Ketton Closure Proposal

Transcription

1 Ketton Closure Proposal Introduction An initial Business Case for the closure of Ketton Surgery was submitted in June 2017 to East Leicestershire & Rutland Clinical Commissioning Group. Following the PCCC meeting held on Tuesday 4 th July, the Committee: Noted that the Practice plans to reduce 1 GP session at each of the branch surgeries for a maximum of 6 months with immediate effect Recommended that the Practice commences a full public consultation on the proposal to close the Ketton Branch Surgery Agree the Practice provides the Committee with a full detailed options appraisal including plans for Practice sustainability. The initial Business Case also for the closure of Ketton included a review of all of the branch surgeries.

2 Business Case for Closure of Ketton Surgery Background Mission Statement We Care About Your Wellbeing At Uppingham Surgery we aim to provide the highest standard of Primary Care for all our patients delivered in a caring, compassionate and friendly environment. The Partners Vision To be an exemplar of Primary Care provision for the people of East Leicestershire and Rutland. We seek to expand and enhance our reputation for excellence and, in federation with like-minded neighbouring practices, deliver an integrated health and social care network funded, staffed and equipped for the demands of our patients now and in the future. The Practice is committed to providing a high standard of care that is consistent across all sites and the whole practice population. Unfortunately, the current position does not support this organisational objective. Therefore the Partners are reviewing a number of options regarding the continuation of services at the branch surgeries, which will consider the impact on patients, their care and the long term sustainability of the Practice. Options for consideration are: Continuation of services as they currently stand at all sites Replacing GP sessions with other clinical staff Reduce the number of sessions at Ketton Reduce the number of sessions at other branch sites Close the Ketton branch surgery Close all branch surgeries The aim of the report is to identify a solution that will ensure the continuation of quality healthcare provision for all patients registered with Uppingham Surgery. Present position and issues Ketton As of September 2017, the Practice has reduced the number of GP sessions available at Ketton (a reduction of two sessions down to one session per week). This is in response to a reduction in working hours and change of working week for the GP that usually attends Ketton Surgery. The nurse clinic at Ketton has been swapped from a Friday to a Monday to accommodate the change in the GP s working pattern.

3 Barrowden The Practice has also elected to reduce the number of nursing sessions at Barrowden from two per week to one, as the demand for nursing appointments was not sufficient to fill two sessions per week. The Practice has taken the decision to reduce the sessions in the short term, as approved by the Primary Care Commissioning Committee (PCCC). This decision was made by the Partners after an extensive recruitment campaign to try and recruit additional clinical staff to fill vacancies. The PCCC has only given approval for the reduction in sessions for a maximum of 6 months up to 31 st December 2017 therefore a long term solution needs to be found. Facilities and Access The standard of the facilities vary between the sites and this in turn affects the type of services that can be offered at each site. The Uppingham Surgery main site (Uppingham) is the only site where a full range of services can be offered. Appendix A Range of services There is limited on-site parking at Gretton, Ketton and Barrowden and ample parking at Uppingham. There is on road parking available at Barrowden and Gretton and some on-road parking at Ketton, although this is restricted due to the location (close proximity to the main road). The Practice rents the three branch site buildings. Gretton and Barrowden are used solely by Uppingham Surgery and therefore offer flexibility in the days and times that clinics can be run. Ketton Surgery is a shared building with Ketton Library, so access is restricted to pre-determined days and times. Rutland County Council previously confirmed that these sessions cannot be moved and the Practice has asked for confirmation if this is still currently the case. Each branch site reception area is fairly small. This makes patient confidentiality an issue, as there is not adequate space to place the reception desk away from the main waiting area. Human resources Uppingham Surgery, like GP practices nationally, has had difficulty in recruiting GPs to fill vacancies left by the reduction in sessions from GP Partners and Salaried GPs. In 2017 Uppingham Surgery has seen a reduction in GP sessions, with locums employed to cover maternity leave. The practice anticipates a permanent reduction in GP sessions for 2017 from 59 sessions per week to 53.5 sessions, as follows:

