Rural Locality GP Network Meeting, 2-5pm, Tuesday 13 June 2017, Bunbury Surgery, Bunbury Chair Steve Pomfret (Chair) APPROVED MINUTES

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1 Rural Locality Network Meeting, 2-5pm, Tuesday 13 June 2017, Bunbury Surgery, Bunbury Chair Steve Pomfret (Chair) APPROVED MINUTES Name Practice Name Practice Manager Name Jonathan Gregson Helbsy Brian Yorke Helen Black Bunbury Alan Courtenay Kylie Daniels Kelsall Apologies Louise Davies Malpas Lynn Suckley Andy Campbell Tarporley (Campbell) Sue Dewhirst Alistair Adey Tarporley (Adey) Samantha Jeffrey Steve Pomfret Princeway - Melissa Siddorn The Village Surgeries Kate Evans Practices not represented by a : In attendance Sarah Murray Head of Primary Care (WCCCG) Colin McGuffie Locality Project Manager Diane Taska Membership Support Officer (Minutes) Barbara Perry Meds Management (M&LCSU) - Agenda Item 3. Sarah Carberry Head of Unplanned Care (WCCCG) Agenda Item 4. James Hardy-Pickering Unplanned Care Team (WCCCG) Agenda Item 4. Claire Baker Primary Care Lead (WCCCG) Agenda Item 5. Laura Jones Primary Care Commissioning Support Manager (WCCCG) - Agenda Item 5. Tracy Palmer Practice Manager (Upton Surgery) Agenda Item 7. Sue Pratt Integrated Care Team Manager Rural Helen Cunningham Integrated Care Team Manager Rural Agenda No Action 1. Welcome & Apologies The Chair welcomed Rural Network members to the meeting. Declarations of Interest No new declarations of interest were raised. Code of Conduct Network members were reminded of the meeting s code of conduct. Minutes of Rural Network 1 Date: June 2017

2 Previous Minutes The minutes of the previous meeting (May 2017) were approved as an accurate record of the meeting. 2. Financial Update/CCG Update The CCG has identified 9.1m of savings for 17/18 but identified a potential gap of 2.6m. The CCG s focus will be around similar schemes to 16/17 IN 17/18 on meds management projects and referral management. The CCG is exploring incentive schemes that are being offered nationally, further details will be advised in due course. The Network raised the issue of CoCH still prescribing over the counter medications to patients upon discharge from secondary care. Action: Sarah Murray to feed through to the Strategic Medicines Managers Group that CoCH Consultants are still prescribing over the counter medications upon discharge and feedback to the September meeting. SM 3. Meds Management Update Barbara Perry, M&LCSU, updated the City Network around the current Meds Management work and the attached presentation was received: MM Barbara Perry City Network present It was noted the medicines optimisation QIPP Plan for 17/18 will focus on the Right Care pathways, Antimicrobial Resistance, Cost Effectiveness Switches, Policy Implementation and Repeat Prescribing. The Network noted that patients will be asked by the community pharmacist to check their meds inside bags before leaving the pharmacy to ensure that drugs wastage is limited (patients can give medications that are not required back to the pharmacist if they haven t yet left the pharmacy). Medicines Management A further update will be provided at the September Rural Network meeting. Minutes of Rural Network 2 Date: June 2017

