ARGYLL & BUTE CHP COMMITTEE / Argyll & Bute Community Health Partnership
Aros
Lochgilphead
ARGYLL
PA31 8LB
/
Council Chambers, Kilmory,Lochgilphead / 9 January 2009 – 13.00
Present
Attendees / Bill Brackenridge, Chairman, Argyll & Bute CHP
Derek Leslie, Argyll & Bute CHP General Manager
Pat Tyrrell, Lead Nurse, Argyll & Bute CHP
Evelyn Hide, Vice Chairman, Public Partnership Forum
Anne Clark, Non Executive Director, NHS Highland,
Elaine Robertson, Non Executive Director, NHS Highland
George Freeman, Argyll & Bute Council Rep
Robin Creelman, Public Partnership Forum Chairman
Mary MacLeod, AHP Rep Argyll & Bute CHP
Donald McIntosh, Argyll & Bute Council Rep
Elaine Garman, Public Health Rep.
Neil Robinson, Area Pharmaceutical Committee Rep.
Tricia Morrison, CVO Rep.
Douglas Hendry, Argyll & Bute Council
Dr Michael Hall, Clinical Director, Argyll & Bute CHP
John Herrick, Area Dental Committee
George Morrison, Head of Finance, Argyll & Bute CHP
David Logue, Head of HR, Argyll & Bute CHP
Viv Shelley, Non Executive Member
Jim Robb, Argyll & Bute Council
Stephen Whiston, Head of Planning, Contracting & Performance Argyll & Bute CHP
Brian McLachlan, Locality Clinical Director, Helensburgh & Lomond
Margaret Johnston, Admin Assistant – Minute Secretary
1.CHAIRMAN’S WELCOME
The Chairman opened the meeting by welcoming everyone to the Council Chambers Lochgilphead.
- APOLOGIES
Apologies for absence were received from:
Kate MacAulay, Staffside Rep.
Donald Barr, Area Optical Committee Rep.
David Ritchie, Communications Manager, Argyll & Bute CHP
- MINUTE OF MEETING HELD ON 14 November 2008
The minute of the meeting on 14 November 2008 was accepted as a complete and accurate record of the meeting with the following amendments
Item 9.1 - Third last paragraph add“both Roger Gibbins, Chief Executive and“before Jan Baird. Last paragraph change Voluntary to “follow through”.
Mr Brackenridge thanked Anne Clark for taking over the chair at the previous meeting.
The Committee noted the contents of the Minute.
- MATTERS ARISING
George Freeman asked if there had been any progress on distribution of In-Year allocation funds since the last Committee meeting. George Morrison advised that the distribution was progressing. George Freeman expressed his concerns regarding the delay and asked if they could not be utilised, if they can be carried forward at the end of the financial year. Mr Morrison confirmed that there is no capacity to carry the funds forward and such allocations must be used by the end of March.
Mr Freeman then referred to his request at the November Committee for more information on prescribing costs. Mr Morrison advised that this information will be covered in the Finance Report.
- DIRECTOR OF PUBLIC HEALTH ANNUAL REPORT
Following a presentation at the earlier Development Session by Elaine Garman the Chairman asked the Committee to formally note the Director of Public Health Annual Report.
Elaine Garman advised that information pertaining specifically to Argyll & Bute input is contained in pages 33 – 36 of the Report.
Anne Clark welcomed the report and the way it had been presented. Mr Brackenridge also suggested that the report should be exposed to a wider audience perhaps in a different format to emphasise the importance of a healthy life style.
The Committee formally noted the Director of Public Health Annual Report
6.FINANCIAL GOVERNANCE
6.1Financial Overview of the NHS in Scotland 2007/08
George Morrison referred to the Audit Scotland Annual Report of 2007/08 which contained some interesting details and reported that there is an expectationof relatively low levels of revenue funding increases in the forthcoming years.
Mr Morrison highlighted three areas of interest in the report
- Exhibit 3 – This table identifies the recurring surpluses and deficits for all NHS Boards and shows the total underlying recurring deficit for all Boards is £16.5m with NHS Highland’s share estimated at £8m.
- Case Study 3 – Greater Glasgow & Clyde’s financial saving plans for 2008/09 – 2010/11 reporting an aim to achieve savings of £46m in 2008/09. This could result in an unavoidable impact on neighbouring Boards regarding cost of services. Mr Morrison emphasised that one third of the CHP’s general fund allocations go to Greater Clyde & Clyde for services.
- Exhibit 16 – Hypothetical example of the impact of the NRAC formula on Boards funding levels for 2007/08. Mr Morrison explained that if the formula was applied NHS Highland funding would reduce by £19.3m. Although this is a hypothetical table the NRAC formula will be applied from next year which means that Boards who are NRAC losers, which included NHS Highland, will be pegged at the lowest level of funding uplift for several years to come whilst Boards who gain will receive slightly higher uplifts.
Mr Brackenridge invited questions on the Financial Overview Report.