4 Total number of sessions worked per week by GP Partners and salaried GP s Pt r1 6 Ptr 1 8 Ptr 2 8 Ptr 2 8 Pt r3 8 Ptr 3 8 Ptr 4 8 Ptr 4 8 Ptr 5 7 Ptr 5 6 Sal 1 4 Sal 1 4 Sal 2 8 Sal 2 6 Sal 3 4 Sal 3 3 Sal 4 6 Sal Uppingham Surgery has advertised extensively through the following channels to recruit: NHS Jobs Indeed Internal (Leics) staff mailshot LMC website Practice website British Medical Journal Recruitment agencies Social Media The Practice also created its own careers website The Practice has also used a number of locums to fill individual sessions on an adhoc basis but locums are not always available for the sessions required and locum cover does not provide the best continuity of care for patients. Locums also have a limited remit and do not cover home visits, telephone triage or administration (medication reviews, pathology results, incoming clinic letter processing). The Practice has explored alternative solutions to the GP recruitment problem and recruited a range of clinical staff, with a broad range of specialist skills. GPs Nurse Practitioners Practice nurses MSK Practitioner Clinical Pharmacist The Practice has been working to develop a system whereby patients are signposted to be seen by the person most appropriate to their needs.

5 This system also means that the GPs have more capacity to deal with complex patients and the additional work associated with having a patient list and Partnership matters. Branch surgeries have a limited number of appointments available so there is not the flexibility to book patients in with the most appropriate person. Patients who usually attend the branch surgery may see a GP for a minor illness or medication review because they are the clinician attending that particular day. It may be more appropriate for the patient to come to Uppingham to see a different clinician. Branch surgery patients may need to travel to Uppingham if they have an acute problem that requires on the day attention. As well as a clinical member of staff, there also needs to be a support member of staff at each site. Each branch site is dispensing and so the member of staff at each site must be qualified to dispense. Medication then also needs to be checked by another qualified member of staff (as per dispensing policy). If a member of staff due to attend a branch site is unexpectedly absent it can be difficult to find a replacement to go out to a branch, whereas the additional work, or appointments, may be more easily absorbed by the rest of the team in Uppingham. Internet connectivity is poor at the branch surgeries, which makes it difficult for staff to access information and documents and the clinical system can be very slow at branch sites. The Practice is aware that there will be occasions where employees are working alone at branch sites. Although the Practice has a Lone Worker Policy, employees at branch sites are vulnerable, as there would be limited assistance available in an emergency. Each site stores and dispenses medication and handles cash. Demand for Appointments Uppingham Surgery currently provides services at four sites for approximately 10,800 patients. The BMA recommends that a minimum of 72 appointments should be provided per week 1 per 1000 patients. It is important the Practice can provide sessions for patients in line with these recommendations and that the number of appointments available at each site is in proportion to the number of patients who chose to use those sites. The demand for appointments is likely to increase significantly in the near future, as the Uppingham Neighbourhood plan proposes the allocation of land for 170 new homes by 2026 in Uppingham.

6 The Practice currently aims for a rota that allows for 1 GP session time for approximately patients across the sites to fulfil this minimum requirement. The current provision is: Site Number of registered patients Number of GP sessions provided Ratio of number of sessions to patients Uppingham * 1/ Ketton / Barrowden / Gretton / Number of recommended GP appts per week *where there is sickness or annual leave to be taken, this number is reduced, rather than branch surgery clinics cancelled to minimise impact on branch surgery patients. The Practice has carried out an audit of number of appointments currently offered at the branch sites and whether those appointments are utilised. Appendix B Appointment utilisation A typical AM GP Session at Branch site will have 22 telephone appointments and 14 face to face appointments. A PM session would have 4 telephone appointments and 11 face to face appointments. A nursing session (all nursing sessions are AM so that bloods, samples and swabs can be returned to the main surgery for pathology collection) would typically have 17 face to face appointments and 2 telephone appointments. Finance Supporting four sites has a significant financial cost to the Practice and the Clinical Commissioning Group (through rent, business rates, clinical waste and water reimbursements). Each year, the Practice receives an average uplift in funding of 1% for core services, but employee, utility and consumable costs are increasing at a greater rate or approximately 6% per year. Funding for enhanced services is changeable and any small incremental increases are effectively cuts when inflation is factored in. Please see appendix C Annual running costs for branches Regulatory - CQC compliance Uppingham Surgery is proud to have a Good CQC rating. Each site is required to meet and maintain the standards needed to comply with legal and CQC regulation.

