[To consider the Wolverhampton CCG Annual Report 2018-19].

The Chair read out an initial statement which praised the CCG for receiving an outstanding rating in July 2018 and also this year.  It had also been a great achievement for the CCG to receive the Clinical Commissioning Award for 2018.  He was very pleased to see the increased uptake in health checks.  He was also pleased to see the CCG using innovative technology in primary care to improve services which included being one of the first areas to implement online triage and GP online video consultation.  He also welcomed the extended GP opening hours. 

 

The Chair had submitted a number of questions on behalf of the Health Scrutiny Panel in advance of the meeting.  The questions and written answers provided were as follows: -

 

Mental Health

 

1)    The report makes reference to you working to minimise your Out of Area Placements in Mental Health.  What steps are being taken to ensure we have enough beds in Wolverhampton to avoid out of area adult placements and how many more do you think would be sufficient for now and in the future?  Crucially it also refers to this not being able to be zero, as you have no female Psychiatric Intensive Care Unit in the Black Country (p.18). 

 

CCG Written Response :-

In this contracting round we are working with BCPFT and DWMHPT to increase the beds we purchase locally – if possible by as many as 8 – from April 1st 2020 (this will involve reducing the access of BSOL CCG to BC&WB STP wide bed stock) we are working with BCPFT to develop an STP wide female PIC Ward – we expect to have this by April 2021.

 

Across both our business intelligence teams (i.e. provider and commissioner) we are working with data to understand the increase in activity and what community models are required to prevent admission and relapse and ensure access to evidence based community care in line with NICE and the constitutional and transformational standards of the NHS Plan.

 

We have raised concerns with PH alcohol and substance misuse commissioners regarding the impact of high levels drug use in Wolverhampton upon mental ill health and have requested a public health comms campaign.

 

We have agreed a service model for primary and secondary mental health and a service specification is in draft.  Additional investment is available however recruitment to required workforce is likely to be an on-going risk for at least 2-3 years while we work with HHE to grow the required workforce and trainees.  

We i.e. the CCG have set a sum aside to invest in promoting emotional health and well-being to mitigate against the impact of Public Health and Social Care cuts in these services and to mitigate against the impact of very high levels unemployment deprivation and substance misuse in Wolverhampton.  We have also identified sums of money for Sec 117 MHA care packages – again to mitigate against social care financial pressures.

 

 

2)    Can you inform us about how the new online counselling service (p.5) for 11-18 years olds is working? It seems like this has great potential to really help.  Is there any capacity or is it fully subscribed?  How do young people get referred to this Service and are GPs using it consistently? What are the overall costs for the service and how long is the contract with the provider “Kooth” set to last? 

CCG Written Response:-

 

In 2018/19 there were 1,237 CYP registered to access the online digital platform – this included counselling sessions, moderated chatrooms and access to articles & self-help resources and a messaging service.  It is an anonymous service where the CYP have to report what area of the city they live in, their age, gender and ethnicity.  Issues and concerns are broken down by gender and ethnicity.  It is already working in excess of the hours commissioned which is for 110 hours per month.  Currently we are possibly using up twice as many hours.  Young people are mainly being signposted through from schools or school teachers – over 600 referrals that way but only 81 through GP.  The current costs are £63,500 for the year and the contract is for 3 years initially, which is the same amount of time as the emotional mental health and wellbeing service.  However, there have been requests from Kooth to increase the contract due to the hours being used.  Only 135 contacts went through the MHSDS for last year – 2 contacts or more and this year 122 contacts have already gone through up until end of September 2019. 

 

 

3)    The Improving Access to Psychological Therapies end of year figure was not available at the publication of the report.  Can you please inform us of the final figure?  Can you give the Panel your views on how well the service is working and where it could be improved?

 

CCG Written Response:-

The final figure was 18.53 %.

 

We are on track to achieve 22% by March 2020 having invested an additional 700,000K including digital IAPT

 

The service is meeting all KPIs and is working closely with GPs and colleagues in Primary Care to embed the service within with PCNs with very good progress

 

 

4)    There were six instances of mental health patients waiting more than 12 hours in A&E in 2018/19 (p.23).  What lessons were learnt? How are you ensuring with health partners that the mistakes are not repeated?

