Agenda and minutes

1.1  Apologies for absence were received from Simon Galczynski, Ilona Sarulakis.

1.2  An apology for lateness was received from Dr Mark Rickets.

1.3  The Chair welcomed Dr Sue Milner the new City and Hackney Director of Public Health.

2.1  The order of business was as on the agenda.

2.2  The Chair stated that he would be asking, under Any Other Business, the CCG to comment on the closure of Sorsby GP Practice.

3.1  Cllr Maxwell stated that she was a member of the Council of Governors of Homerton University Hospital NHS Foundation Trust.

3.2  Cllr Snell stated he was chair of the Board of DABD UK, a disability charity.

4.1  The Minutes of the meeting held on 4 February were agreed as a correct record.

4.2  Members noted the Matters Arising as set out.  Cllr Snell commended the letter which the Chair sent to the Secretary of State regarding the local impact of overseas visitor charging regulations for NHS services on vulnerable migrants.

5.1  The Chair stated that the Commission would proceed with the next evidence gathering session for its review on ‘Digital first primary care and the implications for GP Practices’.  He welcomed to the meeting

Ian Barratt (IB), Training Partner at GP Access (provider of Ask My GP platform)

Irfhan Mururajani (IM), Egton Services Development Manager.

5.2  Members gave detailed consideration to a paper from GP Access and to a tabled presentation from Egton

5.3  Introducing his presentation IB stated that he welcomed with the added impetus the government had given its plans for digital primary care and there was a need for patient demand to be understood and patient need to be managed more quickly.  Ask My GP maintains the GP at the heart of the process and was a complete workflow solution. The sifting was done by GPs and nobody else.  The previous week their GPs had deal with 15000 requests with an average completion time of 83 mins.  Their approach leads to a reduction in stress levels for working GPs and a reduction in the use of locums by Practices as the system is run more efficiently.  He cautioned that online access on its own won’t effect change, instead there need to be full segmentation of the process and they can help with this.

5.4  IM introduced his presentation by stating that Egton was an online triage system and the company was part of the EMIS group which had a long history of working in NHS practices.  Theirs was a web based platform it operated from a cloud and there was no downloading of software and crucially no patient data was held by them.  The two entry points were online or via an EMIS web app and the patient were signposted appropriately.  The practices they worked with in Newham had reduced their number of Do Not Attends (DNAs) by 50% and only 25% of those who completed forms i.e. used the system, needed to see a GP in the end.  Waiting times went down from 4 weeks to 1 or 2 days.  In the past their GPs would see 18 patients in 3 hours face to face.  Now they could process 30 online queries with the result that satisfaction and morale goes up.

5.5  A Member asked how GP Access and  Egton were being evaluated.  The Chair explained that the GP Confederation were overseeing the new pilots involving key providers such as GP Access and Egton and he would ask them for further input on the result of their analysis.  He added that he and Cllr Maxwell had gone on a site visit to Lower Clapton Practice to see Ask My GP in operation and to discuss it with one of the GP partners who was one of the leading early adopter GPs championing a move to digital within the Confederation.

5.6  Members asked what barriers were found in GP training and about those on the wrong side of the digital divide e.g.the elderly, those for whom English  ...  view the full minutes text for item 5.

6.1  The Chair asked if the representatives from GP Access and Egton could remain for this item and they agreed.

6.2  Members gave consideration to a submission from Hackney Keep Our NHS Public (KONP) and the Chair welcomed Shirley Murgraff (SM) who took Members through their briefing.

6.3  SM stated that firstly KONP would like to included as stakeholders on all future reviews which have relevance to their remit.  They also took issue with the reference in the Terms of Reference methodology section which implied Members would only be hearing from Hackney Matters.  In her view that group would be predominantly younger and more digitally enabled residents and so would not would not be very representative on an issue such as digital primary care.  She added that KONP was a well informed group of resident s concerned about the privatisation and financialisation of the NHS. 

6.4  She stated that KONPs objections to GP at Hand were because there had been no independent scrutiny of its parent company Babylon.  They made no reference to patient monitoring or to having any Patient and Public Involvement Groups.  In their view Babylon was about destabilising General Practice with the result that there would be less money available for primary care.  Also, Hammersmith and Fulham CCG had run up a huge deficit as a consequence of GP at Hand being based in their area and the other London CCGS had been asked to bail them out.  She concluded that the contribution of GPs in the local community was immense and it was vital that the Commission and others supported them. 

6.5  The Chair asked whether KONP drew a distinction between Babylon and companies such as Egton and GP Access who are working within local GP Practices. 

6.6  SM replied that once the private sector got involved the public loses transparency and accountability and the primary duty of private companies was to maximise value to shareholders.  This was why these players need independent scrutiny.

6.7  A Member commented that Dr Jacky Applebee of Tower Hamlets LMC had tabled some flyers at the last meeting which Tower Hamlets KONP had produced warning the public about the dangers of being de registered and these were included in the agenda for this meeting under matters arising at p.21-22.  He suggested that the Commission should consider making a recommendation as part of this review that similar flyers and publicity material be produced in Hackney with the same message.  Members agreed.

