working in a Great Yarmouth or Waveney Practice Councillor and Health and Wellbeing representative

Transcription

1 Agenda item 4 Draft Minutes of the Primary Care Commissioning Committee Meeting held in public Thursday 8 February 2018, 09.30am The Assembly Room, Great Yarmouth Town Hall, Hall Plain, Great Yarmouth, NR30 2QF Present Name: Position: Organisation: Cedric Burton (CB) Lay member (Chair) NHS GYW CCG Sadie Parker (SP) Director of Primary Care NHS GYW CCG Chris Armitt (CA) Chief Finance Officer NHS GYW CCG David Stock (DS) Practice Manager currently Millwood Surgery working in a Great Yarmouth or Waveney Practice Hitesh Kumar (HK) General Practitioner from Andaman Surgery Governing Body Parveen Mercer (PM) Assistant Director of Primary NHS GYW CCG Care Norfolk and Waveney (Contracting) Mary Rudd (MR) Local Government Member Waveney District Council Councillor and Health and Wellbeing representative Jean Goffin (JG) Vice-Chair of Patient Participant Group Forum NHS GYW CCG Patient Participation Group Forum Andy Yacoub (AY) Healthwatch representative Healthwatch Suffolk Fiona Theadom (FT) Contract Manager NHS England Michael Dennis (MD) Head of Medicines NHS GYW CCG Optimisation Teresa Knowles (TK) Quality and Safety Senior Manager NHS GYW CCG In attendance Name: Position: Organisation: Alison Smith (AS) PA to Director of Primary Care NHS GYW CCG (Minutes) Tracy Rodgers (TR) Quality and Safety Senior NHS GYW CCG Manager Clare Angell (CA) Transformation Manager, Primary Care NHS GYW CCG Better Health, Better Care, Better Value

2 1. Apologies Melanie Craig, Chief Officer, NHS GYW CCG Action owner Rebecca Hulme, Chief Nurse Dr Ian Hume, Medical Director, Norfolk and Waveney Local Medical Committee Tracey Grimbley, Assistant Head of Finance, NHS England Alex Stewart, Healthwatch representative, Healthwatch Norfolk Penny Carpenter, Local government member Councillor, Great Yarmouth Borough Council 2. Declaration of interest MR declared that she is a patient at the High Street Surgery in Lowestoft. DS and HK are both involved in general practice in GYW. 3. Chairman s Introduction and report on any chairman s actions None to report. 4. Approval of the minutes of the previous meeting held on 9 November 2017 and 25 January 2018 The minutes of both meetings were deemed to be a true reflection of the discussions held and were subsequently approved. 5. Action log Actions 1 5 can be closed. Action 6 Close action. Tracey Parkes to start the process. Action 8 STP Improved Access Stakeholder event has been held close action. Action 10 MD confirmed this month s paper included the mitigations close action. Action 11 RH has reviewed the wording in the Community Phlebotomy proposals and was re-submitted to the Clinical Executive Committee and subsequently approved close action. 6. Primary Care Risk Register SP talked through the Risk Register and summarised as follows: Primary Care Resilience - SP and PM review risks on a monthly basis with the Governance Manager. There is concern about Primary Care resilience for Kirkley Mill, Central, Beccles, Bungay and High Street. A joint letter from all five CCGs is being sent to the LMC and all GP Practices regarding investing 311,000 in general practice for shared care arrangements and confirmation of the five CCG s approach to locally commissioned services from 1 April Business Continuity incidents where practices have initiated business continuity plans recently. Jayde Robinson is helping to co-