3 4. Urgent Care Update The Rural Network welcomed Sarah Carberry, Head of Urgent Care along with James Hard-Pickering, West Cheshire CCG who provided an update on the current Urgent Care work and the following points were highlighted: Intermediate Care Review: The CCG is currently at a point where the clinical model of care (with various partners involved) is being reviewed with an aim to keeping the patient as close to their home as possible. The proposed model will be taken to Finance and Performance Committee shortly (both step up and step down care) for approval. The Network raised concerns around the level of resourcing of general practice and community services to meet the workload of the new models of care as they are developed. Primary Care Streaming: There is currently a national directive to provide a Primary Care Streaming facility in A&E. The Countess is looking at a revised more appropriate model in the long term. Clinical Assessment Unit: The Clinical Assessment Service recently implemented is a combined 5. Dressings Update The Chair introduced Claire Baker, Primary Care Lead and Laura Jones, WCCCG, to the meeting. The Network received an overview of the issues relating to the provision of dressings care in Ellesmere Port and Neston and the whole of West Cheshire. In Ellesmere Port the current waiting time for Doppler is at 14 months (this excludes urgents as these are seen within 2 weeks) CWP are not commissioned to provide dopplers. As an interim measure Practices in Ellesmere Port have agreed to go through their list of patients on the doppler waiting list and review whether they still require a doppler, if they do then the Clinician is asked to make the referral using the revised doppler form. Concerns have been expressed by both the City and Rural localities around the inequity of provision of dressings. The CCG holds data on what each practice does in terms of dressings, with the vast majority of practices in City and Rural providing basic dressings care. In Ellesmere Port all dressings are sent to the dressings clinic from simple suture removals to complex wound care. Claire Baker advised that following the Dressings Task and Finish group meeting on 25 th May, CWP agreed that dopplers already in the system for Ellesmere Port (around 50 patients) need to go back to practices for reassessment. If they are deemed as still requiring a Doppler, practices are requested to refer using an updated referral form as designed by CWP that can be shared with practices shortly. Patients who are deemed as still requiring a doppler will need to be referred on the new proforma, and owing to the additional capacity to be released within Extended Hours, will Minutes of Rural Network 3 Date: June 2017

4 be seen by this service, relieving pressure from the in-hours dressings provision from CWP. All new referrals for a doppler should be referred on the new proforma. The Rural Network raised issued with nurse capacity in the Extended Hours Service currently not providing complex dressings. Action: SM to liaise with the Extended Hours Service to identify nurse capacity to enable complex dressing service to continue/resume (in the short term) and feed back to the July meeting. SM The Rural Network noted the update around Dressings. 6. Primary Care Cheshire Update (including ACO developments) The Rural Network noted a recent workshop has been held to develop a Target Operating Model (TOM). Rural Clusters are coming together on the next Rolling Half Day to develop and align Clusters in preparation for an Accountable Care Organisation (ACO) next April. It was noted that Primary Care Cheshire (PCC) will need to develop systems that enable practices to reflect their population and locality. The Network noted PCC will be interviewing shortly for the post of Programme Director and PCC s AGM is on 27 June Holiday Inn, E Port. 7. Future Agenda Items Brio Leisure MacMillan support agreed July agenda 8. Any Other Business The Care Hub Tracey Palmer, Practice Manager Upton Surgery, provided an update on the Care Hub. It was noted The Care Hub formerly known as The Directory of Services has been funded by practices and is tailored to each practice on a local/individual basis. The information held on the database contains third sector information (no NHS information) such as Brio Leisure, Age UK etc. It was noted locally each service will have to update the information in order for it to be live and current, if the Provider fails to do this the service will drop off the data base. The Network noted the update on the Care Hub. Accenda: It was noted that Bunbury Surgery has resumed using the Accenda system. The Network asked if the CCG has identified outcomes to justify using the system and it was noted the intention is to share outcomes (by the CCG) later in the summer. Minutes of Rural Network 4 Date: June 2017

5 Next Meeting: Overall feedback from the Rural Network around Accenda was negative mainly due to issues around delayed appointments. The 3 main areas of concern are: A lack of resources in the Choice Team CoCH and CWP not coming together to make the system effective Consultants reluctant to triage the referrals A more detailed review of the performance of the Accenda system will be provided at the July Network. Tuesday 12 September Barbour Institute, Tattendhall, pm E Port & City Network Minutes May 2017 attached separately to the as too large to embed. Minutes of Rural Network 5 Date: June 2017

