Primary Care Joint Committees (PCJC) Meetings

Transcription

1 Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Primary Care Joint Committees (PCJC) Meetings The following Joint Committees meetings, listed below, will be held in common at: Bexley Council Chamber, London Borough of Bexley, Civic Offices, 2 Watling Street, Bexleyheath, Kent DA6 7AT. 6.00pm pm on Thursday 18 th August 2016 NHS Bexley CCG and NHS England PCJC NHS Bromley CCG and NHS England PCJC NHS Greenwich CCG and NHS England PCJC NHS Lambeth CCG and NHS England PCJC NHS Lewisham CCG and NHS England PCJC NHS Southwark CCG and NHS England PCJC Primary Care Joint Committees meeting held in common AGENDA (Part One) Item Time Papers Lead 1. Chair s introduction 6:00 Greg Ussher 2. Declaration of Interests 6:05 Enc A Pages 4 29 Greg Ussher 3. Minutes of the last meeting SE London PCJCs meeting (29 June) SE London PCJCs action log 6:10 Enc B Pages 30 52X Enc C Pages Greg Ussher Tom Bunting 1

2 4. Matters arising 6:15 Overview from Director of Primary Care, NHS England (London Region) Estates and Technology Transformation Fund (ETTF) update NHS Bexley CCG: Westwood Surgery Remedial Action NHS Greenwich CCG: Trinity MC Relocation NHS Lambeth CCG: Clapham Park NHS Lambeth CCG: AT Medics NHS Southwark CCG: Avicenna Enc D Pages Verbal Verbal Verbal Verbal Verbal Verbal Liz Wise Jill Webb Jill Webb Jill Webb Jill Webb Jill Webb Jill Webb 5. Public Open Space 6:35 Greg Ussher For discussion 6. Quality, Performance and Finance 6:45 For decisions Month 3 Finance report Quality and Performance report 7. Items for decisions per Joint Committee: NHS Bexley CCG: Bexley diabetes LIS NHS Greenwich CCG: Kidbrooke Village Options for future GP commissioning arrangements NHS Greenwich CCG: Valentine / Francis Street Branch Closure NHS Greenwich CCG: Alderwood Dr Peiris Contract End NHS Greenwich CCG: Horn Park Enc E Pages Enc F Pages :25 Pages Encls: G H I Verbal J Richard Jeffery Jill Webb Jill Webb (unless stated otherwise) Lindsey Coeur-Belle Jill Webb/ Dr Ellen Wright 2

3 Branch Surgery proposal NHS Lambeth CCG: Crowndale / Norwood Surgery Merger NHS Lambeth CCG: Vauxhall Surgery: CQC Requires Improvement NHS Southwark CCG: Nunhead Catchment Area Reduction NHS Southwark CCG: Falmouth Road Requires Improvement Breach and Remedial Report on decisions taken by NHSE on behalf of CCG 8. Items for decisions reported per Joint Committee: For information NHS Southwark CCG: St James Church Surgery CQC Outcome K L M N 8:00 Enc O Pages Jill Webb/ Jean Young Jill Webb 9. Locum Reimbursement Report 8:05 Enc P Pages Public 10. Public Open Space 8:10 Greg Ussher Other business 11. Any other business 8:20 Greg Ussher For reference Glossary of Terms Date of Next meeting: Thursday 20 th October 2016 Main Hall, 1 st floor, Deptford Lounge, Deptford Library, 9 Giffin Street SE8 4RJ Enc Q Pages Greg Ussher Greg Ussher Close 3

4 Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Encl A Date: 29 June 2016 Consolidated Primary Care Joint Committees (PCJC) Declaration of Interests Update and signature list NHS Bexley CCG and NHS England PCJC All committee members and observers to update declarations and sign at each meeting. 4

5 Name (Last / First) Position Held Declaration of Interest Blow, Sarah Chief Officer Nil No change State change or No Change 29 June 2016 = Signed off at or prior to meeting Currie, Mary Governing Body Nurse Member Director Quality for Health Ltd - company offering consultancy service in healthcare sector - Materiality 50% Co-habiting partner is a Director of Physiological Measurements Ltd who deliver NHS clinical services Interim Director of Transformation NHS Bromley CCG No change 5

6 Dr Deshmukh, Sid GP Locality Lead Senior Partner Sidcup Medical Centre PMS Contract - Personal Interest - Materiality 50% Shareholder Bexley Health Limited Shareholder Frognal Limited - Personal Interest Shareholder Blossoms Care Home Ltd - Personal Interest 15% Clinical Lead - Referral Management and Booking Service (RMBS) - Personal Interest Elected member Bexley Local Medical Committee (LMC) - Personal Interest Interest in Dr. Karkare's practice (practice partner) in gynaecology work Chairman fee 200 for meeting gynaecology and dermatology on 25/11/14) Chairman fee 200 for meeting on Alcohol Harm Reduction on 28/01/15 and 11/03/2015 Wife (Dr Sonia Khanna-Deshmukh) is member of NHS Bexley CCG Board Potential conflict as personal interest in Inspire Community Trust re: a. Wheelchair Service b. Joint Equipment Store c. Personal Health budget d. Information and service support for people with physical and sensory impairment - No financial interest Attend various locality/clinical meetings which could be sponsored by drug companies where refreshments are provided (from 5.00 to 30.00) Chairman s fee 200, Cardiovascular update at TUC 2 June honorarium paid by LycaHealth for chairing an orthopaedic educational meeting on 12 March No change Osborne, Theresa Representing Keith Wood ( Lay Member, Governance) Nil No change Dr Kanani, Nikita Chair, NHS Bexley CCG Locum, Bellegrove Surgery Executive Member, National Association of Primary Care General Advisory Council, the Kings Fund No change 6

7 Perrior, Katie Governing Body Lay Member Director and co-founder, Inhouse Communications Ltd Non-Executive Director, Ebbsfleet Urban Development Cooperation School Governor, West Lodge School, Sidcup No change Wood, Keith Lay Member, Governance Nil No change Murray, Anne Hinds Observer - Healthwatch Healthwatch Bexley Manager Employed by MIND in Bexley Dr Money, Richard P Observer - LMC Partner at Station Road Surgery Sidcup Chair, Bexley Health Ltd Director Bexley Neighbourhood Care Ltd No change No change Councillor Teresa O Neill OBE Observer - Health and Wellbeing Board Leader, London Borough of Bexley Chairman, Bexley Heath & Wellbeing Board Lead Member for Health, London Councils Member of London Health Board Member of LGA Community Wellbeing Board No change 7

8 Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Consolidated Primary Care Joint Committees (PCJC) Declaration of Interests Update and signature list Date: 29 June 2016 NHS Bromley CCG and NHS England PCJC All committee members and observers to update declarations and sign at each meeting. 8

9 Name (Last / First) Dr Bhan, Angela Position Held Chief/Accountable Officer Declaration of Interest Honorary Public Health Consultant with Bromley Council State change or No Change 29 June 2016 No change = Signed off at or prior to meeting Guntrip, Harvey Lay Member, Governance (Vice Chair) Nil No change Lee, Martin Lay Member - Patient Public Involvement Nil No change Nelson, Sara Registered Nurse Member Member of Editorial Board of British Journal of Cardiac Nursing Healthy London Partnership (Programme Lead CYP Transformation) Husband (Charles Gostling) is now Clinical Lead on Lewisham CCG Board No Change Dr Paranjape, Ruchira Principal Clinical Lead GP Partner at Knoll Medical Practice (PMS) (27 % share) Visiting Medical Officer (VMO) contract with Care UK for Foxbridge Nursing Home Knoll Medical Practice is a member of the Bromley GP Alliance No change 9

10 Dr Doyle, Jon Governing Body GP GP Partner in South View GMS Partnership, Bromley Member practice of the Bromley GP Alliance South View Partnership holds contract from Bromley Healthcare to provide Visiting Medical Officer (VMO) services at Lauriston House South View Partnership contracted to Bromley GP Alliance to provide GP support to transfer of care bureau, 16/11/2015 to 18/12/2015 Dr Parson, Andrew Clinical Chair Chislehurst Medical Practice (PMS) Partner (13% share) (Chislehurst Medical Practice is a member of Bromley GP Alliance) Bromley Y Wife is an employee Bromley Public Health GP Primary Care Lead for Diabetes (0.5 sessions per week) No change No change Gabriel, Linda Observer - Healthwatch Chair of Bromley and Lewisham MIND Chair of Healthwatch Bromley No change Dr Sahi, Mukesh Observer - LMC GP Partner at Trinity Medical Centre Chair Bromley Local Medical Committee Shareholding - Member of Bromley GP Alliance (Plc) Dr Chelvan, Rishi Observer - LMC Additions: No change No change GP Partner at Highland Medical Practice Co-Vice Chair, Bromley LMC Shareholding member of BGPA Councillor Jefferys, David Observer - Health and Wellbeing Board Employment as a Pharmaceutical physician Senior Vice President, Global Regulatory Government Relations Public Affairs and Product Safety. Eisai Europe Ltd. Full time employee. Member of the ABPI Innovation Board and Chairman of the Regulatory Network. No change 10

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12 Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Consolidated Primary Care Joint Committees (PCJC) Declaration of Interests Update and signature list Date: 29 June 2016 NHS Greenwich CCG and NHS England PCJC All committee members and observers to update declarations and sign at each meeting. 12

13 Name (Last / First) Buckell, Maggie Burn, Annabel Position Held Registered Nurse on the NHS Greenwich CCG Governing Body Chief Officer, NHS Greenwich Clinical Commissioning Group Declaration of Interest Registered Nurse on the NHS Tower Hamlets CCG Governing Body Director/Owner Tester Consulting Ltd (Management consultancy Director Deborah Management Ltd (Residential Property Trustee of the NHS Greenwich Charitable Funds, Charity Commission ref State change or No Change 29 June 2016 No change No change = Signed off at or prior to meeting Dr Patel, Nayan GP Member of the NHS Greenwich CCG Governing Body GP Partner (GP Practice 50 % Owner) Member of Blackheath Charlton LLP Member of Blackheath Charlton LLP GP Member of the Greenwich CCG Governing Body Undertake work for Hurley OOH GP Appraiser for NHS England Undertake work for SELDOC Undertake work for Bromley Healthcare Works for Bromley GP Alliance Member of Grabadoc No change 13

14 Dr Ussher, Greg Lay Member on the NHS Greenwich CCG Governing Body Chief Executive Officer, METRO Charity Chair, Trustee of the NHS Greenwich Charitable Funds, Charity Commission ref Director, Translate Consultancy Honorary Fellow University of Greenwich Member of the Labour Party Chair, Outhouse Chair, National LGBT Consortium East (supporting delivery of LGBT in Essex) Executive Director, Healthwatch Medway Board Member, East Kent Voluntary Action Support (EKVAS) Chief Executive Officer of the charity which holds the contract with RB Greenwich for the delivery of Healthwatch Greenwich No change Dr Vanniasegaram, Iyngaran Secondary Care doctor on the NHS Greenwich CCG Governing Body Director Russets Healthcare Ltd with 25% share holding NELFT (North East London NHS Foundation Trust) Consultant in Audio-Vestibular Medicine No change Wintour, Jim Lay Member on the NHS Greenwich CCG Governing Body Director, Mountfield Gardens Residents Association Director, Helier Court Residents Association Trustee of the NHS Greenwich Charitable Funds, charity Commission ref Sonia Ennals (wife) is Estates Lead, NHS Lewisham CCG No change Dr Wright, Ellen Chair and GP member of the NHS Greenwich CCG Governing Body Clinical Academic Fellow at Kings College London GPCC Shareholder Grabadoc Member Trustee of Kairos Rehabilitation Trust (registered charity helping those who are suffering chronic pain or the after-effects of trauma) Member of an over diagnosis' group (an online working group of the RCGP - a group of healthcare professionals committed to tackling over diagnosis and over medicalisation of patients) Sessional GP at Vanbrugh Group Practice and Greenbrook OOH/UCC provider No change 14

15 Gordon- Mackenzie, Leceia Observer - Healthwatch Chair Healthwatch Greenwich Metro are Healthwatch Greenwich s contract holder No change Landers, Jade Observer - Healthwatch Policy and Research Officer, Healthwatch (Greenwich) Metro are Healthwatch Greenwich s contract holder No change Dr Tran, Tuan Observer - LMC GP Partner Shareholder of GPCC Member of Riverview Health LLP Undertake OOH work for Greenbrook Healthcare Dr Kumar, Aseem Observer LMC MGT Partner Eltham Health LLP Member No change No change Councillor Gardner, David Observer - Health and Wellbeing Board Local Authority Member on the NHS Greenwich CCG Governing Body Elected Councillor and Cabinet Member for Health and Social Care, Royal Borough of Greenwich (RBG) RBG appointee on the Oxleas NHS Foundation Trust Council of Governors Member and Vice Chair of the RBG Health and Wellbeing Board RBG will receive a variety of research and funding grants for projects Member of Charlton Society (for the conservation and improvement of Carlton) RBG will receive a variety of research and funding grants for projects. Co-convenor, Charlton Rail User Group Member of the Labour Party Member of the Co-operative Party Member of the Co-operative Group Member Amnesty International Member National Trust No change 15

16 Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Date: 29 June 2016 Consolidated Primary Care Joint Committees (PCJC) Declaration of Interests Update and signature list NHS Lambeth CCG and NHS England PCJC All committee members and observers to update declarations and sign at each meeting. 16

17 Name (Last / First) Dr Godfrey, Martin Position Held NHS Lambeth CCG Governing Body Clinical Member Declaration of Interest Sessional GP working primarily at Streatham High Practice The practice is a shareholding member of a GP Federation (South West Lambeth Healthcare Limited) Lambeth CCG Clinical Network Lead Self-employed Director of MGMD Ltd Consultant medical advisor to Minerva Research Laboratories (nutriceutical research company) State change or No Change 29 June 2016 No change = Signed-off at or prior to meeting Prof. David, Ami MBE Board member Nurse Director, Quest for Community Health, a subsidiary of Prasand International Limited specialising in risk management and offering consultancy/project management to health care organisations (Private and NHS) & Royal Colleges Partner / close personal friends / business partner Co-Director Prasand International Limited Co-Director / Owner Prasand International Limited - Occasional Consultancy offered on Community Nursing Visiting Professor of Nursing Leadership and Expert Practice London South Bank University Fellow Queens Nursing Institute Nurse Member: Lewisham CCG Governing Body, Lambeth CCG Governing Body, and Southwark CCG Governing Body No change 17

18 Eyres, Andrew NHS Lambeth CCG Chief Officer and NHS Lambeth CCG Governing Body Member Married to Jill Lockett, Director of Performance and Delivery Kings Health Partners from 29/10/12 Director of Lambeth Southwark and Lewisham LIFTco. representing the class B shares on behalf of Community Health Partnerships Ltd with the aim of inputting local knowledge to the LSL LIFTco, for the following LIFT companies: No change o Building Better Health Lambeth Southwark Lewisham Limited o Building Better Health Lambeth Southwark Lewisham (Holdco 2) Limited o Building Better Health Lambeth Southwark Lewisham (Holdco 3) Limited o Building Better Health Lambeth Southwark Lewisham (Fundco 2) Limited o Building Better Health Lambeth Southwark Lewisham (Fundco 3) Limited o Building Better Health LSL Fundco Tranche 1) Limited o Building Better Health LSL (Fundco Holdco Tranche 1) Limited o Building Better Health LSL Bid Cost Holdco Limited o Building Better Health LSL Bid Cost Limited o Building Better Health - LSL (Holdco 4) Limited o Building Better Health - LSL (Fundco4) Limited 18

19 Gallagher, Sue NHS Lambeth CCG Governing Body Lay Member Self Employed Executive Coach, Facilitator and Development Consultant Working on a freelance basis with various organisations in the NHS, parts of the DH and other sectors Married to a Consultant Oncologist, Dr Chris Gallagher, employed at the Barts Health NHS Trust Voluntary work with Teach First Trustee for Guy s and St Thomas Charity No change Laylee, Graham NHS Lambeth CCG Governing Body Lay Member and NHS Lambeth CCG Governing Body Vice Chair and NHS Lambeth CCG Governing Body Audit Chair Nil No change Dr McLachlan, Adrian NHS Lambeth CCG Governing Body Chair and NHS Lambeth CCG Governing Body Clinical Member GP Partner at Hetherington Group Practice which includes membership of SELDOC The practice is a shareholding member of a GP Federation (South West Lambeth Healthcare Limited) Member of Lambeth Living Well Collaborative Member of the GSTT Charity Major Funding Committee Member of Core Strategic Group for Fulfilling Lives, a lottery funded programme with Resolving Chaos Clinical lead and chair of Homeless Health programme within Healthy London Partnership Member Health Improvement Network Board Member CLAHRC Board Member of British Acupuncture Society No change 19

20 Parker, Andrew Pearson, Catherine NHS Lambeth CCG Director of Primary Care Development (Deputising for Graham Laylee) Observer - Healthwatch Nil Chief Executive, Healthwatch Lambeth Member of the Major Grants Committee, Guys and St Thomas Charity No change No change Dr Law, Jenny Observer - LMC Board Director of Londonwide LMCs Chair of Lambeth LMC Married to Dr John Balazs, Lambeth CCG Clinical Member and North Locality Representative Sessional GP No change Dr Jarrett, Penelope Observer - LMC GP Partner, The Corner Surgery. The Corner Surgery is a shareholder in South East Lambeth Health Partnership. Clinical Lead for Dementia, Lambeth CCG Clinical Network. No change Councillor Dixon, Jim Observer - Health and Wellbeing Board Director of Four Communication Four Communications has previously undertaken PR work with NHS Trusts Council of Governors KCH Council of Governors SLAM Chair Lambeth Health and Well Being Board Cabinet Member Health and Well Being Board No change 20

21 Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Date: 29 June 2016 Consolidated Primary Care Joint Committees (PCJC) Declaration of Interests Update and signature list NHS Lewisham CCG and NHS England PCJC All committee members and observers to update declarations and sign at each meeting. 21