3 ordinate all practices have submitted their plans and Jayde is currently reviewing them. CB noted that the risk mitigation centred on compliance with ISO and wondered what mechanism was available to ensure that practices adopted this standard and whether they had the resources to achieve compliance. Additionally, the assurance controls centred on information governance mechanisms and there was significantly more to business continuity assurance than IG. It was agreed that it would be helpful if this risk could be split into two, one dealing with business continuity and the other with information assurance. Action: PM to pick this up with Jayde. Workforce lack of primary care workforce due to vacancies and impending retirements. This is also a national issue and the STP has a joint Workforce Strategy plan which is being overseen by the Workforce Delivery Group and STP workstream. A Local Delivery Group meeting is scheduled for this afternoon and these will be held monthly going forward, focusing on delivering the STP strategy. HK suggested this could have a positive impact on retaining GPs. CB suggested that it would be helpful for the committee to be aware of where and in what specialisms the critical deficiencies and potential deficiencies forecast for the next few years were. Action: PM to provide Workforce Heatmap. MD stated he is working with the practices to mitigate their prescribing spending and will update further through the agenda item on prescribing later in the meeting. PM PM 7. Enhanced Service for the Management of Chronic Obstructive Pulmonary Disease in Primary Care The proposal is for a Local Enhanced Service to improve COPD care. The reasons for commissioners preferring this route, and why this constitutes an enhanced service, are set out in section two of the document. The aim is to get patients to stop using drugs that they don t need or if the use of a particular drug could cause more harm than good, ensure that COPD patients are reviewed appropriately and to enable proactive measures to be put in place for patients at risk of exacerbations. The six key components are: 1. Review of COPD Patients currently prescribed an inhaled corticosteroid (ICS). Each patient will be recommended one of the following actions: a. Step down and stop patients inappropriately prescribed ICS b. Patients who require ICS to be switched to appropriate costeffective inhaler device c. Continue on current regimen 2. Reducing their risk of admission through: a. Issuing a steroid rescue pack if appropriate b. Giving the patient a red card which would gain immediate access to a General Practitioner or nurse practitioner and c. Referring to smoking cessation if appropriate There will be clinical benefits to the patients in terms of receiving treatment of a suitable intensity for their disease. It would provide value for money through:

4 a. Switching of patients on triple therapy to a cost-effective single triple device or b. Step down to LABA / LAMA for 12-month period or c. Trial patients on ICS/LABA with LAMA and step down to LABA/LAMA d. Reduction of non-elective admissions through the above early intervention measures e. Patients taken off steroids are at lower risk of non-elective admissions triggered by infection It was noted there were several abbreviations used in the report which should be clarified for the benefit of non-clinicians. HK queried the category for red card s and MD clarified that the aim was for the patient to get access to a GP or nurse on the same day rather than go to hospital. He also stated that extra support would be needed for patients who rely on a specific drug and who would be reluctant to change. He stated that Andaman Surgery review patients with significant prescribing changes faceto-face. MD confirmed that support the CCG PALS and medicines management teams would continue to provide support through the management of any complaints or queries from patients. Action: MD to raise at the Clinical Executive Committee meeting where the specification would be discussed. MD to share the Clinical specification and share information about red cards with HK, DS and AY. MD In response the questions, MD stated that training for nurses in using inhalers was planned and a prescribing incentive scheme will be introduced to aid practices to engage with community pharmacies. CB observed that the proposal presented the opportunity to improve patient care, deliver a cost effective solution and was based on strong data. It was agreed that the initiative was likely to have applicability across the STP footprint. Subject to the above actions, the recommendation was approved. 8. Phlebotomy Services in Great Yarmouth and Waveney CCG An update on the implementation of the phlebotomy service was provided following approval of the recommendation to invest in new services at the last meeting. A number of risks and associated mitigating actions had been identified. Training Delivery of training within the given timeframes and to an appropriate level that will give staff the confidence to deliver this service. Mitigating Action: An early training date is being planned and training will have clinical approval to ensure the level of training provided meets the needs of the practices. Volume of patients Given the lack of data provided by the JPUH in

