for the medication plus the additional cost of
dispensing it. For example a simple package of Paracetamol, which costs less than 25p in the
supermarket, costs the CCG £2.50.


Despite people’s willingness to self-treat, there are still 57 million GP consultations nationally a
year for minor conditions at a total cost to the NHS of £2 billion. These appointments take up
an average of one hour a day for every GP. Research shows that people often abandon selfcare earlier than they need to, typically seeking the advice of a GP within four to seven days .
It is estimated that by limiting the prescribing of widely available medicines suitable for selfcare:
o every GP in Lincolnshire will have up to one hour a day freed up to see patients with
more serious conditions
o significant reductions in GP prescribing costs will be achieved
o there will be a reduction in medicines waste and costs associated with medicines waste
o patients and carers will be better informed about how to manage minor conditions
What does it include?
These changes apply only to situations and minor conditions where NHS Choices recommends selfcare. For some conditions this will be related to the severity of the condition (e.g. mild acne is
included but severe acne requires prescription only medicines) and/or to the duration of the condition
(for example, a cough that has persisted for more than three weeks requires a GP appointment).
Over the counter medicines refers to the types of medicines that can be bought over the counter
either from a community pharmacy or, in many cases, a general retailer like a supermarket. Some of
these medicines can only be sold under the supervision of a pharmacist, others are deemed safe
enough to be widely available from general retailers. Examples of some of the medicines included
are:
 Painkillers
 Cough and cold
remedies
 Antihistamines and
other treatments for
hayfever
 Antacids for
heartburn and
indigestion
 Diarrhoea – adults
and older children
 Constipation
 Haemorrhoids
 Creams for vaginal
and vulval infections
or thrush
 Nicotine
Replacement
Therapy for smoking
cessation
 Malaria prevention
 Threadworm
 Creams for fungal
infections such as
athlete’s foot
What doesn’t it include?
We will still prescribe any medicines that are available by prescription only, such as antibiotics,
statins, blood pressure treatments etc. Where a treatment is needed which can only be prescribed,
then the patient’s regular doctor will still be able to prescribe this.
Proposal 2: To restrict or limit the prescribing of gluten-free foods
Why are we proposing to stop or limit prescribing these things?





The original NHS decision to make available gluten-free foods on prescription was taken at a
time when there was very limited availability of these foods in the shops. Today gluten-free
foods are widely available at competitive prices in almost all major supermarkets.
Health experts say that as a protein, gluten is not essential in people’s diets and can be
replaced by other foods. There is a lot of information available to patients via the GP, dietitian
or available online about how to eat a healthy gluten-free diet using replacement foods such as
rice or potatoes.
When prescribing gluten-free foods the NHS pays both for the food plus the additional cost of
processing the items. Although costs of these foods are steadily reducing, costs to the NHS
remain high, e.g. the cost of gluten-free foods for an adult male for one month is typically £32,
whereas the same products would cost the NHS £75 if provided on prescription.
Removing or limiting gluten-free foods from prescription will also remove the potential for
inequity, as foodstuffs for patients with other conditions where dietary interventions are
recommended are not prescribed
Last year Lincolnshire CCGs spent £472,000 on gluten-free food which is roughly equivalent to
30 treatments for breast cancer. If this service was restricted then this money could
alternatively be used to maintain and protect other clinical services.
What is included?
We are asking for your views on whether we should do the following unless there are exceptional
circumstances:

Stop ALL prescribing of gluten-free foods with no replacement system.

Limit prescribing to bread, flour and bread mixes only within Coeliac UK recommended
quantities.
What isn’t included?
Gluten free foods will still be prescribed in specific circumstances where a dependent patient could be
at risk of dietary neglect.
Proposal 3: To restrict prescribing baby milks and specialist infant formula
Why are we proposing to restrict the prescription of these things?




Historically, it was difficult for patients’ parents to get hold of infant formula used for lactose
intolerance as there was a limited range available on the high street. Today, almost every
major supermarket has infant formula on their shelves as standard, with even more options
available on the internet. This means there is an ever growing wide range of infant formula
available without the need of a prescription.
Additionally alternatives to cow’s milk, such as soya, almond, and goat milks, are widely
available as alternatives to traditional dairy production.
Parents qualifying for Healthy Start vouchers can use their vouchers to purchase infant formula
milk from general retailers.
Lincolnshire CCGs spend £740,000 annually on prescribing baby milks and specialist infant
formula. If this service was restricted then this money could alternatively be used to maintain
and protect other clinical services.
What is included?
Unless there are exceptional circumstances, prescriptions will no longer be provided for soya and
thickened infant formula, as well as formula for lactose intolerance, as these are widely available to
buy.
What isn’t included?
There will be some babies on specialised formula for certain medical conditions, such as renal or liver
disease or receiving treatment for cancer, that will still be able to receive these supplements on the
advice of a specialist clinician.
Proposal 4: To restrict prescribing nutritional supplements
Why are we proposing to restrict prescribing these things?


Oral nutritional supplements tend to be over used, particularly in patients in care homes. Local
prescribing guidelines recommend that people with low appetite or diagnosed with a degree of
malnourishment should always be treated with a food first approach. For example, foods that
they like in small portions, little and often. Fortification of food, for example using cream, is also
a good way of increasing a person’s calorie intake without resorting to prescribed nutrition.
Self-care using purchased nutritional supplements like Complan and Build-Up is also advised.
Only patients who have had a nutritional assessment undertaken and are specifically identified
as requiring nutritional supplementation are appropriate for prescribed nutritional supplements.
Lincolnshire CCGs spend £2.9M annually on prescribed nutritional supplements which is
roughly equivalent to 750 hip replacements. If this service was restricted this money could
alternatively be used to maintain and protect other clinical services.
What is included?
Unless in exceptional circumstances the prescription of all nutritional supplements will be restricted.
All patients who have not been adequately screened for malnutrition using the Malnutrition Universal
Screening Tool (MUST) or those that do not achieve a MUST score sufficient to warrant intervention
with a prescribed supplement will no longer receive this on prescription.
What isn’t included?
A small number of patients will still be prescribed these supplements after being assessed, usually
following a stay in hospital, for example after a stroke or those who have tried alternative approaches
but still require a prescribed supplement.
Eligibility and exceptionality:
These proposed changes apply to:



All patients registered with or attending a healthcare appointment at a general practice within
Lincolnshire.
All patients, whether or not they pay for their prescriptions. Exemption from prescription
charges does not exempt an individual from self-care for minor conditions.
All prescribers within the area covered by the four Lincolnshire CCGs, including non-medical
prescribers, GPs, out-of-hours and A&E departments.
What happens next?
Implementation of the proposals will depend on the feedback given. After the consultation all
feedback will be used to produce a report with recommendations that will be taken back to the CCG
Governing Bodies for their final decision on the proposals.
Glossary of terms
ACBS guidance:
Advisory Committee on Borderline Substances, the committee responsible for
advising approved prescribers about the prescribing of certain foodstuffs and
toiletries.
Orthopaedic:
Conditions involving deformities of bones or muscles.
Coeliac UK:
Continuing
healthcare:
Complex care
packages:
The UK's leading charity for people affected by coeliac disease (A medical
condition in which the intestine reacts badly to a type of protein contained in
some grains).
The name given to a package of care that is arranged and funded solely by the
NHS for individuals who are not in hospital and have been assessed as having
a primary health need.
Individual packages of care for patients with very complex health needs.
Please tell us your views by completing this short survey
Q1. Do you understand why the Lincolnshire CCGs need to make the changes proposed in
this consultation?
Yes
No
Undecided
Q2. Do you agree that the money being spent on over the counter items would be better spent
on maintaining and protecting other treatments and services?
Yes
No
Undecided
We have considered a number of options for protecting and maintaining key clinical services. Below
are some of the areas we have looked at. We would like to understand how important these areas to
you.
Q3. Please tell us what you would most prefer to spend your money on (write the number in
the boxes where 1 is the most prefer to spend money on and 6 is the least prefer).
☐ Access to Physiotherapy Services
☐ Non urgent referrals to orthopaedics
☐ Prescription of over the counter drugs
☐ Prescription of gluten-free food
☐ Prescription of baby milk and specialist infant formula
☐ Prescription of oral nutritional supplements
Proposal 1
To restrict providing over the counter / minor aliment medicines for short term, self-limiting
conditions.
Over the counter medicines are medicines that can be bought over the counter from either community
pharmacies or general retailers such as supermarkets. They are readily available to buy because
they are deemed safe enough for people to self-manage common and minor ailments. Examples
include painkillers, cough and cold remedies, antihistamines and some skin products which can be
used for conditions described as ‘self-limiting’ – i.e. conditions likely to be short-lived and highly likely
to improve on its own. This proposal does not advocate restriction of any medicine that is only
available by prescription, such as antibiotics, statins etc.
The case for self-care and the use of over the counter medication for the treatment of minor ailments
is further strengthened by the excellent service offered by community pharmacists, which include long
opening hours and seven day opening, all of which provide great access for patients in their local
communities. NHS Choices can also provide useful advice to people on how to access advice and
appropriate medicines relevant to their condition.
Where the clinical need can only be met by a prescription or where there are legal restrictions on the
availability or amount of a medicine that can be purchased over the counter, the patient’s regular
clinician will still be able to prescribe.
Lincolnshire CCGs spend more than £13.5 million a year paying for widely available, over the counter
medicines.
When prescribing for minor ailments the NHS pays both for the medicine supplied as well as the
associated prescribing and dispensing costs.
Q4 When considering the prioritisation of healthcare funding due to more demand on our
budget than we can meet, to what extent to do you agree with the proposal to restrict
prescribing over the counter / minor ailment medicines for short term, self-limiting
conditions?
Strongly
agree
Agree
Disagree
Strongly
disagree
Don’t
know
Q5. Do you currently pay for your prescriptions?
Yes
No
Proposal 2
To restrict the prescription of gluten-free foods.
The original NHS decision to make available gluten-free foods on prescription was taken at a time
when there was very limited availability of these foods in the shops. Today gluten-free foods are
widely available at competitive prices in almost all major supermarkets.
Health experts say that as a protein, gluten is not essential in people’s diets and can be replaced by
other foods. There is a lot of information available to patients via their GP, dietitian or available online
about how to eat a healthy gluten-free diet using replacement foods such as rice or potatoes.
When prescribing gluten-free foods the NHS pays both for the food plus the additional cost of
processing the items. Although costs of these foods are steadily reducing, costs to the NHS remain
high. For example the cost of gluten-free foods for an adult male for one month is typically £32,
whereas the same products would cost the NHS £75 if provided on prescription.
Removing or limiting gluten-free foods from prescription will also remove the potential for inequity, as
foodstuffs for patients with other conditions where dietary interventions are recommended are not
prescribed.
Last year Lincolnshire CCGs spent £472,000 on gluten-free food. If this service was restricted this
money could alternatively be used to maintain and protect other clinical services.
Q6 When considering the prioritisation of healthcare funding due to higher demands on our
budget than we can meet, what is your preferred option for the future prescription of glutenfree food below (please tick only one)
Stop ALL prescribing of gluten-free foods with no replacement system
Limit prescribing to bread, flour and bread mixes only within Coeliac UK
recommended quantities
Don’t know
Q7. Please tell us the reasons for your answer:
Q8. Have you, or a member of your family, been prescribed gluten-free food?
Yes
No
Proposal 3
To restrict prescribing of baby milks and specialist infant formula
Historically, it was difficult for patients’ parents to get hold of infant formula used for lactose
intolerance as there was a limited range available to buy. Today, almost every major supermarket has
infant formula on their shelves as standard, with even more options available on the internet. This
means there is an ever growing wide range of infant formula available without the need of a
prescription.
Additionally alternatives to cow’s milk, such as soya, almond, and goat milks, are widely available as
alternatives to traditional dairy production.
Parents qualifying for Healthy Start vouchers can use their vouchers to purchase infant formula milk
from general retailers.
The CCGs spend £740,000 annually on prescribing baby milks and specialist infant formula. If this
service was restricted this money could alternatively be used to maintain and protect other clinical
services.
Q9 When considering the prioritisation of healthcare funding due to more demand on our
budget than we can meet, to what extent to do you agree with the proposal to restrict
prescribing baby milks and specialist infant formula?
Strongly
agree
Agree
Disagree
Strongly
disagree
Don’t
know
Q10. Has your child, or a member of your family, been prescribed with infant formula or baby
milks?