 

CCG Written Response:-

The delays related to the unavailability of AMHPs and delays accessing a MH bed.  We have supported CWC for 3 years now with additional funding for AMHPs and are awaiting an update regarding the AMHPs gaps at weekends especially.

 

5)    The report refers to people with mental health problems such as schizophrenia or bipolar dying on average 16-25 years sooner than the general population (p.29).  What are you doing to help improve this figure and how much of a factor are the prescription drugs administered, in the early death?  How are we ensuring that people are not on drugs longer than they need to be and at the appropriate dosage? What are the other known factors in the earlier death?

 

CCG Written Response:-

We have commissioned and enhanced service from primary care colleagues to increase health checks for people with SMI in primary care and are monitoring access to health checks in secondary mental health care – building on a CQUIN scheme from last year.  We have invested in BCPFT so that they are able to implement Graph Net allowing primary and secondary care to share EPRS (this is now on line).

 

We will train BCPFT IAPT staff in IAPT LTC and implement these models as soon as training complete working with RWT.  

 

Cancer

 

6)    With reference to the national target of 93% for the percentage of Service Users referred urgently with breast cancer symptoms (where cancer was not initially suspected) waiting no more than two weeks for first outpatient appointment), the performance is only listed at 6.7% (p.21).  Can you provide us with the latest position and what steps you are, and have taken with health partners to rectify this performance gap and ensure continuous improvement?

 

 

CCG Written Response:-

 

At the time of the performance being measured at 6.7%, patients were booking at approximately day 50 and we had a backlog in Wolverhampton of over 500 patients.  We have been working collaboratively with Walsall and Dudley providers and have implemented a dynamic process which informs the patient upon referral of the current waiting times across the area, so that the patient is more informed about how they can be seen more quickly.   We are now being measured on performance as a system, rather than as individual providers.  This has resulted in a more even share across the three providers and Wolverhampton patients are now being seen at day 15 with the backlog down to a manageable position.  We will see performance figures improve as we receive validated cancer data.

 

7)    With reference to the national target of 94% for the percentage of Service Users waiting no more than 31 days for subsequent treatment, where the treatment is surgery, the performance is only listed at 66.7% (p.21). Can you provide us with the latest position and what steps you have taken and are taking with health partners to rectify this performance gap?

 

CCG Written Response :-

An improving position, currently 75.76% (August).  Delays for performance figures are due to validation of patient outcomes.  Breast pathway improvements will have a positive effect with capacity released.  Recent actions taken to help with overall performance are:

 

·       Capacity in August was affected by the summer period (higher DNA’s, clinical A/l)

·       The backlog of patients waiting over 62 day is remaining relatively steady with the largest cohorts of patients being on the Urology and Colorectal pathways followed by Breast.

·       The Trust has successfully recruited 8 additional radiographers, 6 of which have commenced in post with the remaining 2 due to start before the end of the year.

·       The Trust is running monthly “super clinics” in Breast and Gynaecology.

·       The first biopsy list took place in August, the effect of which should be a reduction in the prostate cancer pathway by a minimum of 7 days by moving Template Biopsy to an outpatient procedure.

·       Current waiting time for an outpatient Hysteroscopy is down to 13 days in August from 19 in June.

 

 

 

 

GPs

 

8)    Can we have some more details on the outcomes of the GP Home Visiting Service Pilot (P.5), which aims to free up more GP time in surgeries for more preventative work with patients?

 

CCG Written response:-

The GP Home Visiting service was piloted across 6 practices from November 2018 – October 2019.  The GP Home Visiting Service was developed to improve access to Primary Care and prevent/ reduce the need for patients to attend  Urgent  and  Emergency  care  services such  as A&E, Urgent Treatment  Centre’s  and GP Out of Hours.

 

Improving access to General Practice and other primary care services is a priority for reforming the NHS. The national driver of seeking accessible Primary Care services 8am to 8pm, seven days a week is one of the underlying policy drivers behind the GP Home Visiting scheme.

