Agenda item

The Committee has received reports on the performance of the three clinical commissioning groups (CCGs) at its meetings in September 2019 and January 2020. It was agreed that a further meeting be held and a more detailed report on performance provided.

A report was introduced by Alison Cartwright, South Warwickshire CCG and Andrew Harkness representing Coventry & Rugby and Warwickshire North CCGs. The Committee had received CCG performance reports at its meetings in September 2019 and January 2020, requesting a further report be presented to this meeting. The Chair noted that this report addressed comments raised previously on the required content.

Alison Cartwright confirmed the duties of CCGs to meet NHS constitution indicators and how they set out to meet those duties. There were also national and local performance indicators. Details were provided of the contracts monitored for acute services and mental health services, also setting out the responsibility for service providers to deliver the performance requirements. CCGs held providers to account through contract frameworks, with monthly meetings to assess performance. A collaborative approach was taken to understand the reasons for shortfalls in performance and to require providers to put in place recovery action plans. Performance reports were provided to each CCG governing body, which met in public.

A verbal response was provided to the questions raised at the previous meetings, with further detail from Jane Tombleson of George Eliot Hospital (GEH) and Helen Lancaster from South Warwickshire Foundation Trust (SWFT). The following updates and further questions from members were discussed:

• GEH had an unannounced visit from the Care Quality Commission (CQC) in December 2019. Members asked in January when the committee would be able to discuss the CQC report and associated action plan. It was confirmed that the CQC had given notice of certain ‘must do’ and ‘should do’ actions. The key concern reported was significant shortages in medical staff. There had been a robust response with recruitment of eight middle grade doctors in recent weeks. It was noted that the CQC report was not yet in the public domain, but this would be added to the work programme and be brought to the committee as soon as possible. 
• At the September 2019 meeting, a report from Public Health provided comparative performance information for each CCG against 21 key indicators. The report had caused some confusion, it being explained that this was drawn together from data in June 2019 and the 2018/19  annual report. Over that reporting period there had been a reduction in performance across some of the indicators for South Warwickshire. An example quoted was accident and emergency (A&E) waiting times. Whilst SWFT was fifteenth best nationally in terms of A&E performance, it was not meeting the national performance target.
• There were capacity challenges for A&E departments generally and more use could be made of other services. At SWFT a particular issue was patients being redirected from other areas to the Warwick Hospital instead of their local A&E department. This impacted on the A&E department and caused difficulty for patients in getting back to their local services.
• More information was sought in regard to dementia diagnosis rates with sections of the report quoted on challenges faced by the Coventry and Warwickshire Partnership Trust (CWPT) in relation to post diagnosis support. Dementia performance was multifactorial. There were capacity issues for CWPT and support was being sourced through GPs providing  memory assessment services. More focussed work in care homes was another example. Further information was requested through a briefing document after the meeting.

The detail of the report focussed on current performance through a series of tables, with data as at November 2019. This comprised performance for the NHS constitution rights and pledges and main priority indicators for both the CCGs and providers of services. The main areas of concern were:

• A&E 4 hour waits;
• Referral to Treatment (RTT) 18 week pathway;
• Cancer – Two week wait breast symptoms only;
• Cancer – 31 day standard;
• Cancer – 62 day standard.

The report was formatted with three columns showing the respective performance of each CCG against these indicators to assist comparison. Detailed graphs were provided showing key issues and ongoing actions. The report concluded with hyperlinks to the full performance reports of each CCG.

Questions and comments were invited with responses provided as indicated:

• On dementia services, reference was made to the increasing numbers of cases diagnosed, the difficulty in achieving performance targets, the detailed scrutiny of current services by NHS England & Improvement and its acknowledgement that services were doing all they could. The need for improvements in community support services was referenced.
• A concern had been raised by Councillor Bragg about cancelled operations at short notice. This had been discussed directly with the councillor. The number of such cancelled operations was reducing and there was no data of an operation being cancelled more than once. Each case was reviewed to understand the reasons for cancellation at short notice. Examples were quoted including bed availability, other surgery taking longer than expected and emergency operations. Related to this further detail was sought on cancelled operations that had not been rearranged within 28 days. This related to the GEH and further detail would be provided to the committee after the meeting.
• Guidance was provided on the different cancer measurements reported against with the 31 and 62 day targets referenced particularly. Further information was sought about the causes for delays of over 104 days. It was confirmed that each of those cases was investigated with a harm review undertaken. Causes could include patient choice, complex pathways or diagnosis.
• On the data for 62-day cancer waits, there was a reported issue due to pension implications for the clinical workforce. Many clinicians undertook additional work, but changes to pension rules meant they were adversely affected financially and so were not taking on this additional work. This was an issue being reviewed at the national level. Related points concerned the shortage of clinicians nationally and the difficulty in predicting surges in demand to enable the appointment of permanent staff or use of locum staff. At GEH there was a gap between demand and capacity in several clinical areas. It was questioned if the shortage of clinical staff was worsening. There was no perceived risk associated with Brexit.
• Improving access to psychological therapies (IAPT) was raised previously with a member commenting that the target was not ambitious. An explanation was given of the target and the current challenges with access to services. There was considerable work underway and examples were aligning services around communities, offering digital therapies and improvements were being seen, but there was still more to do. It was stated that once in the system, the services delivered were good. Related points were about staffing levels, developing the community work, GP referrals from Coventry, gaps in provision and how the Health and Wellbeing Board was involved. It was agreed that there needed to be more services based around communities or ideally a specific practice and detail was given on the schemes being implemented. It was considered that better reporting arrangements could be put in place too.
• A concern was reported on ambulance handover times in excess of 60 minutes.
• A general point that there was a continuing increase in demands for services. GEH was a small hospital in terms of bed numbers, but it served a large population and it was understaffed in many areas. It was acknowledged that there were workforce issues for the Coventry and Warwickshire area, as with many areas of the country. There was a system approach to looking at how to deliver services differently, reducing demands and treating people away from acute settings where appropriate, so services were sustainable and delivered within the funding available.
• There was a need to educate the public, to inform them clearly of which services they should use and to reduce reliance on A&E departments. This was an area of focus with work through primary care, services being provided in the community and managing patient flow at hospitals. Triage arrangements were discussed regularly at SWFT. However, once a patient had been to reception at the A&E department, the duty for treatment rested with that acute trust. Better use could be made of the NHS 111 service and pharmacy, but achieving a culture change would take time.
• Referral to treatment targets were raised. Whilst SWFT was achieving its target, the CCG wasn’t overall. This indicator was influenced by patient choice, for example if they lived closer to another service provider. Other factors were the speciality of the service required and waiting time variance at each trust. It was requested that a detailed briefing be provided after the meeting on referral of Warwickshire patients to the Horton General Hospital at Banbury.
• Dementia diagnosis and the memory assessment service were discussed further. GP doctors were often the first point of contact and undertook some of the assessments. However, the focus was not just on GPs to provide this service.
• A point that clearer guidance was needed to ensure patients chose the correct service. Warwickshire’s population was growing and further housing developments were planned. Services needed to grow to meet this demand. There was national work on the integration of urgent care services within the next 12-18 months, so patients could access all urgent care services more easily. Planned care services would continue to be through primary care.
• A reply was given to Councillor Bell on the point raised in January and at the start of this meeting. This concerned the NHS 111 service being unable to book out of hours appointments at an extended access GP practice. It was confirmed that this had been rectified and patients could now book direct appointments at local surgeries providing the out of hours service. This had been a national issue, linked to IT and a change of provider for the 111 service.
• Discussion about the proposed merger of the Coventry and Warwickshire CCGs. A briefing had been circulated to the committee and there was an offer from CCGs for a detailed discussion at the next meeting on 29 April. An outline was given of the process undertaken to date including engagement exercises and the next stages, including further engagement, before the approval of NHS England and Improvement would be sought to the proposed merger. The Chair confirmed this would be added to the committee’s work programme.
• Chris Bain noted the differences in performance levels across CCGs which would be an area of interest for Healthwatch Warwickshire. He  added that the merger would not affect place-based working. The shortages in staff referenced earlier in the debate was also a concern for social care services.

Resolved

That the Adult Social Care and Health Overview and Scrutiny Committee notes the report and:

• The CCGs’ Performance Management approach;
• The CCGs’ assurance and governance processes in place;

·       The CCGs’ current performance reports.