22 Name (Last / First) Prof. David, Ami MBE Position Held Board member Nurse Declaration of Interest Director, Quest for Community Health, a subsidiary of Prasand International Limited specialising in risk management and offering consultancy/project management to health care organisations (Private and NHS) & Royal Colleges Partner / close personal friends / business partner Co-Director Prasand International Limited Co-Director / Owner Prasand International Limited - Occasional Consultancy offered on Community Nursing Visiting Professor of Nursing Leadership and Expert Practice London South Bank University Fellow Queens Nursing Institute Nurse Member: Lewisham CCG Governing Body, Lambeth CCG Governing Body, and Southwark CCG Governing Body State change or No Change 29 June 2016 See Southwark Declaration = Signed off at or prior to meeting Dr McLeod, Jacky Clinical Director Salaried GP, The Vale Medical Centre Clinical Triage, Bexley Health Ltd No change Ramsey, Rosemarie MBE Lay Member on the NHS Lewisham CCG Governing Body Nil No change 22

23 Dr Rowland, Marc Chair GP and Partner, Jenner GP Practice Partner / spouse is a GP at the Deptford Surgery Small sum for GP research received by the Practice. Approx 5000 to Practice Professional Advisor to the Institute of Medical Education at the London Southbank University Member of Lewisham 4 Health Limited No change Warburton, Ray OBE Lay Vice Chair Director of Ray Warburton's Perspectives Limited Registered with a GP practice in Lewisham Membership of the NHS Equality and Diversity Council No change Wilkinson, Martin Chief Officer Nil No change Ramrayka, Peter Observer - Health and Wellbeing Board Elected Member Lewisham Health and Wellbeing Board Managing Director/owner Guycon Healthcare Management Consultancy Limited Chair Institute of Healthcare Management London and Southern England Region Chairman Indo-Caribbean Cultural Organisation Chairman Guyhealth (UK) Chairman Royal Air Forces Association City and Central London Branch Dr Parton, Simon Observer - LMC GP Partner and member of Seldoc (South East London Doctors Cooperative) Director, MMP Oncology Ltd, Ltd company set up to support partners private oncology work in SW London Dr Marina Parton (Partner) Co-Director of MMP Oncology Ltd Chair, Lewisham Local Medical Committee Interviewed for pulse and daily telegraph in capacity as chair of Lewisham LMC Board Director of Lewisham Healthcare Limited No change No change 23

24 Bowness, Nigel Observer - Healthwatch Trustee of Healthwatch Bromley and Lewisham (HWB&L) Chair (Interim) of the Healthwatch Lewisham subcommittee of HWB&L Director of The Crystal Coalition CIC, (non-profit organisation providing counselling and psychotherapy to People Living with HIV and to Gay men) Chair of the Lewisham Homes Resident Scrutiny Committee Member of the Labour Party No change 24

25 Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Consolidated Primary Care Joint Committees (PCJC) Declaration of Interests Update and signature list Date: 29 June 2016 NHS Southwark CCG and NHS England PCJC All committee members and observers to update declarations and sign at each meeting. 25

26 Name (Last / First) Ellery, Joy Position Held Lay Member, Governing Body and Chair of Joint Committee Nil Declaration of Interest State change or No Change 29 June 2016 No change = Signed off at or prior to meeting Bland, Andrew Chief Officer Employed by Southwark CCG Partner employed at NHS England as a Primary Care Contracts Manager for North West London. No change Prof. David, Ami MBE Registered Nurse Member of Governing Body Director, Quest for Community Health, a subsidiary of Prasand International Limited specialising in risk management and offering consultancy/project management to health care organisations (Private and NHS) & Royal Colleges Partner / close personal friends / business partner Co-Director Prasand International Limited Co-Director / Owner Prasand International Limited - Occasional Consultancy offered on Community Nursing Visiting Professor of Nursing Leadership and Expert Practice London South Bank University Fellow Queens Nursing Institute Nurse Member: Lewisham CCG Governing Body, Lambeth CCG Governing Body, and Southwark CCG Governing Body No change 26

27 Gibbs, Richard Lay member and Deputy Chair - Governing Body & CCG Conflicts of Interest Guardian Associate Consultant with Public Health Action Support Team (Public health consultancy), no involvement with PHAST work in SE London. Freelance management consultant in field of healthcare information and analysis No change Dr. Heaversedge, Jonty CCG Chair and GP Clinical Lead Employed Locum GP at Quay Health Solutions Ltd GP at Crowndale Medical Centre in Lambeth Director Vitality Ltd. - specialists in Health Communications Work in the media both broadcast and print - related to work as a medical practitioner and not a health care commissioner or SCCG representative. Contribute to campaigns and conferences on an ad hoc basis which may be sponsored by pharmaceutical companies. Currently working on a campaign with ViiV Healthcare. No change Dr Gibbs, Emily Clinical lead, Governing Body Locum GP across Lambeth and Southwark Macmillan GP role Southwark Local resident in Southwark Sessional GP Manor Place Partnership Sessional GP at Walworth Partnership Locum GP Southwark Extended Access Flexible sessions with Extended Primary Care Access Improving Health Ltd and Quay Health Solutions Ltd No change Hines, Malcolm Chief Financial Officer & Deputy Chief Officer Employed by Southwark CCG No change Gilmartin, Caroline Director of Integrated Commissioning Nil No change Gandesha, Aarti Observer - Healthwatch Nil No change 27

28 Dr Lloyd, Claire Observer - LMC Co-Chair of Southwark LMC Partner at Princess Street Group Practice and member practice of QHS who provide services to patients in North Southwark SELDOC GP member Partner at Nexus, merged practice in Southwark to start in July 2016 No change Dr McAdam- Freud, Kathy Observer - LMC LMC Joint Chair for Southwark Practice is part of Quay Health Solutions CIC a GP federation for north Southwark general practices GPwSI Diabetes, GP lead in Diabetes for the Southwark Diabetes Community team (1.5 sessions/ wk) Support to practices as GP lead for diabetes Southwark Community Team SELDOC GP member Partner at Nexus, merged practice in Southwark to start in August 2016 Change (addition see bold text) Dr Kalentzi, Theodora Observer LMC Londonwide LMCs Medical Director/LMC Secretary Sessional GP Churchill Medical Centre (Chingford) Director, Forward Practice Ltd No change Councillor Hargrove, Barrie Observer - Health and Wellbeing Board Member of Southwark Health and Wellbeing Board and Observer on Primary Care Joint Commissioning Committee No change Tom Bunting SEL CCGs Programme Manager Nil No change 28

29 Name (Last / First) Fryer, Jane Position Held Medical Director NHS England S London - Voting Declaration of Interest Salaried GP one session a week at The Gardens Surgery, Southwark State change or No Change 29 June 2016 No change = Signed off at or prior to meeting Trainer, Matthew Director of Commissioning Operations - Voting Nil No change Wise, Liz Director of Primary Care - Voting Nil No change Webb, Jill Head of Primary Care Non Voting Nil No change Jeffery, Richard Director of Financial Management Non Voting Nil No change 29

30 Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Encl B Primary Care Joint Committees (PCJC) 29 June 2016 Meeting held at: Large Hall (4 th Floor), Bromley Central Library, High Street, Bromley, Kent BR1 1EX Minutes Meeting Chair Executive Support Dr Greg Ussher (GU) Tom Bunting (TB) Bexley Primary Care Joint Committee Attendees: Katie Perrior (KP) Member Committee Chair (Lay Patient Public Involvement) Sarah Blow (SB) Member CCG Governing Body Nurse Dr Nikita Kanani (NK) Member CCG Chief Officer Dr Sid Deshmukh (SD) Member CCG Chair Liz Wise (LW) Member NHS England London (Director of Primary Care) Dr Jane Fryer (JF) Member NHS England (Medical Director for South London Theresa Osborne (TO) Observer CCG Chief Financial Officer Dr Richard P Money (RM) Observer LMC Apologies: Keith Wood Mary Currie Lotta Hackett Councillor Teresa O Neill OBE Committee Vice-Chair (Lay Governance) Governing Body Nurse Observer Healthwatch Observer - Health and Wellbeing Board Bromley Primary Care Joint Committee Attendees: Martin Lee (ML) Member Committee Chair (Lay Patient Public Involved) Harvey Guntrip (HG) Member Committee V Chair (Lay Governance) Dr Angela Bhan (AB) Member CCG Chief Officer Dr Andrew Parson (AP) Member CCG Chair Dr Miranda Selby (MS) Member Governing Body GP (Representing Dr Ruchira Paranjape) Liz Wise (LW) Member NHS England London (Director of Primary Care) Dr Jane Fryer (JF) Member NHS England (Medical Director for South London Dr Mukesha Sahi (MS) Observer LMC Linda Gabriel (LG) Observer Healthwatch Apologies: Sara Nelson Dr Ruchira Paranjape Governing Body Nurse Governing Body GP 30

31 Councillor David Jeffreys Health and Wellbeing Board Greenwich Primary Care Joint Committee Attendees: Dr Greg Ussher (GU) Member Committee Chair (Lay Patient Public Involvement) Dr Iyngaran Vanniasegaram (IV) Member CCG Governing Body - Secondary Care Clinician Annabel Burn (AB) Member CCG Chief Officer Dr Ellen Wright (EW) Member CCG Chair Dr Nayan Patel (NP) Member CCG Governing Body GP Liz Wise (LW) Member NHS England London (Director of Primary Care) Dr Jane Fryer (JF) Member NHS England (Medical Director for South London Dr Tuan Tuan (TT) Observer LMC Funa Hussain (FH) Observer CCG Primary Care Manager Apologies: Jim Wintour Maggie Buckell Ms Leceia Gordon-Mackenzie Councillor David Gardner Committee V Chair (Lay Governance) Registered Nurse GB member Observer Healthwatch Observer - Health and Wellbeing Board Lambeth Primary Care Joint Committee Attendees: Sue Gallagher (SG) Member Committee Chair (Lay Patient Public Involvement) Graham Laylee (GL) Member Committee Vice-Chair (Lay Governance) Andrew Eyres (AE) Member CCG Chief Officer Andrew Parker (AP) Member CCG Director of Primary Care Development Dr Adrian McLachlan (AM) Member CCG Chair Dr Martin Godfrey (MG Member CCG Governing Body Clinical Member Professor Ami David MBE (AD) Member Governing Body Nurse Liz Wise (LW) Member NHS England London (Director of Primary Care) Dr Jane Fryer (JF) Member NHS England (Medical Director for South London Dr Penelope Jarrett (PJ) Observer LMC (representing Dr Jenny Law) Apologies: Dr Jenny Law Jackie Ballard Councillor Jim Dixon Catherine Pearson Local Medical Committee (Lambeth) Associate Member, CCG Governing Body Health and Wellbeing Board (Lambeth) Healthwatch (Lambeth) Lewisham Primary Care Joint Committee Attendees: Rosemarie Ramsey MBE (RR) Member Committee Chair (Lay Patient Public Involvement) Ray Warburton OBE (RW) Member Committee Vice-Chair (Lay Governance) Professor Ami David (AD) Member CCG Governing Body Nurse Member Martin Wilkinson (MW) Member CCG Chief Officer Dr Marc Rowland (MR) Member CCG Chair Dr Jacky McLeod (JM) Member CCG Clinical Director Liz Wise (LW) Member NHS England London (Director of Primary Care) Dr Jane Fryer (JF) Member NHS England (Medical Director for South London Peter Ramrayka (PR) Observer Health and Wellbeing Board 31

32 Apologies: Diana Braithwaite CCG Director of Commissioning and Primary Care Southwark Primary Care Joint Committee Attendees: Joy Ellery (JE) Member Committee Chair (Lay PPI) Professor Ami David (AD) Member CCG Governing Body Nurse Member Andrew Bland (ABl) Member CCG Chief Officer Dr Jonty Heaversedge (JH) Member CCG Chair Liz Wise (LW) Member NHS England London (Director of Primary Care) Dr Jane Fryer (JF) Member NHS England (Medical Director for South London Caroline Gilmartin (CG) Observer CCG Director of Integrated Commissioning Apologies: Malcolm Hines Dr Claire Lloyd Richard Gibbs Dr Emily Gibbs Aarti Gandesha Councillor Maisie Anderson CCG Chief Financial Officer Local Medical Committee (Southwark) Committee Vice Chair (Lay Governance) CCG Governing Body GP Healthwatch (Southwark) Health and Wellbeing Board (Southwark) Other attendees: Jill Webb (JW) Richard Jeffery (RJ) Gary Beard (GB) Nick Langford (NL) Richard Beller (RB) NHS England London (Head of Primary Care) NHS England London (Director of Financial Management) Assistant Head of Primary Care Senior Primary Care Commissioning Manager LSL NHS England (London) Item 1. Introduction and apologies Action GU welcomed members, observers and members of the public to the seventh meeting of the Primary Care Joint Committees of: NHS Bexley CCG and NHS England NHS Bromley CCG and NHS England NHS Greenwich CCG and NHS England NHS Lambeth CCG and NHS England NHS Lewisham CCG and NHS England NHS Southwark CCG and NHS England GU informed members, observers and members of the public that the meeting was to be held in two parts, and that part one was a meeting held in public, rather than a public meeting. GU advised that the meeting would be recorded to help to ensure accuracy of the minutes, which would be published in advance of the next meeting, at which point they would be formally approved by the Joint Committees. Apologies received in advance of the meeting Mary Currie Bexley Primary Care Joint CCG Governing Body 32

33 Lotta Hackett Keith Wood Councillor Teresa O Neill OBE Sara Nelson Dr Ruchira Paranjape Jim Wintour Maggie Buckell Leceia Gordon- Mackenzie Sue Gallagher Jackie Ballard Dr Jenny Law Committee - Member Bexley Primary Care Joint Committee - Observer Bexley Primary Care Joint Committee - Member Bexley Primary Care Joint Committee - Observer Bromley Primary Care Joint Committee - Member Bromley Primary Care Joint Committee - Member Greenwich Primary Care Joint Committee - Member Greenwich Primary Care Joint Committee - Member Greenwich Primary Care Joint Committee - Observer Lambeth Primary Care Joint Committee - Member Lambeth Primary Care Joint Committee - Observer Lambeth Primary Care Joint Committee - Observer Nurse Healthwatch (Bexley) Committee Vice-Chair (Lay Governance) Health and Wellbeing Board (Bexley) CCG Governing Body Nurse CCG Governing Body GP Committee Vice-Chair (Lay Governance) CCG Governing Body Nurse Healthwatch (Greenwich) Committee Chair (Lay PPI) Associate member, CCG GB Local Medical Committee (Lambeth) Councillor Jim Dickson Lambeth Primary Care Joint Committee - Observer Health and Wellbeing Board (Lambeth) Richard Gibbs Dr Emily Gibbs Malcolm Hines Aarti Gandesha Dr Claire Lloyd Councillor Maisie Anderson Southwark Primary Care Joint Committee - Member Southwark Primary Care Joint Committee - Member Southwark Primary Care Joint Committee - Observer Southwark Primary Care Joint Committee - Observer Southwark Primary Care Joint Committee - Observer Southwark Primary Care Joint Committee - Observer Committee Vice-Chair (Lay Governance) CCG Governing Body GP CCG Chief Financial Officer Healthwatch (Southwark) Local Medical Committee (Southwark) Health and Wellbeing Board (Southwark) 33

34 2. Declaration of Interests The following members and observers reported changes to their declarations. In cases where the attendee was representing a member or observer at the meeting, the declarations were noted as new entries to the declarations of interest register. Name Joint Committee Change Dr Kathy McAdam- Freud Southwark Will be partner at Nexus (merged GP Practice in Southwark) from 1 st August Minutes of the last meeting The minutes were agreed to be a correct record of the meeting. Action log TB advised that of the six actions on the log, five had been closed since the previous meeting. An update on the remaining outstanding action (concerning the Quality and Performance Report, and the co-commissioner joint approach in response to its findings) was noted as being scheduled for the next meeting (18 August). 4. Matters arising Overview from Director of Primary Care, NHS England (London Region) LW gave a brief update on the General Practice Forward View (GPFV). Further to her update at the previous meeting, LW had circulated to Joint Committee members in advance of the meeting some briefing materials on this. Copies of this were available for the benefit of members of the public in attendance. LW reminded the Joint Committee of the four key elements that had emerged as national priorities for implementation as part of the GPFV in , which were being taken forward within the London region: Practice Resilience: this is referred to in the Workload and Workforce chapters in the GPFV and specifically involves allocations to the regions of a 16m national fund. NHS England (London region) was in the process of working with Londonwide LMCs and practices, as well as SPG leads to identify the optimum ways to make best use of this funding locally, given the many challenges faced by Primary Care at this time Addressing the costs of medical indemnity: LW advised that this is a national piece of work to address the escalating costs in this area. LW said that she could gather further information on this upon request. Taking forward a number of the initiatives on workforce, including the training/recruitment of additional 5,000 doctors and 5,000 other clinical general practice staff over the next five years. LW also advised that NHS England (London region) was expecting some further announcements on the distribution of the agreed funding to enable improvement patient access to general practice. LW advised that a key aspect to the London approach was the establishment of a programme team to plan and deliver the GPFV recommendations for general practice workforce. 34