6.8  A Member commented that over a relatively short period of time a number of large entities had come to dominate the market and this begged a lot of questions especially for central government.  Another countered that private providers had always been an important part of the NHS and the issue was if these digital systems can be provided in a way which provides equitable  access for all. 

6.9  Irfhan Mururajani (IM) stated that Egton was not looking to decimate patient lists because that was not their  function, instead they  ...  view the full minutes text for item 6.

7.1  The Chair stated that they would now return to the issue of the CQC inspection report on the Council’s Housing with Care services which had been rated ‘Inadequate’ and which had been discussed briefly at the last meeting and at which officers were asked to return with a detailed report. The Chair welcomed for this item:

Anne Canning (AC), Group Director, CACH

Gareth Wall (GW), Head of Commissioning – Adult Services

Jon Williams (JW), Director, Healthwatch Hackney

Amanda Elliot (AE), Commuinications and Intelligence Manger, Healthwatch Hackney

7.2  Members gave consideration to three papers:

(a) Action Plan from Adult Services in response to the CQC report

(b) The CQC Inspection report

and a tabled paper which from Healthwatch Hackney who had been commissioned to run feedback meetings with residents and relatives of those affected after the publication of the CQC report:

(c) Hackney Housing with Care – Feedback from residents’ and relatives’ meetings 6-14 Feb 2019

7.3  Introducing the action plan AC stated that it was important to keep in mind that this service dealt with some very vulnerable residents.  The Council had been able to give reassurance to the CQC on 8 March (deadline for submitting its action plan) that the direction of travel was now towards having a much more stable service. All the most urgent issues (as listed in 2.7 of the report) had been immediately addressed including the risk assessments on medicine management.  Healthwatch had joined managers in the meetings with the residents and their relatives and their report on that would be considered fully.  It was also the intention to work more closely with the housing providers here to improve the housing aspects of the issue.  The publication of the CQC report had had a major impact on the whole department and major resources were deployed to address the problems.  There was a need to do more in relation to service users with dementia and this was being addressed.  Work was also going on to improve governance and management.  Because the directorate was a major commissioner it already had in place a Provider Concern Protocol which was used when problems occurred with commissioned services and those same criteria were now also being employed in assessing and evaluating the shortcomings found in this in house service.  Regular updates were being given to the Lead Member. She concluded that input from service users and evidence of co-production would be a key part of implementing the action plan and she would report back to the Commission following the CQC’s re-inspection. 

7.4  AE introduced the Healthwatch report. She stated that they had found that communication had been patchy and where there had been continuity of care that had been good but there had been too much dependence on agency staff who had been generally less effective.  A general conclusion was that the eye had been taken off the ball as regards this service as so much focus within the directorate was on the commissioned services.  The CQC rightly had  ...  view the full minutes text for item 7.

8.1  The Chair stated that it was customary for Scrutiny Commissions to revisit their reviews one year after the Executive Response to check on implementation of their Recommendations and Members gave consideration to the Recommendations Tracker document for their review on ‘Supporting Adult Carers’.  He welcomed for this item:

Anne Canning (AC), Group Director, CACH

Gareth Wall (GW), Head of Commissioning – Adult Services, CACH

Tessa Cole (TC), Head of Strategic Programme and Governance, CACH

Amanda Elliot (AE), Communications and Intelligence Manager, Healthwatch Hackney

He added that the Recommendations Tracker contained responses from Adult Services, City and Hackney Carers Centre and from the local Alzheimer’s Society.

8.2  GW took Members through the report noting that the Carers Service had since been through a re-commissioning exercise and as part of that they had used co-production approach with a Carers Coproduction Group.  He explained that the new model broadly had 2 elements:

a) tendering for a ‘Prevention, Early Intervention and Outreach’ service AND

b) Insourcing the ‘Longer Term and Targeted Support’ element which would be provided jointly by the Council in conjunction with ELFT

He referred to the response from Carers Centre to Rec 11 and took issue with their scepticism about whether the new model would be effective, adding that by using social workers at this stage of the process they would speed up the assessments. 

8.3  The Chair thanked officers for the report and added that he was pleased that the Commission’s own review had played a role in shaping the design of the new service which was then re-commissioned.

8.4  Members asked whether additional resource was going into the system as social workers would now have more of a role in completing the assessments and whether they would have the time.

8.5  GW replied that the new system was about releasing resource in the system by re-designing the pathways of provision.  He described the ‘3 Conversations’ model that was being applied and explained how resources were being deployed to support staff to better understand assessments. There would also be an increased focus on outreach.

8.6  Members asked how the Carers Co-production Group had inputted to the re-design.

8.7  GW replied that this approach had proved very positive and how working out how to do this had led to real change in the service.  The stakeholders and service users helped the team improve pathways and it helped articulate a lot of issues which had not previously been properly aired.  Participants helped with the design of flow charts and the process revealed problems such as the amount of times carers are required to repeat their story. 