7 This includes compliance with standard business regulations such as fire, health & safety and Legionella, as well as those specific to a healthcare setting such as infection control, medicines management and medical information governance. Each site must be assessed and regularly audited for compliance. Protocols and policies must be site specific and easy to access. Given the current challenges faced by the Practice, the partners at Uppingham Surgery are considering the following options: Option one Continuation of services as they currently stand at all sites The Practice has had to reduce the number of sessions at Ketton and Barrowden as a short term solution to the problem of clinical staff shortages. Despite the recruitment drive, the Practice has been unable to fill all of the vacant sessions with a reduction of 5.5 GP sessions per week. This has meant that the Practice is unlikely to be able to continue to provide the full service provision at all of the branch sites without impacting on the services at Uppingham. The appointment audit indicates that there is a greater percentage of unused appointment slots at branch sites and approximately 54% of appointments are telephone appointments, which can be conducted at any site. The running costs of the branch sites are likely to continue to increase at a greater rate than the funding available to provide the services. Maintaining two GP sessions per week at each branch site would mean the Practice would need to employ the services of locum GPs to cover three sessions per week at Uppingham, at a cost of approximately 42,120 per annum. The Practice are responsible for keeping the branch sites in good order and will have to continue to invest in equipment, repairs and maintenance to ensure that they continue to meet the standards required by the Care Quality Commission. The Practice would need to continue to invest in training to ensure that each branch was staffed with a qualified dispenser, who was also sufficiently trained in patient services skills. The Practice would need to provide cover at the branch sites for any absent staff. Impact on Patients The continuation of services as they currently stand will mean that the patients registered with branch surgeries have a greater number of appointments available to them than are required. Branch surgery patients will have to come to Uppingham for an appointment if they require a service that is not available at their branch or if they have an acute condition that needs to be treated on a day that their branch is closed.

8 Patients registered at the branches will be able to see their registered GP at one of their sessions but will need to come to Uppingham if they wish to see a different GP. Patients will be able to collect their prescription at least three days per week from a branch site. Option Two Replacing GP sessions with other clinical staff Patients who are usually treated at the Uppingham site may be triaged and signposted to see other clinicians who are appropriately qualified to deal with their illness. Replacing some of the GP sessions at the branch site with other clinicians will free up GP time to see more complex patients and deal with administration. Patients with minor complaints and acute conditions would be able to see a Nurse prescriber, Pharmacist, or Nurse Practitioner. Problems with this solution might be that these clinicians occasionally need to refer back to a GP if the illness is more complex than first thought, or the patient presents with a number of complaints that need to be dealt with by a GP. There is also the probability that not all of the appointments slots would be filled, as the range of issues that can be dealt with by one of these practitioners is more restricted than those of a GP. Branch Surgeries are open for limited times, so there is always likely to be a demand for both routine and acute appointments within the same session. The Practice would need to determine which clinicians should attend the branches to make the most appropriate use of the appointments provided. There will need to be more appointments available at the main Uppingham site to deal with more complex conditions that cannot be treated by someone who is not a GP. There will be some staff cost savings if one GP session a week at each branch were covered by another clinician, as it could reduce the GP locum cover required at Uppingham by three sessions per week (saving 42,000). The running costs of the branch surgeries and the cost of support staff would not be reduced, as the sites would still be open for the same duration as they currently are. Impact on Patients The clinician attending the branch may not be able to deal with the full range of conditions that patients present with. Patients may need to attend Uppingham for more complex problems. This may not be immediately apparent when they first present, so could result in duplication of appointments- seeing a nurse for one condition then travelling to Uppingham, or seeing a GP for a separate appointment. Patients would continue to be able to collect prescriptions from their branch at least three days per week.

9 Option Three Reduce the number of sessions at Ketton This is the option that has been taken in the short term largely due to the fact that it is the GP that would usually attend Ketton who has significantly reduced her working hours. Reducing the number of sessions at Ketton from three to two would bring the ratio of appointments available per patient in line with the other branch sites. Currently, the number of appointments/sessions at Ketton is disproportionate to the number of patients using the site. Reducing the number of sessions would bring it line with other branches. Site Number of registered patients Number of GP sessions Ratio of number of sessions to patients Number of recommended GP appts per week Number offered Ketton / telephone 13 face to face Barrowden / telephone 23 face to face Gretton / telephone 23 face to face Reducing the number of sessions would also reduce some of the running costs - including cleaning, dispenser/receptionist time and travel expenses. Business rates and service charges would be reduced as these are currently charged in proportion to the hours of use at the premises. Impact on Patients The patients would only be able to collect their prescriptions two days a week instead of three. Patients may need to travel to Uppingham if they need to be treated before the next available GP session. Patients would have less choice for dates and times of appointments. An audit of appointments in 2016 showed that 54% of patients registered at Ketton had not been to an appointment in Ketton in the previous 12 months. Only 70% of appointments actually attended at Ketton in that period were patients registered at Ketton.