35 Transforming Primary Care programme is looking closely at the non-workforce aspects of the provider support programme which was being developed. LW intends to bring further information on this programme to the Joint Committees at a future meeting. LW referred to the sizeable financial commitment to the funding of infrastructure commitments for estates and technology in general practice over the next three years (as part of the ETTF programme, which was due for an update later on the agenda). LW also referenced another key priority that was being taken forward between cocommissioners, via SPG leads the development of the Sustainability and Transformation Plan for south east London. A significant section of this was around Primary Care. LW acknowledged the significant at amount of work that had gone into the development of this section of the STP, which had progressed well ahead of its date of submission (end of July). The Bromley Joint Committee (ML) asked LW for an update on the PMS review/contract. LW advised that there was a pause on the process that had been agreed as a result of discussions between Londonwide LMCs and NHS England. LW advised that this involved a complex set of issues and that the approach toward implementation of the PMS review was being managed via informal discussions between NHS England (London region) and the Londonwide LMCs, and that SPG leads were being kept abreast of this situation. The focus on the part of all parties concerned was to ensure that benefits to patients would be maximised (in terms of utilisation of the London premium for practices), whilst at the same time ensuring that the general practice system was not in any way destabilised. NHS Lambeth CCG: Vale Surgery / Dr Guna Merger JWe said that at the last Lambeth Primary Care Joint Committee meeting, the above merger had been approved, subject to two conditions. JWe reported on key developments against those conditions: (i) that a full patient engagement and consultation plan for the merger should be developed and approved, and (ii) that this and the merger proposal should be reviewed by the Lambeth Health Oversight and Scrutiny Committee (HOSC). JWe said that the plan had been developed and approved by the Joint Committee, and that the HOSC had approved both the patient engagement and consultation plan and the merger proposal. The LMC had commented on the importance of how the merged practice will ensure that vulnerable patients accommodated in the context of the merger, recognising that there was a distance between the two practices that had merged into a single site. In response to this the practice had produced a comprehensive plan to ensure continuity of care for patients, and/or to assist any patients who find that the distance to travel (as a result of the merger) was problematic by finding an alternative suitable GP to register with. Finally, JWe advised that the date of the merger was due to proceed on 1 st September (it had previously been set for 1 st July). JWe recommended that there should now be no conditions attached to the approval of the merger to proceed. AE confirmed the support of the Lambeth Joint Committee for the recommendation in favour of the proposed merger. 35

36 5. Public Open Space No written questions from the public had been received in advance of the meeting. Eileen Smith (Greenwich Keep Our NHS Public) addressed the Joint Committees. Keep our NHS Public had taken part in a representation outside the Bromley Central Library in advance of the meeting. Eileen said that the protest had been made to appeal against the implications of the Five Year Forward View and the Sustainability and Transformation Plans for patient care, as seen by Keep Our NHS Public. Bob Skelly (South Southwark PPG) referred to numbers of Serious Incidents and Never Events that had been reported at KCH and GSTT in the latest available full year reporting period (156 SIs and 24 Never Events) and asked how these numbers compare nationally, and if they compare unfavourably, what commissioners were doing to mitigate this. JH (Southwark Joint Committee) advised that this data was not immediately available to hand, and that Southwark CCG would need to come back on how the reported figures compare nationally. JH advised that the numbers would need also to be set in the context of the level of complexity and acuity of the patients concerned and that are seen by these Trusts more generally, noting that the volume of incidents as a stark set of figures would not necessarily present the full picture. JH also said that the CCG positively encouraged local providers to meet their statutory responsibility in reporting on such incidents and that the CCG was content with the way the above providers report them that the level of quality of the reporting was high and allowed a full root case analysis to take place (and be acted upon as a partnership of provider and commissioner) in every case. JH said that a full response would be provided to Bob Skelly on this question. JH Anne Garrett (Bromley resident, co-chair of Save Our Local Hospitals and Services (Bromley, Bexley and Greenwich) raised a question regarding the challenged performance of Kings College Hospital Foundation Trust in terms of its Emergency Department at Princess Royal University Hospital, and asked what was being done to improve this. ABh (Bromley Joint Committee) advised that Bromley CCG was working with all partners and providers locally in order to help Kings College Hospital (Princess Royal University Hospital) to meet the 4 hour ED target. This included the provision of General Practice hubs to increase access to general practice (and therefore to reduce the burden on the ED), to enhance the management of patients with long term conditions in community settings, working with hospital to make more beds available in the hospital setting by improving discharge processes and pathways, with the intention of improving the flow of patients through the hospital, which would have a number of benefits for patients, including an improvement to ED performance. ABh advised that in recent weeks, whilst the Hospital site had not reached the achievement of 95% for ED performance, there had been a significant improvement in ED performance at the Princess Royal University Hospital, attributable to these initiatives. Kabir Kapoor (Chair of the Southwark Deaf Forum) asked the Joint Committees how they would give greater access to sign language interpreters in Emergency Departments/A&E Departments in local hospitals. Mr Kapoor said that some boroughs in London had ensured an adequate level of provision for their residents in this regard, but that others had not. ABl (Southwark Joint Committee) asked if Mr Kapoor could provide some further information this following the meeting, so that this could be investigated. KK/ABl Mr Kapoor also asked the Joint Committees whether, in the light of the EU referendum result, that NHS services would be able to benefit from increased 36

37 funding, and whether any of this might be allocated to services for deaf patients. For discussion 6. Quality, Performance and Finance GU advised the Joint Committees that this item would focus on matters of Finance only, given that Quality and Performance reports were available on a quarterly basis. Update on primary care budgets RJ introduced Enclosure D, a brief paper setting the budget position for and the outlook for future years. RJ explained that the monthly finance reports that are normally presented to the Joint Committees do not provide meaningful reporting positions until month 4, as the variances prior to the stage are quite negligible. The available reporting position at the time of this meeting was for month 2. RJ advised that the forecast medical services gap was 3.6m across SE London in 2016/17. The situation was set to improve in future years as further growth becomes available and further developmental funding was anticipated in-year following the publication of the General Practice Forward View. RJ said that the budgets were more robust for than in , when there was a higher QIPP target. The 16/17 QIPP from rate reimbursements would mean an overall reduction in expenditure in RW (Lewisham Joint Committee) asked for clarity on the formula for allocations in and onwards. RW referred to the 5.3% under-target capitation position for London in RJ explained that this was the base year, on which the allocations were set. RJ explained that the Carr-Hill was a distribution formula and did not allocate funding on an assessment of the needs of a population. PJ (Lambeth Joint Committee) asked two questions concerned with the forecast gap for the SE London area in : (i) (ii) PJ asked how confident NHS England (London region) was that SE London CCGs would have sufficient contingency in place. RJ explained that in , the contingency budget was required to off-set the QIPP shortfall. The London Region was confident that this would not happen again in (due to the lower QIPP target), and the contingency was therefore likely to be available. PJ asked how confident NHS England (London region) was of the allocations in , given the present uncertain economic situation. RJ replied by saying that even before the Brexit outcome of the EU referendum, there had been some talk in central government of resetting funding in (although the detail of what this might entail had not been set). However there was no reason that he was aware of to question the allocations for the next three years. 7. Estates and Technology Transformation Fund (ETTF) TO gave a brief introduction to this item, presenting the cover paper to Enclosure E, which summarised the process through which SE London CCGs had agreed their ETTF bids for submission. The deadline for bids to be submitted onto the NHS 37

38 England portal was the 30 th June. At the previous meeting, each Joint Committee had delegated to its appropriate subcommittee, the review and endorsement of ranked bids to be submitted to the ETTF, subject to decisions being made by voting members of the relevant Joint Committee, in accordance with their terms of reference. The bids would be for both estates and digital. It was also agreed that a report on the process and outcome of subcommittee considerations would be brought back to the 29 June meeting of the SE London Primary Care Joint Committees. TO reported that in each borough, prior to prioritisation and submission, the bids had been through local governance, including engagement with practices, GP Federations and Local LMCs. Each bid was required to meet at least one of four national criteria: (i) improved seven day access, (ii) increased capacity for Out of Hospital services, (iii) a wider range of services to reduce unplanned admissions, (iv) Increased training capacity. The main body of Enclosure E set out for each CCG the specific governance processes, local engagement arrangements, the local criteria applied to rank the bids, order of prioritisation of bids as agreed by the subcommittee, confirmation that each bid met at least one of the national criteria (and was therefore eligible for funding). This information had been minuted at the relevant subcommittee meetings, using a proforma template that was used by all six CCGs, to ensure consistency of approach. TO explained that the bids would now be taken forward through an extensive assessment process at London level by NHS England London region, in collaboration with SPG estates and technology leads. The current process indicated that the outcome of the prioritisation process for specific bids will not be known until the end of October 2016, although CCGs would know whether their prioritised schemes had been recommended by London region to join the ETTF 3 year pipeline of projects by the end of July; and whether they had been endorsed on a national basis by the end of August. There will be limited spend on some successful schemes in , as they will not be approved until after the end of October. However, unlike year 1 of ETTF (previously known as the Primary Care Infrastructure Fund), schemes would not need to be completed in one year. JWe advised that the governance arrangements that had been deployed across SE London CCGs for the process of agreeing and determining which bids to submit, and the recording and management of associated issues, had been robust. In her capacity as London Estates and Premises lead for NHS England (London region), JWe was in a position to commend SE London on this. JWe explained that the bidding would not be closing until the 5pm on 30 th June. JWe gave some context on the numbers of bids showing on the NHS England portal, as of 29 June, noting that this was at a fixed point in time. As of the morning of 29 June there had been 1,763 bids submitted nationally. The national allocation for the ETTF was expected to be 900m over the next three years (this was yet to be confirmed). JWe said that in London, there had been 290 bids received as of 29 th June. In SE London, JWe said that 55 bids had been submitted so far (19 of which were for technology schemes). GU asked each Joint Committee chair (or other nominated colleague) in turn to 38

39 confirm that their Joint Committee had followed the process as set out in their set of minutes (as shown in Enclosure E), and that their Joint Committee/CCG would submit the ETTF bids according to the prioritisation as included therein. Each Joint Committee chair confirmed that their Joint Committee had followed the process as set out in their set of minutes (as shown in Enclosure E), and that their Joint Committee/CCG would submit the ETTF bids according to the prioritisation as included therein. GU invited any comments or questions from the Joint Committees. SP (Lewisham Joint Committee) welcomed the approach toward the bids as reported in the paper and by the Joint Committees at this meeting, including the involvement of LMCs in this process in each borough. SP made an observation, saying that the necessity for transformation required a strong backbone, and that general practice was that backbone. SP referred to the importance of the larger ETTF bids in terms of their ability and intention to help to drive transformational change. SP also described the importance of smaller bids, for individual practice development. Accepting that these bids are not appropriate to the ETTF, SP emphasised their relevance to the Improvement Grant and the need for them to be acknowledged in this regard. SP stated support of the movement toward transformation of general practice and the importance of the ETTF in this, and at the same time the need to ensure that general practice is able to maintain its foothold. JWe recognised the importance of both transformation and the sustainability of practices, noting that both were of paramount importance in the development and selection of bids for submission in the ETTF and the Improvement Grant. It was noted that NHS England (London) would be making another bid for capital Improvement Grant funding for 2017/18, to support the sustainability of infrastructure in general practice. RW (Lewisham Joint Committee) noted that the vast majority of the agreed bids were transformational, and said that co-commissioners had a responsibility also to assess the impacts of the bids on health inequalities and to act on this. JWe advised that for the bids that are eventually recommended (by NHS England s national team), a full business case will be required for ultimate approval, and that within the business case will be a requirements for bids to set out their service benefits, which should address health inequalities in their locality. Further detail on the requirements for the business cases will be issued to CCGs once NHS England (national team) had determined which bids to endorse, late in August. 8. Items for decisions per Joint Committee: All SE London CCGs: London Requires Improvement Standard Operating Procedure (SOP) JWe introduced Enclosure F. This was the second presentation of this proposed SOP at a Primary Care Joint Committees meeting. The previous version of it had been approved in principle at the meeting on 28 April, on the condition that Londonwide LMC comments would be factored into the final version for approval and that any further comments from London-wide CCGs and individual LMCs would also be reflected. There had been no material changes made following the CCG inputs across London, therefore it was not necessary to request final comments from Loon LMCs in response. 39

40 In order for the SOP to be incorporated into the London Co-Co commissioning operating model, the six SE London CCGs would need to confirm their approval of it. NHS England (London) had approved the present final draft version. JWe advised that the version distributed had benefited from the above input. In the case of the London LMCs, most of the comments received had been incorporated in this final draft version. As a reminder, the purpose of the SOP is to support primary care commissioners to place due consideration on the issues that have led to GP practices receiving overall Requires Improvement ratings following CQC inspections, and ensure that appropriate actions are taken to remedy contractual quality and safety concerns. Its purpose is also to provide level 1, 2 and 3 Primary Care Commissioners across London with consistent guidance on issues to take into account when considering CQC reports with an overall status of Requires improvement that may require the issue of a contractual breach and remedial notice and/or alternative support. Joint Committees were also reminded that the current outcome of CQC inspections of general practices across England shows London region to be a significant outlier compared to other regions relating to practices who are given an overall Requires improvement status (18.4% as a proportion of inspected practices in England as at 6 th June 2016, compared to the 10.2% average for England). These figures were now based on a considerably higher proportion of GP practices that had completed/published inspections in London than had been reported at previous meetings, where this SOP had been reviewed. The number of practices that had had completed/published inspections in London stood at 521 (out of 1377), or 37.8%. Therefore, the statistical relevance of this SOP had been increased markedly in the course of KM-A (LMC observer member on the Southwark Joint Committee) stated the position on behalf of the London-wide LMC perspective. KM-A advised that the London-wide LMC had been consulted on the development of this SOP, and that the comments had largely been incorporated into the version as distributed ahead of the meeting. However, KM-A advised that the London-wide LMC does not agree that a breach of contract should be applied following a practice being given an overall Requires improvement status following a CQC inspection. Instead, that determination on this should be considered on a case-by-case basis, and that consideration should be given to an alternative approach of working on a less formal basis with each practice concerned, to develop and monitor progress against an action plan in response to the inspection findings, and a written warning, rather than initiating contractual action as a rule. JWe responded, and assured the London-wide LMC that the SOP would not negate their proposed approach on this issue. The SOP looks at the range of considerations that would need to be taken into account in this situation. JWe noted that the CQC, as a statutory body, had its own requirements around responsibilities which it needs to discharge. NHS England s requirements around its responsibilities were manifested via the GP contract itself. In this regard, JWe said that contractual action was not an automatic response by NHS England following a practice being given an overall Requires improvement status following a CQC inspection and agreed with the principle of the point raised. GU asked each Joint Committee Chair to respond with any comments or pints of contention to the SOP, and to confirm on behalf of their Joint Committee whether it is content to approve the recommendation within the paper, to confirm whether they 40

41 wish to adopt the attached final draft A consistent approach to responding to Care Quality Commission Requires Improvement notifications. Each Joint Committee chair confirmed that their Joint Committee confirmed their agreement to adopt the final draft of the SOP, as above. Borough-based Local Incentive Schemes: GU introduced this item, saying that for each of the six Local Incentive Schemes (LIS s), it has been agreed with the CCGs and NHS England (London region) that a designated CCG lead would present a brief outline of the LIS and then to confirm that their Joint Committee had considered the recommendation and approved it. For each LIS, JWe would respond and convey any points of contention (if there are any), and LW would then be asked to approve the LIS on behalf of NHS England (London region). NHS Bexley CCG: Bexley Primary Care Improvement Fund Local Incentive Scheme TO introduced the paper (Enclosure G) that requested that the Joint Committee approve the above LIS on the understanding that all practices will be encouraged to participate, with outcomes suitably monitored. The Primary Care Improvement Fund (PCIF) is the replacement for the previous Kitemark scheme (from 2015/16). The Kitemark scheme was developed five years ago and replaced the previous PBC Local Incentive Scheme. The principles of the improvement scheme are to incentivise practices to complete work that is above and beyond their core contracted service, which ultimately provides better quality care for patients. TO advised that the four elements chosen for the 2016/17 scheme were: Medicines Management, Dementia Identification, End of Life Care, and Childhood Obesity. TO advised that this is a rollover scheme from 2015/16, and was approved by the CCG before the inception of the PCJC and current operating framework. The financial value of the PCIF is 764k for 2016/17, and a Bexley average list size practice would attract a maximum payment of 28,297. TO further advised that the scheme is open to all practices in the CCG area, and there is no financial risk to practices if set targets are not achieved. To confirmed that the LMC has been consulted on the LIS. JWe confirmed that the LIS had been reviewed and fully validated in line with the NHS England (London) Operating Model for primary care co-commissioning. This had been assessed against a standardised template setting out the validation arrangements. The scheme had been originally approved by the Bexley CCG Governing Body before the Joint Committee was in place, therefore it was noted that this was a rollover scheme. JWe echoed the principle pointed out by TO, that all practices should be encouraged to participate in the scheme. JF asked if the Joint Committee was confident that the LIS would address the issue of not meeting national targets on antibiotics usage. RM replied, advising that the data for this year was not available yet, but the data for had shown a notable decrease in the prescription rates of the antibiotics concerned. 41

42 LW gave approval for the recommended approach on behalf of NHS England (London region). NHS Bexley CCG: Bexley Delegated Prescribing Scheme Local Incentive Scheme TO introduced the paper (Enclosure H) that requested that the Joint Committee approve the above LIS on the understanding that all practices will be encouraged to participate, with outcomes suitably monitored and reviewed. The scheme will allow each locality to hold its prescribing budget - whilst the quality of prescribing will be monitored by Bexley CCG s Medicines Management team. It is felt that this scheme will improve cost effective prescribing in each of the three localities. TO advised that it was likely that North Bexley and Frognal will participate in the scheme for It is still hoped that Clocktower locality would also participate. The prescribing budget set for had been approved by both the Medicines Management Committee and the Finance Sub-Committee. If at year end the locality as a whole is underspent the savings achieved would be allocated as follows: 1/3 for locality to divide amongst practices to develop services in practices (using the historical Prescribing incentive scheme rules) 1/3 to CCG for practice staff support including the Medicines Management Team Pharmacists and Primary Care Development Team 1/3 for CCG to spend on patient care with locality advice (via Clocktower locality meetings). If the locality is overspent at year end, no monies will be repaid to the CCG from the locality and there will be no monies for localities to divide and spend to develop services in practices. This scheme would be carried forward from 2015/16 where it was approved by the CCG s Finance Sub Committee in February All three localities participated in the scheme for All practices within each locality must sign up to the agreement for it to take place. Savings will not be used to provide income to the practices, savings will be used to develop services including capital expenditure There is no financial risk to practices, there is a risk that savings will not be achieved locality wide due to some practices not achieving individual prescribing savings, therefore practices will be encouraged to work together to share best practice. Finally, TO advised that the LMC was consulted in 2015, and that this was a continuation of the scheme. JWe confirmed that the LIS had been reviewed and fully validated in line with the NHS England (London) Operating Model for primary care co-commissioning. This had been assessed against a standardised template setting out the validation arrangements. The scheme had been originally approved by the Bexley CCG Governing Body before the Joint Committee was in place, therefore it was noted that this was a rollover scheme. JWe echoed the principle pointed out by TO, that all practices should be encouraged to participate in the scheme. 42