Viv Shelley advised that she had real concerns regarding how the balance of care can be shifted if the funding to do this is not available and asked if the new funding allocation across the Board will be helpful. Mr Morrison advised that this will be difficult as one of the features of the NRAC funding is that it will adversely impact on remote and rural Boards who will have less funding available. Ms Shelley then asked Mr Morrison if cost cube funding is relevant to the CHP. Mr Morrison confirmed that cost cube funding is more relevant to other CHP’s as Argyll & Bute CHP already received its fair share of general fund allocations.
Derek Leslie referred to paragraph 27 in the report which advised that the hospital sector includes community hospitals which are the hub of our community health services. These are largely managed and driven by the Primary Care Sector but there is no credit given that it is a Primary Care led Community Hospital Service for the most part in Argyll and Bute. The CHP’s consultation document on Mental Health Services talks about a very clear shift from hospital service into community and primary care based services and shows an increased investment with an increase in staffing numbers and a decrease in what is going to be hospital based. The Director Public Health’sreport comments about the preponderance of investing new money in acute hospitals to improve access and new technology resulting in their being less chance in showing a shift to Primary and Community Care.
Elaine Robertson asked Mr Morrison if the stage will be reached where funding increases will stop. Mr Morrison advised that this scenario is highly unlikely and advised that the significant shifts in resource distribution in the NRAC formula is shown in the overview report. NRAC formula replaces the Arbuthnot formula which has been in place for approximately 8 years.He confirmed that same principles will apply in that there will be no funding cuts. Next year NHS Highland’s funding uplift will be 3.15% and as far as Mr Morrison is aware all Boards which will be NRAC losers will get 3.15% and the Boards who gain will get marginally more at 3.5%. Mr Morrison explained that substantial changes cannot be made in the short term and it will be a slow progressive change which will be implemented.
Mr Brackenridge thanked Mr Morrison for the report.
The Committee noted the information contained in the Finance Overview
6.2Finance Report
George Morrison spoke to a previously circulated paper asking the Committee to note the Finance Report.
1.Financial Performance – Revenue Position as at 30th November 2008:
Mr Morrison advised that for the 8 months Argyll & Bute CHP recorded a net overspend of £121,000. This represents a slight increase of £30,000 on the overspend of £91,000 recorded at the end of October 2008.
The main factors contributing to this overspend were largely reported at the previous Committee however Mr Morrison reported other significant costs pressures contributing to being successful Agenda for Change reviews and GP locum costs covering the vacancy in Muasdale practice.
2.Patient Services Contract with Greater Glasgow & Clyde
Mr Morrison reported that discussions have been ongoing with Greater Glasgow & Clyde and agreement on the Patient Services Contact for the currently financial year is very close. Mr Morrison reported that the net value for the main element, patient services is £43.5m with a number of small SLAs over and above that amount
3.Progress on Achievement of Savings Targets:
Mr Morrison reported that the CHP has committed to deliver a £3m savings programme in 2008/09 in order to achieve a balanced financial position for the year. Mr Morrison continues to receive assurance from the Locality Managers that they will meet their outstanding targets and confirmed that £2.475m savings had been declared as achieved by the end of November 2008.
4.Prescribing Costs:
Mr Morrison advised that Argyll & Bute CHP is liable for the costs of prescriptions written by GPs in the 34 practices across Argyll & Bute. The CHP wide budget for the GP prescribing is just short of £18m which is more than 10% of the CHP’s total revenue budget. Mr Morrison drew the Committee’s attention to the table providing details of the wide variance in prescribing costs. Mr Morrison reported that there are a number of practices in Argyll & Bute showing an overspend which was the subject of examination by the CHP’s Lead Pharmacist.
5.Forecast Outturn for 2008/09:
Mr Morrison reported that although there are a number of significant risks the CHP expectsto achieve a break-even position by the year-end.
The Chairman invited questions on firstly on Financial Performance and then secondly on Patient Services Contract with Greater GlasgowClyde.
Anne Clark referred to budgets for Outreach Clinics and questioned if monies are recovered for any clinics which do not run and are not rearranged. Mr Morrison confirmed that recovery took place. Stephen Whiston advised that there is a formal monitoring arrangement in place if clinics do not occur, are not rearranged or replaced then budgets are adjusted.
Mr Whiston would provide a report to the Committee showing the percentages of clinics which do not occur.
George Freeman referred to the budget for the outreach clinics and emphasized the importance of getting value for money and asked if the CHP is reasonably confident that this was achieved. Mr Morrison advised that there is a forthcoming West of Scotland Financial Managers meeting when there is ongoing debate between Greater Glasgow & Clyde and the surrounding Boards on the value of these contracts. Mr Freeman asked if there is a more detailed report available on the specific issue of how these charges are arrived so that we are confident that we are not paying money for services which are not being provided and asked how they assess this. Mr Morrison advised that it is a rolling three year average of activity for outpatients and day patients, and inpatients at an agreed price for each of these services.
