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                       THURSDAY 22 MAY 2008

Present:            Chris Turner         Chair, Non Executive Director
                    Shafiq Ahmed         Non Executive Director
                    Peter Dickson        Medical Director (For first part of the meeting)
                    Pam Essler           Non Executive Director
                    Steve Ingleson       Director of Performance
                    Rhys North           Director of Finance & Procurement

In attendance:      For item on BDCT Crisis Resolution Home Treatment Services
                    Mick James         Head of Adult MH Commissioning
                    Angela Moulson     MH Clinical Lead
                    Andy Wilson        MH Clinical Lead

                    For item on Maternity Services and Infant Mortality
                    Ruth Hayward        Head of Children’s Commissioning
                    Shirley Brierley    Consultant in Public Health

                    Ann Petty            Assistant Board Secretary
                    Michelle Turner      Deputy Director of Clinical Development (For
                                         Peter Dickson – for second part of the meeting)

                    Clare Livens         Head of Scheduled Care Development
                    Sharon Hodgson       Project Manager (For part of the meeting)
                    Kathy Pogson         Programme Manager, Strategic Pathway

Apologies:          Matt Neligan         Director of Commissioning


      The minutes of the meeting held on 25 February 2008 were agreed as an accurate


      08/3   Finance and Procurement Report

             At the end of the financial year, the deep clean had been completed by
             Airedale NHS Trust, Bradford District Care Trust and the provider arm of the

             As a result of a capital build programme, Bradford Teaching Hospitals NHS
             Trust (BTHFT) had negotiated with the SHA to complete their deep clean by
             31 March 2009.

             There was a risk around the deep cleaning of Ward 1 in the York Suite at
             BTHFT which was due to complete by 31 December 2008. Due to concerns
             raised, the Performance and Planning Committee asked the Contract
             Management Board to monitor progress in this respect. Any issues to be
             reported back to the Committee.
            A total sum of £1.2m would be spent on the initiative.


     The minutes of the meeting held on 20 March 2008 were agreed as a correct record.


     08/21 Continuing Healthcare Progress Report

            Steve Ingleson agreed to check the number of people still waiting for an
            assessment to determine eligibility for continuing healthcare. ACTION:
            Steve Ingleson.

            The Committee asked to receive a further update on continuing healthcare at
            the meeting in July. ACTION: Ann Petty.


     Mick James outlined the background to the briefing on the crisis resolution and home
     treatment (CRHT) services which had been in operation in Bradford District Care
     Trust (BDCT) since 2004. The target number of teams required for the Bradford and
     Airedale region had been identified as 4.4 which was the equivalent of 61.6 WTE
     staff within the Department of Health’s Policy Implementation Guide (PIG). BDCT
     had applied to the Department of Health for ‘fidelity and flexibility’ (a mechanism for
     getting approved variance from the PIG model) and gained approval to operate two
     larger teams across Bradford and Airedale.

     CRHT services were established to provide an alternative to treatment in acute
     inpatient mental health wards where it was safe to do so in relation to managing
     clinical risk, particularly in relation to potential violence to self or others. The teams
     should provide a gate keeping assessment for all inpatient admissions, should
     provide treatment at home to people who could be managed safely and should
     provide in reach onto the wards as a means of ensuring that length of stay was kept
     to a minimum, thus reducing the number of admissions but also the overall levels of
     occupancy. The introduction of CRHT had led to reductions in bed numbers of
     between 20 – 30% in other areas of England.

     The former PCTs commissioned CRHT from BDCT on a different basis. City and
     South and West provided funding for a full complement of staff to meet the needs of
     the area on the basis that as the service impacted on bed use, savings would be
     made from a reduction in bed numbers and this could be disinvested from BDCT.

     Airedale and North provided lower levels of funding for CRHT as they felt there was
     already a high level of investment in BDCT community services and that there should
     be a service redesign process to ensure that CRHT and other community services
     were working in an efficient and complementary manner. Again there was an
     assumption that there would be savings made from a reduction in bed numbers and
     this would be disinvested from BDCT once the CRHT service was fully established.