 

The implementation of the GP Home Visiting Service pilot was intended to provide an extension of available primary care appointments and give patients improved local access and support.  Home visits are a significant call on GP’s time, and there is a view that in many cases patients can be seen and treated by an alternative suitably qualified health professional. 

 

The GP Home Visiting Service Pilot provided 6 varied case studies that demonstrated that the provider has delivered a high quality; safe service; supported by competent clinical decision making and good clinical intervention.  The service is responsive, patient focused; delivering positive outcomes for patients and their families.

 

The service was able to provide patients with a timely response; patients were able to receive a visit on the same day (where clinically appropriate/required). Patients with complex needs benefitted from a smooth, seamless access/ escalation  to  the  Rapid  Intervention Team whom were able to meet  their needs and prevent  further  deterioration and admission.

 

The overall feedback from GP’s was that the service met the needs of patients, released GP time; allowing them to focus on patients who have complex needs and take part in additional strategic planning/clinical initiatives.  Utilisation by practices was varied during the pilot and during this time the additional workforce being introduced in PCNs has prompted a review of the delivery model.  Whilst the pilot has now ended some of the positive benefits mentioned above will be used to influence a revised delivery model for the future, using PCN workforce

 

9)    On the matter of learning disabilities, you refer to quality audits (p.19) of the resulting Health Action Plans and providing feedback to GPs.  What were the main themes of the feedback given?

 

CCG Response:-

Two practices were audited. The main learnings were:

 

·       GPs and PNs valued the holistic assessment offered

·       It was recognised that Practices were working flexibly addressing needs, making reasonable adjustments and involving families

·       It was recognised that there is a need to support more practices in offering health checks

·       Continue to support practices with Health action plans to ensure they are reasonably adjustable and accessible

·       Raise awareness amongst GPs that they can receive support from the LD team

 

10)NICE TAG Audits (p.27) – What is the outcome of the audits within Primary Care? There are particular national concerns around opioids, antidepressants and benzodiazepines.

 

CCG Response:-

Audits

Valproate & women of child bearing age (12 - 55 years) – audit to show prevalence and highlight patients that have not had a review with their specialist.  Lists of patients sent to RWT & BCPFT – to undertake reviews asap(Ensure women of childbearing potential have been made aware of the risks to the foetus associated with taking valproate).

 

The PCMT identified 230 females of child bearing potential who were prescribed valproate; the records of 161 patients indicated that they had received information about effective contraception

Nitrofurantoin audit.

 

The Specialist Pharmacy Service (SPS) has issued updated guidance regarding drug monitoring in adults in primary care, stating that liver and kidney function should be checked regularly in long-term prescribing.  The guidance recommended to advise patients to report any signs/symptoms suggestive of pulmonary toxicity (e.g. cough; chest pain; dyspnoea), hepatotoxicity, peripheral neuropathy (sensory as well as motor involvement) or haemolysis.

 

An audit was developed to establish if Wolverhampton GPs were currently managing patients prescribed long-term nitrofurantoin in accordance with the SPS guidance.  The audit was conducted across Wolverhampton GP practices to review nitrofurantoin prescribing; 168 patients were identified who had been prescribed nitrofurantoin for 6 months or more.  39% (65) patients had liver or kidney function results recorded in previous 6 months and 9 patients’ records contained a note that respiratory symptoms had been checked or discussed in the last 6 months.  Each practice was given a copy of their practice audit for review at a practice meeting; it is anticipated that all practices will repeat this audit within the next 6-12 months.

 

Morphine Dosage safety work

Following incidents related to the prescribing of morphine liquid elsewhere in the UK; the question was raised “how safe is Wolverhampton GP prescribing of morphine liquid?” The PCMT reviewed every morphine liquid prescription issued in the previous 3 months.  For the purpose of this audit prescriptions were assigned to one of 3 categories; potentially unsafe, safer and safest. Potentially unsafe prescriptions represented 8% of all prescriptions; prescriptions were generally placed in this category because the instructions were unclear or open to interpretation.  All potentially unsafe prescriptions were identified immediately to prescribers for information and action, to ensure patient safety.