Derek Leslie advised that this would be a worthy development session subject. The history of trying to develop and understand this part of the budget since dissolution has been extremely difficult and complicated. For the most part Greater Glasgow & Clyde were well able to explain what was happening between Argyll & Clyde and Greater Glasgow when they were separate Boards. There has been great difficulty is separating out the Clyde element of Argyll & Clyde into Glasgow and assessing what costs were being determined for that part of the service.
It was agreed to bring the topic to a future development session.
Mr Leslie also explained that one of the additional complications will be the achievement of the 12 week waiting time for outpatients as clinics in some areas only happen quarterly.To achieve the waiting time some of our patients may have to travel if an increased cost effective frequency of clinics cannot be delivered locally. Work is currently underway to meet this target.
Anne Clark commented that credit should be given to the team for the way financial information is now clearly reported. Thisenables members to ask informed questions.
Mr Whiston reported that a survey is being carried out by the CHP using a Directed Enhanced Service “Better Working” with GP practices auditing referral demand for out patient appointments, reduce follow up rates in clinics. Dr Brian McLachlan advised that a number of outpatient appointments could be carried out in Primary Care. They are also trying to establish the numbers of patients who received a consultant review as against a junior doctor review. Dr Michael Hall confirmed that the question of junior doctor reviews had been raised before and were advised that such appointments contribute to junior staff training
Anne Clark expressed her concerns that some of the targets are not going to be met. Mr Morrison advised that negotiations were ongoing with the relevant Staff Groups to enable these targets to be met. Mr Leslie confirmed that a paper had been considered by the Management Team earlier in the week and he had received assurances that savings would be achieved.
Mr Leslie referred to Mr Freeman’s earlier question on prescribing costs and advised that the report gives global details. The statistics have been produced by ISD. This is an area of the budget where certain Practices are overspending on their allocated budget and the underwriting of this underspend affects ability to invest in other services. The Prescribing Advisor is engaging with these practices to try support them change their prescribing practices with no impact in the quality of care and outcome delivered to patients within cost.
It was noted one practice was projecting an overspend of 50%. Mr Freeman asked if the CHP has the authority to instruct the practices to prescribe generic drugs and advise them if they do not what the financial implications will be.
Dr McLachlan advised that it is quite easy for a practice to justify its spending and can evidence that the drugs they are prescribing provides a better medical care but what they are not showing is corporate responsibility. Dr Hall advised that there is a degree of corporate responsibility which is recognised in the GMC because if every practice in Argyll & Bute prescribed the most expensive statins, and indeed there is no evidence that they are better then the budget would be rise considerably and confirmed the practices will be advised that they do have a corporate responsibility.
The Committee noted the information contained in the Finance Report.
6.3Revenue Savings Plan 2009/10
George Morrison spoke to a previously circulated paper asking the Committee to note the Savings Plan 2009/10.
Argyll & Bute CHP Forecast Financial Position 2009/10
Mr Morrison reported that Argyll & Bute CHP faces an extremely challenging financial year in 2009/10. The CHP has an existing recurring budget deficit of £2.375m which is likely to rise to £4m in 2009/10 due to cost growth exceeding the likely funding uplift provided by SGHD.
2.Revenue Savings Plan for 2009/10
To achieve a balanced budget for 2009/10, Argyll & Bute CHP has to put in place a savings programme of £4m which is realistic and achievable. This has been planned across a range of budgets and a range of services and is intended to be balanced and deliverable. The savings plan was discussed at length at the Management Team meeting on 6 January 2009.
Mr Leslie referred back to Mr Morrison’s review of the Audit Scotland report which showed the Board coming forward with the declaration on the financial challenges facing it. The savings proposals were set out without prejudice, and presented to stimulate discussion.There has been considerable discussion at the Management Team. It will not be easy to save £2m recurrent this year with a further £4m next year.
Elaine Robertson asked when the budgets for Out of Hours Services will transfer to localities. Mr Morrison advised that the budgets were moved in to the localities last year and are now the responsibility of the Locality Managers. Mr Morrison advised that because of geography considerable costs are invested in out of hours.
Bill Brackenridge highlighted that NHS Greater Glasgow & Clyde spend much the same as NHS Highland on Out of Hours Services. Dr McLachlan said that he was not surprised because of the geography of Argyll & Bute and the spread of population throughout remote and rural areas.
Ms Robertson also asked about resource transfer for Argyll & Bute Council and asked if a paper could be brought to the Strategic Partnership on that. Mr Morrison confirmed that a request has already been received for this information.
Ms Robertson also asked if there will be further bridging funding available. This is being investigated.
Mr Freeman referred to resource transfer relating to the cost of a service being transferred from NHS Highland to the Local Authority. Mr Leslie confirmed that resource release is spread across community Nursing service, Local Authority services and the voluntary sector when joint responsibility is appropriate.