Highland NHS Board
5 August 2008
Item 4.2
HIGHLAND NHS BOARD
DRAFT MINUTE of MEETING of the
CLINICAL PLANNING GROUP
(SERVICE REDESIGN COMMITTEE)
Board Room, Assynt House
Assynt House
Beechwood Park
Inverness IV2 3BW
Tel: 01463 717123
Fax: 01463 235189
Textphone users can contact us via
Typetalk: Tel 0800 959598
www.nhshighland.scot.nhs.uk
Monday 9 June 2008 – 2.00 pm
Present
Dr Ian Bashford, Board Medical Director, in the Chair
Dr Eric Baijal, Director of Public Health & Health Policy
Mr Quentin Cox, Chair, Area Clinical Forum
Prof John Cromarty, Director of Pharmacy
Mr Stuart Denholm, Clinical Director, Raigmore Hospital
Dr Moray Fraser, Clinical Director, North Highland CHP
(videoconference)
Dr Chris Lush, Clinical Director, Clinical Services & Support
Directorate, Raigmore
Ms Una Lyon, Lead Nurse, Raigmore (deputising for Heidi May)
Dr Alistair McIntyre, Chair, Area Medical Committee
Dr John May, Clinical Director, Surgical & Anaesthetic Directorate,
Raigmore
Dr Ken Proctor, Associate Medical Director (Primary Care)
Dr Ian Scott, Clinical Director, South East Highland CHP
In Attendance
Dr Helen Shannon, Consultant Radiologist (item 3)
Ms Katherine Sutton, Superintendent Radiographer (item 3)
Ms Linda Kirkland, General Manager, Medical Directorate (item 4)
Miss Irene Robertson, Board Committee Administrator
Apologies - Ms Margaret Brown, Mrs Helen Bryers, Dr Grace Fergusson, Dr Michael Hall,
Dr Rod Harvey, Mr Nigel Hobson, Dr D A Russell Lees, Dr Chris MacGregor, Ms Heidi May,
Mr Ray Stewart and Dr Angus Venters
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MINUTES
The minute of meeting held on 12/11/07 was approved.
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CLINICAL ADVICE TO THE BOARD – FUTURE OF CLINICAL PLANNING GROUP
A copy of the Group’s current remit had been circulated along with some proposals relating
to membership and working arrangements. The Chair reminded the Group of an earlier
proposal that the Group should merge with the Financial Planning Group. The view held was
that the Clinical Planning Group (CPG) should continue to function as a separate committee
providing a high level of clinical scrutiny of appropriate issues while taking cognisance of
financial considerations, identification of the risks of implementation or non-implementation, a
priority of the issue, and give a view as to the possibility and capacity for implementation.
The submissions to the CPG should be in broad business case form and be comprehensive,
and have undergone the appropriate consultation. It was felt that the Area Clinical Forum
being essentially a professional advisory body would not have the capacity to undertake the
Working with you to make Highland the healthy place to be
high level scrutiny required, whereas the members of the CPG had a managerial mandate
and were better placed to bring a broader clinical perspective to the issues under debate.
The CPG, as currently constituted, brought together primary and secondary care and
provided a forum for comprehensive clinical debate on strategic issues. It was proposed
that the existing membership should be expanded to ensure an inclusive representation, the
revised membership agreed to comprise of the following:
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Board Medical Director - Chair
Nominated Planning Lead (Head of Service Planning)
Associate Medical Director (Primary Care)
Director of Public Health & Health Policy
Clinical Director, Raigmore Hospital
Clinical Directors, Raigmore Directorates
CHP Clinical Directors
Mental Health Clinical Leads
Board Nurse Director
Associate Nurse Director
Head of Midwifery
Associate AHP Director
Director of Pharmacy
Chair of Area Medical Committee
Area Clinical Forum Representative
In the event that a member was unable to attend a CPG meeting, it was agreed that a deputy
should attend.
It was also agreed to co-opt expert members for specific topics, as
necessary and appropriate to ensure that a full and comprehensive clinical opinion was
sought from NHS Highland.
The Chair advised that the CPG had previously been accountable to the Improving Health
Services Committee. As that committee had been disbanded, consideration would require to
be given to lines of accountability, reporting arrangements and links with other committees.
With regard to business, it was felt that the focus of the CPG should be service provision and
redesign. For agenda setting purposes, the following criteria were proposed:
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Issues should be identified as local, regional, tertiary or national.
Proposals should be presented to the CPG in broad business case form. In some
cases, the proposals should have been through other appropriate fora, eg new drugs
requiring service change would have gone through the New Medicines Sub Group of
the Area Drug and Therapeutics Committee.
Proposals should have a clinical sponsor and they should present the case to the
CPG.
The financial considerations must be identified.
The CPG may also commission specific pieces of work as appropriate and should
have a close working relationship with the Planning Group and respond to the
Planning Group request for a clinical opinion on submissions.
It was proposed that meetings be held quarterly, additional meetings to be convened for
urgent business as required. However, some members felt that the Group should meet more
frequently, say every two months.