5 relation to the number of patients requiring bloods, concern has been raised that the number of patients who require phlebotomy services is greater than initially indicated. Mitigating Action: Continue to work with practices once the service has commenced to review the pilot, collect appropriate data to support the future procurement of the service. Practices can review annual phlebotomy requirements of individual patients to ensure testing is carried out once for all conditions/needs. Cutlers Hill surgery has developed a tool to do this within their practice, which has been shared. Recruitment Insufficient staff in place by 1 April Mitigating Action: practices to have recruitment plans in place and highlight any issues to the commissioner and locality as soon as possible. Phlebotomy for Children Practices are concerned that staff may not have the confidence or skill to undertake phlebotomy services for children. There is a risk to the CCG that activity could increase within this service and cause a cost pressure to the CCG. Mitigating Action: The Cove at the JPUH will continue to provide a phlebotomy service for children, this service will continue to see those children who are not able to be seen within the community. Phlebotomists working within the Lowestoft Locality will continue to develop their skills around paediatric phlebotomy, the locality have a paediatric specialist that that has been identified to support this. The service specification has been revised with the following statement: The provider may undertake phlebotomy on children and young people over two years and up to age sixteen on a case by case basis. Discussion with parents/carers and the child or young person should guide decision making as to when this is appropriate and achievable within the practice setting and should be based on a clinical assessment by the phlebotomist. The phlebotomist must hold the relevant qualification to deliver this service. The JPUH Paediatric Phlebotomy Service activity levels will be continuously monitored. ACTION: It was agreed that the risks to implementation should be put on the Risk Register Jayde Robinson to action. A further update on the progress of implementation will be brought to the Primary Care Commissioning Committee in March Jayde R Agenda item 9. GP Practice Prescribing Report The purpose of the paper is to outline the CCG s current prescribing performance and the work with outlier practices, summarised by MD. Outlier practices continue to significantly affect our prescribing performance. Some practices have improved significantly with our support and encouragement but others have been slow or resistant to engagement with support for changes. Items growth is slowly reducing, the implementation of prescription ordering direct (POD) will have a significant effect on this. The focus of the Medicines Optimisation Team is around improving the quality and cost-effectiveness of prescribing. The QIPP target is significant

6 at 2.8m. The GP practice prescribing incentive schemes aims to encourage GPs to focus on spend in high priority areas but also to come in on indicative budget or if a practice was overspent in the previous financial year, a significant move towards budget. A new incentive scheme for 18/19 which will have increased focus on practices remaining within budget is being developed. November prescribing spend again showed a 60k overspend. No Cheaper Stock Obtainable (NCSO) in month was 216K. There was also a high spend of 38k on vaccines, most of which were flu; these are charged out to local authority public health and NHS England. The cost pressure of these drugs will continue through the year. It is anticipated that the cost burden of NCSO will be approximately 155k in December. Items growth is reducing, in November this was 2.7% previously in October it was 3.1% (3.9% in August) This has contributed to a 1m overspend year to date. Improved utilisation of self-care and the stopping of low value medicines will help reduce this growth. The implementation of Prescription Ordering Direct (POD) is likely to have a significant effect on items growth. POD will be launched in April Priorities this month include groundwork to begin implementation of the POD pilot. The team is also working to implement the low value medicines and DROP list guidance by stopping those medicines listed e.g. maintainance vitamin D which patients can buy. MD reported the team is following up with all Practices around the implementation of self-care but this is a little variable at the moment. There is a consistent approach to the implementation of self-care across the STP and the team is are facilitating the close working with community pharmacies that is necessary to its success. The other CCGs are also arranging round table discussions between GPs and local pharmacists. Action: MD to add details about the Prescribing Ordering Direct (POD) service to the report for the next meeting. MD The committee noted the report and briefly discussed the use of Edoxaban. It was noted that this now also formed part of the hospital formulary however its use remains variable. MD is continuing to liaise with the hospital chief pharmacist. 10. General Practice forward view across delivery plan and survey update CA provided an update on the progress of improved access following the patient engagement survey. Over 400 patients (representing 20/21 practices) accessed the survey in paper form or online in Great Yarmouth and Waveney. Most people who accessed the service in paper form said they wanted appointments between 7am and 7pm, however those who did the survey online stated 8am to 8pm. Most of the people who wanted weekend opening said Saturday and Sunday mornings would be preferable.

