Committee Feedback: Authorisation and Assurance Lord Victor Adebowale
Non Executive Director Highlights
The paper is pretty clear as to what we have been up to and why.
There are two things I would draw your attention to.
One is a minor amendment to the Committee's terms of reference, really around increasing
the scope to look at the development of CCGs, because we are moving into a slightly different
phase now.
CCGs are up and running, so it is about improvement en mass, continuous improvement, kaizen and
all that.
The second is the proposed delegate the intervention where necessary; as CCGs move into that operational
mode, it may well be necessary for the subcommittee to intervene, particularly where there are
particular areas of immediate concern.
Malcolm Grant: Thank you, I think we received that report.
Committee Feedback: Directly Commissioned Services
Professor Sir Malcolm Grant and Dame Barbara Hakin
Inaugural meeting overview The second one is from me, which is the report
of the Directly Commissioned Services Committee.
We had our inaugural meeting in August, in which we set about reviewing and trying to
rationalise the terms of reference for the Committee and also the relationship between
the Committee and the Clinical Priorities Advisory Group, which is a group which will
feed its intelligence back up to the main Committee.
We identified the principal areas in relation to the direct commissioning functions, which
are set out in the brief report in front of you and we have received various updates in
relation to primary care and specialised commissioning from the Heads of Commissioning.
I am going to ask Barbara to outline briefly one of the important decisions that we took
and we reflected on quite carefully, which is around interim proposals for patient cohort
and individual funding requests.
Commissioning exceptions Individual funding requests
Barbara Hakin: Thank you, Chairman.
As with all commissioned services, NHS England sets out those services which it routinely
commissions and that we offer for patients and put contracts in place for.
There are, however, times when, for reasons, we need to make an exception to some of the
things that we perhaps would not routinely commission and we have to have a system in
place for doing what are called, 'Individual funding requests'.
To give a couple of examples, that might be an instance where we may not routinely commission
some sort of surgery which, for the most part, is cosmetic, but the patient was having severe
health problems because of that, then that would be a time for an exception; or there
may be certain treatments or drugs which are recommended for certain illnesses and not
others, but there may be an exceptional occasion, particularly at the end of life for patients,
when it would be reasonable to use that drug, even though it is not routinely used for that
particular type of illness.
That is very often common with the cancer drugs.
Group exceptions As such, we have to have in place, across
NHS England, a mechanism for identifying how we deal with those exceptions.
We have a particular difficulty in that when you are likely to have a group of exceptions
-- when it goes beyond a certain number -- you need to have a policy in place for how you
will deal with those patients.
Of course, we are now one commissioning body, when there were once 152.
Consequently, we are in a position where although we have a comprehensive system of exception
reporting of individual funding requests and the way we deal with those, there are now
quite a lot of instances where we need very specific policies for cohorts of patients
for whom the issue would be the same and who therefore do not meet the 'exceptional' category.
Committee decision In essence, what the Committee decided was
that it was absolutely essential that in the interim, patients were not denied treatment
if it was clinical necessary and urgent, whilst we put those policies in place.
It is a big task.
The Committee therefore approved an interim policy whereby the Area Team Directors would
have the authority to make decisions on that basis, until we could get to a place where
we were confident that we had all the cohort policies in place.
Notwithstanding that, we would still need to go on with the individual funding requests.
Supplementary remarks Malcolm Grant: I hope Members of the Board
are happy to approve that.
Our view was that we should simply get on and authorise it and argue about the money
afterwards.
If you are content with that, we will take that as approval.
Thank you.
That is all I have on directly commissioned services.
Let me, then, move on to Finance and Investment.
Committee Feedback: Finance and Investment Dame Moira Gibb
Non Executive Director Remarks and commendation
Paul may have something to add, but I do not have anything to add to the paper, which is
a useful summary.
I will just say, though, that the challenge of monitoring spend during the year when there
are so many wholly new organisations spending the money, as it were, is real.
That is the 'new'.
The 'old' is that we are picking up, as a Committee, lots of things that have been in
the system for a very long time and in a sense, there are sometimes very limited choices for
the Committee to resolve, when it has gone so far.
Otherwise, I commend the paper to the Board.
Malcolm Grant: Thank you, Moira.
Paul, is there anything you would like to add to that?
Paul Baumann: No, I think it is all in the paper.
Malcolm Grant: Okay.
May we, then, move on to the final report, which is Procurement Controls.
Committee Feedback: Procurement Controls Paul Baumann
Chief Financial Officer Summary
This is the new, improved version of the Procurement Controls Committee report, which has values
attached to it, following the request of the last meeting.