10 Option Four Reduce the number of sessions at all Branches Reducing the number of sessions that the branch surgeries are open would offer more rota flexibility at Uppingham. The cost of running branch surgeries would decrease if the opening hours at each branch were reduced. Locum costs to cover sickness and annual leave would also be reduced if there were fewer GP sessions. Uppingham Surgery is a training Practice. Having more GPs at the main site means that the registrars can be supervised and have tutorials more easily and with a wider range of GPs. The dispensers, who cover the reception desk at each branch site, would spend more time based at the main Uppingham Surgery site. One of the branch surgery dispensers currently works solely at a branch site and another spends 50% of her working time at the branch site. Bringing the dispensers back to the main site would mean that they have more training and development opportunities as they would be spending more time with their peers and line manager. They would also be available to attend meetings. Impact on Patients The number of days that patients would be able to collect prescriptions would be reduced from three days to two days per week. Patients would need to attend the main Uppingham site for acute conditions that cannot wait until the next branch GP session. Option Five Close the Ketton Branch Surgery Ketton surgery is the least effective site to run, as the appointment availability and costs of running the site are disproportionate to the number of patients registered at the site. The premises are shared with the Library and there is very little flexibility to alter the clinic days and times to fit in with the needs of the Practice, as they evolve. There is only one clinic room available at Ketton so there is no appropriate place for a patient to wait for an ambulance. Also, there have been two occasions in recent months when there has been flooding on the floor of the clinical room and no alternative room to use. Ketton has the largest number of underused appointments and of the appointments that are used, 24% of the patients seen neither live in Ketton nor have their medication dispensed at Ketton. The GPs and reception staff report that patients

11 who would not usually attend Ketton surgery are offered appointments at the branch because that is where there are available appointments on the day. Ketton has the fewest number of village residents registered with Uppingham Surgery, despite being the largest of the branch surgery villages, with only 17% of the residents registered at the Practice. When the surgery relocated from Geeston to the Ketton Centre (library) it was anticipated that the percentage of residents living in Ketton registering with the Practice would significantly increase.,as the new Practice was in a more central location.this has not been the case, despite the branch surgery offering the same number of appointments as Gretton Surgery. The Partners agreed to support the relocation project on the proviso that the service provision would be reviewed after five years to ensure that it was still sustainable. Village No. residents (2001 census) No. Residents (2011 census) % population increase No. Residents registered with Practice (not all have elected to go to branch surgery) % Residents registered with Practice Ketton % % Barrowden % % Gretton % % Ketton is the farthest branch away from Uppingham and is the closest in proximity to another Practice (Empingham Medical Centre is 2.9 miles away from Ketton). Option Six Close all the branch surgeries Closing all of the branch surgeries would present a number of risks and opportunities for the Practice and patient care. Opportunities Having services run from a central location mean that there can be more efficient use of clinical and non-clinical staff time. There can more flexibility with the rotas and workload can be distributed according to changes in demand on any particular day. Home visits can be coordinated more efficiently. There would be an increase in appointments at Uppingham of approximately 734 GP and 252 nursing appointments per month.