43 LW gave approval for the recommended approach on behalf of NHS England (London region). NHS Greenwich CCG: Greenwich Tuberculosis (TB) Testing Local Incentive Scheme ABu introduced the paper (Enclosure I) that requested that the Joint Committee approve the above LIS on the understanding that all practices will be encouraged to participate, with outcomes suitably monitored and reviewed. The aim of this LIS is to support the national LTBI testing and treatment programme which sets to identify eligible migrant populations through GP registration. This service aims to reduce the rate of TB in Greenwich by improving the early detection and diagnosis of TB amongst local residents. The project is co-ordinated across primary, secondary and community providers. The TB team at Oxleas is supported by consultants at Lewisham and Greenwich Trust in managing patients with latent TB. ABu advised that this addressed a very important issue toward improving patient care in Greenwich. A recent pilot carried out by the CCG involving 11 of its GP Practices had found that 27% of registered patients test positive for TB, which is higher than the national average of 13.5%. ABu referred to the detailed development work of the pilot (as shown in the Enclosure I) and the consultation on it with the LMC who had provided support for it. JWe confirmed that the LIS had been reviewed and fully validated in line with the NHS England (London) Operating Model for primary care co-commissioning. This had been assessed against a standardised template setting out the validation arrangements. JWe also reiterated that all practices should be encouraged to participate in the scheme. LW gave approval for the recommended approach on behalf of NHS England (London region). NHS Greenwich CCG: Greenwich Cancer Local Incentive Scheme ABu introduced the paper (Enclosure J) that requested that the Joint Committee approve the above LIS on the understanding that all practices will be encouraged to participate, with outcomes suitably monitored and reviewed. The Greenwich Cancer Action Plan had been developed in collaboration with the Strategy and Performance Directorate, and the Greenwich CCG Cancer and End of Life Working Group. The Greenwich Cancer Action Plan is intended to improve cancer outcomes in the area and should in time achieve substantial financial savings by working at a GP locality network level to achieve the following four objectives: (i) (ii) (iii) (iv) increase early detection of cancers through improved GP knowledge/education, encourage best practice and robust tracking and safety-netting scheme to increase uptake of bowel screening improved rates of cancer patients satisfaction with support from primary care 43

44 JWe confirmed that the LIS had been reviewed and fully validated in line with the NHS England (London) Operating Model for primary care co-commissioning. This had been assessed against a standardised template setting out the validation arrangements. JWe also reiterated that all practices should be encouraged to participate in the scheme. LW gave approval for the recommended approach on behalf of NHS England (London region). NHS Lewisham CCG: Supporting Medicines Optimisation through the implementation of the Prescribing Incentive Quality Scheme 2016/17 (PIQS) MW introduced the paper (Enclosure K) that requested that the Joint Committee note and review the NHS England Assessment Template and NHS Lewisham CCG s prescribing Incentive Quality Scheme Specification, and to approve the above LIS on the understanding that all practices will be encouraged to participate, with outcomes suitably monitored and reviewed. The aim of this LIS is to encourage cost effective, quality prescribing and to ensure that payments made to practices are to be utilised to improve services to patients. The scheme consists of the following three prescribing work areas: 1. Clinical Review a. to help reduce falls risk and subsequent hospital admission, or b. medication reviews to reduce hospital admission risk 2. Financial Indicator - a. to identify patients currently prescribed drugs that are restricted to specialist prescribing and make arrangements to transfer clinical care to the appropriate specialist unit, and b. review one high cost prescribing area with potential to improve cost effectiveness in the practice 3. Antibiotic Stewardship a. attendance to a microbiologist led antibiotic learning event b. meet the CCG antibiotic quality premium targets MW advised that elements within the scheme had continued from the 2015/16 scheme, and that the 2016/17 LIS was agreed by the Lewisham CCG Prescribing and Medicines Management Group meeting, with LMC representation. JWe confirmed that the LIS had been reviewed and fully validated in line with the NHS England (London) Operating Model for primary care co-commissioning. This had been assessed against a standardised template setting out the validation arrangements. JWe also reiterated that all practices should be encouraged to participate in the scheme. LW gave approval for the recommended approach on behalf of NHS England (London region). NHS Southwark CCG: Medicines Management Local Improvement Scheme CG introduced the paper (Enclosure L) that requested that the Joint Committee note and review the NHS England Assessment Template and NHS Southwark s CCG s Medicines Management LIS, and for NHS England (London region) to 44

45 confirm that this LIS satisfies NHS England s assurance, and for the Joint Committee to confirm agreement with this LIS in line with the Operating Model. The aim of the Local Improvement Scheme (LIS) is to encourage cost effective, quality prescribing by financially rewarding practices that achieve specific quality and efficiency savings targets. The scheme aims to introduce and support a population based approach in line with NHS Southwark CCG s Primary and Community Care Strategy and other population based contracts delivered in Southwark to improve population outcomes and reduce variation. This scheme includes 2 based indicators that have targets set at both population level and practice level. Practices are encouraged to work collectively within their federations for delivery of the population element of these indicators. This could be achieved through sharing good practice, sharing data, having population level champions for antibiotics or diabetes and through peer review groups. The 2016/17 LIS was agreed by Southwark CCG s Medicines Optimisation Committee with LMC representation JWe confirmed that the LIS had been reviewed and fully validated in line with the NHS England (London) Operating Model for primary care co-commissioning. This had been assessed against a standardised template setting out the validation arrangements. JWe also reiterated that all practices should be encouraged to participate in the scheme. LW gave approval for the recommended approach on behalf of NHS England (London region). Other items for decisions per Joint Committee NHS Greenwich CCG: Trinity Medical Centre Premises Relocation JWe advised that the Business Case (circulated as part of Enclosure M) and NHS England s associated analysis provides compelling information and evidence that recommends the relocation of the Trinity Medical Practice, currently based in Burrage Road, Plumstead to Garland Road Clinic, Plumstead (0.7 miles away) as soon as possible. If approved, this would result in a minimum cost pressure of 80,688 per annum on the Greenwich GP NHS England budget, and the recommendations address how this should be managed. JWe introduced the paper (Enclosure M) that requested that the Joint Committee agree to the recommendation that the Trinity Medical Centre relocate to the new premises at the Garland Road Clinic as soon as possible. The Joint Committee was also asked to endorse the following: (i) That Community Health Partnerships confirms that the changes that they have agreed to make to the building will not result in additional revenue consequences for commissioners. (ii) That the practice produces a patient communications plan, which will be 45

46 agreed and supported by co-commissioners. (iii) That the cost of notifying patients and any IT configuration changes are borne by NHS England and the CCG respectively. (iv) That the specified anticipated fye recurring revenue cost pressure of 80,688, currently unfunded by NHS Greenwich, is funded from PMS Key Performance Indicator clawback monies in 2016/17. This amounted to a value of around 185k in 2015/16. This means that in theory, the additional part year cost of Garland Road could be managed within the existing Greenwich budget for 2016/17. (v) This additional recurrent cost would need to be a first charge on Greenwich medical services growth funding in 2017/18, and any shortfall in funding, regardless of whether the CCG remains as a level 2 co-commissioner or is approved as a level 3 commissioner, would need to be funded from the CCG s wider budget. (vi) The practice is able to be considered for service charge support, utilising the recently approved NHS England (London) policy: Transitional Financial assistance towards running costs & service charges. The practice has agreed to submit its NHS income & expenditure figures, in order for its eligibility for financial support. It also understands that once the practice has submitted its figures that they may not be eligible and in this scenario, the practice accepts it will be responsible for the required service charge costs, utilities and soft facilities management. Garland Road is the fit for purpose new premises, located 0.7 miles from the existing premises at Burrage Road. The existing premises have been an ongoing concern for co-commissioners for a number of years, during which time a small number of premises options have been explored and not been able to be progressed. The practice will be inspected by the CQC in July, and it is also likely to confirm the practice should not be operating from their current premises. There are a number of alternative practices within 1 mile for patients to choose to register with, if the proposed relocation is agreed, and patients would prefer to find a practice closer to where they live. Patient consultation about the proposed move has been positive. It was noted that the Oversight Health and Scrutiny Committee (HOSC) would need to comment on the business case. ABu confirmed that the CCG would take this forward. ABu The most significant issue associated with this proposed relocation is that the additional minimum recurrent cost of the relocation will be 80,688 per annum (not including any service charge support that the Contractor may be eligible to receive). This can only be funded non-recurrently from the NHS England Greenwich medical services budget in 2016/17, as the final projected position against the 2016/17 allocation figure is an over-spend of 400k, once allowance for business rules has been made. On behalf of the Greenwich Joint Committee, ABu advised that there was certain support for the approval of the relocation, as the current premises were unfit for 46

47 purpose. Therefore the relocation gave an important opportunity to improve services to local residents. The CCG had been involved significantly in this and the move was in line with the CCG s strategy. However, ABu advised that the CCG had not agreed in full to the financial position (as referred to in points (iv) and (v), above). The CCG was in agreement with the conditions as set out in point (iv), and to the first section of point (v), above. The CCG had not agreed to the latter clause in point (v), that any shortfall in funding, regardless of whether the CCG remains as a level 2 co-commissioner or is approved as a level 3 commissioner, would need to be funded from the CCG s wider budget. ABu said that, as the CCG was currently in a position of financial turnaround that this meant that it could not absorb any additional cost pressures (as above) from its wider budget in It was agreed between ABu, LW and JWe that the CCG s position would be reviewed outside of the meeting and that NHS Greenwich CCG and NHS England (London region) would work together on this with the SE London Strategic Planning Group to find an alternative solution, which should not delay the relocation of the practice. Greenwich Joint Committee gave its approval for the recommended approach, subject to reaching agreement on the additional recurring premises revenue costs from , and receipt of any comments from the Greenwich HOSC. LW gave approval for the recommended approach on behalf of NHS England (London region), subject to reaching agreement on the financial position for , and the approval by the Greenwich HOSC. NHS Greenwich CCG: Conway Medical Centre CQC Rating Inadequate issue of contractual breach and remedial notice JWe introduced the paper (Enclosure N) that requested that the Joint Committee approve the issue of a breach and remedial notice to the above practice for failure to adhere to and provide: requirement to abide by all legislation requirement to have an effective system of Clinical Governance requirement to ensure that the persons providing care or treatment had the necessary qualifications, competence, skills and experience requirement to provide Essential Services to meet the reasonable needs of patients Following an inspection by the CQC on 2nd February 2016 and the subsequent publication of the visit report on 27 May, Conway Medical Practice received an overall rating of Inadequate for the quality of care provided by the practice. NHS England therefore feels that it is both proportionate and reasonable to issue a contract remedial notice at this time. A link to the Practice report at the CQC website was included in the paper and is available at the address below: 47

48 JWe noted that NHS England and Greenwich CCG will arrange a joint visit to the practice as soon as possible to ensure that they are in a position to provide the CQC with a robust improvement plan. The practice has the optional choice of involving the Royal College of GPs, who offer support in relation to policy development and the development of practice systems and processes in conjunction with the LMC, Greenwich CCG and NHS England. Greenwich Joint Committee gave its approval for the recommended approach, stating a commitment to help to support the practice to improve. LW gave approval for the recommended approach on behalf of NHS England (London region). NHS Lambeth CCG: Streatham Place Opening Hours Proposal JWe introduced the paper (Enclosure O) that requested that the Joint Committee support the business case proposal (for a seven day service), pending confirmation of a reasonable lead in period and the associated patient communications. Currently, Streatham Place patients can be seen for routine appointments Monday Saturday. If an appointment is required on a Sunday, then the patients is booked at the Access Hub at Gracefield Gardens or advised to visit the WIC. AT Medics is proposing to move Saturday appointments from Streatham Place to Edith Cavell, 600m from Streatham Place (as covered in Appendix 2 of Enclosure O) core hours will remain at Streatham Place during Monday Friday. Under this proposal: Patients would be able to book appointments in advance and on the day at Edith Cavell Surgery on Saturdays and Sundays Patients would be able to access services during the 52.5 core during Monday to Friday at Streatham Place. Patients would be able to access the current number of appointments that are provided at Streatham Place from Edith Cavell on a Saturday morning Patients would be able to access additional appointments from Edith Cavell on a Sunday morning The service would be delivered by a GP and Nurse, supported by three receptionists, which may be flexed, to meet local demand and our access targets. The service would provide; o Bookable appointments up to 4 weeks ahead. o o On the day appointments will also be available for urgent needs. A reception and phone service will be available throughout the opening period Co-Commissioners are agreed that this proposal would provide additional access and choice for registered patients, and were recommending that the business case be approved and that there is a variation to the current APMS contract at Edith Cavell to allow for this. The practice has met with their PPG to discuss the proposal. The general consensus was that this was a very good proposal which would be supported by the group, and 48

49 the group felt reassured that the service would only be enhanced by this proposal. A survey was issued and ran for 22 days, both in house and via SMS sent to all patients. There were just over 300 respondents. Responses confirmed that 85% of patients were in favour of the proposal to offer Sunday appointments from Edith Cavell, 10% against and 5% did not know. For the combined 15% of patients who either did not support, or did not know whether they were in support of the proposal, AT Medics will look to develop an enhanced telephone access offering on Saturday mornings so that patients who don't want to physically attend another site can be advised and often dealt with over the phone. In addition, AT Medics will continue to engage and work with their PPG post implementation to ensure refinements and suggestions are taken on. PJ (LMC observer member on the Lambeth Joint Committee) raised two questions relating to the proposal. Firstly, to question whether Sunday appointments were required, as there was evidence elsewhere to show that appointments on Sunday are regularly unfilled. PJ also queried what the knock-on effect of implementing the service/appointments on Sundays would be on the primary care access hub PJ also asked for the detail on the financial costs for the opening hours and whether the cost of the contract will be funded to provide the extra opening hours. JWe advised that this was being funded by the practice at its own cost, rather than being separately funded by NHS England (London region) or by NHS Lambeth CCG. Lambeth Joint Committee gave its approval for the recommended approach. LW gave approval for the recommended approach on behalf of NHS England (London region). 9. Items for decisions reported per Joint Committee: NHS Southwark CCG: Avicenna Health Centre JWe introduced the paper (Enclosure P) that requested that the Joint Committee note the actions and emergency decision taken by PCJC members (as contained in the paper) as recommended by NHS England (London) to secure emergency arrangements for continuation of the provision of services for the registered patients of Avicenna Health Centre. On Wednesday 11 May, NHS England (London) received notification from the Care Quality Commission (CQC) of their intention to serve Dr Kadhim with an Urgent Notice of Decision to temporarily suspend primary care medical services at the Avicenna Health Centre under S31 of the Health & Social Care Act (2008) for a period of up to three months. This followed a CQC Inspection of Dr Kadhim s practice at the Avicenna Health Centre on 10 May 2016, and the CQC confirmed that it was their intention to serve the papers during the morning of Friday 13 May The papers were served by to Dr Kadhim on Friday 13 May Based on a NHS England led option appraisal proposal, in line with the NHS England (London) Operating Model, Liz Wise - Director of Primary Care Commissioning, NHS England (London), in consultation with Andrew Bland Chief Officer for NHS Southwark CCG and Jane Fryer - Medical Director for NHS England (London), voting members of the Primary Care Joint Committee, approved a short 49

50 term caretaking arrangement with the Aylesbury Health Centre, which commenced at 8am Monday 16 May 2016 for a period of up to 3 months. Immediate temporary caretaking arrangements were required and implemented for patients registered with the Avicenna Health Centre. The Aylesbury Partnership is providing emergency caretaking services for registered patients for a period of up to 3 months NHS England (London) will work closely with the CQC to understand the progress of the temporary suspension of services and will inform registered patients and local stakeholders of developments in partnership with co-commissioners Southwark CCG. NHS England (London), working with NHS Southwark CCG, will advise the PCJC on the status of and developments relating to the temporary suspension of services. NHS England (London) is pleased to report that there was no interruption of services to patients despite the very short time frame. Letters were sent to all stakeholders including registered patients, local GP practices, Southwark Overview and Scrutiny Committee and relevant Councillors, MPs, other local providers e.g. District Nursing, Health Watch and the LMC. CG advised that there had been a typo in the paper, referring to the temporary suspension of the practice by the CQC with effect from 16 March. This was in error and should have referred to 16 May. The error would be amended in the paper. Southwark Joint Committee and NHS England noted the decision made as reported. For Information 10. None Public 11. Public Open Space Eileen Smith asked a question about the ratio of numbers of GPs to registered patients in south east London. ABl agreed that Co-Commissioners would gather to the existing data on this for the six SE London borough and share back with her. ABl Other Business 12. Any other business GU advised that Local Joint Committee Terms of Reference were up for their 12 month review and that any changes to them would be reported at the 18 August PCJCs meeting. GU advised that Chair/vice Chair arrangements for south east London PCJC had also recently passed their initial 12 month review point and to report that the PCJC Chairs had agreed that the present arrangements will continue (Greg Ussher and Martin Lee, respectively). For reference Glossary of Terms The Joint Committees noted the contents of the Glossary of Terms. GU reported that the Glossary had been updated by TB to make it more user-friendly and up-todie with current policy development, and that the Joint Committee Chairs had 50

51 approved the updated version. Date of Next Meeting Thursday 18 th August 2016, 6-8pm at Bexley Council Chamber, Bexley Civic Offices DA7 6LB Close 51