You can see the numbers on the following page.
I have to say, this is a Committee which has an enormous workload simply to keep the business
flowing, given the nature of the procurement controls which we work under; and I think
the statistics on the page behind, the 79 that we have done in the period since the
last report, gives some measure of the challenge that we face in that.
We continue to work with the Department of Health on the right level of procurement controls
and in particular, in pursuit of the earned autonomy which comes from having the sort
of system which we have put in place to manage procurement, which will prevent the risk,
if you like, of double controls and therefore delays and bureaucracy in the system.
We are not quite there yet, but we continue to work on that and I anticipate that progress
will be made on that in the next few weeks.
Beyond that, it is just for your information as to what we have been up to.
Malcolm Grant: Thank you very much.
May we take that report?
Okay.
Thank you.
May we please now move on to item nine, which is the performance report?
It is a very comprehensive document and I am assuming that it has been widely read by
Board members.
I am going to ask Tim to start off, but other Members of the Executive team have also had
responsibility for different parts, including Bill, Barbara and Paul.
Tim, would you please kick off?
Performance Report Tim Kelsey
National Director for Patients and Information Data challenges
Yes.
This is the second iteration of the Board report.
We have tried to take account of comments made in the previous meeting, to go back to
the actions that I did not talk to when we covered the minutes; for example, giving greater
ability to look at regional variation and institutional variation at local organisational
level in the data, where it is possible.
A number of things still remain beyond our grasp, however, I am afraid and that is a
system wide issue to do with data and its frequency, which we are working on.
In broad terms, we are still unable, on a month by month basis, in any meaningful way
to, for example, track clinical outcomes at a level we would want to, except in very rare
instances.
You will still see that the section of, as it were, historic data is large, larger than
the data we are able to manage in relation to monitoring the scorecard we have set ourselves
in the business plan.
That is the bad news, although it has been and incredibly helpful stimulus really to
putting pressure on getting better data out.
Data progress The good news is that, having said all that,
we have actually produced a whole bunch of new data which, I think, does really help
us start to frame the way in which we are considering our performance.
The first of those is, obviously, the friends and family test.
As I mentioned before, response rates across the service by June were up to over 15% which
is, I think, an exceptional achievement; although, of course, as I have also said, that is variable
by provider institution.
Broadly put, in in patient care, the friends and family test was scoring the NHS at around
70 across England; and on A&E performance, that was lower, at around 50.
These are useful baselines.
I think we should not worry too much about month on month, but I think as we start to
accumulate more volume and response rates go up, this will be a very important, useful
measure for us, longitudinally as well as to give us comparison with other industries
and other healthcare systems that use this as a measure, of which there are a lot.
We are also able to report on cancer waiting times.
We have included the results of the NHS England Staff Barometer for the first time and we
now have a full suite of financial data.
I can take any further questions we have on the friends and family test, but I feel we
have probably covered that quite fully in previous comments.
Perhaps I could hand over to Barbara, then, to cover urgent care; then, after Barbara,
to Bill to speak to some of the business plan highlights which are in the summary report;
then, perhaps, on to Jo, to cover off on organisational health; and finally, to Paul, to cover off
the financial data which is now in the report.
Urgent care Section C
Barbara Hakin: Thank you, Tim.
May I take everyone to section C, because we want to look at some of the key areas of
NHS performance that we have included?
As well as the list on here, I would like to talk for a few minutes about improving
the access to psychological therapies, which is another major initiative in NHS England
to which we are absolutely committed.
I would welcome any questions on the slides, which cover what we have tried to do here
following the last Board meeting.
Target delivery Firstly, you will see that we have put more
information in about the numbers of patients who are routinely seen in A&E departments
for elective care, because we felt that was important for understanding the magnitude
of the task which the NHS has.
We have tried, in a number of the areas, to give more indication of the spread, rather
than just one national figure.
For example, on A&E performance, you can see that we have shown that the vast majority
of organisations do meet the 95% standard and a very, very small number are a long way
adrift from it, with a middle sized number coming quite close.
Again, on the 18 week activity and the Ambulance Trust activity, we have tried to break this
down to show the range that we get.
Again, if I can move you on to the 18 week -- which is page seven -- you will see that
there is quite a significant variation by Trust as to how well they meet the standards
of seeing patients.
If you remember, the standard is about making sure the patient receives treatment within
18 weeks of being referred by their GP; and you can see that many Trusts do this very
well, but we have a tail of those that really are not delivering that standard of care for
patients.
111 One other thing I would highlight is the 111,
which is on page five.
