Agenda item

Documents attached detail Southwark NHS / Clinical commissioning’s global spend on contracts, thier planed savings (QIPP) and polices on managing conflicts of interest.

5.1  Chief Finance Officer for the Clinical Commissioning Business Support Unit, Malcolm Hines,  Richard Gibbs, Vice Chair of Southwark NHS and Andrew Bland, Managing Director of the Business Support Unit (BSU) introduced themselves.

5.2  The Chief Finance Officer gave an overview of expenditure. The highest spend by is in the secondary sector; £422, 954 000, and the biggest spend  is in the General and Acute services; £230 909 000. The primary sector spends £ 106 366 000.  The total spend is £529 320 000. He reported that Southwark NHS is receiving a similar amount this year, and while this is generous considering other areas, it still represents a big challenge.

5.3  He then went on to speak about the QIPP programme and explained that Southwark NHS has had this for some time as the health service has always had to make efficiency changes. This helps enable the services to invest in growth areas by making savings in areas that no longer justify continuing with the same rates of expenditure.  Southwark NHS is looking at efficiency savings of about 4%, which is around 20 million. He reported that future allocations will similar, and under the rate of inflation, and there will be a requirement for greater efficiencies.

5.4  The Chief Finance Officer explained that because around 50% of Southwark NHS spend is on the acute services most of the efficiency savings are made to this area; this is also an area of growth.  He explained that they are looking at areas of low take up and other areas that would be best delivered in the community. One focus is agreeing prices with providers which will make efficiencies. For example Southwark NHS negotiated a better tariff around sexual health services.

5.5  Significant efficiencies have also been delivered by limiting access to services of little clinical value; such as cosmetic procedures. There is an Urgent Care Centre redesign to reduce cost associated with unscheduled care that need not attend A & E. There has also been a Primary Care Productivity Programme which is related to general practice contracting.

5.6  The chair invited questions and a member asked if we are expecting to see an increase in primary care and a reduction in secondary care. Clinical Commissioning officer  explained that in the past we have talked about moving more into primary care, now it is more about blurring the lines. This means we may have secondary services delivered in peoples’ homes. However there has been a year on year increase in Acute spending and admissions. This has led to a bigger investment in urgent care to meet expanding need and to achieve efficiency savings. For example we are investing in a minor injuries unit that will have many benefits, not just financial. It is better that primary care doctors see certain patients and A & E doctors deal with real emergencies.  It is about the right practitioners seeing the right patients. QIPP is about innovation, not overall financial savings.

5.7  A member asked if Mental Health spending going to be preserved and the officer advised that Southwark NHS has quite high spend on both Mental and Sexual Health. There has been some modelling and sometimes there is 1% or less variation.

5.8  There was a question about any savings that can be made from proscribing drugs and it was explained that Southwark NHS is making savings by moving to generic drugs and being more efficient. The member asked a followe on question and enquired if a less effective drug would be used because it was cheaper. The members were assured that this did not happen.

5.9  A member asked if Southwark NHS invest in research and it was explained that Southwark NHS does not sponsor research, but there is a national programme that the Acute services bid for.

5.10  A member enquired more about efficiencies and it was explained that the process involves looking at productivity; whereby local performance is judged by national benchmarks, with a view to identify areas that need to improve.

5.11  A member asked about the renegotiation of contracts to improve performance and asked how Southwark NHS ensured that patient care did not fall when a lower price was agreed. The officer explained that Southwark NHS still ask for the same outcome and use Equality Impact Assessments, among a range of tolls,  to ensure that care standards are maintained. The member pointed out that it is possible that the renegotiated contract and the savings made would have an adverse impact, and asked if there are ever unintended consequences. The officer explained that this is mitigated by good contract management, and explained that Clinical Commissioning is very active in scrutinising contracts and undertakes reviews. 

5.12  A member asked about the demands the health service is facing and how these will be met. Officers explained that population growth is about 2%, and inflation is about 4 %. The services are also constantly evolving pathways and treatments and this adds costs. There are pressures from an aging population and new drugs. This means that we need to be making at least 6 % efficiency savings each year to meet increased demand and inflation.