52 Primary Care Joint Committees 29 June 2016 Signed Attendance Sheet (Public and other observers) Simon Heard-White Richard Comaish Jackie Peake Keith Fowler Ashley O Shaughnessy Nick Langford Gary Beard Kabir Kapoor Tatjana Kapoor Ann Garrett John Catlin Bob Skelly Bill Solmesow Eileen Smith Claire Martin Joanne Sanderson N/A N/A Bromley CCG Bromley CCG Lewisham CCG NHS England NHS England Southwark Disablement Association Chairman Southwark Deaf Forum Community Bromley CCG N/A S. Southwark CCG Public KONP Rosemont Pharmaceutics KONP 52

53 Enc: X Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Enc C Last updated: 11 August 2016 Primary Care Joint Committees (PCJCs) meeting Action Log Ref Meeting Committee Action Due Owner Action Taken Status Date 1. 28/4/16 All Quality and Performance 11/8/16 JWe Co-commissioner joint approach (in Closed report: co-commissioner joint response to the data findings within approach in response to the Quality and Performance report) is currently being developed between data findings within it. This is NHS England (London region) and an ongoing piece of work the SE London CCGs. An update on being developed between this will be brought to the SE London NHS England (London PCJCs meeting on 18 August. region) and the SE London CCGs. JWe advised that a joint agreed approach to this was in development, that would set out agreed actions in response to the various findings within the report, and that this would be brought back to a future south east London PCJCs meeting /6/16 Southwark Bob Skelly (South Southwark PPG) referred to numbers of Serious Incidents and Never Events that had been 20/7/16 JH JH has written to Bob Skelly with a full response. Closed 53

54 reported at KCH and GSTT in the latest available full year reporting period and asked how these numbers compare nationally, and if they compare unfavourably, what commissioners are doing to mitigate this /6/16 Southwark Kabir Kapoor (Chair of the Southwark Deaf Forum) asked the Joint Committees how they would give greater access to sign language interpreters in Emergency Departments/A&E Departments in local hospitals. Mr Kapoor said that some boroughs in London had ensured an adequate level of provision for their residents in this regard, but that others had not /6/16 Greenwich Trinity Medical Centre Premises Relocation: It was noted that the Health Oversight and Scrutiny Committee (HOSC) would need to comment on the business case /6/16 Southwark Eileen Smith asked a question about the ratio of numbers of GPs to registered patients in south east TBC KK/ABl ABl (Southwark Joint Committee) asked if Mr Kapoor could provide some further information this following the meeting, so that this could be investigated. This information has been requested but has not been received at the time of writing. TBC ABu ABu confirmed that the CCG would take this forward. 20/7/16 ABl ABl has written to Eileen Smith with a full response. Open Open Closed 54

55 London. ABl agreed that Co- Commissioners would gather to the existing data on this for the six SE London borough and share back with her. 55

56 Encl D General Practice Forward View National announcement: 28 th July 2016 General Practice Development Programme Releasing Time For Care A 9-12 month National programme of collaborative service redesign to release time for care. Building Capability for Improvement General Practice Improvement 9 month Leader training programme from NHS England s sustainable improvement team Training for Reception and Clerical Staff 45 million Nationally available over the next five years to develop capabilities of practice workforce. 5m in , and 10m available in each of the subsequent 4 years. Funding will be allocated to CCGs on a per-head-of-population basis Practice Manager Development we will support the growth of local networks of practice managers. These will promote sharing of good ideas, action learning and peer support. Funding for this will be available for three years from 2016/17. On-Line Consultation Systems 45m over three years to support the purchase of online consultation systems by practices. This will become available from 2017/18, with 15m in 2017/18, 20m in 2018/19 and 10m in 2019/20. Central funding will be allocated to CCGs 56

57 General Practice Forward View National announcement: 28 th July 2016 General Practice Resilience Programme 40M over the next 4 years to support struggling practices, 16 M in London total allocation: 6.554M ( M) Operational and funding arrangements at NHSE Local team level. Fair shares calculated on registered patient population basis Practices (individual or groups) identified using existing national criteria* A menu of support will be offered by local teams and tailored to local needs Key partners with NHSE will be CCGs, provider GPs, LMCs, RCGP and Regional Ambassadors Quality Assured by enabling learning and sharing of best practice Support offered conditional on matched commitment from practices October 2016 Sustainability and Resilience Procurement Framework for Primary Care (not mandatory) Regional learning events (led by RCGP peer support teams) 57

58 Resilience Programme National Criteria for eligibility Range of criteria can be used as a screening tool by local commissioners to guide their assessment on offers of support to improve sustainability and resilience SAFETY CQC Rating Inadequate CQC Rating Requires Improvement Individual Professional Performance Issues WORKFORCE No. of patients/wte GP and/or Nurse Vacancies (including long term illness) EXTERNAL PERSPECTIVE Other external perspectives not covered in above criteria, e.g significant support from LMC, CCG or NHS England local team. Primary Care Web Tool ORGANISATIONAL ISSUES Practice Leadership Issues (partner relations) Significant Practice changes Professional Isolation EFFICIENCY QOF % achievement Referral or prescribing performance compared to CCG average PATIENT EXPERIENCE/ACCESS List Closure (inc application to close) GP patient survey x 3: Recommend GP surgery to someone Ease of getting through on phone Ability to get appointment 58

59 Enc: E Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Primary Care Joint Committees (PCJC) Meetings DATE OF MEETING: 18 August 2016 ENCLOSURE: E Primary Medical Services Financial Report AUTHOR: R Jeffery Director of Financial Management NHS England, London Region SUMMARY: The overall financial position for South East London Primary Medical services is showing a year-to-date breakeven position against issued budgets for the 3 months to 30 th June. The forecast outturn is currently for break-even as it is too early in the year to establish a trend. There remains a shortfall between the expenditure budget and the published allocations for SEL for 2016/17, which will need to be jointly managed by CCGs and NHSE as cocommissioners. Discussions continue to establish if this can be mitigated non-recurrently without the need for further PC QIPP. The outcome is expected by the end of August. KEY ISSUES: The shortfall between the allocations and forecast expenditure will need to be managed in 16/17 and expenditure planned within the resource on an STP-level from 2017/18. RECOMMENDATIONS: The Joint Committee is asked to note Month 3 Medical services financial reports. CCG CONTACT: Name: R Jeffery richardjeffery@nhs.net AUTHOR CONTACT: SEL Clinical Commissioning Group Name: Toyin Akinyemi takinyemi@nhs.net 59

60 NHS England - London Region Primary Care Services - South East London (Summary by Contract Type) Medical Services Financial Summary - 3 Months to 30th June 2016 South East London Total Service Annual Budget YTD Budget YTD Actual Expenditure YTD Variance Forecast Forecast Variance Forecast % Variance 2015/16 Outturn YTD Variance % 000's 000's 000's 000's 000's 000's % 000's % PMS 199,151 49,788 49, , % 191, % GMS 22,256 5,560 5, , % 21, % APMS 17,804 4,450 4, , % 17, % Other Medical Services % % Prior Year Accruals 0 0 (390) (390) QIPP (1,197) (299) (1,197) 0 0.0% % Total Primary Care Medical Services 238,384 59,591 59,589 (2) 238, % 230, % Bexley CCG PMS 24,784 6,196 6, , % 23, % GMS 2, , % 2, % APMS % % Other Medical Services % 2 0.0% Prior Year Accruals 0 0 (35) (35) 0 0 QIPP (138) (35) 0 35 (138) 0 0.0% 100.0% Total Primary Care Medical Services 27,464 6,867 6, , % 26, % Greenwich CCG PMS 32,677 8,169 8, , % 31, % GMS % % APMS 2, , % 2, % Other Medical Services % 3 0.0% Prior Year Accruals 0 0 (178) (178) 0 0 QIPP (178) (44) 0 44 (178) 0 0.0% 100.0% Total Primary Care Medical Services 35,502 8,874 8,873 (1) 35, % 34, % Bromley CCG PMS 24,100 6,025 6, , % 23, % GMS 13,286 3,321 3, , % 12, % APMS 1, (12) 1, % 1, % Other Medical Services % % Prior Year Accruals 0 0 (37) (37) 0 0 QIPP (196) (49) 0 49 (196) 0 0.0% 100.0% Total Primary Care Medical Services 39,005 9,750 9, , % 37, % Lambeth CCG PMS 43,895 10,973 10, , % 42, % GMS 2, , % 2, % APMS 7,008 1,752 1,737 (15) 7, % 6, % Other Medical Services % % Prior Year Accruals 0 0 (52) (52) 0 0 QIPP (267) (67) 0 67 (267) 0 0.0% 100.0% Total Primary Care Medical Services 53,125 13,279 13, , % 51, % Southwark CCG PMS 35,817 8,955 8, , % 34, % GMS 1, , % 1, % APMS 4,856 1,214 1,199 (15) 4, % 4, % Other Medical Services % % Prior Year Accruals 0 0 (39) (39) 0 0 QIPP (212) (53) 0 53 (212) 0 0.0% 100.0% Total Primary Care Medical Services 42,327 10,581 10,580 (1) 42, % 41, % Lewisham CCG PMS 37,878 9,470 9, , % 36, % GMS 2, , % 2, % APMS (2) % 1, % Other Medical Services % % Prior Year Accruals 0 0 (49) (49) 0 0 QIPP (206) (51) 0 51 (206) 0 0.0% 100.0% Total Primary Care Medical Services 40,961 10,240 10, , % 39, % 60

61 Enc: F Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Primary Care Joint Committees (PCJC) Meetings DATE OF MEETING: 18 th August 2016 AUTHOR: ENCLOSURE: F Title: Quality & Performance Report Dean Musson, Programme Office Manager, Primary Care Commissioning Directorate, NHS England (London) Jill Webb, Head of Primary Care, South East London NHS England SUMMARY: The last report was considered at the April 2016 SEL PCJC. This report, produced quarterly, includes: A summary cover paper An accompanying high level analysis of the reportable quality metrics for primary care services Appendix 1 which includes NHS England s reportable quality metrics for primary care services Not all supporting data sets are refreshed quarterly, However, where this is the case, that section of the report will be repeated (and clearly labelled) based on the previous quarter, until fresh information is available. It should also be noted that data sets are refreshed at different points, and cover differing time periods. The report is produced for Part 1 of the committee. The information is therefore at a summary level. Specific issues will be sensitive and confidential. They will be considered in Part 2 of the meeting, if a decision is required. Underlying detail behind this data would be used to assure delivery, i.e. all sources would be used to triangulate to identify potential practice level issues. The report provides information on quality and performance, at a CCG level. It is a draft format that is being developed between NHS England and CCGs, to provide an enhanced, standardised report to support commissioning committees. The report draws on available data sets: - GP Patient Survey (pages 3-8 of appendix 2); 61

62 - CQC reports (page 14 of appendix 2); - Quality & Outcomes Framework (page 12 and 13 of appendix 2); and - Friends and Family returns (pages 9 and 10 of appendix 2). An explanation of what these datasets include and measure is set out on the relevant section of the annex to the report. A summary of GP contractual variations are also included in this report (page 18 of Appendix 2), which have previously been reported on separately, in line with NHS England s Operating Model. Whilst an analysis of the data within the report has been provided, NHS England and CCG commissioners have begun the process of discussing future reporting arrangements, including their joint response and respective actions where they have concerns about practice results which show a statistically significant variation from the norm. NHS England and the Healthy London Partnership Transforming Primary Care are working together to develop the process for how this is jointly undertaken, between NHS England and CCGs. A summary of CQC practice outcomes has now been included in this report, as the CQC has covered a greater number of practices in SE London. It also draws on information collated by the Medical Directorate (performer reporting on page 16 of appendix 2) and Contract teams (contract information on pages 19 and 20 of appendix 2) at NHS England. The analysis within this report has currently been developed between NHS England PC and Medical Directorates, the latter of which continue to be responsible for Performer issues. It is anticipated that reports will increasingly include CCG relevant information about general practice, and be authored by both CCGs and NHS England. This will ensure the most relevant information and associated analysis is factored in to determining what actions may be needed to address what appear to be outlying concerns. RECOMMENDATION: The SEL PCJCs are asked to consider and note report contents. CCG CONTACT: Name: Relevant to all CCGs 62

63 AUTHOR CONTACT: Name: Jill Webb 1. Introduction and Context This report is prepared to support information sharing in relation to patient experience and quality for the co-commissioning of Primary Care by NHS England London and the CCGs within South East London (NHS Bexley CCG, NHS Bromley CCG, NHS Greenwich CCG, NHS Lambeth CCG, NHS Lewisham CCG and NHS Southwark CCG) for the 243 practices within the combined CCGs areas. The availability of reported quality metrics for primary care services is limited and national primary care dashboards are under development. This report details the current level of quality information routinely collected and collated by NHS England. Additional data may also be available to the CCG. This report contains data on the GP Patient Survey information as at July 2016, CQC inspections as at 27 th June 2016; Friends and Family Test data as at April 2016, QOF data as at October 2015, high level performer information, and any contractual issues up to the end of June GP Survey (pages 4-8, appendix 2) The annual GP survey covers aspects of patient experience for primary care services, including access to services, waiting times, satisfaction with opening hours, the quality of care received from GPs and practice nurses, out of hours GP services, and NHS dental services. It also captures information about the general population state of health. The GP survey is updated every six months. The latest available information is as at July Overall positive experiences of GP surgeries are slightly lower in SE London, than the national average. Overall, the position has improved since the last GP Patient Survey in January 2016, although this is not marked. SE London reported results at or near the national average on satisfaction, for ease of getting through on the telephone, with the exception of Bexley and Lewisham which are reporting results lower than the national average, but slightly improved since the last GP survey. Satisfaction levels are generally steady across all CCGs, with only marginal changes. Satisfaction with the overall experience of making an appointment is at or near the national average across SE London, with the exception of Bexley, which has seen a slight improvement in patient satisfaction levels since the last report, but currently remains some 8% below the 63

64 national average. Southwark reported satisfaction levels are steady at 6% lower than the national average. Satisfaction levels are generally stable, with only marginal changes. Confidence and trust in GPs and Nurses is at, or is near national levels of satisfaction across SE London. Satisfaction levels reported have all increased significantly, as a result of the exclusion of "don't knows" from the results by IPOS Mori. Satisfaction with opening hours is near the national average for most of SE London, and is slightly ahead of the national average in Lambeth CCG. Satisfaction in Bexley is 6% below the national average, but slightly improved since the last GP survey. Satisfaction levels are steady, showing only marginal changes. Two Key Performance Indicators (KPIs) focussing on patient experience are planned to be introduced, as part of the London offer which has been developed and adopted by London CCGs, as part of the review of PMS contracts. CCG will be also offering these to GMS and APMS contract holders. It is anticipated that incentivising improvements in patient experience could lead to an improvement in performance in this area. 3. Friends and Family Test (pages 9 and 10, appendix 2) It is a mandatory requirement that practices report data to NHS England every month, as well as publishing their own results locally. The practices in the CCG have been participating in Friends and Family Test (FFT) surveying supported by the NHS England FFT team. GP practices across England have now been reporting FFT feedback for one year. The contractual requirement for practices is primarily to submit monthly statistical data to enable NHS England to publish numbers of response, % recommended and % non-recommended. Practices are also advised to publish results locally including feedback outcomes to patients via the You Said We Did poster. 64

65 This is the latest available monthly data, as at April There was no return from 60 practices during this period, a substantial increase on the last report. Overall response levels are generally low, and fell Bexley, Greenwich and Lambeth CCGS. Response levels in Southwark saw a substantial increase. CCGs may wish to work with PPG leads to try and secure a greater level of participation. Overall satisfaction levels are close to London and national levels, with the exception of Southwark, which is slightly lower. London region is developing a FFT SOP with CCG and LMC representatives which will enable it to consistently address actions required when practices do not make data returns. 4. QOF (pages 12 and 13, appendix 2) This section has not been updated since the last report. Quality and Outcomes Framework (QOF) is the annual reward and incentive programme detailing GP practice achievement results. Latest available information is as at October The information presented in this report is therefore unchanged from the previous report presented in December. The QOF is the annual reward and incentive programme detailing GP practice achievement results. It rewards practices for the provision of quality care and helps standardise improvement in the delivery of primary medical services. It is a voluntary process for all surgeries in England and was introduced as part of the GP contract in The indicators for the QOF change annually, with new measures added and other indicators retired. For 2014/15, the QOF awards practices achievement points for: - managing some of the most common chronic diseases, e.g. asthma, diabetes - managing major public health concerns, e.g. smoking, obesity - implementing preventative measures, e.g. regular blood pressure checks QOF measures are static or improving across the board, with Bexley showing the most marked improvement, and Lambeth showing little or no change. The most significant deviation from average performance is in Greenwich, which currently is below average London performance (2.2%) and national performance (3.9%) on the clinical domain and on overall QOF (London by 1.8% and national by 3.2%). It should be noted, however, that Greenwich's rate of improvement on these two measures is ahead of that of London overall, and of national improvement. 65

66 5. Care Quality Commission (CQC) GP Inspections (page 14, appendix 2) At the time of this report, the CQC is progressing with visiting practices under their inspection regime introduced in October Within SE London 112 practices have had an inspection report published. 3 were rated as outstanding, 89 as good, 15 require improvement and 5 practices have been rated as inadequate. It is currently challenging to compare performance to London or National benchmarks, given the low proportion of practices in some CCGs currently inspected, which the CQC is seeking to redress in Of particular note is that 55.2% of practices are still awaiting inspection or their report. This limits the conclusions that can be drawn on overall performance within SEL. The available results at this stage show rating levels slightly better or near to London levels, and either close to or below national averages. Conclusions cannot be drawn given inspection coverage of CCG areas is not uniform. The following actions are taken for practices rated as Inadequate: - The Standard Operating Procedure (SOP) Policy Book for Primary Medical Services Chapter 7 Contract Breaches and Termination, outlines the approach to be taken by NHS England when a contract is considered to have been breached. It does not cover the process of investigation, roles and responsibilities leading up to that decision. i.e. Remedial Notice: 3.4 Where a contractor has breached the contract and the breach is determined to be capable of remedy, the Commissioner may issue a Remedial Notice to the contractor setting out the actions that must be taken to remedy the breach. - In the first instance, NHS England, the CCG and the contractor will work together to resolve the matter; - The issuing of a breach notice, application of a sanction or a move to terminate a contract will be considered as the final stage in a process; - The approach taken will be designed to mitigate risk to patients and ensure continued patient confidence in the local NHS and primary care services. At the last meeting of the SEL PCJCs, the NHS England (London) Standard Operating Procedure for Primary Medical contracts: A consistent approach to responding to Care Quality Commission Requires Improvement ratings was approved by each PCJC. This will now be adopted by co-commissioners to respond to these ratings. CQC overall ratings and their definitions Outstanding - The service is performing exceptionally well. Good - The service is performing well and meeting our expectations. Requires improvement - The service isn't performing as well as it should and we have told the service how it must improve. 66