7 Since the completion of the survey, NHS England (NHSE) has brought forward the 100% access deadline from 31 March 2019 to 1 October In project terms, this is a significant loss in time to prepare GP practices for the extended hours, design sufficient IT processes for data sharing and strengthen a workforce under pressure. Concerns over the short time frame have been registered with NHS England However, from a strategic perspective, and assuming we are able to meet the deadline, it should help to ease winter pressures in 2018/19. Due to the revised deadline of 1 October 2018, there are concerns that 3.34 funding per head is not sufficient. The aim is to monitor the impact of improved access to GP appointments on primary and secondary care activity. CB observed that the three project management parameters of cost, time and performance meant that it was likely that the NHSE decision would result in either increased cost to mount to extended service or a reduced scope. The committee were sighted on a paper in November describing plans to engage with patients for improved access to primary care at evenings and weekends. The engagement phase of the project is now complete and we are able to evidence need and demand for such appointments across Norfolk and Waveney. The committee noted that DNA s continue to bear a problem. It was suggested that direct dedicated telephone lines should be set up in the Practices to enable more patients to cancel appointments that are no longer required. A concern was raised about the Expression of Interest letter that was sent to the Practices. Practices are unsure whether a positive response constitutes a commitment or not. Also the impact of the change in service provisions on vulnerable patients was raised. Action: CA to clarify to the Practices that the Expression of Interest is only to express interest and is not a commitment. Action: Improved Access to be put as a critical issue on the Risk Register by Jayde Robinson. CA Jayde Robinson The committee noted the report and the critical significance of the initiative. 11. Dementia Diagnosis Report TK provided an update on the progress against the dementia diagnosis performance standard. Dementia diagnosis rates are at 62.7% against the national target of 66.7%. There is an action plan in place for this to be achieved by the end of March 2018, which was submitted to NHS England in August 2017 and which identified a range of actions designed to progress performance. Dr Ardyn Ross (Mental Health Clinical Lead) will participate in a teleconference with NHS England to explore how this could be addressed locally. Representatives from the CCG and the wider Norfolk and Waveney STP attended a dementia interactive workshop organised by NHS England. A work stream in relation to dementia has now been established as part of the Norfolk and Waveney STP and the priorities are in the process of being agreed. There is a Work Stream meeting arranged for 20 February.

8 In discussion the Committee noted the uncertainty surrounding the assessments of prevalence against which targets were benchmarked. Without greater confidence in these assessments it was harder to determine whether more effort or different approaches to meeting the targets would yield benefit. Action: TK to raise concerns by the Primary Care Commissioning Committee at the Work Stream meeting. TK

9 12. Learning Disabilities Health Checks PM provided an update on the current Learning Disabilities Health Checks (LD Health Check) programme across the Norfolk and Waveney STP. The LD Health Checks programme is a Designated Enhanced Service (DES) delivered within primary care on behalf of the CCGs under their delegated commissioning responsibility. The national target for LD Health Checks is 50%, stretch target is 65% and practices are currently funded 140 per health check. The Learning Disabilities QOF prevalence data for 2016/17 shows that all five CCGs have higher prevalence than the England average. There is significant evidence that shows that people with learning disabilities have poorer health outcomes, lower life expectancy and at least 50% of patients will have at least one significant health problem. LD Health Checks programme is an annual (DES) currently expiring on 31 March 2018 and has two components: Annual health check for patients with learning disabilities. Completeness of the GP Learning Disability Register. The mandated cohort are patients aged 14 and over that have moderate to severe learning disabilities. All patients on the GPs Learning Disability Register are entitled to and should be invited to receive an annual LD Health Check, which is an evidence based intervention that supports the early identification of disease and other health related conditions. GPs must liaise with local authorities to identify which of their registered patients are known to the local authority and vice versa because of their learning disabilities and ensure these patients are captured on the GPs Learning Disabilities Register and be invited for an annual health check. The LD annual health check in order to be compliant has a minimum requirement to address the patients physical and mental health ranging from, screening, lifestyles advice, medication accuracy, transition arrangements on attaining the age of 18, communication methods, family carer needs and self- care and management. Following the LD annual health check a health action plan should be produced that addresses the patient s needs, best practice would be to do this in conjunction with the patient, family, carer and other agencies involved and a copy given to the patient in format suitable to their specific needs. Update the patient s medical records with relevant information following the health check. Some of the Community LD Team nurses have delivered training for Practice Nurses these were last carried out in Nov and Dec 2017 Practice Nurses have been given named contacts within the Great Yarmouth LD Team and the Waveney LD Team. The named contacts have gone into individual practices when contacted to provide direct support, information and advice and also how to address any issues that they may be experiencing. Millwood is a good example of the joint working between the Practice and the local LD Team in delivering on the health checks and have presented at