 

 

Bisphosphonate review audit

Bisphosphonates have been widely used in the treatment of osteoporosis for many years.  There is robust data demonstrating efficacy in fracture risk reduction over three to 5 years of treatment.  As these agents accumulate in bone with some persistent anti-fracture efficacy after therapy is stopped.  The British National Formulary and Summary of Product Characteristics for oral bisphosphonates contain advice that duration of treatment should be reviewed periodically and the benefit and potential risk should be re-evaluated for each patient particularly after 5 years of use.  An audit was designed to check if patients under 75 years who have been prescribed oral bisphosphonates (alendronate, ibandronate, risedronate) for 5 years or more have been reviewed. A copy of the audit report template is attached to this report.

 

Number of patients on bisphosphonates <75years for over 5 years included in the audit	373
Number of patients <75y prescribed oral bisphosphonate for over 5 years with documented review	81
Number of patients <75y prescribed oral bisphosphonate for over 5 years who have been reviewed with a date set for next review of bisphosphonate treatment	5

 

Each practice has been given a copy of their practice audit for review at a practice meeting; all patients were booked in for a review and the audit will be repeated in 12 months. The PCMT has advised the use of the bisphosphonate review read code (8BT4 or XacFU) and the use of diary dates to facilitate re-audit. 

 

 

Audit title and purpose	Action identified to practices
NICE- Gestational diabetes and no HbA1c or fasting blood glucose NICE guideline [NG3] - offer an annual HbA1c test to women who were diagnosed with gestational diabetes who have a negative postnatal test for diabetes	819 patients required HbA1c blood test
SGLT2 with eGFR <60ml/min/1.73m2 SGLT2s (canagliflozin, dapagliflozin and empagliflozin) require regular renal function blood tests and appropriate dosage to ensure safe prescribing.	1419 patients prescribed SGLT2; 121 patients (8.5%) required a renal  function blood test and 42 patients (3%) required a dosage review
MHRA - metformin and GFR <30ml/min/1.73m2 Manufacturer advises avoid if eGFR is less than 30?mL/minute/1.73m2	31 patients identified for review
MHRA - mirabegron & uncontrolled hypertension Mirabegron contraindicated in uncontrolled hypertension (systolic blood pressure ?180?mmHg or diastolic blood pressure ?110?mmHg).	60 patients required blood pressure check; 1 patient required a review

Hydrochlorothiazide: risk of non-melanoma skin cancer, particularly in long-term use

 

An MHRA Drug Safety Update (DSU) on 14 November, advised that patients taking hydrochlorothiazide-containing products should be informed about the cumulative, dose-dependent risk of non-melanoma skin cancer, particularly in long-term use, and the need to regularly check for (and report) any suspicious skin lesions or moles.  It was further advised that patients should be counselled to limit exposure to sunlight and UV rays and to use adequate sun protection.  The PST ran searches to identify all patients taking the product and issued letters 414 patients advising them of the risks, 24 of which were advised to see a GP due to a history of skin cancer.

 

Esmya® (ulipristal acetate) and risk of serious liver injury: new restrictions to use and requirements for liver function monitoring before, during, and after treatment

 

On 7 August 2018, an MHRA alert was issued to UK healthcare professionals to inform them of the new measures to minimise the risk of serious liver damage.  In light of the safety advice the decision was taken to repatriate prescribing for patients on Esmya® back to RWT gynaecology.  During the current work plan a search was completed in all practices, resulting in the identification of 2 patients for whom prescribing was repatriated.

Prophylactic Antibiotics for UTI

There is good evidence to show that prophylactic use of antibiotics for up to six months is effective for preventing UTIs in patients with recurrent infections.  However there is a lack of evidence that this is an effective treatment strategy beyond six months. The PCMT ran searches in practices to identify patients for whom prescribing was for longer than six months and took appropriate action.