67 Inadequate - The service is performing badly and we've taken action against the person or organisation that runs it. 6. Performer Performance Issues (page 16, appendix 2) Performer performance issues are summarised for information, as these remain the management responsibility of NHS England. There are currently 7 live cases out of 1,469 practitioners in SE London. This represents 6.6% of the total number of practitioners. Three of these are flagged as likely to lead to contractual action, with two cases in Southwark with a high probability of contractual action, and one case in Greenwich with a low probability of contractual action. Key thematic issues of performer issues being investigated are: - Clinical issues; - Inappropriate behaviour; - Financial probity; - Criminal allegations; - Manner and attitude; and - Health issues. 7. Contractual Issues (pages, 18 to 20, appendix 2) A summary of contractual changes is included on the Contractual tab of the attached spread sheet. During quarter 1 there were: 23 partnership changes and 13 GP retirements. This includes variations where a GP has retired from a number of contracts held by the same organisation. It also includes GPs who have taken 24 hour retirement and will be returning to the contract. There was 1 contractual breach by the 243 practices in SE London during quarter 1, as follows: Greenwich PMS contract breach & remedial notice due to CQC Inadequate rating. 67

68 DRAFT South East London CCGs July 2016 GP Commissioning and Contracting Quality and Performance Report 68

69 DRAFT South East London CCGs July 2016 SEL Primary Care Joint Committee Quality and Performance Report Prepared By: NHS England Date: 06/07/2016 Index Section Title Page Data Source 1.0 Patient Satisfaction GP Patient Survey 4 GP Patient Survey 1.2 Friends and Family Primary Care Quality Data QOF Performance Data 12 HSCIC QOF report 2.2 CQC Assessment Data 14 CQC 3.0 Performer Data Summary Summary of Performer Performance Concerns 16 Medical Directorate 4.0 Contractual Data Summary Summary of Primary Care Service Provision 18 Contract team 4.2 Summary of Contractual Issues and Concerns 20 Contract Team 69

70 DRAFT South East London CCGs PATIENT SATISFACTION 70

71 DRAFT South East London CCGs GP PATIENT SURVEY Overall Experience of GP Surgery National Bexley Bromley Greenwich Lambeth Lewisham Southwark 5% 7% 6% 6% 6% 5% 9% 85 % 80 % 83 % 82 % 85 % 84 % 79 % Overall positive experiences of GP surgeries are slightly lower in SE London, than the national average. Overall, the position has improved since the last GP Patient Survey, although this is not marked. Ease of Getting Through on the Telephone National Bexley Bromley Greenwich Lambeth Lewisham Southwark 26 % 70 % 36 % 61 % 29 % 67 % 25 % 70 % 21 % 73 % 31 % 63 % 26 % 68 % SE London reported results at or near the national average on satisfaction, for ease of getting through on the telephone, with the exception of Bexley and Lewisham which are reporting results lower than the national average, but slightly improved since the last GP survey. Satisfaction levels are generally steady across all CCGs, with only marginal changes. 71

72 DRAFT South East London CCGs Helpfulness of Receptionist National Bexley Bromley Greenwich Lambeth Lewisham Southwark % % % % % % % 87 % 85 % 86 % 87 % 87 % 87 % 85 % SE London reported satisfaction levels at, or marginally lower than national averages on this measure. Satisfaction levels with the helpfulness of receptionists are largely steady across SE London. Overall Experience of Making an Appointment National Bexley Bromley Greenwich Lambeth Lewisham Southwark % % % % % % % 73 % 65 % 70 % 70 % 72 % 70 % 67 % Satisfaction with the overall experience of making an appointment is at or near the national average across SE London, with the exception of Bexley, which has seen a slight improvement in patient satisfaction levels since the last report, but currently remains some 8% below the national average. Southwark reported satisfaction levels are steady at 6% lower than the national average. Satisfaction levels are generally stable, with only marginal changes. Confidence and Trust in GP 72

73 DRAFT South East London CCGs National Bexley Bromley Greenwich Lambeth Lewisham Southwark 5% 5% 5% 6% 5% 5% 7% 95 % 95 % 95 % 94 % 95 % 95 % 93 % Confidence and trust in GPs is at, or is near national levels of satisfaction across SE London. Satisfaction levels reported have all increased significantly, as a result of the exclusion of "don't knows" from the results by IPOS Mori. Confidence and Trust in Nurse National Bexley Bromley Greenwich Lambeth Lewisham Southwark 3% 4% 3% 5% 5% 5% 6% 97 % 96 % 97 % 95 % 95 % 95 % 94 % Satisfaction with confidence and trust in nurses is at or near the national average for SE London. Satisfaction levels reported have all increased significantly, as a result of the exclusion of "don't knows" from the results by IPOS Mori. 73

74 DRAFT South East London CCGs Satisfaction with Opening Hours National Bexley Bromley Greenwich Lambeth Lewisham Southwark 9% 12 % 13 % 11 % 9% 9% 11 % 76 % 70 % 72 % 73 % 78 % 76 % 73 % Satisfaction with opening hours is near the national average for most of SE London, and is slightly ahead of the national average in Lambeth CCG. Satisfaction in Bexley is 6% below the national average, but slightly improved since the last GP survey. Satisfaction levels are steady, showing only marginal changes. 74

75 DRAFT South East London CCGs Key dissatisfied satisfied Increasing levels of satisfaction Stable levels of satisfaction Decreasing levels of satisfaction Notes The GP Patient Survey (GPPS) is an England-wide survey, providing practice-level data about patients experiences of their GP practices. Ipsos MORI administers the survey on behalf of NHS England. For more information about the survey please visit The data in this report are based on the July 2016 GPPS publication. This combines two waves of fieldwork, from July to September 2015 and January to March 2016, providing practice-level data. 75

76 DRAFT South East London CCGs The GP Patient Survey measures patients experiences across a range of topics, including: - Making appointments - Waiting times - Perceptions of care at appointments - Practice opening hours - Out-of-hours services The GP Patient Survey provides data at practice level using a consistent methodology, which means it is comparable across organisations and over time. The survey has limitations: - Sample sizes at practice level are relatively small. - The survey does not include qualitative data which limits the detail provided by the results. - The data are provided twice a year rather than in real time. All comparisons are indicative only. Differences may not be statistically significant particularly when comparing practices due to low numbers of responses. However, given the consistency of the survey across organisations and over time, GPPS can be used as one element of evidence. It can be triangulated with other sources of feedback, such as feedback from Patient Participation Groups, local surveys and the Friends and Family Test, to develop a fuller picture of patient journeys. 76

77 DRAFT South East London CCGs FRIENDS AND FAMILY Percentage of practices recommended / not recommended in Friends and Family feedback CCG Practices Expected to Submit Practices Submitting Responses % Recom % Not recom Bexley ,102 85% 10% Bromley ,226 83% 9% Greenwich ,365 87% 8% Lambeth ,147 91% 7% Lewisham ,181 88% 8% Southwark ,046 80% 11% SEL ,067 86% 9% London 1, ,797 86% 8% National 7,594 5, ,985 88% 7% Direction of Travel 120% 100% 80% 60% 40% 20% 0% % Not recom % Recom Commentary This is the latest available monthly data, as at April There was no return from 60 practices during this period, a substantial increase on the last report. Overall response levels are generally low, and fell Bexley, Greenwich and Lambeth CCGS. Response levels in Southwark saw a substantial increase. CCGs may wish to work with PPG leads to try and secure a greater level of participation. Overall satisfaction levels are close to London and national levels, with the exception of Southwark, which is slightly lower. 77

78 DRAFT South East London CCGs What is GP FFT? FFT gives patients the opportunity to submit feedback to providers of NHS funded care or treatment, using a simple question which asks how likely, on a scale ranging from extremely unlikely to extremely likely, they are to recommend the service to their friends and family if they needed similar care or treatment. GP practices have been required to make the opportunity to provide feedback through the FFT available to their patients since 1 December 2014, and submit data to NHS England each month since the end of January Further information can be found on the FFT webpage: Usage of the data The FFT does not provide results that can be used to directly compare providers because of the flexibility of the data collection methods and the variation in local populations. This means it is not possible to compare like with like. There are other robust mechanisms for that, such as national patient surveys and outcome measures. The FFT can help mark progress over time for organisations and still provides patients with useful data to inform choice, alongside other information. The real strength of the FFT lies in the follow up questions that are attached to the initial question, and a rich source of patient views can be used locally to highlight and address concerns much faster than more traditional survey methods. The comments are not submitted to NHS England but may be available from your practice locally to view alongside the monthly data. 78

79 DRAFT South East London CCGs PRIMARY CARE QUALITY 79

80 DRAFT South East London CCGs QOF PERFORMANCE CCG List Size 1. Clinical 2. Public Health 3. Public Health - Additional Services 4. All Domains 2013/ /15 % Change 2013/ /15 % Change 2013/ /15 % Change 2013/ /15 % Change 2013/ /15 % Change Bexley 224, , % 92.1% 96.7% 4.6% 95.3% 97.6% 2.3% 96.9% 99.1% 2.2% 93.9% 97.0% 3.3% Bromley 329, , % 90.5% 93.4% 2.9% 93.1% 94.4% 1.3% 98.5% 98.3% -0.2% 92.4% 93.8% 1.5% Greenwich 273, , % 88.5% 90.6% 2.1% 94.3% 94.3% 0.0% 95.3% 96.5% 1.2% 90.1% 91.6% 1.6% Lambeth 370, , % 93.4% 94.3% 0.9% 95.4% 96.2% 0.8% 97.6% 97.4% -0.2% 94.9% 94.8% -0.2% Lewisham 303, , % 91.1% 92.1% 0.9% 93.0% 94.4% 1.4% 93.3% 97.1% 3.9% 92.2% 92.9% 0.7% Southwark 302, , % 91.0% 91.9% 0.8% 94.0% 95.7% 1.7% 92.8% 95.8% 3.0% 91.9% 92.7% 0.9% London 8,970,868 9,245, % 91.5% 92.8% 1.3% 93.8% 94.9% 1.1% 95.0% 95.5% 0.5% 92.9% 93.4% 0.5% National 55,768,700 56,817, % 92.5% 94.5% 1.9% 93.7% 95.3% 1.5% 97.3% 97.3% 0.0% 93.9% 94.8% 0.9% Commentary Population growth outstrips national averages across SE London, and is at, or greater than the London average in Greenwich and Bexley. QOF measures are static or improving across the board, with Bexley showing the most marked improvement, and Lambeth showing little or no improvement. The most significant deviation from average performance is in Greenwich currently lags average London performance (2.2%) and national performance (3.9%) on the clinical domain and on overall QOF (London by 1.8% and national by 3.2%). It should be noted, however, that Greenwich's rate of improvement on these two measures is ahead of that of London overall, and of national improvement. 80

81 DRAFT South East London CCGs Quality Outcomes Framework Last updated 29 October 2015 Quality and Outcomes Framework (QOF) is the annual reward and incentive programme detailing GP practice achievement results. The QOF is the annual reward and incentive programme detailing GP practice achievement results. It rewards practices for the provision of quality care and helps standardise improvement in the delivery of primary medical services. It is a voluntary process for all surgeries in England and was introduced as part of the GP contract in The indicators for the QOF change annually, with new measures added and other indicators retired. For 2014/15, the QOF awards practices achievement points for: - managing some of the most common chronic diseases, e.g. asthma, diabetes - managing major public health concerns, e.g. smoking, obesity - implementing preventative measures, e.g. regular blood pressure checks The QOF contains three main components, known as domains. The three domains are: Clinical; Public Health and Public Health Additional Services. Each domain consists of a set of achievement measures, known as indicators, against which practices score points according to their level of achievement. The 2014/15 QOF measured achievement against 81 indicators; practices scored points on the basis of achievement against each indicator, up to a maximum of 559 points. clinical: the domain consists of 69 indicators across 19 clinical areas (e.g. chronic kidney disease, heart failure, hypertension) worth up to a maximum of 435 points. public health: the domain consists of seven indicators (worth up to 97 points) across four clinical areas blood pressure, cardiovascular disease primary prevention, obesity 16+ and smoking 15+. public health additional services: the domain consists of five indicators (worth up to 27 points) across two service areas cervical screening and contraception. The QOF gives an indication of the overall achievement of a surgery through a points system. Practices aim to deliver high quality care across a range of areas for which they score points. Put simply, the higher the score, the higher the financial reward for the practice. The final payment is adjusted to take account of surgery workload, local demographics and the prevalence of chronic conditions in the practice's local area. 81

82 DRAFT South East London CCGs CQC GP PRACTICE INSPECTIONS CCG Number of practices Outstanding Good Requires Improvement Inadequate No Published Rating Bexley % % % 1 3.7% % Bromley % % 3 6.8% 0 0.0% % Greenwich % % 2 4.8% 2 4.8% % Lambeth % % 2 4.2% 0 0.0% % Lewisham % % 1 2.3% 0 0.0% % Southwark % % 2 4.3% 2 4.3% % SEL % % % 5 2.0% % London % % % % % National % % % % % Commentary It is currently challenging to compare performance to London or National benchmarks, given the low proportion of practices currently inspected % 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Percentage of practices in each CQC assessment category Outstanding Good Requires Improvement Inadequate No Published Rating Of particular note is that 55.2% of practices are still awaiting inspection or their report. This limits the conclusions that can be drawn on overall performance within SEL. The CQC's programme of inspection is now providing greater coverage, however, which will increase the meaningfulness of this information. Limited results at this stage show rating levels slightly better or near to London levels, and either close to or below national averages. Conclusions cannot be drawn given inspection coverage of CCG areas is not uniform. Last updated 27th June

83 DRAFT South East London CCGs INDIVIDUAL PERFORMER DATA SUMMARY 83

84 DRAFT South East London CCGs Individual Performer Performance Issues ENCL F Number of CCG Performer Contractual Impact live cases High Med Low Bexley 13 Bromley 14 Greenwich 16 1 Lambeth 18 - Lewisham 18 Southwark 18 2 SEL Commentary 97 live cases out of 1,469 practitioners in SE London (6.6%). Three of these are flagged as likely to lead to contractual action, with two cases in Southwark with a high probability of contractual action, and one case in Greenwich with a low probability of contractual action. Thematic key issues: - Clinical issues: - Inappropriate behaviour: - Financial probity: - Criminal allegations: - Manner and attitude: - Health issues: Dark Blue - potential contractual termination Mid Blue - potential breach Light Blue - monitor 84

85 DRAFT South East London CCGs CONTRACTUAL DATA SUMMARY 85

86 DRAFT South East London CCGs Primary Care Service Summary CCG Total Partnership Changes GP Retirements Change in Practice Details Contractual Change Mergers Terminations PMS to GMS List Closure % Single Handers Bexley % Bromley % Greenwich % Lambeth % Lewisham % Southwark % SEL % National proportion of single handed practices 18.0% Comments Data correct as at 22 July 2016 Agreed by nature of contractual change or action The following contractual changes have been actioned since April Where necessary, these changes have been discussed jointly with respective CCG. CCG Change Comments Bexley Partnership Change Three partners resigned from Cairngall Medical Practice One partners joined Cairngall Medical Practice One partner resigned from Northumberland Heath Medical Centre Bexley GP Retirement Bromley Partnership Change Bromley GP Retirement One Partner joined Whitehouse Surgery One Partner took 24 hour retirement from Poverest Medical Centre Greenwich Partnership Change Greenwich GP Retirement Lambeth GP Retirement Lambeth Partnership Change Lewisham GP Retirement 1 partner retired from Hurley Clinic Ebenezer House 2 partners joined Hurley Clinic Ebenezer House 1 partner retired from Hurley Kennington 2 partners joined Hurley Kennington 1 partner retired from Riverside Medical Centre 2 partners joined Riverside Medical Centre 2 partners retired from Mawbey Group 1 partner joined Mawby Group 1 partner joined Paxton Green 1 partner resigned from Paxton Green 1 partner took 24 hour retirement from Hilly Fields 1 partner took 24 hour retirement from Morden Hill 1 partner retired from Queens Road 1 partner retired from The Waldron 2 partners joined The Waldron 1 partner retired from New Cross Health 2 partners joined New Cross Health 86

87 DRAFT South East London CCGs Lewisham Partnership Change Southwark GP Retirement Southwark Partnership Change 1 partner resigned from Bellingham Green 1 partner joined Baring Road 1 partner joined Wells Park 1 partner took 24 hour retirement from Surrey Docks 1 partner retired from Hurley at Lister 2 partners joined Hurley at Lister 1 partner retired from Sternhall Lane 2 partners joined Sternhall Lane 1 partner took 24 hour retirement from Acorn and Gaumont House 1 partner retired from St Giles 2 partners joined St Giles 1 partner joined Albion Street 1 partner joined Borough Medical 1 partner resigned from Forest Hill 5 F t Hill P t hi R i ti 87