Yes
No
Proposal 4
To restrict prescribing oral nutritional supplements
Oral nutritional supplements tend to be over used, particularly in patients in care homes. Local
prescribing guidelines recommend that people with low appetite or diagnosed with a degree of
malnourishment should always be treated with a food first approach. For example, foods that they like
in small portions, little and often. Fortification of food, for example using cream, is also a good way of
increasing a person’s calorie intake without resorting to prescribed nutrition. Self-care using
purchased nutritional supplements like Complan and Build-Up is also advised. Only patients who
have had a nutritional assessment undertaken and are specifically identified as requiring nutritional
supplementation are appropriate for prescribed nutritional supplements.
Lincolnshire CCGs spend £2.9M annually on prescribed nutritional supplements. If this service was
restricted this money could alternatively be used to maintain and protect other clinical services.
Q11. When considering the prioritisation of healthcare funding due to more demand on our
budget than we can meet, to what extent do you agree with the proposal to restrict prescribing
nutritional supplements?
Strongly
agree
Agree
Disagree
Strongly
disagree
Don’t
know
Q12. Have you, or a member of your family, been prescribed oral nutritional supplements?
Yes
No
Comments
Q13. Please provide us with any further information below to explain or support your answers
About you
It’s important that we reach and listen to the views of as many people in Lincolnshire as possible
during the consultation. To help us ensure that our consultation is fair and doesn't leave anyone out
please take time to answer the questions below.
We won’t share your information with anyone else and will only use it to help us make decisions and
improve services.
Are you: (please tick one)
☐ A member of the public
☐ A GP
☐ Another healthcare professional
☐ A pharmacist
☐ A representative of a group or organisation with an interest in these proposals
☐ Other, please specify…………………………………………
If you are a representative of a group/organisation with an interest in these proposals please provide
details of your organisation below
What is the first part of your postcode?
Age
☐ 17 or younger
☐ 18-20
☐ 21-29
☐ 30-39
☐ 40-49
☐ 50-64
☐ 65-74
☐ 75-84
☐ 85+
Gender
☐ Male
☐ Female
☐ Prefer not to say
Are you the same gender
you were assigned at birth?
☐ Yes
☐ No
☐ Prefer not to say
Sexual Orientation
☐ Heterosexual / Straight
☐ Bisexual
☐ Gay man
☐ Gay woman
☐ Prefer not to say
Are you a carer?
☐ Yes
☐ No
Do you consider
yourself to have a
disability?
☐ Yes
☐ No
☐ Prefer not to say
If yes, please specify nature of disability
☐ Learning disability
☐ Long term mental health condition
☐ Physical impairment (mobility)
☐ Blind/Sight impairment
☐ Deaf or Hearing impairment
Do you consider
yourself to have a long
term condition?
☐ Yes
☐ No
☐ Prefer not to say
What is your employment
status?
☐ Employee in full time work
(over 30hrs)
☐ Employee in Part time
work (under 30hrs)
☐ Retired
☐ Permanently sick/disabled
☐ Full time carer
☐ Unemployed
☐ Self-employed (full or part
time)
☐ Looking after home
☐ Full time education
(college/university)
☐ Part time student
☐ Government supported
training
If yes, please specify
nature of your
condition
☐ Heart condition
☐ Diabetes
☐ COPD
☐ Chronic Kidney
Disease
☐ Cancer
☐ Coeliac Disease
☐ Other (please specify
below)
What is your ethnicity?
☐ Asian or Asian British - Bangladeshi
☐ Asian or Asian British - Indian
☐ Asian or Asian British - Pakistani
☐ Other Asian background
☐ Black or Black British - African
☐ Black or Black British - Caribbean
☐ Other Black background
☐ Mixed Heritage - White & Asian
☐ Mixed Heritage - White & Black
African
☐ Mixed Heritage - White & Black
Caribbean
☐ Other mixed heritage background
☐ White - British
☐ White - Irish
☐ White - Polish
☐ White - Gypsy/Traveller/Roma
☐ Other white background
☐ Chinese
☐ Other Ethnic Group , please
specify…………………………….
☐ Prefer not to say
Thank you for completing the survey.
Please return your completed survey (address on 2nd page of document) by the
deadline of 18 November 2016
Medicines Management Consultation
Your views on what we prescribe in Lincolnshire
Impact Assessment on the Proposals
November 2016
1. Introduction/Context
The Lincolnshire CCG medicines management consultation1 is asking for feedback on a
number of proposals:




To restrict prescribing of over the counter/minor ailment medicines for conditions
other than those where the clinical need can only be met by a prescription.
To restrict or stop the prescription of gluten free foods.
To restrict the prescribing of baby milk including specialist infant formula.
To restrict the prescribing of oral nutritional supplements in line with the Advisory
Committee on Borderline Substances (ACBS) guidance.
The consultation outlines the rationale for the proposals:



The four CCGs have a big financial challenge to meet in the short term. Whilst the
NHS budget has increased, demand for healthcare has increased faster. Currently
the CCGs are spending £38million more than their existing budget.
The money being spent on items that are readily available over the counter might
be better spent on treatments, staff and essential services that patients cannot get
in any other way for the greatest benefit of patients.
The CCGs have reviewed the money spent on prescribing certain medicines,
treatments, products and food items. The items reviewed are either:
o
o
o
Widely available over the counter (in pharmacies or shops) at a retail price
that is lower than the NHS prescription charge (currently £8.40 per item).
Prescribed for conditions that have no clinical need of treatment.
Supported by insufficient evidence of clinical benefit or cost effectiveness.
From this review, the CCGs have identified a range of items currently available over
the counter to buy, which are part of the proposals in the consultation.
2. Impact Assessment on the Proposals
Impact assessment is a process by which a policy, programme or project can be judged for
its potential effects on the health of a population, and the distribution of those effects within
the population. The aim of this impact assessment is to:
- Understand how the proposals might impact on the population of Lincolnshire.
- Identify activities that might mitigate the risk of the planned proposals.
Specific effects on the population with protected characteristics will be included. These are:
age, disability, gender reassignment, marriage and civil partnership, pregnancy and
maternity, race, religion or belief, sex and sexual orientation.
1
Medicines Management Consultation. Your views on what we prescribe in Lincolnshire. Lincolnshire CCGs.
2
Table 1: Impact Assessment
Proposal
Rationale, Scope, Impacts, Mitigation
Proposal 1:
To restrict
prescribing of
over the
counter/minor
ailment
medicines for
conditions
other than
those where
the clinical
need can
only be met
by a
prescription.
Rationale (as outlined in the Consultation document):
The Lincolnshire CCGs spend approximately £13.5million annually on the medicines that are available to buy over the counter.
Many of these prescriptions are for the short term relief of minor ailments. When prescribing for minor ailments the NHS pays
both for the medications and the additional cost of dispensing it. There are 57million GP consultations nationally a year for minor
conditions at a total cost to the NHS of £2billion.
Scope:
This proposal applies to situations and minor conditions where NHS Choices recommend that self-care is suitable. Examples of
medicines include painkillers, cough and cold remedies.
Impacts:
Some self-care strategies are targeted at the general population and are designed to promote good public health and prevent
illness. Other self-care strategies focus on giving people the confidence and necessary information to self-treat minor ailments,
such as headaches. This consultation proposal mainly supports the latter approach to self-care. There are potential risks of this
approach to self-care which could impact on all affected groups of the population2. These are:
 Self-care relies on the patient making correct decisions, in response to the symptoms they are experiencing.
 The patient may miss something subtle but important about their symptoms.
 Promoting self-care may deter people from visiting their GP which could lead to delays in diagnosing more serious
illnesses.
This proposal impacts on the general population, meaning people with protected characteristics will be affected, for example,
pregnant women and people with disabilities.
Financial
The proposal will impact financially on the population who would otherwise be entitled to free prescriptions, for example, those
receiving income support, pregnant women (or had a baby in the previous 12 months) and people under 16 years (or 18 in full
time education) and people 60 years and over. This could result in people on lower incomes not having the financial means to
purchase over the counter medicines and not receiving optimum self-care, therefore impacting on health inequalities.
2
Self-care: question & answer. British Medical Association.
3
Proposal
Rationale, Scope, Impacts, Mitigation
The proposal could also impact on people who pay for prescriptions and purchase prescription prepayment certificates. Prepayment enables people to save money if they need more than 3 prescribed items in 3 months or more than 12 items a year. It
could result in people needing to purchase some items thereby reducing their number of prescribed items to less than the
amount which makes pre-payment beneficial, resulting in additional costs for patients.
The proposal will impact on people who are eligible for free prescriptions as part of medical exemption certificates. Depending on
the medication, it could result in people needing to purchase some items, resulting in additional costs for patients.
Access
The proposal could impact on people who are less able to physically access larger supermarkets and community pharmacies
where a wide range of products can be purchased. This could therefore impact on people living in rural locations in Lincolnshire
and people with disabilities.
It could also impact on people who have over the counter/minor ailment medicines on repeat prescription. If this proposal is
implemented, repeat medications may need reviewing to include only those items where the clinical need can only be met by a
prescription.
Smoking rates
Nicotine replacement therapy (NRT) is included in the proposal. Whilst this is available to purchase over the counter it is not for
short term relief of minor ailments. NRT supports the promoting good public health and preventing illness approach to self-care.
There is strong evidence that NRT increases the rate of quitting3. The proposal will impact on people who currently receive NRT
as part a smoking cessation service, potentially impacting on their ability to stop smoking.
Mitigation:
Access to support and information
It is important that people wanting/needing self-care have access to quality advice and information, at the right time, together
with the right support, for example:
 NHS Choices4 (Health A-Z section) provides information on a range of health conditions, including when to seek
medical advice and treatments available, including over the counter medicines.
3
4
www.nice.org.uk
https://www.nhs.uk/
4
Proposal
Rationale, Scope, Impacts, Mitigation




Where they can obtain self-care support, particularly from community pharmacy. NHS Choices provides information
on the 'Services near You' section.
Self-Care forum5 provides facts sheets on various conditions.
Lincolnshire CCG websites should promote NHS Choices and local services promoting self-care.
CCG specific resources, for example, Lincolnshire East CCG myhealthlincolnshire web app.
Access to minor ailment medicines
Prescribing treatment should be based on clinical factors and not influenced by socio-economic factors. An increasing range of
medicines are available to purchase. To receive optimum self-care, people should be encouraged to stock an affordable first aid
supply at home which includes cream/spray to relieve insect bites/stings, painkillers such as paracetamol/ibuprofen, cough
medicine and antihistamine tablets.
Where people are advised to purchase over the counter medicines, following a general practice appointment, it is suggested that
they are given information on the Lincolnshire self-care approach and written information on the medicine(s) that it is
recommended that they purchase. This may help people adhere to the advice from the health professional and purchase the
over the counter medication to receive optimum self-care.
Where repeat dispensing medicines are reviewed, it is important that patients are engaged in this process so that they are aware
what medicines will continue to be eligible as part of repeat dispensing and those that will need to be purchased over the
counter.
NHS England is leading work on integrating pharmacy into urgent care so that supporting people with minor ailments becomes a
core part of NHS pharmacy practice, and pharmacy becomes an integral part of the NHS’ urgent care system (Pharmacy
Integration Fund6). The implications of this for Lincolnshire should be considered given the relationship with the consultation
proposal.
Development of a policy and raising awareness amongst public/professionals
It is essential that people know what conditions/symptoms need medical advice. The CCGs should develop a policy defining
which medicines will not be prescribed in the management of minor ailments and common conditions and any exceptions where
the condition may not be suitable for self-care and may require a medical opinion/prescription. For example, in relation to
5
6
www.selfcareforum.org
https://www.england.nhs.uk/2016/10/pharmacy-integration-fund/
5
Proposal
Rationale, Scope, Impacts, Mitigation
migraine where they are so painful or frequent that they affect daily activities. NRT should also have some exceptions where
prescribing is appropriate given its public health role in supporting people to stop smoking.
The Lincolnshire policy needs to be promoted to the Lincolnshire public so they understand when self-care is appropriate and
when medical advice is required. This will address the risks of self-care highlighted by the BMA.
The CCGs should plan awareness raising campaigns to encourage and promote self-care and the purchase of over the counter
medicines. This should be aimed at the general public and health professionals to support the adherence of this proposal if it is
implemented.