     Within the current BDCT contract there was sufficient investment to fund
     approximately 75% of the team required to deliver the full complement of staff that
     the PIG identified.

There were two performance targets associated with CRHT:
    a workforce target which related to mental health provider trusts. For BDCT
       this was the 4.4 teams as set out within the PIG;
    for the commissioning tPCT, there was a separate activity related target
       which measured the number of people receiving home treatment episodes
       each year. The Bradford and Airedale CRHT service had a target of 1,298
       home treatment episodes per annum.

Historically and currently BDCT struggled with performance. A number of attempts
had been made to look at how services could be redesigned to try to improve
performance and the recording of information. There had been no significant impact
to date. In November 2007 BDCT carried out a more systematic review of the
causes of poor performance. These were the subject of a paper to the Contract
Monitoring Board in April. Via the paper BDCT requested funding for the cost of
recruiting the additional 16.1 WTE staff required to meet the full complement of staff
described by the PIG at a cost of £495k. The paper also outlined various reasons for
BDCT’s underperformance. A major reason was that CRHT teams were conducting
too many assessments which did not turn into home treatment episodes.

To improve performance BDCT proposed a number of actions based around whole
system redesign. By reducing the number of initial assessments carried out the
CRHT teams would have more time to carry out home treatments and facilitate
clients early discharge from inpatient units. The gap of 16.1 posts had been filled
internally by recruiting resources at risk from other care group services. Recruitment
to these posts as well as providing additional work capacity would also see the
service operating 24/7. It was envisaged with the additional resource input CRHT
would deliver 90 episodes in April and May.

The whole service redesign was due to be completed by June and should see BDCT
benefiting from a number of efficiencies. These would see the number of home
treatment episodes increase further. In order to meet the tPCT’s target of 1,298
episodes CRHT would deliver 112 episodes per month for the coming ten months.

BDCT have requested an additional £495k to fund this development on the basis that
any consequential savings from reduced inpatient activity would be seen as part of
future years efficiency savings.

There were a number of risks to the tPCT in that BDCT’s proposals would not deliver
on the home treatment episode target.

Following discussion it was agreed that for the tPCT to be prepared to fund services
in 2008/09, a number of actions needed to be taken forward by BDCT:

(i)     redesign of urgent care and crisis resolution needed to be looked at together;

(ii)    the tPCT needed to ensure BDCT achieved at least the 90 target episodes;

(iii)   from a commissioning view point, the criteria for crisis resolution needed to
        be clarified;

(iv)    contract arrangements should include a qualitative set of indicators and a
        means whereby both the patient and GP could indicate how good the service

     (v)     a model was needed for the reduction in bed base – there should be no
             longer term costs to the service;

     (vi)    the tPCT needed to look at some sort of clinical and social audit to ensure
             that patients were receiving the right treatment provided in the right setting by
             the right provider.

     The Chair thanked Mick, Angela and Andy for attending the meeting.

     It was acknowledged that the quality of information from BDCT was a recurring
     theme. Targeted quality improvements/quality indicators were needed. Work would
     take place with the tPCT’s commissioning team to bring this about. ACTION: Peter


     Ruth Hayward informed the Committee:

     (i)     the national focus on maternity services had been increasing over the last
             few years. In 2004 the Department of Health (DH) published the NSF for
             Children, Young People and Maternity Services with an expectation that by
             2014 local health economies would be able to demonstrate implementation of
             Standard 11: maternity services which indicated that women have easy
             access to supportive, high quality maternity services, designed around their
             need and those of their babies;

     (ii)    in 2007 the DH published Maternity Matters: Choice, access and continuity
             of care in a safe service, which advised that by the end of 2009 four national
             choice guarantees would be available for all women:

                choice of how to access maternity care
                choice of type of antenatal care
                choice of place of birth – depending on their circumstances, women and
                 their partners would be able to choose between the following options:

                 *   a home birth
                 *   birth in a local facility, including a hospital, under the care of a midwife
                 *   birth in a hospital supported by a local maternity care team including
                     midwives, anaesthetists and consultant obstetricians. (For some
                     women this would be the safest option) and
                 *   choice of place of postnatal care;

     (iii)   the final draft Maternity and Newborn Care NHS Stage (Darzi) Review for
             NHS Yorkshire and the Humber made five recommendations around the
             development of maternity services:

                Maternity Matters be used as a foundation for the future commissioning
                 and delivery of maternity and new born services
                improve commissioning and workforce capacity
                create high quality, responsive services and reduce variations in care
                reduce health inequalities
                increase uptake of breast feeding;

(iv)     in 2008, following an inquiry into the safety of NHS maternity services, the
         King’s Fund published Safe Births: Everybody’s Business, which set out the
         findings and recommendations around the safety of mothers and babies
         during birth. There was a need for the Maternity Workstream to work with
         service providers to review current service provision against the findings of
         this document and identify and prioritise areas for development;

(v)      the tPCT was committed to securing assurance on the quality of all services
         and would continue to seek assurances on the Statutory Supervision of
         Midwives to ensure that both acute trusts meet or exceed the NMC
         requirements of a 1:15 ratio. There was a need to develop appropriate links
         with the tPCT clinical quality team to ensure all quality requirements,
         including NICE guidelines, were reflected in commissioning developments;

(vi)     there were IT issues. The tPCT needed to assess the risks of not using
         computerised records on labour wards; there was a need to agree a way
         forward to develop the appropriate use of computerised recording systems
         across maternity services;

(vii)    a workforce capacity review lead by the SHA had highlighted some significant
         gaps in staffing;

(viii)   guidance issued by the DH in February 2006 indicated that every area should
         have ‘an effective multi disciplinary services forum, where commissioners,
         providers and users of maternity services bring together their different
         perspectives in partnership to plan, monitor and improve local maternity
         services’. PCTs were charged with establishing, organising and maintaining
         these maternity services liaison committees (MSLC) with the MSLC acting as
         an independent advisory committee to the tPCT. The local MSLC was
         suspended some time ago. There was a need to re-establish this with
         immediate effect;

(ix)     BTHFT held an Achieving Sustainable Quality in Maternity Services event in
         February 2008 at which service users and health professionals were asked to
         identify their priorities for improvement during 2008/09. Access to services in
         community settings, development of peer support for breast feeding and
         availability of home births were the top three priorities identified. The tPCT
         needed to ensure it used this information when agreeing the priorities for
         service development within the Maternity Workstream;

(x)      the 2007 Review of Maternity Services carried out by the Healthcare
         Commission (HCC) resulted in Airedale NHS Trust being scored as a Better
         Performing Trust and BTHFT being identified as a Least Well Performing
         Trust. Both trusts had developed action plans to address issues. The tPCT
         would support them to take forward actions identified;

(xi)     the DH had developed a self assessment and benchmarking tool for child
         health and maternity services. Local service providers had added their
         provider specific information to this tool and there was a need to ensure that
         tPCT commissioning and public health information was added to inform local
         and regional planning discussions;

(xii)    local maternity services had been under resourced for a number of years and
         service providers continue to redesign their services within the financial
         envelope available to them and both BTHFT and Airedale NHS Trust were

              currently developing their Maternity Support Workers and Health Care
              Assistants to improve their skill mix. However they would require substantial
              investment if they were to meet the requirements of Darzi and Maternity

     (xiii)   Bradford and Airedale had a more complicated delivery rate than most other
              areas because of the high number of late presentations and the difficult births
              linked to high rates of consanguinity. The area also had a rising birth rate;

     (xiv)    there were concerns around tariff arrangements for maternity services which
              required consideration. There were particular implications from the relatively
              high numbers of women who chose to deliver at provider units out of the
              district but required their antenatal and postnatal care within the Bradford and
              Airedale district;

     (xv)     a Maternity Services workstream had been established as part of the
              Bradford and Airedale Managed Clinical Network for Children, Young People
              and Maternity Services. Anne Connolly and Ruth Hayward had joined the
              group. The group’s terms of reference were being reviewed. Membership
              needed to include a wider range of stakeholders.