10 a number of forums to showcase the way in which this has been achieved. There was discussion over the disparity between Council held and Practice held registers and the potential for patients to be missed. There are also data accuracy issues across the five CCGs. PM also found that there was no clear pathway on how information is exchanged against the two registers. There was also a lack of clear health and social care plans and how these were monitored to deliver better outcomes for patients. There was also concern raised over the lack of data and under 14 year olds. PM has requested from Norfolk public health to obtain data on the number of children under 14 with a learning disability and to forecast a trajectory over the next 5 years, so the impact this will have on primary care can be assessed. PM has set a task and finish group across the STP to look at the issues and develop an improvement plan that will improve the quality of service provision within primary care for LD Patients and improve CCGs performance. First initial meeting is on the 15 February 2018 In the meantime Mencap have produced a best practice communication guide to use in primary care for LD Patients. This has been sent out to all Practices. AY asked whether the CCG delivered LD Health checks in the community. PM advised that this was not done across Norfolk and Waveney at present but it is an area that would be looked at as it has been done elsewhere. Action: PM to provide monthly performance figures for LD. Action: PM to bring back improvement plan on LD within the next quarter. Action: PM to gather and cleanse data. PM PM PM The Committee noted the contents of the paper. 13. Update on the Sustainability and Transformation Plan development of Primary and Community Care Work Stream SP provided an update on the STP development of Primary and Community care work stream with a particular focus on the development of the strategic plan for primary care aligned to the GP Forward View and the Five Year Forward View. The next stage in the STP Primary and Community Care work stream is to develop Local Delivery Groups, coterminous with the CCGs. The overall purpose of each Local Delivery Group will be to implement the strategic direction set by the STP Primary and Community Care Programme Board including new models of care; provider development; access and resilience; prevention and self-care. This is in line with the national NHS Five Year Forward View and the General Practice Forward View and is essential to meet patient need. In Great Yarmouth and Waveney formal invitations to join the Local Delivery Group have been and the first meeting date confirmed as 8 February CB observed that it would be helpful to have clarification, perhaps in the

11 form of a diagram, of the lines of accountability between the Programme Board, PCCCs, local delivery Boards and Localities. SP to provide an update on progress at the next meeting. 14. Primary Care Finance Report CA reported the CCG s year to date primary care financial performance to the period ending 31 December 2017, the CCG view of 2017/18 forecast outturn and the associated risks impacting financial delivery. For month nine the CCG reported a balanced year to date and forecast outturn position to NHS England. As part of the overall CCG balanced position the CCG reported a year to date underspend on primary care budgets of 0.3m which does not include the year to date costs of the national No Cheaper Stock Obtainable (NCSO) issue. These were not included at month nine while waiting for clarity from NHS England on the treatment. If these costs were included this would increase reported costs by 1.6m and therefore there is a year to date deficit position of 1.3m. As directed by NHS England outside of forecast the CCG has reported an unaffordable 2.4m unmitigated risk for in year No Cheaper Stock Obtainable (NCSO) drugs costs. Subsequent to month nine reporting the CCG has been informed by NHS England that the forecast at Month 10 should include NCSO costs. The CCG are reporting a year to date underspend across primary care budgets of 0.3m; Underspends of 1.1m underspend on the primary care co-commissioning budget, 0.1m Practice Transformation Fund and 0.1m GPIT. Overspends of 1.0m Prescribing, 0.1m GP Out of Hours and rounding 0.1m. The Committee noted the paper. 15. Norfolk and Waveney Contracting Update PM provided an update on contracting and any issues regarding Primary Care across the Norfolk and Waveney STP footprint. Main activity since the November 2017 briefing has been centred on the Local Medical Committee (LMC) correspondence regarding Local Enhanced Services (LESs) delivered within primary care GP Practices. Further information on this is contained in a separate paper tabled under part two of this committee. Great Yarmouth and Waveney have developed a GP dashboard which details key performance information as well as acting as an Early Warning for CCGs and practices that are at resilience risk whether that be workforce or service delivery. PM reported that the dashboard will now be adopted across the five CCGs. The committee were advised in the November 2017 meeting that the team are currently reviewing the SAS scheme across the STP footprint and looking to procure a new model of service delivery. All five CCGs PCCs approved the November paper. The NHSE assigned team are working to draw up some interim protocols around how they share information about patients on the scheme with other practices to reduce any risk of harm to