88 DRAFT South East London CCGs Variations Where There Was No Like For Like Variation CCG Type of Variation Practice Bexley Northumberland A Partner Heath Medical Centre resigned Confirmation of sufficient Partners / Salaried GP s remain to service the practice list of Yes/No Comments Yes All sessions will be covered by locums and remaining Partners until a Salaried GP is in place. The Practice will also have the services of two ST3 GP Registrars. Bexley Cairngall Medical Practice 3 Partner resigned 2 Partners joined Yes Agreed by PCJC April 2016 meeting Bromley Poverest Medical Centre A Partner took 24 hour retirement Yes The Practice recruited a Salaried GP to cover the reduced hours Greenwich Lambeth Mawbey group 2 Partners retired Yes 1 Partner joined - 2 other partners had previously joined Southwark Forest Hill 1 Partner resigned Yes The Partner resigned and became a salaried GP. Lewisham Bellingham Green 1 Partner Resigned Lewisham Queens Road 1 Partner Resigned Yes Yes Recruited a salaried GP plus existing responsibilities will be covered by the remaining partners while the practice looks to recruit a new partner 6 partners remain on contract and will be covering the work with salaried GPs 88

89 DRAFT South East London CCGs Summary of Contractual Breaches Number of breaches CCG YTD Last Quarter Bexley 0 0 Bromley 0 0 Greenwich 1 1 Lambeth 0 0 Lewisham 0 0 Southwark 0 0 SEL 1 1 Commentary One breach out of 243 practices in SEL and 1,390 practices in London. Thematic key issues: - CQC 89

90 Enc: G Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Primary Care Joint Committees (PCJC) Meetings DATE OF MEETING: 18 th August 2016 ENCLOSURE G Title: Bexley CCG LIS Diabetes AUTHOR: Theresa Osborne, Chief Financial Officer, Bexley CCG SUMMARY: All practices within Bexley CCG are offered the opportunity of participating in the Diabetes LIS for The LIS is revised from a previous scheme in place within the CCG. The scheme has been considered by a conflicts of interest policy and was approved by the CCG s Governing Body on 24 th March 2016 and. The scheme has been discussed with the LMC who approved the scheme in principle on 14 th July, with minor amendments which have now been incorporated. The scheme fits with a number of strategic and commissioning priorities of the CCG and supports improvement in the quality of primary medical care, as outlined in the paper. There is no overlap with existing payments made, but the scheme does include stretch targets on similar outcomes. Practices are supplied detailed guidance, clinical system searches and templates to ensure successful and uniform implementation across Bexley. The total scheme is valued at 398,071. The maximum earnings are per registered diabetic patient based on delivery of KPIs to the registered population of diabetic patients. The average per practice is therefore a maximum of 14,740. Each KPI is weighted within an explicit and transparent payment structure. Payments are made for delivery of quality, training and education indicators. Payments are made on achievements at the end of the financial year and no payment if a specified threshold is not reached. KEY ISSUES: This scheme was approved at the Governing Body on 24 th March 2016 to replace a previous scheme. All practices are offered the opportunity to participate in the scheme. No LIS payments are made to practices if specified thresholds for each area are not 90

91 met. The LMC was consulted in July 2016 and have approved the scheme in principle. RECOMMENDATIONS: The scheme should be approved by the PCJC on the understanding that all practices will be encouraged to participate, with outcomes suitably monitored and reviewed. CCG / NHS England CONTACT: Name: Gary Beard gbeard@nhs.net AUTHOR CONTACT: Name: Theresa Osborne theresaosborne@nhs.net 91

92 SCHEDULE 2 THE SERVICES A. Service Specifications Mandatory headings 1 4. Mandatory but detail for local determination and agreement Optional headings 5-7. Optional to use, detail for local determination and agreement. All subheadings for local determination and agreement Service Specification No. Draft Version 01 Service Diabetes General Practice Service (Adults) Tiers 1 and 2 Commissioner Lead Providers Lead Sarah Valentine Period The contract will be for a 3 year period from 1 April 2016 Date of Review August Population Needs 1.1 The latest GLA borough population projections recorded Bexley s resident population at 240,644, in The population of Bexley s registered population is slightly lower at 233,654 as at June Key characteristics of Bexley s population as identified in the 2011 census include the following: the population aged 90 and over increased by 37% 1,700 between the 2001 and 2011 censuses adults aged decreased by17% to 15,000 over the same period children aged under 5 increased by 14%. 1.2 The population is predicted to increase by 9% between 2011 and 2020, compared to a national estimated increase of 7.8%. This increase is predicted to continue beyond 2020, rising to 280,000 by 2035, an overall increase of 22% compared to projected overall increase of 17% across England. The increase is expected to be seen across all age bands with the most significant increase being those aged 65+ with a much smaller increase for those of working age (16-65 years). Source: Population Projections Unit, ONS. Crown copyright In 2015 there were 12,482 people aged 17 years or older who had been diagnosed with diabetes and included in GP registers in NHS Bexley CCG. This equals 6.9% of this age group. In England, the diagnosed diabetes prevalence is 6.4%.At GP practice level in NHS Bexley CCG, the percentage of patients receiving all eight care processes ranged from 25.6% to 79.4%. For three treatment targets, the percentage ranged from 37.3% to 61.8%. 1.4 The incidence of diabetes, and particularly of Type 2, is set to increase year on year, 92

93 and in particular with younger age groups. Bexley (CCG and local authority) are a national first wave site for the National Diabetes Prevention Programme (NDPP) which went live in June The programme aims to build on successful Public Health led initiatives such as Health Checks and the BEAT project which enable people with inactive lifestyles to increase their activity level and access the Walking Away From Diabetes Project. 1.5 Commissioning for Value data illustrates that Bexley performs above our peer group of CCGs in terms of delivering the eight care processes (21.9% above). There are approximately 12,000 registered diabetes patients in Bexley, over half of whom (63%) received the recommended care they need complications (Right Care data ) 1.6 The CCG is committed to delivering the highest quality of care to patients and consequently the LES is designed to incentivise general practice to maintain and improve outcomes for the local diabetic population 1.7 This Specification seeks to support delivery of the eight care processes and the performance indicators have been designed to encourage GPs to deliver stretched targets (section 3). 1.8 The complications relating to diabetes are wide reaching, including: The most common reason for renal dialysis and the second most common cause of blindness in people of working age 1 Increases the risk of cardiovascular disease (heart attacks, strokes) by two to four times 2 Increases the risk of chronic kidney disease, from an incidence of 5-10% in the general population to between 18% and 30% in people with diabetes 3 Results in almost 100 amputations each week, many of which are avoidable (approximately 8 out of 10 of these) This contract is a key delivery vehicle for the primary care outcomes agreed at the CCG Public Governing Body of March The service model outlined in this Specification seeks to build upon and provide continuity of achievement in the provision of primary care provided services. The local enhanced service (LES) has been highly effective, although with some variability and maintaining the resource is seen as important locally. The Providers will be fully accountable 1 Commissioning Excellent Diabetes care: at a glance guide to the NHS Diabetes Commissioning Resource NHS Diabetes & Diabetes UK February 2012 Second edition State of the Nation England Diabetes UK Stamler J, Vaccaro O, Neaton J, Wentworth D (1993) Diabetes, other risk factors, & 12 year cardiovascular mortality for men screened in the multiple risk factor intervention trial Diabetes Care 3 Commissioning Excellent Diabetes care: at a glance guide to the NHS Diabetes Commissioning Resource NHS Diabetes & Diabetes UK February 2012 Second edition 4 Best Practice for commissioning diabetes services: an integrated care framework Diabetes UK

94 to the Commissioner for the successful delivery of the primary care service, against the specification and contract terms. This includes the responsibility for any sub-contracted services and the payment for the same. 2. Outcomes 2.1 The majority of Diabetes Care delivered in Primary Care will be for people with T2 Diabetes. But not exclusively as the position statement (ABCD / Diabetes UK April 2015) summary below: In general, support for adults with Type 1 diabetes should be coordinated by a multidisciplinary specialist diabetes team. The team can be based either in the hospital or in a community setting. This is because managing Type 1 diabetes is complex and requires significant expertise, and there can be serious consequences if things go wrong. Access to specialist services, as soon as they are needed, is vital. It may be possible for adults with Type 1 diabetes to have their ongoing care and support managed outside of the diabetes specialist team provided there is effective integration between those delivering care and the specialist diabetes team, and the person with Type 1 diabetes chooses this. ABCD / Diabetes UK April The overall aim of the Diabetes GP Local Enhanced Services Contract is to effectively manage most diabetic patients within local GP Practices. Approximately 90% of the Diabetics on the Practice Register, (a QOF requirement), will be Type 2. This will require the right resources, training and education to be in place tailored to each practice population and is facilitated by this contract. 2.3 The Diabetes GP Contract incentivises essential and enhanced diabetes care including: Management of 90% or more of type 2 patients within the Primary Care Practice setting In-practice management of Type 1 patient where appropriate, responsive and the preferred choice of the Diabetic patient. Providing a service to other Tier 1 practices to include insulin initiation in people with Type 2 diabetes, following accredited training. 2.4 It is anticipated that all GP practices will provide the level of service set out in the contract and will strive to achieve against all of the KPIs within this specification. This will be 94

95 confirmed through on-going review and audit by commissioners and supported by nonpatient identifiable evidence. 2.5 Key quality aims for commissioners are as follows (taken from Nice Quality Standards for Adults with Type 2 Diabetes revised 2015): o Commissioners ensure services are commissioned that provide training for healthcare professionals and encourage people with diabetes to participate in their own care. o Commissioners ensure they commission structured educational programmes that fulfil nationally agreed criteria and are ongoing and accessible to people with diabetes and/or their carers. o Commissioners ensure they commission services that provide training and assess ongoing competency of healthcare professionals for initiating and managing insulin therapy within a structured programme. o Commissioners ensure they commission diabetes services that allow people with diabetes to agree and document a target HbA1c with their healthcare professional and receive ongoing review of treatment to minimise hypoglycaemia o Commissioners ensure that they commission services so that people with diabetes at risk of foot ulceration receive regular review by a foot protection service in accordance with NICE guidance. 95

96 3. Bexley CCG: Diabetes LES proposed Key Performance Indicators:Quality KPIs KPI 1 KPI 2 KPI 3 KPI 4 Description Target by end Q Weighting 90% of diabetic patients (type 2 and, where appropriate, >90% = 100% payment 25% type 1*) receiving routine care processes, although not 70%+ = 50% payment exclusively, in the primary care setting. As long as a <70% = 0% Type 1 diabetic patient has an annual review in the GP surgery too, it will be counted towards this KPI. Each GP Practice to have a diabetes practice team: to include, as a minimum, a lead GP; and a Nurse Practitioner, Nurse or HCA who can demonstrate their competence in diabetes care.. A member of the diabetes practice team to respond to patient enquiries within a clinically appropriate timescale. Audit all patients on the GP list aged 18 and over % of patients aged 18 years and over and not already on the diabetic register to identify potential diabetics at an early stage (using HBbA1c and other codes*) % of diabetic patients with an agreed structured care plan, and their clinical results shared with the patient in writing before their annual care plan review Evidence: team details 100% start (& leave) date name, role, qualification , phone details to share learning & discussion Search and screenshot report of % of patients at high risk of developing diabetics 4% = 100% 3% = 50% < 2% = 0% 40% = 100% 25% = 50% < 25% = 0% 5% 15% 5% for each of two Read codes.=10% KPI 5 % of diabetic patients with all three of the following recorded within the last 15 months: HbA1c 58 (mmol/mol (7.5%), BP 140/80, Total cholesterol 5 40% = 100% 35% = 25% 20% KPI:6 % of diabetic patients with total cholesterol >4 and on a lipid lowering agent (lla), unless coded as patient refused lla or patient intolerance 75% = 100% 10% KPI 7 KPI 8 Achieving distribution and return of completed diabetes patient survey. Practices will need to distribute the survey to their registered diabetic population and evidence this KPI by providing a report on the outcome from the survey. Each Practice to provide the numbers of diabetic patients at a) Moderate or b) High risk of developing a diabetic foot problem 90% distribution and 20% return, submission of an action plan from survey returns. Search and screenshot report showing the number of patients with moderate and high need * Identification of patients - QOF reference NICE Id NM74 5% 10% Max payment per registered patient 100% 96

97 KPI 1 Type 1 patients may receive some, but not all, (eg annual secondary care review) of their diabetic treatment and care within primary care KPI 3 Codes 14O80 - at high risk of diabetes (HbA1c 42-47) L Gestational diabetes C11y0 - steroid induced diabetes C11y1 - drug induced diabetes without coma C11y2 - impaired glucose tolerance C11y3 - impaired fasting glycaemia C11y4 - impaired glucose regulation C11y5 - pre diabetes (which is essentially the same situation as 14O80) but until we know which codes the NDPP will use we should use both) The CCG have previously used R10D011 - Impaired fasting glucose but in future practices should add C11y3 to those patients already coded. KPI Diabetes treatment satisfaction questionnaire Practices should record this code when they give the questionnaire to the patient. KPI 8 CCG will provide a search that practices can run which will identify numbers from QOF clinical audit directly 97

98 Education and Training KPIs 2016/17 Training budget allocation Half-yearly payments in advance with claw back if target not met. Half-yearly payments in advance (70:30 split) with claw back if target not met. Description Target assessed quarterly Max per patient Team members must provide evidence Written evidence from Practice 8 of CPD/training for each half year. of CPD required half-yearly for annually This may include attendance at a each member of team = 100% per recognized and approved course e.g. diabetes Kings, Warwick. The remaining patient training can be selected from the on each following virtual clinic, training by practice expert in field, locally arranged refresher course. list Number of patients attending recognised training course on the management of their diabetes (100% of new patients and 10% of all Type 2 diabetic patients) should be referred for training) Payment will be based on the number of patients attending courses. Achievement will be calculated at the year end. If the Diabetes Education service is outsourcedto an education service provider the n the table below details the combined attendance level required for all 27 Bexley practices, including a year on year increase, to be achieved. Using the 2014/15 figures as a baseline of attendance this should be achieved each year with an increase in attendance allowing practices to earn a higher payment. 12 annually per patient Max payment per registered patient YEAR --> 16/17 17/18 18/19 98

99 PERCENTAGE OF PAYMENT 70% 80% 90% 100% 70% 80% 90% 100% 70% 80% 90% 100% PERCENTAGE INCREASE IN ATTENDANCE BEXLEY BASELINE 2% 3% 4% 4% 5% 6% 7% 7% 8% 9% 10% ACTUAL NUMBER ATTENDING 6 WEEK COURSE The attached information Appendix (A) contains the DIABETES (NON-EMERGENCY) ACCURATE REFERRAL AND TRIAGE (DART) PROCESS REFERRAL GUIDANCE FOR GPs 99

100 Appendix A: DIABETES (NON-EMERGENCY) ACCURATE REFERRAL AND TRIAGE (DART) PROCESS REFERRAL GUIDANCE FOR GPs The Diabetes Accurate Referral and Triage (DART) process for Diabetes Non-Emergencies provides a single referral point for patients with diabetes who need further care outside of the GP setting. All non-emergency diabetes referrals should be sent via E-Referrals (formerly Choose and Book) and will be received by the Diabetes team within Bexley Health Ltd. Diabetes Emergency Referrals should NOT be made via this service these include: Diabetic Ketoacidosis Hyperosmolar Hyperglycaemia Non-responsive Hypoglycaemia These should be referred directly to the Diabetes Centre or A&E as appropriate. Direct Line to Diabetes Centre Diabetes Foot Emergencies should be referred to the Oxleas Podiatry team using the High Risk Podiatry Referral Form and faxed to Telephone STAFF LINE ONLY! (The patient number is ) This is for acute foot ulceration / infection, recurrent foot issues or patients with other micro vascular diabetes related complications. WHICH SERVICES ARE REFERRED VIA DART? As you will see on the following pages (copy of blank DART form, electronic copies are present on your practice software e.g. Vision, EMIS) there are tick boxes on the right hand side for all of the services that you can refer into via DART. These services are: Clinical telephone advice from Tier 3 DSN Clinical response from Tier 3 DSN Clinical telephone advice from Diabetes Consultant Assessment for Insulin on GLP-1 Receptor Agonist Tier 3 Community DSN Clinic Tier 3 Community DSN domiciliary visit (meeting criteria) Tier 4 Specialist full diabetes care (meeting criteria) Tier 4 Specialist clinic: advice and care plan Pre-conception advice X-PERT Education (Type 2 ) Taster Session X-PERT Education (Type 2) Full Course DAFNE 5 Day Education Programme (Type1) Low Risk Podiatry in clinic Low Risk podiatry domiciliary Further information on referrals and criteria on following page. If you require any further assistance with the diabetes referral process or E-Referrals then please do not hesitate to contact Natasha Collett on or natasha.collett@nhs.net 100

101 CONDITIONS TO BE REFERRED TO DART: Diabetes patients who have: Assessment for insulin / insulin start within practices not able to start injectable therapies (if you cannot start injectable therapies but someone with your practice is trained then refer internally) Consideration for incretin mimetics within practices not able to start injectable therapies (if you cannot start injectable therapies but someone with your practice is trained then refer internally) Advice required by GP or practice nurse regarding treatment of specific patientsadvice can be telephone or to community DSN s or consultant Further care required in the community or secondary care setting meeting criteria Hypoglycaemia recurrent, loss of hypo awareness Pre-conception advice Low risk podiatry- in clinic ( 14 cost to patient) Low risk podiatry domiciliary ( 24 first assessment then 18 patient) X-PERT Education (Type 2) - taster session X-PERT Education (Type 2) full programme DAFNE 5 day education programme (Type 1) Diabetes Manual one-to-one education session Housebound patients requiring domiciliary care by community DSN Type 1 patients that are new to the area and require referral back into hospital setting Type 1 patients that were previously discharged but now wish to return to secondary care CONDITIONS TO BE REFERRED DIRECTLY: Podiatry high risk service Please use existing referral form ( service running separately) Diabetes Centre Suspect new diagnosis of Type 1 Diabetes Acute foot ulceration / infection Gestational Diabetes A&E Diabetic Ketoacidosis Hyperosmolar Hyperglycaemia Hypoglycaemia Diabetes Foot Emergencies (Acute foot ulceration / infection) Refer to Oxleas Podiatry team using the High Risk Podiatry Referral Form Contacts: STAFF LINE ONLY! (The patient number is ) The fax number is Diabetic Retinopathy Screening: Refer new patients to digital retinal screening programme using separate process. Having followed local treatment guidelines Evidence of nephropathy Resistant hypertension Abnormal lipid profile Painful neuropathy 101