 

No. patients prescribed antibiotic for >6 months for UTI	179
No. patients with documented review in last 6 months	11
No. patients referred to GP for review	168
No. patients for whom antibiotic stopped (latest information)	61

 

C.Diff Medication Reviews

Clostridium difficile work has continued to involve medication reviews for CDI patients, completed by the practice based pharmacist or the patient’s GP.  A total of 50 patients have had a full medication review post CDI with the majority of the changes being made around laxative and PPI use.

Controlled Drugs

The PST worked to identify to practices patients prescribed a quantity of controlled drugs exceeding a 30 days’ supply in order that the quantity could be reduced or the patient record annotated if greater than a 30 day supply was clinically required for patient care.  The number of patients where the quantity was reduced as result of the intervention during the last quarter was 1003.

 

Work planned for Q4:-

 

·       Focus on Pain medicines especially Opioids

·       NOAC – improve monitoring and dosing based on renal function

·       Hypnotics work conducted in 17/18 – to bring back in 20/21

 

 

11)Please can you give us the latest position on Medicines of Limited Clinical Value (p.38)?

 

CCG Response:-

18/19 – implementation started in October

Prescribing of Medicines of Limited Clinical Value reduced by 44K

 

19/20 – Medicines of Limited Clinical Value reduced by 33k in first 5 months – against an annual target of 60K

 

18/19 – OTC meds – implementation from November

Prescribing reduced on OTC products by 22K

 

19/20 – OTC – fall of 22K based on first 5 months – against a target of 100K for the year

 

12) How are you ensuring that the GP surgeries are located in the correct areas and with the right staffing across Wolverhampton.  How are you planning for the future demographic changes of the City?

 

CCG Response:-

 

Practice locations and ensuring population health needs are met is largely covered by the CCG in partnership with our PCNs who focus on sections of the community and changes / challenges presented in those neighbourhoods whether this be additional housing, health needs/changes in demographic etc.  In addition, we are sighted on any housing developments through the Black Country and Health Liaison Strategic planning meeting which meets every quarter.  This is considered and any new practice development then form part of the Primary Care strategic planning discussions

 

Risks on Maternity Services

 

 

13)The report refers to managing risks (p.10) associated with a number of service areas including maternity services.  Do you look at other CCG areas such as Shropshire, which has had significant issues in this area and how do you learn from their mistakes?

CCG Response:-

 

Through working at the Black Country and West Bham LMS level, we take a whole system approach to managing risks, regularly reviewing demand and capacity across all Trusts in the footprint, as well as working closely with the Local Maternity Systems on our borders to understand any potential impact on the Black Country of any current issues and their future plans.  We conduct regular quality, safety and performance monitoring and implement such measures as timely patient diverts to neighbouring trusts when needed, by working collaboratively with all stakeholders to ensure consensus and consistency of approach.

 

We have seen this at work recently in maternity services where a cap on births, implemented in 2007 in RWT was lifted, following assurance that sufficient medical workforce/capacity now exists, in line with national standards regarding midwife to birth levels.  Similarly, a cap on births in Walsall was also recently lifted.

 

 

 

Health Inequalities

 

14)The report refers to reducing health inequalities in Wolverhampton (p.10).  Can you give some examples where this has taken place?  Some case studies in future would be ideal, to give a human element, making it relatable. 

CCG Response:-

 

To be discussed.

 

 

There were a number of supplementary questions asked in response to the written responses which had been tabled at the meeting.  A Member of the Panel asked for some more information on the GP Home Pilot.  The Director for Strategy and Transformation responded that the pilot had been initially for six months and had been extended by a further six months to allow a full evaluation to take place.  Some practices had made extensive use of the resource available, whilst one practice had only used it on two occasions during the twelve months of the Pilot.  The Pilot had been underutilised by approximately 40% of the resource available, which meant the intervention for a home visit was costing an average of £163.00 per intervention. 

 

The Director for Strategy and Transformation stated that the average cost of an intervention was not deemed an appropriate use of public funding.  The decision was consequently made to cease the pilot but not to cease the principle.  They were in discussions with West Midlands Ambulance Service about the opportunity of having paramedics operating a home visiting service, which would hopefully be less expensive in terms of delivery costs.  The intention was therefore not to stop a home visiting service, but to find a more financially sustainable delivery model. 