It is also important that people are aware of the complications of medications they are buying over the counter, for example,
stomach ulcers if ibuprofen is not taken appropriately. Patient information should be available to ensure people are aware of
these potential complications.
Implementing the proposals
A consultation implementation plan should consider these impacts and mitigations.
Proposal 2:
To restrict or
stop the
prescription
of gluten free
foods.
Rationale (as outlined in the Consultation document):
The original NHS decision to make available gluten free food on prescription was taken at a time when there was limited
availability of these foods in shops. Today they are widely available at competitive prices in almost all major supermarkets.
Health experts say that as a protein, gluten is not essential in people's diets and can be replaced by other foods. When
prescribing gluten free food, the NHS pays for the food plus the additional cost of processing the items. Last year, Lincolnshire
CCGs spent £472,000 on gluten free prescribing.
Scope:
The proposal asks for views on:
(a) stopping all prescribing of gluten free foods with no replacement system.
(b) limiting prescribing to bread, flour and bread mixes only within Coeliac UK recommended quantities.
Gluten free foods will still be prescribed in specific circumstances where a dependent patient could be at risk of dietary neglect.
6
Proposal
Rationale, Scope, Impacts, Mitigation
Impacts:
Coeliac disease is a common digestive condition. The disease affects approximately 1 in 100 people in the UK where women
are two to three times more likely to develop coeliac disease than men. It can be diagnosed at any age7. There are no medicines
available to treat the condition and it cannot be cured. People with confirmed coeliac disease must give up eating all sources of
gluten for life.
This proposal impacts on the coeliac disease population who receive gluten free food on prescription. People with protected
characteristics will be affected, for example, pregnant women and people with a disability. Proposal (a) and (b) will have different
impacts for the population.
Financial
Whilst the consultation states that gluten free food is widely available at competitive prices in almost all major supermarkets,
there is evidence that the cost of some gluten free alternatives can be significantly more than the gluten equivalents, for
example, bread and flour. Research carried out by the British Specialist Nutrition Association (BSNA) found that the greatest
impact of gluten free prescribing restrictions was a financial one8.
The proposal will impact financially on patients who would otherwise be entitled to free prescriptions, for example, those
receiving income support, pregnant women (or had a baby in the previous 12 months) and people under 16 years (or 18 in full
time education) and people 60 years and over. This could result in people on lower incomes not having the financial means to
purchase gluten free products and therefore not receive optimum care for their condition.
The proposal could also impact on people who pay for prescriptions and purchase prescription prepayment certificates. Prepayment enables people to save money if they need more than 3 prescribed items in 3 months or more than 12 items a year. It
could result in people needing to purchase gluten free foods, thereby reducing their number of prescribed items to less than the
amount which makes pre-payment beneficial, resulting in additional costs for patients.
Access
Gluten free products are not always readily available to purchase in the low cost supermarkets and convenience stores. The
proposal could impact on people who are less able to access larger supermarkets which will have a wide range of products that
can be purchased. This could therefore impact on people living in rural locations in Lincolnshire and people with disabilities.
7
8
A consideration of future options for the prescribing and supply of gluten free products in Lincolnshire. Arden and GEM CSU.
British Specialist Nutrition Association. Survey of 3500 coeliac patients. October 2010.
7
Proposal
Rationale, Scope, Impacts, Mitigation
Adherence
The proposal could impact on people's adherence to a gluten free diet. Evidence suggests that adherence is associated with
prescriptions of gluten free food9. For patients with coeliac disease there is evidence that adhering to a gluten free diet improves
control. If someone with coeliac disease is exposed to gluten they may experience a range of symptoms and adverse effects
which can be mild or very severe (for example abdominal pain, diarrhoea, weight loss in adults or failure to grow at the expected
rate in children, malnutrition, tiredness, headaches, skin rash, mouth ulcers, tooth enamel problems and osteoporosis).
Mitigation:
Access/adherence
The consultation outlines that gluten free foods will still be prescribed in specific circumstances where a dependent patient could
be at risk of dietary neglect. CCGs need to develop a policy defining the circumstances by which this would apply.
A range of non-specialist non gluten containing foods are available, for example, rice, potato, plain meat, fish, eggs, cheese,
milk, fruits, vegetables and pulses are naturally gluten free and suitable for the diet10.
For people who do not have access to gluten free food in supermarkets etc., purchasing items online could be an option where
they have the ability to do this. It is acknowledged this will not be an option for some groups of the population.
Coeliac UK provides advice on a gluten free diet and lifestyles and this should be promoted to the impacted population in
Lincolnshire. Where available, people should also be offered practical skills in cooking a gluten free diet.
Coeliac UK recommend a number of units to be prescribed a month, i.e. 6-8 units. Coeliac UK does not support the prescribing
of non-staples such as sweet biscuits, cookies and cakes. The consultation proposal to restrict prescribing rather than stopping
would be aligning with Coeliac UK recommendations.
Implementing the proposals
A consultation implementation plan should consider these impacts and mitigations.
9
Hall, Rubin and Charnock (2009). Systematic review: adherence to a gluten free diet in adult patients with coeliac disease. Alimentary Pharmacology and Therapeutics
30: 315-330.
10
www.coelic.org.uk
8
Proposal
Rationale, Scope, Impacts, Mitigation
Proposal 3:
To restrict the
prescribing of
baby milk
including
specialist
infant
formula.
Rationale (as outlined in the Consultation document):
Historically it has been difficult for parents to get hold of infant formula used for lactose intolerance as there was a limited range
available on the high street. Today, almost every major supermarket has infant formula as standard, with more options available
on the internet. Alternatives to cow's milk are widely available as alternatives. Parents qualifying for Healthy Start vouchers can
use their vouchers to purchase infant formula. Lincolnshire CCGs spend £740,000 annually on prescribed baby milks and
specialist infant formula.
Scope:
Unless there are exceptional circumstances, prescriptions will no longer be provided for soya and thickened infant formula for
lactose intolerance.
Impacts:
Lactose intolerance is a common digestive problem. It can develop at any age. Many cases first develop in people aged 2040years although babies and young children can also be affected11. For many children, lactose intolerance is only temporary and
will improve after a few weeks.
Babies/infants with gastro oesophageal reflux disease (GORD) and gastro oesophageal reflux (GOR) may be managed initially
with specialist infant formula, i.e. thickened12.
This proposal impacts on babies/infants and their families, meaning people with protected characteristics will be affected, for
example, people with disabilities.
Financial
The proposal will impact financially on people who currently receive baby milk and specialist infant formula on prescription as
babies/infants are entitled to free prescriptions. This could result in people on lower incomes not having the financial means to
purchase baby milk/specialist infant formula and therefore not receiving optimum care for their child.
Access
Lactose free formula milk may not be as accessible in the low cost supermarkets and convenience stores. The proposal could
impact on people who are less able to access larger supermarkets or community pharmacists. This could therefore impact on
11
12
www.nhs.uk
Gastro-oesophageal reflux disease in children and young people: diagnosis and management. NICE Guideline 1. 2015.
9
Proposal
Rationale, Scope, Impacts, Mitigation
people living in rural locations in Lincolnshire and people with disabilities.
Clinical advice
Current PACEF13 guidance is that specialist lactose free formula should only be provided for a short time if initiated in primary
care. If longer term use is required, specialist opinion must be sought. It is vital that this proposal does not delay people seeking
out this specialist opinion.
Mitigation:
Financial/access
Lactose free and specialist infant formula is available to buy from pharmacies and supermarkets. For people who do not have
access to these, purchasing items online could be an option where they have the ability to do this.
Healthy Start14 vouchers can be used to buy infant formula milk. Healthy Start is a means tested scheme, for people who are 10
weeks pregnant or have a child under 4 years.
Clinical advice
It is essential that people know what conditions/symptoms need medical advice and when specialist opinion must be sought after
short term use of lactose free formula. The CCG should develop a policy outlining when people should seek this advice.
Implementing the proposals
A consultation implementation plan should consider these impacts and mitigations.
13
14
Infant feeding formulary for cows milk protein allergy and lactose intolerance. GEM CSU. October 2013.
www.healthystart.nhs.uk
10
Proposal
Rationale, Scope, Impacts, Mitigation
Proposal 4:
To restrict the
prescribing of
oral
nutritional
supplements
in line with
the Advisory
Committee
on Borderline
Substances
(ACBS).
Rationale (as outlined in the Consultation document):
Oral nutritional supplements tend to be over used, particularly in care homes. Local prescribing guidelines recommend that
people with low appetite or diagnosed with a degree of malnourishment should always be treated with a food first approach. Only
patients who have had a nutritional assessment and identified as requiring nutritional supplementation are appropriate for
prescribed nutritional supplements. Lincolnshire CCGs spend £2.9million on prescribed nutritional supplements.
Scope:
Unless in exceptional circumstances the prescription of all nutritional supplements will be restricted.
Impacts:
The proposal will impact financially on the population who would otherwise be entitled to free prescriptions, for example, those
receiving income support and people 60 years and over. This could result in people on lower incomes not having the financial
means to purchase nutritional supplements.
The proposal could also impact on people who pay for prescriptions and purchase prescription prepayment certificates. Prepayment enables people to save money if they need more than 3 prescribed items in 3 months or more than 12 items a year. It
could result in people needing to nutritional supplements, thereby reducing their number of prescribed items to less than the
amount which makes pre-payment beneficial, resulting in additional costs for patients.
This proposal will impact on settings/organisations that use nutritional supplements, i.e. health and social care.
Mitigation:
Current PACEF Bulletin provides guidance15 on prescribing oral nutritional supplements and includes information on the
malnutrition universal screening tool (MUST) which needs to be undertaken for all patients considered to be at risk of
malnutrition. The bulletin outlines that there is usually no role for prescribed oral nutritional supplements first line. The
information contained within the Bulletin should be promoted to health and social care professionals as part of this proposal, for
example care homes. This includes advice on the importance of, for example, having nourishing snacks and drinks between
meals and drinking more milk based drinks.
A previously circulated leaflet entitled 'Eat Well, Feel Well' could be refreshed and re-circulated. This contains advice on easy
and low cost ways to fortify foods to increase their nutritional benefit.
15
nd
Lincolnshire PACE Bulletin Vol 8. No 8. May 2014. Guidance on the prescribing of oral nutritional supplements (2 Edition).
11
Proposal
Rationale, Scope, Impacts, Mitigation
Additional information is also provided by NICE and this should be promoted to health and social care professionals16.
Implementing the proposals
A consultation implementation plan should consider these impacts and mitigations.
Emma Marshall
Public Health, Lincolnshire County Council.
November 2016
16
Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. NICE Clinical Guideline CG32. 2006.
12
GOVERNING BODY MEETING
Date of Meeting:
30 November 2016 – public session
Title of Report:
Report Author and Title:
Appendices:
Information Governance Update
Jo Wright, Chief Finance Officer
IG12 – Email Policy
IG14 – Freedom of Information (FOI) & Environmental Regulations
Information (EIR) Policy
Privacy Notice – How your information is used
(All circulated separately.)
Appendix 1 – Information Governance Update – October 2016 v1
1.
Agenda item:
13.
Purpose of the Report (including link to objectives)
The report presents an update on the Information Governance (IG) Toolkit.
2.
Recommendations
The Governing Body is asked to note the IG Toolkit update and to adopt the updated policies presented.
There are no additional financial or resource consequences of this paper.
3.
Executive Summary
IG Toolkit Update
As statutory NHS bodies, CCGs are required to complete an Information Governance Toolkit (IGT)
version 14 return. The Toolkit is a mandatory self-assessment tool produced by the Department of
Health, hosted by NHS Digital (formerly the Health and Social Care Information Centre (HSCIC)). The
IGT draws together the legal rules and central guidance in relation to information processing and
presents them as a set of 28 information governance requirements covering the following areas –
• Information Governance Management
• Confidentiality and Data Protection Assurance
• Information Security Assurance
• Clinical Information Assurance
The purpose of the assessment is to enable the CCG to measure compliance against the law and central
guidance and to see whether information is handled correctly and protected from unauthorised access,
loss, damage and destruction. CCGs are required to achieve compliance at level 2 of the Toolkit by 31
March 2017. This means that standards at level 1 should also be met. CCGs can aspire to achieve
level 3 of the Toolkit, but this is not a requirement.