12 Patients can be offered a greater choice of clinicians and have an appointment with the most appropriate person, or choose a female/male GP if preferred. Working at one site is safer for staff and patients as there is minimal chance of lone working. Single site working allows for more training and development opportunities, as staff will have easier access to the support of their colleagues and line managers. The standard of service and the range of services are consistent for the entire patient population. Patients have access to a wider range of services, such as the wellbeing advisors, screening services, family planning and the opportunity to speak to specifically trained administrative staff for advice on non-medical issues such as support with online access. Additional staff training can be focused in new areas, such as website administration, phlebotomy and dementia champions, as there will be fewer qualified dispensers required (the Practice usually has at least one member of staff on an NVQ dispensing course at any one time). Safety risks are reduced as there is no transportation between sites of medication, prescription paper, confidential documents and samples. The main site has more modern facilities including separate clean and dirty utility rooms and treatment rooms fitted to surgical specification. There is sufficient parking at the main site to cater for the number of staff and patients attending at any one time. There will a reduction in running costs for the practice as travel costs, consumable costs, heating and lighting, waste, fire and security costs for the branch sites would be eliminated. There will be a reduction in costs to the CCG, as there will be no rent, business rates and clinical waste reimbursements to be claimed. It will be easier to manage medication stock control and drug disposal. The practice could develop IT communications, such as the Practice intranet. The branch surgeries do not have adequate IT connections to easily access shared documents and the internet. There are also CCG plans to have patient wi-fi in reception areas which may not be possible at branch sites. Risks The Practice could potentially lose patients to neighbouring practices if branch sites close, as there are close Practices to their home than Uppingham.

13 Appendix D Proximity of branches to other Practices (including public transport links) Closing all branch sites has an impact on the Business Continuity Plan- if there is an emergency situation at Uppingham services cannot be redirected to branch sites. There may not be sufficient space available at Uppingham to accommodate the staff and clinics that would have been at the branch sites (although the number of appointments that are not utilised at the branches would suggest that not all of the 9 sessions lost from the branches need to be transferred to Uppingham). The demand for home visits and prescription deliveries may increase as patients may find it more difficult to get to Uppingham. Patients who use that branch surgeries frequently, especially for prescription ordering and collection are likely to be very disappointed if they lose their branch surgery. Patient satisfaction in the branch surgeries is currently high. There is a risk that this will decline if the branches close. Source Healthwatch Rutland Primary Care Survey June 2017 Data has not yet been collected by Healthwatch Northamptonshire for the Gretton Surgery. Closing all of the branch sites would mean that there are too many employees based in the dispensary at Uppingham. The Practice may have to consider cuts to working hours or possible redundancies. Recommendation for closing Ketton Surgery It has been established that the practice cannot sustain the practice branches as they are, due to recruitment issues, rising running costs and the underutilisation of appointments. Centralising services from the main site at Uppingham would provide a more consistent service to all patients and allow for more flexibility and resilience in staff cover. An audit of appointments at Ketton demonstrated that only 70% of appointments attended there were actually patients living in Ketton. The remainder of

14 appointments are offered to patients who would not usually attend Ketton but did so because they were available. Closing all of the branch surgeries at the same time would be very difficult logistically. It is evident that Ketton Surgery is the most underused Practice. Despite the relocation from Geeston on the outskirts of the village to a central location in 2012, there has not been a noticeable increase in the number of Ketton residents registering with the Practice (only 17% or village residents are registered with Uppingham Surgery). This site offers the fewest facilities (only one clinical room) and the least flexibility in appointment days and times, due to the shared space. The dispenser working at Ketton currently splits the day between Uppingham and Ketton, so has to travel between the sites each day the branch is open. If this branch is closed then the time would be spent at Uppingham, reducing traveling time and allowing for more dispensary rota flexibility and cover for the other branch sites. There would be no need for a reduction of working hours. Some of the patients that currently use Ketton surgery may elect to join Practices in Empingham or Stamford. Others may opt to use Uppingham or Barrowden surgery, which is within 5 miles of Ketton and also in close proximity to the villages of Collyweston, Duddington, Tixover and North & South Luffenham. There is also a bus service that operates every two hours between Uppingham and Stamford via Barrowden and Ketton, providing a public transport link for patients to use either Barrowden or Uppingham Surgery. By closing Ketton Surgery, the Practice would be able to deliver a more consistent service to the majority of patients. By offering more GP appointments at the main site and giving more flexibility in appointment times to patients, there would be a reduction in the number of cancelled or re-arranged appointments, as the clinicians based at the main site can absorb any unexpected absences more easily. The closure would see an increase in appointment availability at the main surgery site for face to face appointments by approximately 39 appointments per week.