 

A Member of the Panel asked about GP requirements for home visits when specifically requested by a patient.  The Director for Strategy and Transformation responded that GPs in their contract had to undertake home visits during in-hours, provided that the individual was bed bound and of a certain age.  The out of hours home visiting service was contracted through Vocare, who were the urgent treatment care provider.  The Member of the Panel asked if there were any statistics for GPs providing in-hours home visits.  The Director for Strategy and Transformation responded that he didn’t believe there were any statistics on this question.  He suspected the amount of home visits undertaken would be variable across practices.  The Member of the Panel asked if consideration could be given in the future to collecting data on GP home visits.  The Director for Strategy and Transformation responded that it was something which could be looked into. 

 

The Panel asked supplementary questions on the finances relating to community services and on Improving Access to Psychological Therapy (IAPT).  The Director for Strategy and Transformation confirmed that IAPT was a CBT (Cognitive Behavioural Therapy) model.  IAPT was the lowest level of mental health intervention.  He detailed the cluster model and how the IAPT referral system worked and the waiting times for the service.  They did recognise that the community mental health service was not performing as well as it should, which was causing them serious concern. 

 

There was a discussion about health inequalities.  The Director for Strategy and Transformation of the CCG commented that health inequalities was a very complex issue.  The historical headline indicator for health inequality had been longevity.  There were other indicators which he thought needed to be considered, such as years of healthy life.  Another indicator could be access to services, but this indicator had problems.  Attendance at urgent care appointments, referral rates for conditions and conversion into an outpatient first appointment and subsequent procedure lacked consistency across Wolverhampton.  He made reference to the fact that in some areas in Wolverhampton the GP ratio to number of patients varied considerably.  Other indicators for the determinants of health could be the natural and built environment, income, poverty, crime, and education.  It was the CCG’s role to ensure they worked with Public Health to ensure all people had the right access to health services. 

 

With reference to the response that had been given on the waiting time for a breast cancer appointment, a Panel Member asked what was meant by the term “a more manageable position.”  In response the Director for Strategy and Transformation commented that by using the scanning services of Dudley and Walsall the waiting time had reduced in Wolverhampton to less than 14 days, that had of course had an adverse effect on the waiting times in Dudley and Walsall. 

 

The Medical Director of the Royal Wolverhampton NHS Trust commented that the Trust’s Cancer Services had been under intense pressure to deliver the 14 day initial breast assessment.  There had been a significant rise in the number of women presenting with symptomatic breast lumps.  The conversion of those referrals into a cancer diagnosis had remained the same and so there had been a true increase in the number of breast cancer patients presenting to the service, which reflected the national position.  There had been some problems with radiographers and radiologists undertaking some of the images and biopsies.  The situation had reached an unacceptable position, but what had helped was other Trusts in the Black Country and in particular Walsall and Dudley, being able to accommodate women from Wolverhampton. The waiting time figures in Wolverhampton were now much better.  The whole pathway problem was not solved, as it was much more complex than the 14 and 28 day target position, but significant work was ongoing to address the problems.  CT scanning and MRI scanning was in great demand.

 

A Member of the Panel asked for some information on how long people were kept waiting for cancer scan results. This was in reference to different types of cancer and not just breast cancer.  Their personal experience was that people were waiting a long time for the results of scans.  The Medical Director of the Royal Wolverhampton NHS Trust agreed to provide a written response and commented that the times would vary depending on the organisation undertaking the scan on behalf of the Trust (there were now 3) the type of scan and cancer.

 

The Consultant in Public Health on the subject of cancer care commented that early diagnosis and prevention was important to reduce the burden on cancer services.  He remarked that it was clear there was inequality in relation to cancer screening.  South Asian women were much less likely to undertake cervical screening compared to white women, there was a 1 to 10 disparity.  There were other issues relating to age and deprivation in terms of access to bowel screening.  Equalities information was important to consider alongside targets.  The Panel agreed that health inequalities could be an item for them to consider in the future.

 

 

Resolved: That health inequalities be added as a future item for the Panel to consider in the future.