In order to meet these requirements, an action plan for compliance has been prepared by Optum
Commissioning Support Services and reviewed by the Senior Information Risk Owner (SIRO) and IG
Lead (Chief Finance Officer).
Progress has been made on all areas of the IG toolkit submission for 2016/17. Appendix 1 gives a
summary of progress so far this year. The position as at 12th October 2016 (latest report produced) is
achievement of 59%. The predicted score for 31st March 2016 is 93%. The key areas outstanding for
work by the CCG to achieve the mandatory level 2 compliance are:
1
•
•
Information Asset Register – the work to identify the CCG’s information asset owners is due for
completion by end January and will be submitted to the IG team as part of the toolkit work.
Information Governance Training – a face-to-face training session for Governing Body members
was held on 21 September 2016 for Governing Body members and staff, to achieve compliance
with the toolkit requirements.
Further work is required to achieve a score at level 3 (93%), and to demonstrate improvement over last
year.
Updated Policies
Unified policies are being prepared for adoption by CCG governing bodies, to achieve compliance with
the IG Toolkit and to protect the CCG from a breach of Information Governance rules. Policies are
discussed and reviewed by the IG Working Group, made up of IG leads, SIROs and Caldicott Guardians
across the four CCGs.
The following policies have been reviewed and updated:
Policy Name
Description of policy
The purpose of this document is to provide guidance
to all CCG staff on permissible usage of the email
system.
This document sets out what the Clinical
IG14
Freedom
of Commissioning Group, its Commissioning Support
Information
(FOI)
& Service and associated organisations will do to comply
Environmental Regulations with obligations under the Freedom of Information Act
2000 (hereafter referred to as the Act) and includes
Information (EIR) Policy
the procedure to be followed when handling requests.
IG12 Email Policy v3.0
The policies will be circulated separately to Governing Body members for reference and consideration
prior to adoption.
Fair Processing Notice
The CCG is required to publish a Fair Processing Notice or Privacy Notice on its website under the Data
Protection Act 1998. The document outlines the type of information that the CCG may hold about
individuals and how that information is used, who it may be shared with and how we keep it secure.
The document that has been circulated separately to the Governing Body members is the current
version and can be found on the CCG website. It was finalised during September/October 2016 and has
been reviewed and signed off by NHS Digital.
The Governing Body is requested to consider the update and adopt the policies and fair processing
notice as presented.
4.
Management of Conflicts of Interest
There are no conflicts of interest.
5.
Finance, QIPP and Resource Implications
All policies have been developed/reviewed for the CCG by Optum Commissioning Support Service.
2
6.
Legal/NHS Constitution Considerations
Policies which are current and up to date minimise the risk to patients and the organisation and support
compliance with the NHS Constitution.
The Policies presented comply with the latest legislation. The CCG is required to publish a Fair
Processing Notice/Privacy Notice by the Data Protection Act 1998.
7.
Analysis of Risk including Assessments
Risk of non-achievement of requirements resulting in non-compliance with standards. This risk is not
significant – at the current time there is little risk of the CCG not complying with the required standards.
Information Governance risks will be reflected in the risk register as and when they are identified and
reviewed on a regular basis.
Please state if the risk is on the CCG Risk Register.
8.
Yes
No

Outline engagement – clinical, stakeholder and public/patient
Not Applicable
9.
Outcome of Impact Assessments
Not Applicable
10.
Assurance Departments/Organisations who will be affected have been consulted
Insert details of the departments you have worked with or consulted during the process:
Finance
Commissioning
Contracting
Medicines Optimisation
Clinical Leads
Quality
Safeguarding
Other – Information
Governance

Not applicable.
11.
Report previously presented at:
Not Applicable
12.
For further information or for any enquiries relating to this report, please contact
Jo Wright – [email protected] Tel 01476 406578
3
Information Governance Report
NHS South West Lincolnshire Clinical Commissioning Group
November 2016
The purpose of this report is to inform NHS South West Lincolnshire Clinical Commissioning
Group’s (CCG’s) Governing Body of the current Information Governance Toolkit (IGT)
baseline score and predicted score position in relation to the CCG’s final IGT v14 to be
submitted 31st March 2017. The report presents an achievable action plan to attain the
predicted score indicated.
CONTEXT
On 31st March 2016, OPTUM Commissioning Support Services (CSS) published a
‘satisfactory’ Information Governance Toolkit submission on behalf of NHS South West
Lincolnshire CCG with a score of 81%. As at 12th October 2016, the baseline IGT score for
NHS South West Lincolnshire CCG is currently 59%. This short term reduction in
percentage compliance reflects NHS Digital automatically stripping the CCG’s v14 IGT
return of evidence it perceives as not relevant to the v14 submission for March 2017.
Supported by a comprehensive Action Plan, as discussed on a regular basis at Information
Governance Working Group Meetings attended by representatives of the CCG’s Senior
Information Governance Management Team and representatives from OPTUM
Commissioning Support Services, it is anticipated the CCG will achieve a ‘satisfactory’ score
showing a significant increase from 81% to 93% for the CCG’s 2016/17 submission (Version
14).
The purpose of the IGT assessment is to enable NHS South West Lincolnshire CCG to
measure their compliance against the law and central guidance and to see whether
information is handled correctly and protected from unauthorised access, loss, damage and
destruction.
ACTION PLAN
Appendix A provides an overview of the 28 Information Governance Toolkit (IGT)
requirements the CCG is mandated to complete to at least Level 2. The Action Plan
demonstrates where the CCG is anticipated to achieve Level 3 showing the CCG is working
to continually improve compliance.
It is recommended:
•
100% of all staff to complete mandatory IG Training by 31st March 2017
Staff have access to mandatory Information Governance Training via ESR, face to
face training delivered by OPTUM for staff members and Governing Body members
upon request by the CCG. A training session for Governing Body members was held
on 21st September 2016.
1
IGT Update 15th November 2016 v1
•
•
•
•
•
•
OPTUM CSS IG Team and the members of CCG staff with additional IG
responsibilities (IG lead, SIRO, Caldicott Guardian and Records Manager) to
complete required specialised IG training modules on the HSCIC (NHS Digital)
Information Governance Training Tool by 31st March 2017.
OPTUM CSS to support the CCG with a data flow mapping exercise in January
2017. OPTUM CSS to provide the CCG with the relevant reporting templates and
provide a report to the SIRO on the outcome of the Data Flow Mapping exercise.
OPTUM CSS in conjunction with Arden GEMCSU to support the CCG in obtaining a
comprehensive Information Asset Register and the CCG to identify suitable
Information Asset Owners and Information Asset Administrators to support the Senior
Information Risk Owner.
OPTUM CSS in conjunction with Arden GEMCSU to provide revised comprehensive
ICT policies to support the 14-300 series requirements within the CCG’s IG Toolkit.
The CCG to promote the use of Privacy Impact Assessments when reviewing
existing projects and planning new projects where person confidential data will be
processed as part of the project when it is up and running.
OPTUM to undertake ID and Smartcard checks when delivering face to face IG
training and ad hock checks as necessary.
IGT Update 15th November 2016 v1
2
APPENDIX A
INFORMATION GOVERNANCE TOOLKIT SCORES
- NHS SOUTH WEST LINCOLNSHIRE CCG
Req.
14-130
14-131
14-132
14-133
14-134
14-230
14-231
14-232
14-234
14-235
14-236
14-237
Description
Percentage ‘Satisfactory Score’
There is an adequate Information Governance Management
Framework to support the current and evolving Information
Governance agenda
There are approved and comprehensive Information
Governance Policies with associated strategies and/or
improvement plans
Formal contractual arrangements that include compliance
with information governance requirements, are in place with
all contractors and support organisations
Employment contracts which include compliance with
information governance standards are in place for all
individuals carrying out work on behalf of the organisation
Information Governance awareness and mandatory training
procedures are in place and all staff are appropriately
trained
The Information Governance agenda is supported by
adequate confidentiality and data protection skills,
knowledge and experience which meet the organisation’s
assessed needs
Staff are provided with clear guidance on keeping personal
information secure, on respecting the confidentiality of
service users, and on the duty to share information for care
purposes
Confidential personal information is only shared and used in
a lawful manner and objections to the disclosure or use of
this information are appropriately respected
There are appropriate procedures for recognising and
responding to individuals’ requests for access to their
personal data
Staff access to confidential personal information is
monitored and audited. Where care records are held
electronically, audit trail details about access to a record can
be made available to the individual concerned on request
All person identifiable data processed outside of the UK
complies with the Data Protection Act 1998 and Department
of Health guidelines
All new processes, services, information systems, and other
IGT Update 15th November 2016 v1
Actual
V13 IGT
Score
31/03/2016
Anticipated
V14 IGT
Score
31/03/2017
81%
93%
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
2
3
2
3
Not
Relevant
Level 3
3
3
3
14-250
14-340
14-341
14-342
14-343
14-344
14-355
14-346
14-347
14-348
14-349
14-350
14-351
14-352
14-420
14-421
relevant information assets are developed and implemented
in a secure and structured manner, and comply with IG
security accreditation, information quality and confidentiality
and data protection requirements
Individuals are informed about the proposed uses of their
personal information
The Information Governance agenda is supported by
adequate information security skills, knowledge and
experience which meet the organisation’s assessed needs
A formal information security risk assessment and
management programme for key Information Assets has
been documented, implemented and reviewed
There are established business processes and procedures
that satisfy the organisation’s obligations as a Registration
Authority
Monitoring and enforcement processes are in place to
ensure NHS national application Smartcard users comply
with the terms and conditions of use
Operating and application information systems (under the
organisation’s control) support appropriate access control
functionality and documented and managed access rights
are in place for all users of these systems
An effectively supported Senior Information Risk Owner
takes ownership of the organisation’s information risk policy
and information risk management strategy
Business continuity plans are up to date and tested for all
critical information assets (data processing facilities,
communications services and data) and service - specific
measures are in place
Policy and procedures are in place to ensure that
Information Communication Technology (ICT) networks
operate securely
Policy and procedures ensure that mobile computing and
teleworking are secure
There are documented incident management and reporting
procedures
All transfers of hardcopy and digital personal and sensitive
information have been identified, mapped and risk
assessed; technical and organisational measures
adequately secure these transfers
All information assets that hold, or are, personal data are
protected by appropriate organisational and technical
measures
The confidentiality of service user information is protected
through use of pseudonymisation and anonymisation
techniques where appropriate
The Information Governance agenda is supported by
adequate information quality and records management
skills, knowledge and experience
There is consistent and comprehensive use of the NHS
Number in line with National Patient Safety Agency
requirements. The IGT Toolkit states that: ’The CCG is not
an Accredited Safe Haven (ASH) and does not have access
IGT Update 15th November 2016 v1
2
3
3
3
2
2
Not
Relevant
3
2
3
2
3
2
3
2
2
2
2
2
2
2
3
2
3
2
3
Not
Relevant
3
3
3
Not
Relevant
NR or Level
2
4
to patient identifiable information.’
NOTE: The CCG is seeking ASH status and a data Access
Request Service applications was made to NHS Digital on
8th November 2016. The timescale for NHS Digital to
approve the application and assign status is not confirmed.
If status is provided before the date of submission of v14
IGT then level 2 will be achieved
IGT Update 15th November 2016 v1
5
GOVERNING BODY MEETING
Date of Meeting:
30 November 2016 – Public session
Title of Report:
Report Author and Title:
Development of Joint Health and Wellbeing Strategy for Lincolnshire
David Stacey, Programme Manager (Lincolnshire County Council, Public
Health)
Appendix A - Joint Health and Wellbeing Strategy Prioritisation Framework
Appendices:
Agenda item:
14.
1.
Purpose of the Report (including link to objectives)
The purpose of this report is to inform the Governing Body about the review of the Lincolnshire Health
and Wellbeing strategy as the current strategy is due to expire in 2018.
A statutory duty under the Health and Social Care Act 2012 requires the Local Authority and each of its
partner clinical commissioning groups to produce a Joint Health and Wellbeing Strategy (JHWS) for
meeting the needs identified in the Joint Strategic Needs Assessment (JSNA). This report sets out a
proposed approach to developing the next JHWS for Lincolnshire with a specific focus on the framework
and principles of how evidence from the JSNA will be synthesised and prioritised into the themes and
priorities for the next JHWS.
2.
Recommendations
Governing Body is asked to note the report for information.
3.