15 Increase in GP face to face appointments Increase in GP telephone appointments Increase in Nurse face to face appointments Increase in Nurse telephone appointments Total Per week The closure of Ketton would reduce the necessity for locum cover for at least the 12 sessions per year that provide cover for the branch GP annual leave (a cost saving of approximately 3,240) and further savings where cover is required for sickness or study leave absences. The GP that would usually attend Ketton would also be available to cover sessions at Uppingham, further reducing the necessity for locum cover. There would be an immediate saving on the site running costs of the Practice of 3,694 per annum for services and utilities and 1,053 on travel expenses for staff travelling between sites. There would also be a reduction on dispensary staff overtime payments, as there would be an adequate level of staff at the main site to cover annual leave and sickness. The Ketton dispensary currently holds stock at a level of approximately 5,000. Closing Ketton would assist in stock management and reduce the level of stock needed to be held at any one time. The Practice would also be able to bring back equipment from the Ketton site, such as vaccine refrigerators, couches and BP monitors. Money saved on equipment purchase and maintenance costs can be reinvested into buying additional equipment to support patient care, rather than duplicates of existing equipment. This could include diagnostic equipment (dermatology scanner) or patient blood pressure monitors. Resources may be utilised to develop IT projects. (The Practice is keen to link up with other local health and social care providers to create an online information portal for patients). Consideration is being given to having an online station in the reception area, with a tablet, so that patients can be assisted in finding information on the website, or learning to use the online access services, with support from a member of staff. Uppingham Surgery has recently held some successful open day events for patients including a Memory Matters Day, Diabetes information event and Online access day. The Practice would like to like to hold more events, as patient feedback from the events has been very positive. Bringing more resources back to the main

16 would mean the Practice has greater capacity, both financial and in human resources, to continue these events. Investment can also be made into training for both clinical and non-clinical staff. The Practice would be able to fund further courses such as chronic disease management for nurses, and NVQ training for dispensers and administrative staff, all of which will enable to the Practice to improve patients care. The Practice has considered how this decision would affect different patient groups using the Ketton site. Older people There are 123 patients registered with Ketton surgery aged 60 or over (43%). Patients at the care home in the village Chater Lodge are registered with a Practice in Stamford. The Practice acknowledges that there may be an increase in demand for GP home visits for some patients who are unable to get to the main site in Uppingham. The Practice also has a nurse who provides a home visiting service to carry out annual reviews and influenza vaccinations. The Practice is also engaging with the PPG and village Good neighbour schemes to assist with prescription ordering and delivery services. People with long-term conditions The main site at Uppingham offers a full range of services and a greater number of appointments are available to see clinicians that specialise in specific conditions. The Practice has introduced online prescription ordering and an automated telephone ordering system for those patients on repeat medication, so ordering is not restricted to the opening times of the surgery. Families, children and young people There is a wider range of services for families, children and young people at the main site that cannot be provided at the branch surgery. These include- antenatal clinics, baby immunisations (appointments are sent by Bridge Park Plaza for Uppingham clinics), health visitor clinics, family planning & contraception. Working-age people (including those recently retired and students) The appointment times available at Ketton are during working hours. The main site offers extended access appointments from 7.40am on two days and up to 7.30pm on a Monday. There is a greater flexibility in the appointments available for patients that have to work around other commitments.

17 People whose circumstances may make them vulnerable Ketton Surgery does not have adequate space in the waiting area, or in the clinical room to offer patient confidentiality. There is no separate area where patents can be taken away from other patients waiting. There is no opportunity to have a chaperone at the branch sites, as there is only one other member of staff, who is required to be in the reception area. There are more staff at Uppingham available to assist those who are vulnerable. There is a wellbeing advisor in the reception area available to help vulnerable people with non-medical issues. People experiencing poor mental health (including people with dementia) Uppingham has a mental health advisor and wellbeing advisor who work alongside the GP to help people with poor mental health. The main site offers a safer environment for both staff and patients dealing with those with mental health issues. People with mental health issues and dementia will benefit from consistency of care, which is easier to deliver at the main site. Patient and Public Participation (PPG) The Practice has engaged the PPG and they are aware of the difficulties with GP recruitment and support the Practice in the changes it has made. PPG Meeting minutes 4 th July 2017 However the recruitment of GPs is difficult and this is clearly a national problem. One GP has already left the Practice and has not been replaced; another is reducing the number of hours worked. This means that, from September, there will be less GP time available to patients. The Practice is very aware of the need to retain present GPs. Nor do they want to lose the good outcomes of a successful Practice and the service offered, for example same-day appointments and named GPs. Consequently they are considering ways to use staff differently by taking on more Advanced Nurse Practitioners, a Physiotherapist to run an advisory clinic and a full time Pharmacist who would deal with the management and reviewing of prescriptions. This would allow the GPs to focus on more complex needs while still seeing patients. Members supported the changes in organisation to ensure best service to patients does continue, and will circulate further information once it becomes available as they cover most local areas. The Practice plans to work with the CCG to undertake a formal stakeholder consultation. This process will include a public meeting(s) with representatives from the Practice attending and surveys sent to patients attending Ketton Surgery. Surveys will also be made available in Practice and via the Practice website for all patients registered with the Practice.