I think you will see just what a dramatic improvement there has been in 111 performance,
particularly if you recognise that we have moved from 20% coverage of the country to
90% coverage of the country.
The graph on the left shows that actually, people are really meeting the quality indicators
for this service absolutely consistently and calls are being answered very quickly.
We have a really great satisfaction rate: 92% of patients satisfied with the service
they are getting from 111.
One of the most important ones is that apart from a small number of calls, even if they
have to be passed on to a clinician, the vast majority are being passed on to the clinician
immediately; patients are not waiting to be rung back, except in a small number of cases.
It is still not good and we will continue to try to improve this so that all patients
are dealt with immediately.
NHS Direct transitioning I would like to reassure the Board that -- as
everyone is aware -- NHS Direct indicated that it felt it could no longer provide this
service.
We are having very constructive discussions with alternative providers; dominantly our
Ambulance Trusts, but often working in partnership with out of hours providers.
The CCGs who commission this service I know are close to being in a position to sign new
contracts with the Ambulance Trusts and the other cohort of providers for them to be able
to take over the service.
Again, we are managing that very carefully and absolutely in line with the Garland Report,
so in every aspect of this transfer and the way it is dealt with, we will take the lessons
from the Garland Report and make sure that we have full checkpoints for any transfer
to a new service and contingency from other places to cover the transfer and we will put
phasing in place to make sure that that service stays stable.
IAPT May I just finish with IAPT, then see if anyone
has any questions?
This is a really important initiative and very important to us.
Question: [Inaudible] Barbara Hakin: Sorry, it is not in the papers,
I am afraid.
I just wanted to give a verbal update on where we were with improving these therapies.
It is really important for us in terms of ensuring that we have parity of esteem between
physical and mental health.
It is a service which CCGs commission.
There has recently been a change in the way we collect and report on the data, which does
look as if we have had a worsening of our performance or our trajectory to ensure that
the right number of patients are seen and treated over the next 18 months.
We are hoping that the next letter of information, which comes out in October, will show that
we are back on track to deliver the Government's targets on this.
We certainly have a huge range if initiatives in place in order to support CCGs to deliver
this service, including strong clinical leadership, champions at CCG level and a lot of central
initiatives from Martin McShane and his team in Bruce's directorate, to ensure that we
get back on track and we make sure that patients do have good access to these services.
Bruce, I do not know whether you want to add anything on IAPT?
Supplementary remarks on IAPT Bruce Keogh: I might just say a few words,
if you do not mind.
The case for improving access to psychological therapies is based on really good economic
and clinical grounds and we have, I think, some quite tough implementation targets.
By the end of 2015, we are meant to have access of 15% and a recovery rate for people who
receive the services of 50%.
We are on schedule for 12.4% access by the end of 2014 and we have quite a comprehensive
place to accelerate progress.
The point I think I would like to make is that with endeavours of this nature, the progress
is seldom linear.
It tends to accelerate as momentum is gained and that is not least of all because training
with therapists is taking time; and secondly, because one has to roll out, if you like,
the acknowledgement of the economic and clinical case at a time when many CCGs and others are
having to deal with some very difficult and conflicting clinical priorities.
Our anticipation is one of optimism in terms of meeting the targets and we have a comprehensive
plan for engaging with CCGs.
We are using the strategic clinical networks; we have a National Clinical Director, who
is focusing very heavily on this; we have engaged NHS Improving Quality; and the Department
of Health, who I have spoken to and they are engaging with Health Education England, to
help us on the difficult issue of recruiting people to deliver the services and training.
IAPT comment David Nicholson: I am sure you did not mean
to do it in that way, Barbara, but when you started this you said it was a Government
target.
I think that is a very interesting way of putting because in a sense, this is the issue
we have been dealing with over the last period, where quite a lot of people have seen this
as a 'Government target' in the sense of a politically driven target.
One of the big differences, I think, that we can make -- and I think Bruce pointed that
out really well -- relates to the fact that the way to get this change is to get the engagement
and clinical leadership and to get people locally to understand the nature and scale
of the challenge, but also the evidence behind it to make it happen.
That is what we have been focusing our attention on over the last few months: how can we create
that understanding in clinical/patient leadership at a local level to make it happen?
That takes time and effort.
It is not a question of setting out a trajectory and issuing instructions; that is not the
way you get the kind of clinical change that you need here to make it happen.
All credit to Bruce and to Martin and his team that they have tried to take, I think,
a very different approach, much more consistent with the way in which we operate as an organisation,
to make this really important thing go forward.
I share with Bruce: I think we should be confident that we can make this happen.
Malcolm Grant: Thank you.
Let us move of.
Barbara, is that all from you?