     Following discussion which covered preconceptual care, teenage pregnancy
     midwives, HCC action plans, specialist maternity care and the tariff, it was agreed:

     (a)      Ruth Hayward would speak to Gordon Coventry regarding specific
              contractual issues and the tariff. ACTION: Ruth Hayward;

     (b)      there was an excellent opportunity to work in collaboration with partners via
              Children’s Centres;

     (c)      the tPCT needed closer involvement with BTHFT and ANHST in order to
              have input into their action plan in response to the HCC assessment.
              Measures needed to be put in place to ensure maternity services were fit for
              purpose as this had a knock on effect on infant mortality;

     (d)      the Committee would receive an update on progress on both maternity
              services and infant mortality at their meeting in September. ACTION: Ruth
              Hayward/Shirley Brierley/Ann Petty.


     Shirley Brierley outlined the close links between maternity care and infant mortality
     and went on to inform the Committee:

     (i)      infant mortality had been identified as a priority in the tPCT’s Commissioning
              for Health Strategy 2008/2011 and Operational Plan 2008/09 as part of
              efforts to address health inequalities. It was one of the six priorities for health
              inequalities in the district’s Sustainable Community Strategy for 2008;

     (ii)     the Bradford Infant Mortality Commission (IMC) which reported in 2006 found

                 poverty and deprivation were associated with higher risk of death in the
                  first year

                deprivation alone did not provide the whole explanation for Bradford’s
                 higher rates
                pre-term birth, smoking and substance misuse, and younger motherhood
                 were greater risk factors for white mothers
                risk of being affected by autosomal recessive disorder was relatively
                 small but could be fatal and was more likely within Pakistani populations
                early and full access to good quality antenatal care was essential for
                 women living within the two most deprived areas of Bradford;

     (iii)   although infant mortality rates were coming down, they remained higher in
             deprived populations.

     Committee members were interested in the numbers of babies dying within one year
     and the causes of death stated on death certificates and asked that this information,
     including a summary of trends and issues, be reported to the Board on a regular
     basis via the Performance Report. ACTION: Steve Ingleson;

     (iv)    in response to the IMC report a dissemination and implementation group had
             been established, recently renamed the ‘Every Baby Matters Group’ (EBMG).
             Its role was essentially advisory helping to turn the IMC recommendations
             into practical action. The group’s membership was drawn from partners and
             partnership bodies that could contribute to the delivery of the
             recommendations through influencing their own organisations and services
             and identifying priorities which had maximum impact on infant mortality;

     (v)     the EBMG was using a systematic approach to work on four areas:

                smoking
                breast feeding
                early access to antenatal care
                genetic/inheritance issues;

     (vi)    a commissioning proposal was being drafted which identified where
             investment was needed around the four areas mentioned which took into
             account other proposals which were either underway or in transit. The group
             was clear where investment was needed, this now had to be progressed;

     (vii)   main risks were around identifying areas for investment which were then not
             chosen to be funded. Priorities had to be evidence based and related to
             outcomes, and getting partners to contribute in the areas where the tPCT was
             not the lead could be difficult.

     The Chair thanked Shirley for the report and said that requests for investment
     needed to be looked at alongside other priorities which had already been identified.
     Matt Neligan and Rhys North were tasked to take this forward with the Board.
     ACTION: Matt Neligan/Rhys North.


     An update on performance would be made at the Board meeting on 27 May.


     Rhys North said that at the Board meeting on 27 May he would be updating on the
     2008/09 financial position and the risks involved in the investment programme.


     Rhys North informed the Committee that Stage 2 approval had been received from
     the SHA for the Bingley development.

     Financial close should take place on 17 June.


     The next meeting of the Committee would take place at 9.30 am on Monday 23 June
     2008 in the Board Room, Level 4, Douglas Mill.


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