5.13  The Chief Finance Officer was asked about the shadow budget process whereby financial management moves from Southwark NHS to clinical commissioning. It was agreed that a paper would be circulated regarding this.

5.14  A member asked about change to Maternity services and officers explained that Maternity services have not been redesigned to save costs; but rather to improve quality.

5.15  A member noted that cosmetic procedures would be limited and sought assurances that people involved in major trauma would still be able to access these services. Practitioners assured members this was the case and there was a policy available.

5.16  There was a question about drug and alcohol training for general practitioners and Clinical Commissioning officers agreed this was still an issues and it was acknowledged that there is a need to make training more attractive to G.P's and increase participation. 

5.17  The chair invited the Vice Chair of Southwark NHS and Clinical Commissioning lead on Conflicts of Interest to present on Conflicts of Interest, with the assistance of the Managing Director of the BSU. They referred to the documents circulated, and explained that tomorrow there is an intention to sign up to the Nolan principles of public life at the Board meeting. The Vice Chair said that the Clinical Commissioning board intends to make conflicts of interest publically available. Declarations of Interest will be taken at the start of the meeting.

5.18  The Vice Chair explained that the policy states that they have a Non Executive Director (NED) as a champion, and this is his role. He went to explain this was a role suggested by the G.Ps, and is also now being rolled out nationally as a result of the ‘listening’ exercise.  His role is to implement the guidance; this can be a judgment call.

5.19  A member asked the Vice Chair how a conflict of Interest is defined and he responded that one measure is by asking if participating in the decision about a provider could enrich the G.P. There is a system of alerts through the Declarations Of Interests procedure. The Vice Chair explained he sits on the Board and is aware of practitioners’ business interests.

5.20  The Vice Chair went on to refer to the definition given in the papers supplied, this says:” Put simply, a conflict of interest can occur when an individual’s ability to exercise judgment in one role is impaired by the existence of competing interests.  In particular, a conflict of interest may occur when a member could be influenced by financial or other commitments or relationships and as a result could fail to adequately represent the views of his/her constituents (where representing others) or make impartial decisions.  It can also arise when a member working for or having a link to a private company is involved in discussions at which information useful to the private company could be available”

5.21  The definition goes on the say: ”For a clinical commissioner, a conflict of interest would exist when their judgment as a commissioner could be, or reasonably be perceived to be, influenced and impaired by their own concerns and obligations as a healthcare provider, as an owner, director of shareholder in an organisation doing business with the NHS, or as a member of a particular peer, professional or special interest group, or by those of close family members. “

5.22  A member asked the Vice Chair to define the role of G.Ps on the Board and how the Board relates to the wider governance structure. The Vice Chair responded that the Clinical Commissioning board has 8 G.Ps operating under the auspices of the Southwark NHS board, and the Department of Health. Eventually this responsibility will move to the National NHS commissioning board.

5.23  A member commented that this is an unusual set up whereby providers (G.P’s) are also commissioning services. The Vice Chair responded that social workers and head teachers are professionals with a similar role. There is a potential for GP led commissioning to lead to better integration with secondary care and better pathways.

5.24  A member commented that Declarations of Interest are noted in the minutes, but details are not given.  While there are details on the piece of paper circulated it would be better practice if a Declaration of Interest was recorded in the minutes.

5.25  Members noted that the meeting of the Clinical Commissioning Board meet alternately in public and then in private; making it difficult to follow, particularly given that the same papers are used. The Vice Chair and BSU Managing Director undertook to get back to the committee on this.

ACTION

Members asked for more information on the shadow budget process, as the Clinical Commissioning consortium gradually takes control of the budget now spent by Southwark NHS.

Clinical Commissioning  under took to get back to the committee about their meeting arrangements in response to members comment that the present arrangements,  whereby one meeting is held on public and one in private, are confusing and can make following meetings difficult.