8.8  AE stated that the Local Account had revealed that there had been a drop in the number of carers in receipt of Direct Payments and this fall off in numbers was worrying.  There were issues here around a significant cohort who were effectively hovering round the edges of statutory provision and who are not receiving the support they badly needed. Too many  ...  view the full minutes text for item 8.

9.1  The Chair stated that each year the Commission received the Local Account of Adult Social Care Services and he welcomed for this item:

Tessa Cole, Head of Strategic Programmes and Governance, CACH

Anne Canning, Group Director CACH

9.2  Members gave consideration to a cover report summarising they key issues and to the full Hackney Local Account of Adult Care Services 2017/18.

9.3  TC took Members through the reports adding that this Local Account was non statutory but was still done by the Directorate as it provided a useful survey and overview of activity over a year.  They had taken on board all the suggestions from improvement to the style and format of the document which they had received last year, including from the Commission.  She added that they also welcomed the valuable input of Healthwatch.

9.4  Members commended the report as accessible and very well presented.  The Chair commented that it covered the year to the end of April 2018 but was being published in February 2019 and questioned whether this time lag made it less useful. 

9.5  TC replied that yes it did look backwards but a shorter lead in would have resource implications.  The delay was because, to be useful, it has to include Hackney’s statutory national returns and these then do not get validated for some time before they can be used.  During April to June a lot of time in the team is focused on other statutory reporting and this has to take precedence.  It would be challenging to produce it earlier in the year in any useful level of detail, she added. 

9.6  Members asked why it didn’t pick up on the issues with Housing with Care. 

9.7  AC replied that it would have been difficult for it pick up on larger systemic issues although it did pick up on some live issues. There is a question for next year in how it might be re focused.  There was a need to examine where the critical inputs were and for example one ongoing challenge of whether Healthwatch could also be able to access social care clients receiving services in their homes as they do with NHS patients or care home patients as part of Enter and View inspections.

9.8  The Chair thanked the officers for the reports and for their attendance.

10.1  The Chair stated that further to the cover note he now also had details of the agenda items for the next meeting which would be held on 3 April at the Old Town Hall in Stratford. These would be:

a)  North East London Estates Strategy

b)  NHS Long Term Plan and update from the Single Accountable Officer for the ELHCP (Jane Milligan)

c)  NHS Staffing

d)  INEL JHOSC terms of reference and protocols

For the Estates Strategy item there would be a response to the paper from the North East London Save Our NHS (NELSON) group which comprises the Keep Our NHS Public groups from the 8 boroughs.

11.1  Members noted the updated work programme.

12.1  The Chair stated that he had two items of AOB:

  Minor Ailments Scheme being continued to 1 Oct 2019

12.2  The Chair reminded Members that the Commission had lobbied on the end of the Minor Ailments Scheme in City and Hackney pharmacies and he was pleased to report that NHSE had sent a letter to the CCG confirming that they would continue to commission existing minor ailments schemes in London whilst they have further discussions with the Pharmacy Providers about the recommissioning of revised schemes.  The letter stated that

“The current Minor Ailment Schemes will continue to be commissioned and paid for beyond 31st March 2019, until the process for an alternative scheme has been exhausted with the CCGs, after which, either a revised scheme, that does not conflict with the OTC guidance, will be commissioned or formal notice will be served on the existing services”

Call from Healthwatch for public reps to join Integrated Commissioning Workstreams

12.3  The Chair stated that Healthwatch, on behalf of the Integrated Commissioning workstreams, was inviting potential public representatives to an information session on 13 March at Graeae Theatre, 138 Kinglsand Rd at 7.00pm and he encouraged Members to spread the word.  The representatives need to be “Hackney or City residents, interested in improving the health and wellbeing of their community and keen to develop new ways to help people to live longer and happier lives” he added.

Closure of Sorsby GP Practice and dispersal of list

12.4  The Chair invited the Chair of the CCG to provide an update on the just announced closure of the Sorsby GP Practice. 

12.5  Dr Mark Rickets (Chair, City and Hackney CCG) stated that Sorsby had an APMS type GP contract which was time limited and when the CCG decided to re procure  there had been no takers for the contract.  Because of this Lower Clapton Medical Practice had taken on the management of it on an interim basis and had operated it as a satellite but that arrangement had now also come to an end.  The Practice was in a poor state of repair and for some time had been kept going with locums.  It lost staff and nursing staff and patients had also decided to move to Lower Clapton, where most of the staff were coming from.  The process of securing a new provider was being overseen by the local NHS Commissioning Support Unit. The list size at Sorsby had been dropping and it would only operate at a loss and despite the work to turn it around, it was proving impossible to secure a GP contract holder.  Because of this a decision was taken by the CCG’s Primary Care Contracts Committee (GPs Practices are now commissioned locally) to have the list dispersed among the local practices.  Sorsby had 4000 patients but this had dropped to 3000 and the benchmark in the NHS was that any practice below 6000 was a candidate for dispersal if a procurement exercise failed.  At  ...  view the full minutes text for item 12.