6 Key: Red Overdue Amber On-going Outstanding Actions NB: Actions will be taken off the table upon completion Green Completed Blue For future / On agenda Date Initiated Action By Whom Due Date 11 April 2017 SJ to meet with CWaC re: Turning Point and feed back to the June meeting. SJ July 2017 June 2017 Sarah Murray to feed through to the Strategic Medicines Managers Group that CoCH Consultants are still prescribing over the counter medications upon discharge and feedback to the September meeting. SM September 2017 June 2017 SM to liaise with the Extended Hours Service to identify nurse capacity to enable complex dressing service to continue/resume (in the short term) and feed back to the July meeting. SM July 2017 Minutes of Rural Network 6 Date: June 2017

7 Minutes of Rural Network 7 Date: June 2017

8 Minutes of Rural Network 8 Date: June 2017

9 Rural Locality Network Meeting, 2-5pm, Tuesday 11 July 2017, Barbour Institute, Tattenhall Chair Andy Campbell (Chair) APPROVED Name Practice Name Practice Manager Name Jonathan Gregson Helsby Brian Yorke Helen Black Bunbury Alan Courtenay Kylie Daniels Kelsall Julie Johnson Louise Davies Malpas Lynn Suckley Andy Campbell Tarporley (Campbell) Sue Dewhirst Alistair Adey Tarporley (Adey) Samantha Jeffrey Steve Pomfret Princeway Paul Smith Melissa Siddorn The Village Surgeries Kate Evans Practices not represented by a : N/A In attendance Sarah Murray Head of Primary Care (WCCCG) Colin McGuffie Locality Project Manager Diane Taska Membership Support Officer (Minutes) Matthew Adams Project Manager CAMHS (WCCCG) Agenda Item 4. Amanda Ridge Head of Planned Care (WCCCG) Agenda Item 5. Agenda No Action 1. Welcome & Apologies The Chair welcomed Rural Network members to the meeting and in particular Dr Jian Hor, Reg, Bunbury. Apologies were received from Steve Pomfrett and Louise Davies. Declarations of Interest No new declarations of interest were raised. Code of Conduct Network members were reminded of the meeting s code of conduct. Previous Minutes The minutes of the previous meeting (June 2017) were approved as an accurate record of the meeting. The Network noted there are currently 2 nurses that have the competencies to undertake complex dressings in the Extended Hours service with a 3 rd nurse currently being trained. A further update will be provided in due course. Minutes of Rural Network 1

10 An updated Extended Hours service timetable is now attached below for your information (page 6). 2. Financial Update/ CCG Update The Rural Network noted the CCG s financial position. The deficit of 11.7m remains unchanged with a 900k QIPP gap. The outstanding QIPP gap carries significant risk if the current schemes do not fulfill their potential. The Repeat Prescribing project should realise more savings than planned and NHS England are more assured than in recent times about the CCG s Financial Recovery Plan. It was noted the CCG will shortly be writing to community pharmacies to advise them of the savings made to date through the Repeat Prescribing scheme and thank them for their support. Sarah updated the group that the Extended Hours provision at Tarporley Hospital on Sunday would continue though there would no longer be an Out of Hours service. It is anticipated that the capacity available within the Extended Hours service would be able to cater for patient demand to see a. 3. Primary Care Cheshire Update (Including ACO/ACS developments) The Network noted a strategic body has been formed with terms of reference and a Governing Body to make decisions for the 4 CCGs that will sit below it (West Cheshire, South & Vale and East Cheshire). Brian Yorke, Primary Care Cheshire (PCC), provided the attached update to the Network: PCC ACO update.docx The Rural Network also noted that PCC has recently appointed a Programme Director, working 3 days a week and it is hoped this person will attend (part) of future Network meetings to update on PCC s work. 4. Engaging s in CAMHS Transformation Matthew Adam, Transformational Lead, West Cheshire CCG, was welcomed to the meeting with an update on the CAMHS mental health transformation in line with current legislation and the following presentation was provided: Presentation a.pptx The Network noted overall the transformation of mental health in CAMHS is about early detection and prevention and an increased access to mental health support by multi agency services. The Network noted currently the CCG is working with the local Minutes of Rural Network 2