12 staff and patients. Advice has been sought from the NHS national Information Governance team who have advised that they cannot share a generic list of patients on the scheme and any information shared has to be proportional to the risk etc. Once we have an interim solution a further paper will come back to the CCGs PCCs. A concern was raised on issues with access to the online patient record and it was noted that the form was changed in October 2017, however there were insufficient copies for all practices nationally. This should now be rectified, however there was confusion over whether practices were using the correct form. Action: PM to check with the practices to see whether they are using the correct updated form. PM 16. Falkland and Millwood Practices Merger SP provided an update on the merger of partnerships which took place on 1 January The partners of both Practices received approval from the primary care committee in private in October 2017 to progress towards a merger. The merger of the partnerships took place on 1 January, however as the two practices do not run on the same clinical system, the process to merge the two separate contracts is dependent on the implementation of SystmOne across the two sites. This is due to happen late March/ early April. Both practices have advertised the merger to their patients and this can be seen on their practice websites. It is our understanding that the merger has been well received. The merger is a very positive move towards the delivery of resilient and sustainable primary medical care in the Gorleston area. The CCG primary care team is working with all practices in Gorleston to support their plans for improving resilience and where relevant, performance. It was noted there are currently six CCG practices in total using the EMIS system and SP stated that those practices are likely to be encouraged to switch to SystmOne as part of the development of new models of integrated care led by the STP primary care workstream. DS stated that Millwood have suspended access to the online registering, due to issues relating to their system migration. The practice will re-register patients for on-line services once their new clinical system has been implemented. The Committee noted the paper.

13 17. Care Navigator Training Update SP provided an update on the progress of care navigator training and the plans for the roll out of phase one of the programme from 2 March Most GP Practices across Great Yarmouth and Waveney have released their reception staff and nominated GPs to attend face to face training sessions facilitated by West Wakefield Health. These staff have also completed the accredited care navigation on line training. The only practices who decided not to take part in the training are Park, Longshore and Sole Bay surgeries who feel their staff already sign post their patients to non GP services where appropriate. Final training sessions with the top six chosen providers to sign post to have been arranged for late February to coincide with the launch and roll out of the programme from the 2 March 2018 Before this date a comprehensive communication plan will be produced advising patients and stakeholders of the positive benefits of the programme. Communications and engagement will also be aimed at alleviating any concerns patients may have. As part of the communication plans a nominated GP from every GP Surgery will voice a message on their telephone systems advising patients of the care navigator s role and how it can benefit them. Final training workshops with providers have been arranged for 28 February for Waveney GP Practices and 1 March for Great Yarmouth practices. Lorraine Rollo, Head of Communications and Corporate Affairs is working on a communication plan to advise patients and key stakeholders of the positive benefits of sign posting via care navigation. Communications and engagement will also be aimed at alleviating any concerns patients may have. As part of the communication plans a nominated GP from every GP Surgery will voice a message on their telephone systems advising patients of the care navigator s role and how it can benefit them. Roll out of phase one of the care navigation programme is planned for 2 March and will see the care navigators signposting patients where appropriate to one of six named providers. Templates will be uploaded on the practice IT systems which will include the access criteria for these services. Templates will be completed by the care navigators on their GP IT systems which then will be used by our business intelligence department to monitor the success of access to the six non GP services and record any associated benefits as well as the amount of time saved through avoidance of GP appointments. Data will be collected via the practices IT systems which will be used to evaluate the outcomes of the care navigation programme. A progress report will come to the PCCC in September. It was noted that some patients have voiced their concerns about having to inform receptionists the reason why they want to book an appointment. The Committee were advised that most practices now have a message on the

14 telephone forewarning people that they may be asked for a reason. 18. Revised Terms of Reference An external audit was carried out by Deloitte on the 4-15 December 2017, assessing how the CCG was operating within the parameters of Managing Conflicts of Interest statutory guidance. The audit included a review of the terms of reference for the Primary Care Committee as well as membership, delegated authority and reporting lines. A number of recommendations in reference to the PCCC Terms of Reference (TOR) for change were made, which have been approved by the Governing Body on the 25 January This moved the practice manager member to a non-voting member in line with the GP members and correspondingly reduced the number of voting members from eight to seven. These TOR will be reviewed on an annual basis and will be submitted to NHS England as part of the revised Constitution process. The Committee noted the changes to the Revised Terms of Reference. 19. Any Other Business CB stated informed the Committee that a second GP and another Lay Member will be recruited and the aim was to have them in place by the April meeting. Date, time and venue of next meeting Thursday 8 March 2018, 9.30am, Norfolk Room, The Kings Centre, 30 Queen Anne s Road, Great Yarmouth, NR31 0LE.