Dr Bashford undertook to further refine the proposals relating to membership and
organisational arrangements, taking into account the points raised during discussion, and
would circulate these in advance of the next meeting for the Group’s consideration and
agreement.
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The Group Remitted to Ian Bashford to substantiate the proposals for membership and
working arrangements for consideration and agreement.
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MRI SERVICES, RAIGMORE HOSPITAL
The Chair welcomed Dr Helen Shannon, Consultant Radiologist and Katherine Sutton,
Superintendent Radiographer to the meeting.
Dr Shannon spoke to the circulated business case for the provision of appropriate MRI
scanning facilities to deliver Government waiting times targets, reducing access time for MRI
scanning from 9 to 4 weeks by 31/03/09, and MRI imaging of an appropriate quality to allow
the highest levels of diagnostic accuracy for MRI examinations of Highland patients. Timely
MRI investigation was key to underpinning the proposed 18 weeks RTT plan. NHS Highland
had also committed to a 2 week diagnostic waiting time for suspected cancer patients. This
would require a significant increase in capacity to support the delivery of the targets and
effective contingency arrangements to allow for predictable down time. The existing scanner
had reached its technological limit, further upgrades were not an option. In addition, the
advice of the College of Radiologists was that scanners should be replaced every 7 years
and the existing machine had been installed in 2002/03. Dr Shannon confirmed that the
Department of Radiology was developing an equipment replacement programme to ensure
timely replacement of expensive items of equipment in the future. It had been their
expectation that an updated MRI scanner would be required in the financial year 2009/10 to
meet the increasing demands for scanning but also in terms of complexity of cases. Dr
Shannon detailed activity and rising demand for services year on year – predicted to grow
nationally at up to 15% per annum. It was noted that Highland provided services to Western
Isles, while patients in Argyll and Bute were covered by an SLA with NHS Greater Glasgow &
Clyde. To achieve and maintain a 9 week waiting time with one scanner, allowing for
existing demand it would be necessary to extend the operational hours of the scanner to 72
hours per week. Discussions had taken place with staff regarding the possibility of extending
the working day; however this would impact on their other commitments such as on call
rotas.
Extending the working day was one of seven options set out in the business case. Of these,
Option 7- the provision of a second staffed MRI scanner within the MRI Department at
Raigmore Hospital with the existing scanner continuing in use for more routine cases to the
end of the 10 year term of its lease in 2012, was the preferred clinical option. This option
would address clinical concerns over image quality, the limitations of the existing technology
and also allow the building in of business continuity by having contingency MRI scanning
services available. It would also allow the best quality of MRI scanning services to be
provided for the Highland population. In addition, the two scanners could operate using a
shared control room area, making more efficient use of staff. Dr Shannon indicated that
despite running two scanners it was anticipated that the working day would require to be
extended within the coming 2 – 3 years.
John Cromarty enquired about activity in other boards in terms of utilisation of scanners and
if there might be lessons to be learned from benchmarking. He also asked if any of the other
options could be implemented more quickly, eg referral to other centres. It was noted that
there was no spare capacity currently at any of the other Scottish centres. This option was
also counter to the principle of treating patients as near to their home as possible and it could
potentially impact on other specialist services in Highland.
It was suggested that in order to maximise the use of the equipment, consideration should be
given in the short term to restructuring the model of service, looking at skill mix, training
requirements, increasing the staffing pool with the potential for shift work.
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The paper also provided a financial evaluation, summarising the financial consequences of
each of the purchase options over a 6 year period. Dr Shannon explained that lease options
were not included in the paper, as they had proven not to be viable. She added that the
Planning Group had asked for clarification on a number of the financial aspects of the case
and she would be gathering some further information which she would also share with the
Clinical Planning Group.
The Group:
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Agreed to clinically support the purchase of a second scanner as detailed in Option 7
of the business case on clinical grounds, noting that further financial clarification was
being sought concerning purchase/lease options.
Recommended that consideration be given in the short term to developing a mixed
model of service with a view to maximising scanning resources.
Recommended that the business case be re-referred to the Planning Group.
MS TREATMENT – NATALIZUMAB (TYSABRI)
The Chair welcomed Linda Kirkland, General Manager, Medical Directorate, who spoke to
her circulated report. She explained that the paper and business case referred to Old
Highland, essentially Raigmore patients, as the patient pathway for Argyll and Bute residents
lay within NHS Greater Glasgow & Clyde. The paper outlined the advantages of
Natalizumab.
A resubmission of Natalizumab 300 mgs concentrated solution for infusion was considered
by the Scottish Medicines Consortium (SMC) who gave a decision on the product on 10
August 2007. The SMC advises NHS Boards and Area Drug and Therapeutics Committees
on its use in NHS Scotland. The advice is summarised as follows:
“Natalizumab is accepted for restricted use within NHS Scotland as a single disease
modifying therapy in highly active relapsing remitting multiple sclerosis (RRMS) only in
patients with rapidly evolving severe RRMS, defined by two or more disabling relapses in
one year and with one or more gadolinium-enhancing lesions on brain magnetic resonance
imaging (MRI) or a significant increase in T2 lesion load compared with a previous MRI.