11 Authority (evidence based work) with schools. Schools are in some instances inappropriately referring children through the Behavior Pathway to the and the CCG is aware of this and addressing issues with schools. Practice nurses have met with local schools and fed back that pupils sometimes do not know their school nurse and therefore there is a gap in offering these children support. It was noted the attached presentation contains links to resources that s might chose to use to support referrals through in to the system. 5. Planned Care Update Amanda Ridge, Head of Planned Care provided an update on Planned Care and the attached Accenda data was provided: Copy of Accenda dashboard.xlsx The original anticipated outcomes of implementing the Accenda system included: reducing admin workload in primary care enabling them to take on additional admin responsibilities, thus freeing up clinician time supporting demand management in secondary care, ensuring only appropriate referrals are progressed through into secondary care ensuring that patients are sent to the most appropriate specialty providing timely information/insight about the referrals that are being made, providing additional transparency it also supports the NHSE directive for CoCH to be paper light by 2018 The issues around the Accenda backlog were raised and it was noted that the initial guidance provided by Accenda recommended 4 members of staff to man the Choice Team and the associated workload which has proved to be incorrect. Other CCGs using the Accenda system have had the production of letters outsourced to a bureau for printing, this will be implemented by CWP for West Cheshire from September. The Network noted patients with an urgent referral appear at the top of the list so there is no delay. Some practices have taken referrals back in-practice which has also helped reduce the backlog in the interim period, practices were thanked for this. An evaluation of the Accenda referral system will be carried out Minutes of Rural Network 3

12 between August and October after which outcomes will be shared with practices. The Rural Network asked if Accenda is reducing referrals. The CCG is working with CoCH to address the number of Specialties that are triaging referrals. Currently there are 1200 referrals outstanding (from 20 June 2017), it is anticipating this will be cleared by the end of summer The dashboard shared with practices on a regular basis from the CCG provides a trends tab which will provide practices with information around trends and themes that are emerging. The Network highlighted that in the outcome column on the Accenda system the terminology booked is misleading as the patient isn t actually booked at that point but referred through to the acute trust for allocating an appointment. Action: HB to provide AR with examples of patients appointments sitting in the outcome column as booked but who have not yet received an appointment. HB/AR Next Steps: The final specialties will be live on the Accenda system by the end of July and an evaluation will be carried out throughout August, September and October. Outcomes will be shared with the Networks in due course. Health Optimisation: It was noted a working group including senior colleagues from the CCG, CoCH, CWP and PH has now agreed a pre-operative health optimisation pathway which enables patients to be referred in to weight management and other programmes before surgery to provide these patients with the best possible outcomes from surgery. All principles have been acknowledged around patients health before surgery (ie: high bmi/smoking and excessive alcohol consumption) in designing the pathway now attached for information: July Networks Health optimisation pr A communication strategy is planned from 1 September 2017 in order to engage patients and stakeholders and ensure the whole of the health economy has a consistent approach before it is implemented as a pathway from November Network members highlighted the potential for patients to come back to primary care to ask for letters so as they are excused (a get out clause) from the policy if they are over- Minutes of Rural Network 4

13 weight or smoke, so, the message coming from secondary care must be consistent and aligned to what primary care are telling patients. The CCG is meeting Public Health and Brio Leisure to ensure there is enough capacity and availability within their services eg: the Weight Management programme, should the volume of their work increase. However, Brio Leisure doesn t have a weight management programme in a rural setting as they there aren t the Local Authority run venues for them to use, Amanda Ridge will pick this up with Brio when she meets with them, for feedback at the September Network. Action: AR to link in with Brio around the lack of provision of a rural weight management programme etc. Updated Procedures of Limited Clinical Priority Any Questions: The Network noted the summary from the updated policy, Procedures of Limited Clinical Priority, included in the papers. Additionally, it was noted that Intrauterine Insemination (IUI) is available to all couples (same sex also) and patients seeking varicose vein operations will be referred on to a 6 month self-management (compression) programme. It was noted an individual funding request can still be submitted to the CCG if there is a special case for consideration. Headache Pathway/Neurology: The Rural Network noted the Headache pathway and neurology papers included with the agenda. This pathway will also go to the Rolling Half Day in December. There are now generic neuro nurses at Fountains that s can refer into for ie: MS and Parkinson s along with a neuro advice line, (number included in the papers). The Consultant Advice Line (CAL) number for s to use is Find out more about the CAL by clicking here: INNS (Integrated Neurology Nurse Specialists) Minutes of Rural Network 5