Executive Summary
A report was presented to the Health and Wellbeing Board (HWB) in June 2016 setting out some
proposed principles for developing the next JHWS as well as a draft prioritisation framework which the
HWB agreed should be further reviewed and tested as part of its informal session on 12th July 2016.
The HWB agreed in June that adopting a prioritisation framework will assist with the prioritisation
process in a systematic way, ensuring a clear, rational approach and a defensible, transparent process
for local decision making, whilst ensuring the active engagement of key stakeholders in the development
of the JHWS. In order to achieve this, five core principles for developing the JHWS were agreed as
follows:
1.
2.
3.
4.
5.
Stakeholder engagement (that builds public and patient confidence in the process)
A clear and transparent process
Careful information management
Decisions based on clear value choices (underpinned by a sound evidence base)
Selection of an agreed prioritisation methodology that takes into account the ranking/scoring of a
range of factors, or 'criteria’.
On the 12th July a workshop was held with members of the HWB alongside wider partners and
stakeholders, including representatives from the CCGs. The objectives of the session were to:
1. Agree the key criteria for use within the prioritisation framework for the next JHWS
2. Weight the criteria to reflect the varying importance each one has in prioritising JSNA evidence
3. Test the prioritisation framework with a JSNA topic commentary (the draft Breastfeeding topic
commentary was used due it already having been completed).
These objectives formed the basis of three separate exercises in the workshop.
1
In total 31 people attended the workshop and were placed across five tables. Each table worked through
each objective in turn. All tables at the workshop successfully reviewed the criteria and made
recommendations for amendments, agreed a weighting for and assigned a score to each criterion within
the framework. Following the workshop the framework has been amended along with a proposed
weighting of criteria based on feedback and weighting from individual tables at the workshop. There are
some limitations to the framework however with some further testing and refinement it is expected that
these can be addressed.
The framework itself performed in a fairly consistent way following sensitivity analysis and so is judged to
be fit for purpose from this perspective.
Following the HWB meeting on 27th September final amendments have now been made to the
prioritisation framework and this is shown in Appendix A.
4.
Management of Conflicts of Interest
Not applicable
5.
Finance, QIPP and Resource Implications
None identified.
6.
Legal/NHS Constitution Considerations
A statutory duty under the Health and Social Care Act 2012 requires the Local Authority and each of its
partner clinical commissioning groups to produce a Joint Health and Wellbeing Strategy (JHWS) for
meeting the needs identified in the Joint Strategic Needs Assessment (JSNA).
7.
Analysis of Risk including Assessments
As the HWB does not commission services itself it will be for commissioning members of the board
(including each CCG) to assess the risks and service delivery impacts of the strategy as part of their
commissioning planning.
Please state if the risk is on the CCG Risk Register.
Yes
No

8.
Outline engagement – clinical, stakeholder and public/patient
Initial stakeholder engagement has helped to shape the approach that the Lincolnshire Health and
Wellbeing Board will take to the development of its next Joint Health and Wellbeing Strategy for
Lincolnshire (JHWS).
Further engagement is planned throughout the process of its development to ensure the view of people
who live and work in the county are taken into account within the JHWS.
9.
Outcome of Impact Assessments
Equality and health impact assessments will be developed as part of the engagement and development
of the JHWS.
10. Assurance Departments/Organisations who will be affected have been consulted
Not applicable.
Insert details of the departments you have worked with or consulted during the process:
Finance
Commissioning
Contracting
Medicines Optimisation
Clinical Leads
Quality
2
Safeguarding
Other
11. Report previously presented at:
None.
12. For further information or for any enquiries relating to this report, please contact
David Stacey, [email protected] or 01522 554017
3
Appendix A – Joint Health and Wellbeing Strategy Prioritisation Framework Sept 2016
JHWS Prioritisation Framework
Criteria
Supporting prevention
Does addressing the topic area (i) improve
the overall health and wellbeing of the
population; (ii) reduce the escalation of
health and care needs in future, e.g.
through identifying individuals at risk of
health conditions or events; (iii) maximise
peoples independence through effective
treatment and recovery of health
conditions?
Strategic fit:
National requirement or Outcome
Framework indicator (PH, NHS, ASC) or
local policy priority.
Weighting
of criteria
(High=3,
Medium=2,
Low=1)
Very Low
(Score = 1)
Low
(Score = 2)
Mid-scale
(Score = 3)
High
(Score = 4)
High
No evidence of
improvement to
health, delay or
prevention in the
use of healthcare
services and/or
improvement
treatment and
recovery
Slight evidence of
improvement to
health, delay or
prevention in the
use of healthcare
services and/or
improvement
treatment and
recovery
Moderate evidence
of improvement to
health, delay or
prevention in the
use of healthcare
services and/or
improvement
treatment and
recovery
Significant evidence
of improvement to
health, delay or
prevention in the
use of healthcare
services and/or
improvement
treatment and
recovery
Strong evidence of
improvement to
health, delay or
prevention in the
use of healthcare
services and/or
improvement
treatment and
recovery
Medium
Not a national
requirement or
indicator and no
clear local policy
priority
Addresses one or
more national
requirements or
indicators but is not
a local policy priority
Addresses one/two
national
requirements or
indicators and is a
local policy priority
Addresses three
national
requirements and/or
indicators and is a
local policy priority
across two or more
partners
Significant evidence
of geographic or
population-based
inequalities,
affecting multiple
groups of
individuals
Addresses four or
more national
requirements and/or
indicators and is a
policy priority
across multiple
partners (three plus)
Strong documented
evidence exists
demonstrating the
impact of persistent
& widescale
geographic or
population-based
health
inequalities/inequity
affecting a large
section of the
community.
Evidence of need is
robust containing
strong and
consistent evidence
of need derived
Health inequalities/equity:
The criteria incorporates both health
inequity (an unfair or unjustifiable difference
in health) and health inequality (differences
in health arising from social inequalities in
the conditions in which people are born,
grow, live, work & age). The criteria
assesses the scale of inequalities (defined
as inequalities in access and outcomes) as
relevant to the JSNA topic area.
High
No evidence of
inequalities/inequity
amongst different
groups of
individuals, as
relates to the topic
area.
Limited amount of
evidence of
inequalities/inequity
affecting a small
number/group of
individuals, as
relates to the topic
area.
Evidence of
geographic or
population-based
inequalities,
affecting a
moderate
number/group of
individuals
Strength of evidence:
How strong is the evidence of need
contained within the topic commentary?
Does it include a mixture of both qualitative
& quantitative data sources to provide a
High
Evidence of need is
poor
Evidence of need is
limited to one type
of data source
Evidence of need
includes a
combination of
qualitative &
quantitative data
1
Very High
(Score = 5)
Evidence of need
includes a
combination of
qualitative &
quantitative data
JHWS Prioritisation Framework
Criteria
Weighting
of criteria
(High=3,
Medium=2,
Low=1)
Very Low
(Score = 1)
Low
(Score = 2)
broader context around the topic area?
Mid-scale
(Score = 3)
High
(Score = 4)
Very High
(Score = 5)
sources but there is
no consistent
'message' regarding
needs
VFM calculations
available showing
cost effective
service
interventions (or the
potential for them to
be delivered) across
a short timeframe
only (1-2 years)
from multiple &
diverse data
sources.
Value for money:
The criteria assesses the extent to which
value for money considerations regarding
service/activity interventions are evidenced
in the JSNA topic area. Have any
calculations been undertaken, e.g. Spend
and Outcome (Return on Investment) Tools
(SPOT)?
High
No VFM
calculations
available
VFM calculations
available and
demonstrate poor
value for money
Magnitude of benefit:
What is the benefit in terms of quality of life
improvements and proportion of the
population (potentially) affected? The
criteria incorporates (i) the scale of
improvements in health and (ii) life
expectency and healthy life expectancy
Number of people benefitting:
What is the scale of the benefit in terms of
quality of life improvements and size of
population (potentially) affected? The
criteria incorporates the number of people
likely to benefit/be affected.
High
No or negligible
improvement in
health or life
expectancy
evidenced
A small
improvement in
health or life
expectancy
evidenced
Moderate
improvements in
health or life
expectancy
evidenced
with a coherent &
consistent
'message' regarding
needs
VFM calculations
showing cost
effective service
interventions that
deliver (or the
potential to deliver)
sustained value for
money across a
short and medium
term period (3-5
years)
Significant
improvements in
health or life
expectancy
evidenced
Medium
<1% of the
population (up to
approximately 700800 people)
affected/benefiting
1%-3% of the
population
(approximately 800
to 20,000 people)
affected/benefiting
3%-5% of the
poulation
(approximately
20,000 to 35,000
people)
affected/benefiting
Between 5%-7% of
the population
(approximately
35,000- 50,000)
people
affected/benefiting
>7% of the
population
(approximately
>50,000 people)
affected/benefiting
Medium
No evidence of
views from
stakeholders,
patients, residents
and/or service users
Weak evidence of
views from
stakeholders,
patients, residents
and/or service users
Evidence of views
from stakeholders,
patients, residents
and/or service users
is provided but no
consistent
'messages' are
Some evidence of
strong views from
stakeholders,
patients, residents
and/or service users
Comprehensive
engagement
leading to evidence
of strong & informed
views from
stakeholders,
patients, residents
Public Understanding & Engagement:
This criteria considers the extent to which
there is consistent and robust evidence
regarding the local views and priorities from
stakeholders inc. residents and/or service
users.
2
VFM calculations
and/or good
programme
budgeting
intelligence to
support investments
that deliver (or have
the potential to
deliver) VFM across
short, medium and
longer term
Large and proven
improvements in
health or life
expectancy
evidenced
JHWS Prioritisation Framework
Criteria
Weighting
of criteria
(High=3,
Medium=2,
Low=1)
Very Low
(Score = 1)
Low
(Score = 2)
Mid-scale
(Score = 3)
High
(Score = 4)
Very High
(Score = 5)
Risk is high.
Available evidence
suggests high risk
(i.e. data
demonstrates need
is worse when
compared to
regional, national
and/or comparator
areas and/or a
worsening trend that
is predicted to
continue).
and/or service
users.
Risk is very high.
Available evidence
suggests very high
risk (i.e. data
demonstrates need
is significantly
worse than regional,
national and/or
comparator areas,
with a rapid
worsening of need
over time if not
addressed.)
evident
Risk of not prioritising:
This criteria considers the risk of not
prioritising the topic area having considered
the level of need (incorporating trend,
severity of need, comparator data, etc.)
evidenced in the topic commentary.
3
Medium
No risk
Risk is low.
Available evidence
suggests low risk
(i.e. data
demonstrates needs
are stable & in-line
with regional,
national or
comparator area
data)
Risk is fairly high.
Available evidence
suggests fairly high
risk (i.e. data
demonstrates
above-average
prevalence/need
relative to regional,
national or
comparator areas
and/or a gradual
worsening trend)
NOTES OF THE LINCOLNSHIRE CCG COUNCIL MEETING
HELD ON WEDNESDAY 5TH OCTOBER 2016 AT 1.30 PM
PHILLIPS ROOM, THE SHOWROOM, TRITTON ROAD, LINCOLN, LN6 7qy
PRESENT
Peter Holmes
John Turner
Kevin Hill
Tony Hill
Sunil Hindocha
Sarah Newton
Sandra Williamson
Rob Croot
Gary James
Allan Kitt
IN ATTENDANCE
Janet Bouch
Rebecca Neno
APOLOGIES
Paula Pilkington
Richard Childs
Wendy Martin
Liz Ball
Vindi Bhandal
Pam Palmer
Jo Wright
Tracy Pilcher
Jane Hainstock
Andrew Rix
GP Chair, Lincolnshire East CCG and Chair of CCG Council
Chief Officer, South Lincolnshire CCG
GP Chair, South Lincolnshire CCG
Director of Public Health, Lincolnshire County Council
Clinical Chief Officer, Lincolnshire West CCG
Chief Operating Officer, Lincolnshire West CCG
Chief Finance Officer, Lincolnshire East CCG
Chief Finance Officer, Lincolnshire West CCG
Chief Officer, Lincolnshire East CCG
Chief Officer, South West Lincolnshire CCG
PA, South West Lincolnshire CCG (minutes)
Deputy Chief Nurse, Lincolnshire West CCG
Acting Chief Finance Officer, South West Lincolnshire CCG
Independent Chair, Lincolnshire West CCG
Executive Nurse and Quality Lead, Lincolnshire West CCG
Executive Nurse and Quality Lead, South Lincolnshire CCG
GP Chair, South West Lincolnshire CCG
Executive Nurse and Quality Lead, South West Lincolnshire CCG
Chief Finance Officer, South West Lincolnshire CCG
Executive Nurse and Quality Lead, Lincolnshire East CCG
Programme Director Continuing Healthcare, Lincolnshire East CCG
Head of Commissioning, Lincolnshire East CCG
STANDING ITEMS
1.