18 Appendix A Range of Services available at each site Site Service Uppingham Barrowden Gretton Ketton GP Advanced Nurse Practitioner Practice Nurse Pharmacist MSK triage Dispensary Blood tests Well woman (implant, IUCD, cervical smears) Midwife - Antenatal Health Visitor Private services Osteopath, Physiotherapist, Podiatry Retinal/AAA screening Immunisations & Vaccinations Chronic disease management Wound care/dressings Ear Syringing Minor Surgery Wellness Advisor Extended Hours NHS Health Checks Chaperone

19 Appendix B Appointment Utilisation Barrowden Surgery Dr Total Slots Dr Unused Slots Nurse Total Slots Nurse Unused Slots Gretton Surgery Dr Total Slots Dr Unused Slots Nurse Total Slots Nurse Unused Slots Ketton Surgery Dr Total Slots Dr Unused Slots Nurse Total Slots Nurse Unused Slots Jan Jan Jan Feb Feb Feb Mar Mar Mar Apr Apr Apr May May May Jun Jun Jun Branch Site % GP Appointment slots unused % Nursing appointment slots unused Barrowden 29 % 22 % Gretton 28 % 15 % Ketton 41 % 25 %

20 Appendix C: Annual running costs for branch surgeries Costs included are those that are variable across each site. Other costs such as treatment room consumables, stationery and equipment repair/calibration costs are consistent across each site. Barrowden Gretton Ketton Rent 6,950 12,500 4,750 Rates 1,398 1, Water ** Clinical Waste Total (reimbursed by CCG) 9,369 15,061 6,173 Electricity & Gas 1, ,579 Non clinical waste ** Telephone Cleaning 2,962 2,410 1,607 Fire & Security GP 18,362 18,362 18,36 Nurse 5,842 5,842 5,842 Dispenser 14,485 14,485 14,485 Travel expenses 281 1,123 1,053 Total (Practice costs) 44,603 44,379 43,436 Number of registered patients per branch Cost per registered patient per annum to practice Dispensary stock held 13,371* 9,760 5,006 *Barrowden dispenses medication for all Dossette system patients ** Mains utilities costs are combined in an overall service charge noted in the Electricity & Gas Section

21 Appendix D Proximity of branches to other Practices (including public transport links) Ketton Empingham Surgery 2.9 miles St Mary s Stamford 3.6 miles The Little Surgery Stamford 3.6 miles The New Sheepmarket Stamford 4.1 miles Kings Cliffe Surgery 5 miles Wansford & Kings Cliffe Practice 6.8 miles The Uppingham Surgery 7.5 miles Oakham Medical Practice 8.1 miles

22 Appendix D Proximity of branches to other Practices (including public transport links) Barrowden Kings Cliffe Surgery 4.1 miles The Uppingham Surgery 5 miles Empingham Surgery 5.3 miles St Marys Stamford 6.7 miles The Little Surgery Stamford 6.7 Weldon Branch Surgery 6.8 miles The New Sheepmarket Stamford 7.2 Barrowden, opp Church Lane Next departures 12 Uppingham 12:01 12 Uppingham 14:01 12 Uppingham 16:01 12 Uppingham 17:26 12 Uppingham 17:26 12 Uppingham 18:10 Tuesday 47 Peterborough 07:31 12 Uppingham 08:03 12 Uppingham 10:01 12 Uppingham 12:01

23 Appendix D Proximity of branches to other Practices (including public transport links) Gretton The Studfall Partnership Corby 3.4 miles Dr Sumira, Studfall Court Corby 3.4 miles Weldon Branch Surgery 3.4 miles Forest Gate Medical 3.5 miles Lakeside Healthcare Corby 3.8 miles Woodsend Corby 4.2 miles The Uppingham Surgery 4.4

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