14 6. Future Agenda Items Brio Leisure MacMillan Cancer Update Agreed September 7. Any Other Business Next Meeting: The Rural Network noted the Nursing Home LES is progressing and an update will be provided to the September Network meeting. PMS developments: Monies from PMS practices will be recycled to all practices in due course. No further business was raised. Tuesday 12th September Barbour Institute, Tattenhall, pm E Port & City Network Minutes June2017 attached separately to the as too large to embed. Minutes of Rural Network 6

15 Overview of Extended Hours services available from the different locations w/c 14 th August 2017 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1829 Building Countess of Chester Health Park Ellesmere Port Hospital Tarporley War Memorial Hospital Helsby Health Centre Nurse Counselling Nurse* Wellbeing 18:30 20:00 18:30 20:00 tbc Neston Surgery 18:30 21:00 tbc Laurel Bank Surgery, Malpas 18:30 20:00 tbc Nurse* Wellbeing 18:30 20:00 tbc Nurse Counselling Nurse Wellbeing 18:30 20:00 Nurse tbc tbc Nurse Wellbeing Nurse 18:30 20:00 Counselling tbc 18:30 21:00 Nurse tbc tbc tbc Nurse 18:30 20:30 from tbc Nurse* Nurse* Wellbeing 18:30 20:00 tbc 09:00 14:00 Nurse (09:00-18:00) Wellbeing (09:00 13:00) 09:00 14:00 Nurse (09:00-18:00) Wellbeing (09:00 12:00) 09:00 14:00 Nurse (1 session /month) 09:00 12:00 09:00 14:00 Nurse (09:00-18:00) (09:00 11:30) from Counselling 09:00 14:00 Nurse (09:00-18:00) (09:00 11:30) from Wellbeing 09:00 14:00 Minutes of Rural Network 7

16 Note: Counselling and Wellbeing Co-ordinator sessions are arranged by the service themselves from their patient lists. All other appointments can be booked through Single Point of Access (SPA) team: Opening hours 08:00 20:00; seven days a week Tel: Option 3 These services are also available through EMIS Cross-Organisational Appointment facility (more nursing sessions to be available via EMIS over next few weeks). * shows regular session that may not be delivered this particular week. This could be due to annual leave or if service seeking to confirm availability of clinician Red font indicates service to be delivered and are to be finalised Minutes of Rural Network 8

17 Outstanding Actions Key: Red Overdue Amber On-going NB: Actions will be taken off the table upon completion Green Completed Blue For future / On agenda Date Initiated Action By Whom Due Date 11 April 2017 SJ to meet with CWaC re: Turning Point and feed back to the June meeting. SJ October agenda COMPLETE June 2017 Sarah Murray to feed through to the Strategic Medicines Managers Group that CoCH Consultants are still prescribing over the counter medications upon discharge and feedback to the September meeting. SM September 2017 June 2017 SM to liaise with the Extended Hours Service to identify nurse capacity to enable complex dressing service to continue/resume (in the short term) and feed back to the July meeting. SM Further feedback to the September 2017 meeting July 2017 HB to provide AR with examples of patients appointments sitting in the outcome column of the Accenda system as booked but who have not yet received an appointment. HB COMPLETE Actioned by AR and Carl Jones July 2017 AR to link in with Brio Leisure around the lack of provision of a rural weight management programme etc. (AR has linked in with Health Box who do provide weight management and other facilities in the rural area which will compliment Brio Leisure services.) AR Feedback to the September 2017 Network meeting Minutes of Rural Network 9

18 Minutes of Rural Network 10

19 Minutes of Rural Network 11

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