WELCOME AND INTRODUCTIONS
Dr Holmes welcomed everyone to the meeting.
2.
DECLARATIONS OF PECUNIARY AND NON-PECUNIARY INTERESTS
The GPs present declared an interest in the items relating to prescribing, PACEF and prior
approval.
3.
NOTES OF THE MEETING HELD ON 7 SEPTEMBER 2016
The notes were agreed.
4.
MATTERS ARISING
Item 6 Regional Medicines Optimisation Committee
Dr Holmes advised that the letter on behalf of Lincolnshire had been actioned.
1
Item 7 ULHT GI Referral Guidelines
Dr Holmes would be meeting with Dr Kapadia the following week to discuss the guidelines.
COLLABORATION AND GENERAL ISSUES FOR DISCUSSION
5.
ULHT A&E PERFORMANCE
Dr Holmes suggested that this item be discussed at a future meeting when there was a wider
attendance. In the meantime the following was noted:
• Grantham A&E Temporary Closure - the figures had shown no material impact of the
closure at night. There were concerns amongst the Consultants at Pilgrim Hospital that
events at Grantham might have an adverse effect on the future of A&E facilities in Boston.
• Sleaford Urgent Care Centre was currently seeing more patients at weekends that
Grantham A&E
Further discussion took place around the future of services across the county.
Action : Mrs Bouch
6.
EAST MIDLANDS AFFILIATED COMMISSIONING COMMITTEE TERMS OF REFERENCE
Mr Turner advised that he had not as yet discussed this with Mr Rix and felt that there should be a
representative for all four CCGs on the East Midlands group and suggested Mr Rix as the most
appropriate person.
The significant financial implications were noted and it was agreed that Mr Rix should be the
Lincolnshire representative on the group. Mr Turner undertook to discuss further with Mr Rix.
Action : Mr Turner
7.
QiPP CONSULTATION
OTC, IFR and Prior Approval Policy
Mrs Newton reported that a consultation document for OTC had been produced and a meeting had
taken place regarding IFR and Prior Approval Policy. Thresholds around hip and knee
replacements had also been discussed and this would be included as the only additions to the
policy.
Amendments to the documents had been made and sent to all CCGs. The documents would need
to be sent to providers for immediate implementation. However, ULHT had rejected the documents
and considered CCGs should be the ‘gate-keepers’ for the process. Communication would be sent
to GPs and providers regarding the system so that all parties had clarity. A review of waiting lists
for certain procedures (especially cataracts) would need to take place.
Dr Hindocha commented that dedicated time needs to be set aside to look into hips, knees and
shoulder replacements and it was agreed that Mrs Williamson would raise this with Kate Schroder
(Interim Turnaround Director, LECCG).
Dr Hindocha undertook to produce the letter for all Chief Officers to sign and provide Dr Bhandal,
Dr Holmes and Dr Hill with a copy.
Action : Dr Hindocha/Mrs Williamson
2
Prescribing
Dr Hindocha advised that two practices in the West were not undertaking electronic prescribing and
this was considered to be very poor practice. Dr Hindocha undertook to draft a letter to the
surgeries in question giving examples of poor practice with members providing comments before
the letter is issued.
Action : Dr Hindocha
Mrs Williamson commented that Healthwatch had produced a survey on medicines and undertook
to send this to members to ascertain whether this could be useful and Dr Holmes undertook to
speak to Sarah Fletcher.
Action : Mrs Williamson/Dr Holmes
8.
CONFIRMATION OF END STATE FOR CAPITATION SHARE BASED ON “RISK SHARING”
Mrs Williamson requested that this item be discussed outside of the meeting.
Action: Mrs Williamson
9.
ESTABLISHMENT OF LINCOLNSHIRE CO-ORDINATING BOARD
Mr Kitt advised that this was a newly established group and it had been suggested that initially is
attended by Chairs to agree how the meeting will run.
ANY OTHER BUSINESS AND INFORMATION
10.
TO NOTE AN UPDATE ON CONTRACTS WITH KEY PROVIDERS:
ULHT, LCHS, EMAS, NLAG, LPFT AND PSHFT
The reports were noted by the CCG Council.
11.
DELIVERING THE STP
Dr Holmes suggested that a facilitated workshop for CCG Council regarding the above might be
useful and to be held for half a day.
Lengthy discussion took place and it was agreed there would be a development session to discuss
this further.
Action : All to note
12.
MR TONY HILL, DIRECTOR OF PUBLIC HEALTH, LINCOLNSHIRE COUNTY COUNCIL
It was noted that Mr Hill would be retiring in October. The CCG Council expressed their thanks to
Mr Hill for his valued input to the meetings and wished him well in this retirement.
Mr Hill expressed his thanks to members for their kind wishes and
Mr Glen Garrod would be acting as interim Director of Public Health until such a time as a
permanent replacement was made.
3
13.
SHARED CARE
Dr Holmes commented that a practice in the East had terminated their I&R contract and another
practice giving up their shared care agreement and both these issues had caused problems.
It was noted that Kieran Sharrock had requested Dr Holmes arranged a meeting to discuss
enhanced service for shared care arrangements. It had been suggested that PACEF, CCG Council
(ie. Dr Holmes) discussed this in more detail.
Mr Kitt advised that mental health long term depo injections required consideration within these
discussions.
Dr Holmes undertook to have an initial conversation with Kieran Sharrock regarding shared care
and then access the next steps.
Action : Dr Holmes
14.
CONTRACT OPTIONS AND CONTRACT NEGOTIATIONS FOR 2017-19
Mrs Williamson presented the tabled paper regarding the above. The paper detailed options that
could be considered for the contracting round in 2017/18. The paper mainly focussed on acute but
could be considered for LPFT and LCHS.
The planning guidelines had been issued with a very tight timescale with contract offers to be on
the table by 4th November for two financial years.
Lengthy discussion took place around types of contracts going forward and whether an alliance
arrangement might be the way forward.
It was agreed that a separate meeting was required to discuss this in more detail and members
were requested to nominate the most appropriate attendees and advice Mrs Williamson.
Action : All/Mrs Williamson
15.
EMAS PERFORMANCE
Mr Turner raised the issue of poor performance within Lincolnshire from EMAS and the need for an
improvement plan.
The need for a Lincolnshire blue light service (possibly provided by Lincolnshire Fire and Rescue)
was highlighted and it was noted that Malcolm Burch would be the most appropriate person to
contact.
Action : Mr Turner
16.
CHILDREN’S SERVICES – HEALTH VISITING AND SCHOOL NURSING
Mr Kitt commented that there were various rumours regarding the possible establishment of a new
NHS organisation within Lincolnshire around health visiting and school nursing.
It was agreed that further discussion was required at a future meeting.
Action : Mrs Bouch
4
18.
DATE, TIME AND VENUE OF NEXT MEETING
Wednesday, 2nd November 2016, 1.30pm, New Life Centre, Mareham Lane, Sleaford NG34 7JP.
5
1
LINCOLNSHIRE HEALTH AND
WELLBEING BOARD
27 SEPTEMBER 2016
PRESENT: COUNCILLOR MRS S WOOLLEY (CHAIRMAN)
Lincolnshire County Council: Councillors C N Worth (Executive Councillor for
Culture and Emergency Services), D Brailsford, B W Keimach and C R Oxby
Lincolnshire County Council Officers: Debbie Barnes (Executive Director of
Children's Services), Glen Garrod (Executive Director of Adult Social Services) and
Dr Tony Hill (Executive Director of Public Health Lincolnshire)
District Council: Councillor Jeff Summers (District Councils Representative)
Jeff Summers (District Councils Representative)
GP Commissioning Group: Dr Kevin Hill (South Lincolnshire CCG) and Dr Sunil
Hindocha (Lincolnshire West CCG)
Healthwatch Lincolnshire: Sarah Fletcher
NHS England: Mr Jim Heys
Officers In Attendance: : Steve Blagg (Democratic Services Officer) (Democratic
Services), Alison Christie (Programme Manager, Health and Wellbeing Board),
Mandy Clarkson (Consultant Public Health Wider Determinants) (Public Health),
Philip Garner (Adult Health Improvement Manager), Chris Weston (Consultant in
Public Health, Public Health Intelligence) (Consultant in Public Health, Health
Intelligence), Sophie Dickinson (Lincolnshire Health and Care), Sarah Furnley
(Lincolnshire East CCG) and David Stacey (Programme Manager, Public Health)
11
APOLOGIES FOR ABSENCE/REPLACEMENT MEMBERS
Apologies for absence were received from Councillors Mrs P A Bradwell (Executive
Councillor for Adult Care, Health and Children's Services), N H Pepper (Support
Councillor Culture and Emergency Services) and Dr P Holmes (Lincolnshire East
CCG).
12
DECLARATIONS OF MEMBERS' INTEREST
There were no declarations made at this stage of the meeting.
2
LINCOLNSHIRE HEALTH AND WELLBEING BOARD
27 SEPTEMBER 2016
13
MINUTES OF THE LINCOLNSHIRE HEALTH AND WELLBEING BOARD
MEETING HELD ON 7 JUNE 2016
RESOLVED
That the minutes of the previous meeting of the Lincolnshire Health and Wellbeing
Board held on 27 September 2016, be confirmed as a correct record and signed by
the Chairman.
14
ACTION UPDATES FROM THE PREVIOUS MEETING
The Board received an update of actions since the previous meeting of the Board on
7 June 2016.
A Board Member enquired about the reason for the delay in examining the Board's
composition with regard to District Council membership. He requested that this
matter should be brought forward for consideration. The Chairman stated that the
ideal time to address the matter was after the County Council Election in 2017 as the
Council might have new Members elected who would require training, support and
added that the Board was a Committee of the Council.
RESOLVED
That the report be noted.
15
CHAIRMAN'S ANNOUNCEMENTS
The Board received a report in connection with the Chairman's announcements.
The Chairman drew attention to the details of letter she had sent to the Chief
Executive of the United Lincolnshire Hospital Trust raising concerns about the level of
emergency provision in the south of the county, in particular, the capacity of the
Ambulance Service to be able to respond to any increase in demand. She stated that
there had been a campaign in the south of the county about the lack of a proper
ambulance service and its detrimental impact locally.
Comments by the Board and officers included a specific case of a patient from
Grantham who had refused to be taken to Lincoln because of his concerns about
getting back to Grantham and the Police had taken patients to hospital because there
was no ambulance available. It was noted that the South Lincolnshire CCG was
examining this issue because of the importance of this service.
RESOLVED
That the report be noted.
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LINCOLNSHIRE HEALTH AND WELLBEING BOARD
27 SEPTEMBER 2016
16
DECISION/AUTHORISATION ITEMS
16a
Annual Assurance Report
The Board received a report in connection with the progress being made to deliver
the outcomes in the Joint Health and Wellbeing Strategy. The progress was detailed
on the Strategy's Scorecard and Theme Dashboard for 2015/16.
Discussion between the Board and officers included the following topics:1. There was a declining trend in the eight indicators which was welcomed.
2. It was noted that cases of liver disease were increasing and there was a need to
focus on the strategy to tackle this issue and for a partnership approach.
3. The elderly population was increasing rapidly and finding beds was becoming an
issue. The strategy was going in the right direction but it was recognised that this
issue was becoming more prominent.
4. Increased mortality amongst the under 75's was becoming an issue in some
communities due to inappropriate life styles. It was noted that an audit of GP
practices was being undertaken to assess the take-up of health checks.
5. The District representative queried the point in the report that the Board agreed to
hold each other to account but there had been no discussion about at the Board
about the decommissioning of services. The District representative was advised that
the 2016/17 commissioning intentions for CCGs, Adult Care, Children's Services and
Public Health were discussed at the informal Health and Wellbeing Board meeting in
February 2016, to which all District Councils were invited to attend. In addition, the
CCGs Operational Plans for 2016/17 were formally presented to the Board in March
2017
6. The Council had written to the Government about the reduction in funding for
Public Health. It was hoped to address the reduction in funding of Public Health when
local authorities had responsibility for setting their own priorities.