In a post-hoc sub-group analysis of the pivotal trial, which included patients with rapidly
evolving severe RRMS, it was associated with a significant reduction in the annualised
relapse rate and the probability of a sustained progression of disability over two years
compared with placebo.”
The number of patients involved in NHS Old Highland would be small: there were currently
approximately 70 patients in the SMC highly active relapsing remitting multiple sclerosis of
whom approximately 22% would be eligible and suitable for the treatment. John Cromarty
referred to the advice issued by the SMC and estimated that this may involve possibly five
additional patients a year.
As the prevalence of MS was evidently higher in the Highlands and Islands than elsewhere in
Scotland, it was suggested that it might be useful to benchmark the prevalence in other
Scottish Board areas and attempt to identify possible contributory factors.
In response to a specific question, Professor Cromarty confirmed that horizon scanning in
NHS Highland for new drugs coming on line was undertaken in conjunction with Pharmacy
and Specialist Consultants projecting their potential requirements: two patients were
identified in 07/08 and ten potentially for 08/09.
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Where SMC approval had been given to a drug and there were no suitable alternative drugs,
the Group were of the view that it was unnecessary for such cases to be submitted to it for
clinical consideration. However, if there was some doubt surrounding the clinical case, the
efficacy and cost-effectiveness, there were associated staffing or ancillary costs, and
significant service redesign, then the Group agreed that it would be appropriate for
consideration of such cases in order to provide a broader and more comprehensive clinical
perspective.
(Subsequent to the meeting, Professor Cromarty clarified that Natalizumab was not included
in the Highland Joint Formulary. As it was now SMC approved, it was suggested that a
Highland Joint Formulary application should be submitted, probably following consideration
of this business case. Having considered the business case and the SMC advice, the Group
agreed that the clinical case for Natalizumab within the SMC restricted use was clinically
effective and sound.)
There could also be potential savings in terms of social care and this issue could perhaps be
raised with the Highland Council.
The Group Remitted to Ian Bashford to convey its recommendation to the Planning
Group that the clinical evidence for restricted use was sound and that the Planning Group
should consider the case.
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DVT
The Group was advised that some further work required to be done on deep-veinous
thrombosis throughout NHS Highland. Once this had been progressed, Maimie Thompson
would prepare a comprehensive report for the Group’s consideration at a future meeting.
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ANTICOAGULATION
Dr Chris Lush spoke to the topic:
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Currently, the consultant haematologists undertook testing and dosing and there was
a need to review the present service provision model and to review the clinical
governance issues of providing a consistent and quality assured service
Variations in testing and dosing arrangements existed throughout NHS Highland
One model of redesign would be to consider transferring anticoagulation and monitoring to
primary care: this would require a coordinated approach to ensure consistency of equipment,
training and quality control for a standardised quality service.
There would be resource implications for funding this technical service based within primary
care and also remuneration for primary care staff.
A wider discussion ensued and there was a significant number of models that needed to be
considered for delivering this service across NHS Highland within primary care.
The Group:
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Supported this early proposal in principle generally.
Noted that there were a number of key actions required at an operational level to
define the models for the process of implementation
Suggested that a business case required to be completed and resubmitted.
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FUTURE AGENDA ITEMS
The following topics were agreed for future consideration:

Clinical Planning Group working arrangements, agenda, links with other committees
(next meeting)
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MRSA screening – a general update on the pilot screening sites currently, the
principles of MRSA screening generally and any specific implications for NHS
Highland (next meeting)
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DVT (future meeting)
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Diabetes Enhanced Service – a comprehensive update on proposed arrangements to
consider moving the management of insulin-dependent diabetic patients into the
primary care setting – this will require a comprehensive paper and clinical
sponsorship (future meeting)
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AOCB
8.1
Referral Prioritisation
The Chair reported briefly on this issue raised by the Area Medical Committee. It related to
GP referrals being made on patients to hospital consultants and the subsequent
reprioritisation of the referral by hospital consultants. As this was involved with e-referral and
online triage, the Chair indicated that he would pursue the issue within the eHealth
Department of NHS Highland. He would report back to the Group on the outcome in due
course.
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SCHEDULE OF MEETINGS IN 2008
A proposed schedule of meetings for the remainder of the year was circulated for the
Group’s agreement. It was suggested that meetings be held quarterly, however there was
some feeling that more frequent meetings were required, say every two months. After
discussion, the Group agreed the following dates for 2008:(Mondays, 2pm)
 8 September
 13 October
 8 December
The Group would give further consideration to the frequency of meetings in 2009.
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DATE OF NEXT MEETING
The next meeting would be held on Monday 8 September 2008 at 2.00pm in the Board
Room, Assynt House.
The meeting concluded at 4.30pm
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