7. The challenge faced was where to direct preventive resources and how to prioritise
these resources as there were no easy choices for the NHS or Local Authorities.
There was a need to consult the public and other agencies to identify constraints and
the alternative options available.
8. Elected Members faced election every four years and therefore there was a need
to regularly examine priorities and the allocation of resources. Prevention was better
than cure in the long term.
9. The statistics in Theme One for physical activity did not match those given by
Sport England. Officers were unaware how Sport England had produced their
statistics or whether it was possible to measure statistics down to a District Council
level.
10. The presentation by The Sports Partnership was about the Sports England
Strategy and their new arrangements on how funding was going to be allocated. The
Chairman stated that engagement had taken place around these new arrangements
and not everyone was aware. Officers stated that they would check exactly what the
Sports England document was and get back to the Board.
11. Gainsborough Town Council had received funding from West Lindsey District
Council to support football at youth level but this funding was coming to an end. Over
2,000 young people had been involved and the activity should be encouraged. It was
the case that the dividend from physical activity did not become apparent for many
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LINCOLNSHIRE HEALTH AND WELLBEING BOARD
27 SEPTEMBER 2016
years and it was necessary to convince funding bodies that this was worth
supporting.
12. Theme 4 – there had been a lot of good work taking place with improving
education attainment and narrowing the gap between those receiving free school
meals and those not receiving them. The key challenge was obesity in children which
was being tackled by the Government's national plan which Lincolnshire was
following.
13. The integration of health teams was welcomed.
14. Children needed to feature in the Transformation Plan and District Councils also
had a part to play.
15. There was a lot of work to do in connection with reducing the number of NonAccidental Injury cases particularly in teenagers and there would be a focus on this
area in the future.
16. Mental illness in children was an issue. Officers stated that the Safeguarding
Board was examining risk in this area.
17. There was a lot of emphasis on examination results compared to other areas of
the curriculum. Officers stated that examination results had been chosen particularly
the increased emphasis on Maths and English. The authorities were trying to see if
there were any gaps between those living in financial disadvantage and those not
and concentrating on this area.
18. Efforts to reduce obesity were welcomed. Officers stated that there was a need to
target this area.
19. One of the reasons why Lincolnshire was not narrowing the education attainment
gap was because Lincolnshire was not as well funded as other local authorities.
Officers stated that there was a lot of work taking place in Lincolnshire to narrow the
attainment gap especially with children on free school meals and the government
was being lobbied about funding. There needed to be more joined up thinking in this
area particularly for GPs and CCGs to share information at an earlier stage.
20. It was agreed that housing problems had an effect on health and was being
addressed in the Strategy. Officers stated that support was given to people living
independently and that fuel poverty was still a major issue. Details of the Energy
Switch initiative were available on the County Council's website. Officers stated that a
review of housing and support accommodation for 16-24 year olds was also needed.
RESOLVED
That the report, comments made by the Board and the responses of officers, be
noted.
16b
Prioritisation Framework for the Development of the Joint Health and
Wellbeing Strategy
The Board received a report in connection with the need to agree the Prioritisation
Framework for the development of the Joint Health and Wellbeing Strategy following
a workshop held on 12 July 2016, involving members of the Board, partners and
stakeholders.
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LINCOLNSHIRE HEALTH AND WELLBEING BOARD
27 SEPTEMBER 2016
Discussion between the Board and officers included the following topics:1. There was an error in the criteria within the table under Exercise 2 of Appendix A
of the report. Officers agreed to change the Public Acceptability weighting from high
to medium to correct this.
2. A similar error was included in Appendix B. Officers agreed to review weighting of
all criteria in Appendix B to ensure the weighting of criteria in the Prioritisation
Framework was correct.
3. The District Councils stated that the Prioritisation Framework accurately the
findings from the workshop.
4. The Framework stood up to scrutiny and it was very good to show that
comparisons had been made.
5. The Board discussed whether the criteria covering "Magnitude of benefit" and
"Number of people benefitting" should be combined into one criterion as
recommended. It was agreed that these were two different things and, as such,
should be separated back out into two criteria as originally proposed. Officers agreed
to make the necessary changes to the Prioritisation Framework to reflect this.
RESOLVED
(a) That the feedback from the workshop on the Prioritisation Framework be noted
and welcomed.
(b) That, subject to the amendments identified by the Board in Exercise 2 of
Appendix B, for developing the next Joint Health and Wellbeing Strategy for
Lincolnshire, the Prioritisation Framework be agreed.
17
DISCUSSION ITEMS
17a
Joint Commissioning Board - Update Report
The Board received a progress report of Lincolnshire's Better Care Fund (BCF)
2016/17.
Officers highlighted various aspects of the report including potential changes to the
BCF which were likely to be announced with the Comprehensive Spending Review in
November. Disabled Facilities Grants was another issue in Lincolnshire as one
District Council had requested their full funding allocation and the Joint
Commissioning Board had recommended that the Board should not release the full
allocation although there was a risk that this action could lead to a financial challenge
by the District Council. Discussions were on-going with the District Council.
Discussion between the Board and officers included the following topics:1. Officers stated that the Delayed Transfer of Care (DTOC) raised inequality issues
in connection with people with dementia and mental health issues being kept in
hospital.
2. With regard to the issue raised in the report about Disabled Funding Grants did the
District Council concerned have its own housing stock as some Local Authorities
allocated this responsibility to Housing Associations? Officers replied that the Council
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LINCOLNSHIRE HEALTH AND WELLBEING BOARD
27 SEPTEMBER 2016
concerned did have its own housing stock. Officers stated that supporting people
suffering from dementia and mental illness in their own homes was their priority and
the effectiveness of this action would not be known until Spring 2017.
3. Had officers spoken to the District Council concerned in connection with its funding
issues? Officers stated that all of the District Councils had been informed about this
matter.
4. The Board needed a consistent approach to all of the District Councils in
connection with the Disabled Funding Grants.
5. What were the legal and financial implications for District Councils? Officers stated
that the District Councils needed to hold a collective view on this matter. The financial
risk was accounted for in the Business Rates.
6. The integration of the BCF and the Sustainability Transformation Plan was
important particularly the integration of social care which was a key part of the
strategy. There was a need to improve care provision to allow people to stay in their
own home rather than in hospital and it was important to maintain this vision.
RESOLVED
(a) That the report be noted.
(b) That the recommendation of the Joint Commissioning Board not to accede to the
request from the concerned District Council in connection with their Disabled Fund
Grant for 2016/17, be agreed.
17b
Lincolnshire Sustainability and Transformation Plan - (including Lincolnshire
Health and Care)
The Board received a progress report in connection with the Sustainability and
Transformation Plan (STP).
Discussion between the Board and officers included the following topics:1. Planning for the STP had been on-going for the last two years.
2. Uncertainty about the ability of being able to transpose information from the
Lincolnshire Health and Care Programme to the STP.
3. The public did not have enough information about the STP and there was a need
to ensure that they were fully informed. Officers stated that it was proposed to consult
the public and there had been a lot of consultation already. It was proposed to have
an engagement plan to show how the STP would be delivered. The STP would be
published before Christmas 2016 and there would be full engagement with the public.
4. How robust were the financial plans for the STP? Officers stated that there were
two elements, one element for changing the requirement and secondly a judgement
was required in connection with increasing the workforce as it was going to take a
number of years to recruit staff.
5. It was important that questions to the public should be kept simple as simple as it
was a complicated subject.
RESOLVED
That the report be noted.
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LINCOLNSHIRE HEALTH AND WELLBEING BOARD
27 SEPTEMBER 2016
17c
District/Locality Updates
It was noted that there were not any District/Locality updates to report.
18
INFORMATION ITEMS
19
AN ACTION LOG OF PREVIOUS DECISIONS
The Board received a report which gave details of decisions taken by the Board since
its previous meeting held on 7 June 2016.
RESOLVED
That the report be noted.
20
LINCOLNSHIRE HEALTH AND WELLBEING BOARD - FORWARD PLAN
The Board received its Forward Plan. It was noted that the meeting of the Board
scheduled for 28 March 2017, had been brought forward to 7 March 2017 because of
the County Council Election.
21
RETIREMENT OF TONY HILL, EXECUTIVE DIRECTOR OF COMMUNITY
WELLBEING AND PUBLIC HEALTH
The Chairman stated that this was Tony Hill's last meeting as he was retiring. She
thanked him for his services to the Board and added that Tony had been at the
forefront in establishing the Board and on behalf of the Board she wished him well in
his retirement.
The meeting closed at 4.00 pm
Minutes of NHS South West Clinical Commissioning Group
Executive Committee
Held on Wednesday 12th October 2016, 2pm until 4pm
Witham Room, SKDC, Grantham
Present:
Dr David Baker
Mrs Shona Brewster
Dr Kakoli Choudhury
Mr Adrian Down
Dr John Elder
Mrs Jodie Knight
Dr Andrew Pilbeam
Mrs Paula Pilkington
Dr Salman Quadar
Mrs Clair Raybould
Dr Timothy Ryder
Miss Jo Wright
Chairman & GP, Vine House, South West Lincolnshire CCG
Senior Commissioning Manager, South West Lincolnshire CCG
Consultant in Public Health, Lincolnshire County Council
Practice Manager, Ancaster Surgery, South West Lincolnshire CCG
GP, Market Cross Surgery, Corby Glen, South West Lincolnshire CCG
Practice Manager, Harrowby Lane, South West Lincolnshire CCG
GP, St Peter’s Hill, South West Lincolnshire CCG
Deputy Chief Finance Officer, South West Lincolnshire CCG
GP, Sleaford Medical Group, South West Lincolnshire CCG
Chief Commissioning Officer, South West Lincolnshire CCG
GP, Ruskington Medical Practice, South West Lincolnshire CCG
Chief Finance Officer, South West Lincolnshire CCG
Apologies:
Mrs Jeanette Arnold
Mrs Sharon Hayler
Miss Vicky Hundleby
Mr Allan Kitt
Deputy Executive Nurse, South West Lincolnshire CCG
Prescribing Advisor, Arden GEMCSU
Senior Finance Manager, South West Lincolnshire CCG
Chief Officer, South West Lincolnshire CCG
In Attendance:
Dr Vindi Bhandal
Mrs Val Blankley
Mrs Christine Cobham
Ms Jane Day
Ms Diane Hansen
Ms Jo Hart
Chair of Governing Body, South West Lincolnshire CCG
Improvement & Delivery Manager, South West Lincolnshire CCG
Quality Lead, South West Lincolnshire CCG
Secretary to Executive Committee, South West Lincolnshire CCG (Minutes)
Head of Engagement & Inclusion, South West Lincolnshire CCG
Improvement & Delivery Manager, South West Lincolnshire CCG
1.
WELCOME, APOLOGIES AND INTRODUCTIONS
Introductions. Apologies noted as above.
2.
TO DECLARE DETAILS OF PECUNIARY AND NON-PECUNIARY INTERESTS
Dr Baker, Mr Down, Mrs Knight Dr Pilbeam, Dr Quadar and Dr Ryder all declared an interest as
being a member of the Federation K2 Healthcare.
Dr Elder declared an interest as being a federated member of Allied Health South Lincolnshire Ltd.
All dispensing practices present declared their interest in Agenda Item 5 – PMOS Report.
Dr Pilbeam declared an interest in Agenda Item 5 – PMOS Report. He stated that he was a
Director of SPH Pharmacy.
3.
TO RECEIVE AND APPROVE MINUTES OF THE MEETING HELD
The minutes of the meeting held on 14th September were presented and considered and the
Executive Committee agreed to:
•
Approve the minutes as a true and accurate record subject to the following
amendments: Jeanette Arnold - Deputy Executive Nurse, Clair Raybould - Chief
Commissioning Officer.
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4.
TO RECEIVE THE EXECUTIVE COMMITTEE ACTION LOG
Mrs Brewster presented the Executive Committee Action Log and gave a verbal update.
14/09/2016 – PMOS – Care Co-ordinators – Miss Hart was working on a paper to present to the
November Executive Committee.
14/09/2016 – PMOS – Prescribing Budgets – Practice level budgets are yet to be finalised.
14/09/2016 – Grantham Hospital – Kent & Canterbury Urgent Care Centre Visit – Several dates
have been sent to Kent & Canterbury and Ms Day was waiting on them to confirm which date was
mutually convenient.
14/09/2016 – AOB – DVT – A communication has been circulated to practices detailing the audit;
the ULHT Registrar would contact practices if they have identified any cases. A specific audit
template was not required to be completed as some practices may not have any patients that meet
the criteria.
14/09/2016 – AOB – DVT – The statins audit is due for refresh in October and was still to be
circulated. Mrs Brewster requested that she become the assigned action lead.
Action: Mrs Day
14/09/2016 – AOB – STM/ADHD – A meeting was being arranged with clinicians from both Primary
and Secondary Care to discuss the issues highlighted with the monitoring requirements in the
current shared care agreement for ADHD drugs.
14/09/2015 – AOB – Treatment Room – Contract packs have been sent to 14 practices. Five
practices have not returned their due diligence form and these are being followed up directly by
contracting.
14/09/2016 – AOB – Day Case/Out Patients Tariff – Miss Wright was still trying to ascertain the
dates of the workshops in order to circulate to the members.
Following discussions it was deemed that the following actions were complete:
14/09/2016 – Urology
14/09/2016 – Enhanced Services Review
14/09/2016 – Enhanced Services Review – Sonography – All sonographers have all been
trained and are able to satisfy PACEF guidance. Radiology results will be available within the
clinical portal due for roll out in January 2017.
14/09/2016 – Dementia Family Support Service – The DFSS is funded by Lincolnshire County
Council for 3 years and the service is currently running in its first year.
14/09/2016 – Dementia Family Support Service – The relevant information on the DFSS was
circulated to practices on 19th September 2016.
14/09/2016 – Health Based places of safety – The bid had not been submitted due to Chief
Officers and the Joint Delivery Board not approving it. There had not been a full business case to
support the bid due to not receiving agreement from the four CCG’s.
14/09/2016 – AOB – Dermatology – The group have met to discuss the options and are looking at
GP education sessions and referral audit. The group is scheduled to meet again in November. It
was agreed that this action would be transferred onto the project update report.
Action: Mrs Blankley
The Executive agreed to:
• Note the contents and verbal update of the action log.
5.
TO RECEIVE THE PMOS REPORT
Mrs Raybould presented the PMOS report on behalf of Mrs Hayler.
•
•
•
•
A discussion has taken place with Optum regarding the production of a report that covered
all aspects of prescribing.
An award for the PMOS service through the LPF had been given but this was now in a 10
day standstill period.
Mrs Raybould advised that she had recently met with Optum with regards to the QIPP
project. The project was doing well but there were a couple of issues namely how the CCG
deals with issues surrounding practices that have either got their own pharmacy or have a
concern around dispensing.
The pharmacists have identified another list of switches that they can do and Mrs Hayler
2
•
•
has confirmed that the switches are suitable.
Members highlighted that they had received an email stating that there was the possibility of
additional funding for medication reviews and practices had to respond within 24 hours. Mrs
Raybould advised that this was a miscommunication from a conversation she had had with
Optum and added that there was a GP Resilience Programme that was open for practices
to submit bids i.e. additional pharmacy support non-recurrently.
Following discussions members highlighted that practices could not absorb the cost of
posting letters out to patients regarding medication reviews. Mrs Raybould agreed to speak
to Optum regarding the costs associated to practices with regards to the additional work of
sending letters to patients regarding their medication review.
Action: Mrs Raybould
Further discussions took place and it was agreed that the Executive Committee needed to receive a
position statement of what savings have/are being obtained. Mrs Raybould advised that she would
share the prescribing report from Optum with the Executive Committee.
Action: Mrs Raybould
The Executive Committee agreed to:
• Note the contents of the report and the verbal update.
6.
NEIGHBOURHOOD TEAM LIAISON OFFICER
Miss Hart presented a paper entitled Neighbourhood Team Liaison Officer. The main points to
highlight from the report are:
The current Neighbourhood Team Liaison Officer is employed on a secondment from her
substantive role within LPFT until 31st December 2016. The role is hosted by LPFT, with the CCG
covering the employment costs.
The proposal for discussions and approval:
•
•
•
Fund the Neighbourhood Team Liaison Officer role on a permanent basis.
The Neighbourhood Teams require additional support than the current 22.5 hours provided.
o The proposal will increase the total hours to 30 hours per week, 15 hours for
Sleaford and 15 hours for Grantham.
The role is a band 4, the cost to employ for 30 hours per week, including on-costs will be up
to £22.5K per year.
Discussions took place about the Neighbourhood Team Liaison Officer role and Miss Hart advised
that the role would evolve and would move to the wider network of health and social care.
Mrs Pilkington advised that from a governance point of view, if the Executive Committee were
spending additional money there was a need to be very clear on validation and for there to be a
clear rationale for the post.
Dr Baker highlighted that the committee needed to be really clear that the role of the
Neighbourhood Team Liaison Officer was needed and to ascertain how the role would interface
with the Care Co-ordinators and to become more aligned to each other and to have them linked in
with other services such social care.
Further discussions took place about the Neighbourhood Team Liaison Officer and all agreed that
the role was needed but there was a need to clearly define the role and to look at other means of
funding the role such as the STP.
The Executive Committee agreed to:
• Extend the post of Neighbourhood Team Liaison Officer for another year.
7.
COMMUNITY SURGICAL SCHEME TARIFF
Mrs Blankley presented and gave a verbal overview of the Community Surgical Scheme Tariff
report. The main points to highlight from the report are:
The AQP CSS contract is now coming to an end and therefore must be re-procured.
3
Previous pricing had been agreed as new procedures were added and would have been done via a
time and motion study but more recently has been done in varying different ways. The current
pricing formula has not been uplifted for a few years and Lincolnshire West CCG have been looking
into how the CSS tariffs compare to PbR tariff for Outpatient Procedures.
With regards to procurement pricing it was intended to simplify the process for tariffs for CSS by
offering a % of the PbR outpatient procedure (OPPROC) tariff. However, this has proven
problematic due to the high variations in the OPPROC tariff to the current CSS tariff (some much
more expensive, others much cheaper). If the tariffs were to drop significantly there would be a
large risk of providers not responding to the AQP offer (and then lack of capacity both in CSS and
secondary care). Additionally if the activity went back to secondary care as Day Case (DC) this
would be more expensive.
It has therefore been necessary to take a reasonable approach to deciding how to set the tariffs,
whilst still utilising PbR. The suggested approach was to still utilise the PbR tariff, and also to have
an easier way of including new procedures, the recommendation for pricing is to use a % of either
DC or OPPROC tariff linked to a HRG appropriate for the CSS procedure. By taking this approach
it would mean that each year the relevant uplift/deflator would be easily calculated by reviewing the
new tariff. It is hoped that by taking this approach that we would still keep providers in the CSS
market, but also retain savings from the service.
In addition to the Community Surgical Scheme, a review was to be conducted in relation to the Low
Priority Procedure Policy.
Discussions took place about the report and it was suggested that providers do ‘baskets of
procedures’ rather than individual procedures. Mrs Blankley agreed that she would feedback to
Lincolnshire West CCG regarding the suggestion of providers having a ‘basket of procedures’.
Action: Mrs Blankley
The Executive Committee agreed to:
• The proposed approach of using a % of either DC or OPPROC tariff linked to an
appropriate HRG.
• Note the contents and verbal overview of the report.
8.
CANCER CLINICAL LEAD
Mrs Raybould highlighted to the Executive Committee that the CCG needed a Cancer Clinical Lead
especially since Cancer was one of the CCG’s most problematic areas in terms of performance and
outcomes.
Mrs Raybould advised that the role was mainly working virtually but there could be a requirement to
attend the Cancer Board. Mrs Raybould agreed to ascertain as to whether the Cancer Board met
in person or virtually and report back.
Action: Mrs Raybould
Dr Pilbeam agreed to be the Executive Committee Clinical Lead and would be happy to be involved
in any clinical pathway discussions virtually but would be difficult if he was required to attend
numerous meetings. A suggestion was put that a letter be sent to practices asking if a clinician
wished to become the CCG representative for Cancer.
Action: Dr Baker
Dr Pilbeam highlighted to the committee that Peterborough Hospital currently had a 2WW cancer
pathway that could be utilised by the CCG practices. Dr Elder agreed to circulate the Peterborough
Pathway for 2WW undiagnosed. Mrs Brewster agreed to ask Mrs Sadler to conduct a piece of work
looking into the various provider cancer pathways.
Action: Dr Elder/Mrs Brewster
The Executive Committee agreed to:
• Note the update.
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9.
NHS HEALTH CHECK ANNUAL REPORT
Dr Choudhury presented the NHS Health Check Annual Report 2015/16. The main points to
highlight are:
Lincolnshire as a whole was on track with a number of patients invited and assessed at the 3 year
point in the 5 year cycle. Individual practice performance remains varied with some excelling,
inviting their full eligible population each year and achieving high uptake rates and some performing
poorly with low numbers invited and assessed against target.
The target to invite annually is 100% of the eligible population and SWLCCG are almost on target.
The findings of the Phase One audits were mixed. All practices had some areas that were very
good and some areas that needed improvement and it was noted that the majority of practices did
not have a high risk register, or if a register was present, then the patients were not routinely added
to this or followed up annually.
Public Health will run Phase Two audits during 2016/17 following on from the Phase One audits
conducted in 2015/16.
Referrals to lifestyle services were low across all CCG’s. Ranging from 9.7 to 5.5% of patients with
a BMI 30+ referred to weight management services and 21 – 17.2% for current smokers referred
into a smoking cessation service.
Discussions took place about the report and a number of issues were highlighted namely:
•
•
Dementia – The chances of a patient being identified as having Dementia at a health check
was practically zero and the question was raised as to why the question was even asked.
Lifestyle Services - The reason as to why referrals to lifestyle services were low was due
to the fact that during the reporting period some of the services were not been available.
The Executive Committee agreed to:
• Note the contents of the report and the verbal update.
10.
LINCOLNSHIRE MEDICINES MANAGEMENT CONSULTATION DOCUMENT
Mrs Raybould presented and advised that the Lincolnshire Medicines Management Consultation
document had been circulated for information purposes.
Miss Hansen advised a link to consultation had been included on the CCG website; press releases
had been issued, in addition to the document being placed within public buildings such as libraries.
Mrs Raybould then advised that the outcome of the consultation would be discussed at the
November Governing Body.
The Executive Committee agreed to:
• Note the contents and verbal update.
11.
ANY OTHER BUSINESS
Mortality Audits – Mrs Knight requested that any patient data practices needed to use in order to
conduct the audit, to not to be sent out as individual patients but as a collective practice list. Mrs
Cobham agreed to speak to Mrs Palmer regarding this request.
Action Mrs Cobham
Safeguarding Audits – Dr Baker advised that following a recent safeguarding update Dr
Saggiorato had advised that should any practices receive a request to conduct an audit then to
contact him and both he and the safeguarding team would help with the facilitation of the various
forms. Mrs Cobham agreed to obtain some clarification from Mrs Arnold with regards to the
safeguarding audit.
Action: Mrs Cobham
5
St Johns Medical Centre – The practice has received another CQC inspection and will be
remaining in special measures. Mrs Cobham and the LMC have visited the practice to offer any
assistance they may need in relation to their action plan and submission of evidence.
Mrs Raybould advised that the Primary Care Commissioning Committee has given officers of the
CCG delegation to look at contingency plans in relation to St Johns Medical Centre.
Dermatology Task & Finish Group – The group has been looking at GP Education sessions but
due to the CCG’s policy with regards to pharmaceutical sponsorship was unable to accept any
sponsorship. Discussions took place GP training and it was agreed that practices would arrange
their own training via any pharmaceutical company. Mrs Blankley agreed to liaise with Mrs Knight
regarding the GP education session.
Action: Mrs Blankley
Learning Disability Consultation – Miss Hansen advised that a Learning Disability Consultation
was to be launched at the end of November. The consultation was with regards to the permanent
closure of Long Leys Court and a paper would be going to the four CCG’s Governing Bodies in
October.
Mrs Raybould advised that the national direction was that patients be cared for within a community
setting. Should a patient have specific specialist needs then this would result in an out of county
placement.
The Executive Committee agreed to:
• Note the various updates.
12.
DATE AND TIME OF NEXT MEETING
12th October 2016 – 1pm until 4pm – Witham Room, SKDC, Grantham
In case of difficulty accessing the papers, please contact Jane Day, Secretary to Executive Committee on
01476 406597
(via e-mail at [email protected])
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