102 102

103 Bexley CCG: Diabetes LES proposed Key Performance Indicators:Quality KPIs KPI 1 KPI 2 KPI 3 KPI 4 Description Target by end Q Weighting 90% of diabetic patients (type 2 and, where appropriate, type 1*) receiving routine care processes, although not exclusively, in the primary care setting. As long as a Type 1 diabetic patient has an annual review in the GP surgery too, it will be counted towards this KPI. Each GP Practice to have a diabetes practice team: to include, as a minimum, a lead GP; and a Nurse Practitioner, Nurse or HCA who can demonstrate their competence in diabetes care.. A member of the diabetes practice team to respond to patient enquiries within a clinically appropriate timescale. Audit all patients on the GP list aged 18 and over % of patients aged 18 years and over and not already on the diabetic register to identify potential diabetics at an early stage (using HBbA1c and other codes*) % of diabetic patients with an agreed structured care plan, and their clinical results shared with the patient in writing before their annual care plan review >90% = 100% payment 70%+ = 50% payment <70% = 0% Evidence: team details 100% start (& leave) date name, role, qualification , phone details to share learning & discussion Search and screenshot report of % of patients at high risk of developing diabetics 4% = 100% 3% = 50% < 2% = 0% 40% = 100% 25% = 50% < 25% = 0% 25% 5% 15% 5% for each of two Read codes.=10% KPI 5 % of diabetic patients with all three of the following recorded within the last 15 months: HbA1c 58 (mmol/mol (7.5%), BP 140/80, Total cholesterol 5 40% = 100% 35% = 25% 20% KPI:6 % of diabetic patients with total cholesterol >4 and on a lipid lowering agent (lla), unless coded as patient refused lla or patient intolerance 75% = 100% 10% KPI 7 KPI 8 Achieving distribution and return of completed diabetes patient survey. Practices will need to distribute the survey to their registered diabetic population and evidence this KPI by providing a report on the outcome from the survey. Each Practice to provide the numbers of diabetic patients at a) Moderate or b) High risk of developing a diabetic foot problem 90% distribution and 20% return, submission of an action plan from survey returns. Search and screenshot report showing the number of patients with moderate and high need * Identification of patients - QOF reference NICE Id NM74 5% 10% Max payment per registered patient 100% 103

104 KPI 1 Type 1 patients may receive some, but not all, (eg annual secondary care review) of their diabetic treatment and care within primary care KPI 3 Codes 14O80 - at high risk of diabetes (HbA1c 42-47) L Gestational diabetes C11y0 - steroid induced diabetes C11y1 - drug induced diabetes without coma C11y2 - impaired glucose tolerance C11y3 - impaired fasting glycaemia C11y4 - impaired glucose regulation C11y5 - pre diabetes (which is essentially the same situation as 14O80) but until we know which codes the NDPP will use we should use both) The CCG have previously used R10D011 - Impaired fasting glucose but in future practices should add C11y3 to those patients already coded. KPI 8 CCG will provide a search that practices can run which will identify numbers from QOF clinical audit directly 104

105 Education and Training KPIs 2016/17 Training budget allocation Half-yearly payments in advance with claw back if target not met. Half-yearly payments in advance (70:30 split) with claw back if target not met. Description Target assessed quarterly Max per patient Team members must provide evidence Written evidence from Practice 8 of CPD/training for each half year. of CPD required half-yearly for annually This may include attendance at a each member of team = 100% per recognized and approved course e.g. diabetes Kings, Warwick. The remaining patient training can be selected from the on each following virtual clinic, training by practice expert in field, locally arranged refresher course. list Number of patients attending recognised training course on the management of their diabetes (100% of new patients and 10% of all Type 2 diabetic patients) should be referred for training) Payment will be based on the number of patients attending courses. Achievement will be calculated at the year end. If the Diabetes Education service is outsourcedto an education service provider the n the table below details the combined attendance level required for all 27 Bexley practices, including a year on year increase, to be achieved. Using the 2014/15 figures as a baseline of attendance this should be achieved each year with an increase in attendance allowing practices to earn a higher payment. 12 annually per patient Max payment per registered patient YEAR --> 16/17 17/18 18/19 PERCENTAGE OF PAYMENT 70% 80% 90% 100% 70% 80% 90% 100% 70% 80% 90% 100% PERCENTAGE INCREASE IN ATTENDANCE BEXLEY BASELINE 2% 3% 4% 4% 5% 6% 7% 7% 8% 9% 10% ACTUAL NUMBER ATTENDING 6 WEEK COURSE

106 106

107 Local Improvement Scheme: NHS England Assessment Template The template should be submitted with the full specification. Title of scheme CCG name Named Commissioner Status of CCG Approval of Scheme Either 1. Approved by CCG subject to NHS England approval 2. Draft yet to be considered by CCG Governance structure Has the CCG consulted with the LMC? NB. NHS England cannot approve schemes unless the LMC has reviewed and commented CCG to complete for each LIS scheme NHS Bexley CCG Revised LIS for General Practice Diabetes NHS Bexley CCG Lindsey Coeur-Belle Approved by NHS Bexley Governing Body 24 th March 2016 Yes proposal discussed on 14 July Minor amendments agreed 18 July NHS England to complete at the point of assessment Validated Validated What was the outcome of LMC engagement? Does the Scheme fit strategic and/or commissioning priorities of CCG? CCGs need to specify the link to their primary care strategic priorities. LMC approved in principle on 14 July 2016 Validated approved 18 th July 2016 Yes: Fits both Primary care Strategy: - NHS Bexley CCG Contracts with primary care providers for diabetes, care homes and the Primary Care Improvement Fund (PCIF) - Better Health For London: Improving GP Access for people with long term conditions. - Increase proportion of spend on Validated 107

108 CCGs should specify whether the scheme supports improvement in the quality of primary medical care services under the following categories? 1. Reducing variation in quality 2. Improving quality 3. Undertaking clinical audit 4. Peer review 5. Other Does the scheme have clear, measurable processes and/or clinical outcomes? NB. These need to be articulated clearly and process outcomes should show how progress will be tracked against milestones throughout the year in order to demonstrate how the expected outcomes will be achieved. Is the scheme rewarding outcomes? NB. NHS England cannot approve schemes that do not reward outcomes. Primary and Community Services. - Transforming Primary Care in London - Responds to evidence from primary care web tool that Bexley underperforms in LTCs screening and management including selfmanagement. - Strategic Priority: more proactive population health management and approach to focus more on prevention and self-management. Yes: 1. Potential to identify variations in quality and support subsequent improvement 2. Supports the delivery of high quality care to patients, continued CPD for primary care staff and consistency 3. Includes Clinical Audit 4. Diabetic Patient survey undertaken with action oriented outcomes. There are clear, measurable quality and training and education outcomes with performance related remuneration. A template will be produced for practices to complete Validated Validated clear measurable KPI s Yes Validated Review and monitoring of patients Practices can achieve up to per registered patient Education and Training Practices can achieve up to per registered patient. 108

109 Is there any overlap with what is paid for under the Primary Medical Care Contract, DES, QOF? NB NHS England cannot approve duplicate payments but there will be situations where a LIS scheme is paying for work in excess of existing arrangements What are the proposed Contractual arrangements? e.g. SLA, Letters of Intent, National Contract (not mandated) What is the total financial value of the scheme? What is the payment structure? NB. It is expected that there will be a payment that is only realised on achievement of key deliverables. i.e. not all of the payment will be made up front What are the arrangements if outcomes are not achieved? e.g. Clawbacks or no achievement payment released Is participation in the scheme optional or mandatory for CCG member practices? If other scenarios apply, please specify FOR NHS ENGLAND USE ONLY Does remuneration and pricing model appear reasonable (when compared No overlap. Where there are similar outcomes to QOF the local implementation scheme only incentivises improved, stretched targets. Practices are supplied detailed guidance, clinical system searches and templates to ensure successful and uniform implementation across Bexley. 398,071 in total. The maximum earnings are per registered diabetic patient based on delivery of KPIs to the registered population of diabetic patients. Each KPI is weighted within an explicit and transparent payment structure. Payments are made for delivery of quality, training and education indicators ie identifying patients, reviewing patients, treatment delivery and referral into bespoke education. Payments are made on achievements at the end of the financial year. No payment if a specified threshold is not reached. Optional for all NHS Bexley CCG practices but all practices are encouraged to participate. Validated scheme provides for addition audit and monitoring of patients that are not already on diabetic register and therefore is not overlapping measures of QOF. Validated Validated Validated Validated no penalty or clawback to practices for non-achievement Validated 109

110 with specification requirements)? Assessor recommendation to Bexley PCJC Approval Comments/Feedback following the PCJC Assessor recommending to the PCJC Sarb S Bansal Approved by NHS England & PCJC: Yes/No: Date 110

111 Enc: H Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Primary Care Joint Committees (PCJC) Meetings DATE OF MEETING: 18 August 2016 ENCLOSURE: H Title: Options Appraisal for GP Primary care Provision at Kidbrooke Village Health centre AUTHOR: Jan Matthews Primary Care Transformation Manager Greenwich CCG Gary Beard, Assistant Head of Primary Care, NHS England (London) INTRODUCTION: The Kidbrooke Village housing development is currently underway, led by Berkeley Homes and the Royal Borough of Greenwich, which includes the construction of a Health Centre funded from Section 106 monies. This development is included in the Greenwich CCG Local Estates Strategy, which prioritises this development and makes reference to identifying the precise requirements of the health centre. The forward planning and design of the health centre are key to ensuring the building is fit for the provision of future healthcare. The constructed health centre is expected to be handed over by Berkley Homes as a shell and core in 2020 at the earliest. NHS England has appointed a Clinical Architect to work with Berkeley Homes, the CCG, NHS England and the Royal Borough of Greenwich, to identify and design suitable space for a best of type Health Centre which will accommodate the 15,000 residents of the village. In order to do this well, it is necessary for a decision to be made as to whether one or two GP surgeries are housed within the health centre. BACKGROUND The original Ferrier Estate on the site was home to three GP Surgeries, Henley Cross, Wellbrook and Dr Guram s surgery. Wellbrook PMS merged with Sherard Road PMS and Dr Guram retired in April This left Sherard Road PMS and Henley Cross PMS co located in a building on Tudway Road in the new Kidbrooke Village development. Late in 2015 Dr Bassi, the sole partner of Henley Cross, after discussion with NHS England, took immediate retirement. As a result, an urgent unplanned decision was taken by Greenwich PCJC to ask Sherard Road to be the caretaker practice for 1 year whilst the future of the contract was decided Currently Sherard Road PMS is operating two surgeries 111

112 from the Tudway Road building, its own and Henley Cross, under a caretaking arrangement. The attached Options Appraisal paper sets out the options for providing primary care from the future health centre in the village and for the future of the current arrangement with Sherard Road PMS. OPTIONS CONSIDERED AND KEY ISSUES: The two options appraised are: o Option 1 Sherard Road PMS move into Health Centre and Henley Cross PMS is closed and patients are asked to register with a different Practice. o Option 2 Sherard Road PMS and a newly Procured APMS Practice, incorporating the Henley Cross patient list are housed in the Health Centre. CONCLUSION AND RECOMMENDATION: A full evaluation using weighted criteria based on the Proprietary model used by the CCG for its tender criteria evaluations, against criteria agreed with NHS England, produced the result of Option 1. The Primary Care Joint Committee is asked to agree, in principle, that Sherard Road PMS transfers into the health centre once it is built and that Henley Cross PMS list is closed and patients are asked to register with a practice of their choice, at the end of the caretaking period, taking into consideration views sought from: Further patient engagement Greenwich LMC Greenwich Overview & Scrutiny Committee. NHS England CONTACT: Name: Gary Beard gbeard@nhs.net 112

113 AUTHOR CONTACT: Name: Jan Matthews 113

114 Options Appraisal for GP Primary Care provision from Kidbrooke Village Health Centre, 1. Introduction The Kidbrooke Village housing development is currently underway, led by Berkeley Homes and the Royal Borough of Greenwich, which includes the construction of a Health Centre funded from Section 106 monies. This development is included in the Greenwich CCG Local Estates Strategy, which prioritises this development and makes reference to identifying the precise requirements of the health centre. The forward planning and design of the health centre are key to ensuring the building is fit for the provision of future healthcare. The constructed health centre is expected to be handed over by Berkley Homes as a shell and core in 2020 at the earliest. NHS England has appointed a Clinical Architect to work with Berkeley Homes, the CCG, NHS England and the Royal Borough of Greenwich, to identify and design suitable space for a best of type Health Centre which will accommodate the 15,000 residents of the village. In order to do this well, it is necessary for a decision to be made as to whether one or two GP surgeries are housed within the health centre. 2. Background The area that is now Kidbrooke Village, was formerly a large council housing estate called the Ferrier Estate. It was an area used to house tenants of high need and deprivation. Primary Care services were provided by three surgeries on the estate, the result of partnership break up, where all three partners split. Two of the surgeries, Wellbrook and Henley Cross held PMS contracts and one, Dr Guram s Surgery, held a GMS contract. Wellbrook and Henley Cross shared a large purpose built surgery in Tudway Road on the estate and a converted house as a branch surgery within 1 mile of the estate. Dr Guram was housed in a converted shop on Telemann Square, part of a large concrete block with housing above. As part of the Berkley homes redevelopment of the area, the building in Tudway Road was subject to a compulsory purchase order, with the building being rented back to the GP surgeries until the health centre is built. Dr Guram was housed in a temporary building on the estate close by. In March 2016 Dr Guram chose to retire and handed back the GMS contract. Wellbrook Surgery chose to go into partnership with Sherard Road Surgery in This left two surgeries: Henley Cross and Sherard Road providing Primary Care services from the Tudway Road building. Late in 2015 Dr Bassi, the sole partner of Henley Cross, after discussion with NHS England, took immediate retirement. As a result, an urgent unplanned decision was taken by Greenwich PCJC to ask Sherard Road to be the caretaker practice for 1 year whilst the future of the contract was decided. 114

115 Currently Sherard Road PMS is operating two surgeries from the Tudway Road building, its own and Henley Cross, under a caretaking arrangement. Sherard Road has very recently been successful in their application to receive Targeted Investment in GP Recruitment funding under the national pilot arrangements. They plan to utilise this to attract named GPs to work at Henley Cross to improve service provision and continuity. This paper sets out the options for providing primary care from the future health centre in the village and for the future of the current arrangement with Sherard Road PMS. 3. Options for providing GP Primary care services from Kidbrooke Village Health Centre. There are two possible options for consideration (discounting the option of Do Nothing which is not an option given the time limited nature of the current arrangements). Both options allow for Sherard Road to move into the new Health Centre as there is a s106 commitment to transfer existing practices on the Kidbrooke Village site to the new health centre facility. 4. Criteria for Option Appraisal The following criteria have been identified as key for the appraisal: Access and Patient Choice Ability of Competition to Drive up Performance and hence Quality Utilisation of Premises Financial Implications Strategic Fit with the GP Forward View, SSTP and CCG Direction in Primary Care Patients Views 5. Weighting of Criteria Of these six criteria, two are of particular importance. Firstly, the CCG is not able to meet its statutory duty to balance in 2016/17 and has set a deficit budget. In these circumstances, coupled with our financial reset, financial considerations weigh particularly heavily given the importance placed on them by the Sustainability and transformation process. In this case the financial criteria have been given the highest weighting of 25 % out of a possible 100% Secondly, the Five Year Forward View emphasises the importance of putting primary care on a new and more resilient footing, with larger practices acting in concert with associated community health services, as set out in the Community Based Care Programme of OHSEL, now reflected in the South East London STP. The criterion, Strategic fit, has consequently 115

116 been given the second highest weighting of 20 % out of a possible 100%. The remaining criteria have been evenly distributed. Each of the six criteria has been applied to each of the two options and the weighted percentage recorded. Each category has a sub-weighting of 100% divided into four blocks of 25%. Criterion weightings for marking are EVALUATION CRITERIA WEIGHTING (%) Access Patient Choice 10 Quality/competition/ Performance 15 Utilisation of Premises 15 Finance/Cost implications 25 Strategic Fit 20 Patient Views 15 Total 100 Each criterion weighting will contain sub-weighting Sub-weighting marks GRADE LABEL GRADE DEFINITION OF GRADE Unacceptable 0 Acceptable with shortcomings 25% Totally unacceptable option with no means of mitigation. Unacceptable option with options that go part of the way towards mitigation. Acceptable 50% Meets criteria Acceptable with additional advantages Acceptable with exceptional advantages 75% 100% Acceptable with additional advantages that support CCG strategies. Acceptable with exceptional advantages supporting CCG plans or strategies. 116

117 6. Option One Option 1 Sherard Road PMS move into Health Centre and Henley Cross PMS patients are asked to register with another general practice. Sherard Road PMS currently has a registered list of 9,981 across its three sites. It will be relocated from its branch site at Tudway Road into the Health Centre. There remains a possibility that one of the sites situated outside of Kidbrooke Village on the Rochester Way will be closed at some point, as the retired owners, Dr Bassi and Dr Mahesh wish to sell the building. Approximately 4,000 patients are registered there, 2,600 for Sherard Road and 1400 for Henley Cross. Whilst some of these would move to the main Sherard Road Surgery, it is likely that the majority will move to Tudway Road and then subsequently into Kidbrooke Village Health centre. Henley Cross has a list size of 4,648. This includes the 1,400 registered at Rochester Way branch surgery. This list will be dispersed in this option. It is likely that most of the patients will simply register with Sherard Road PMS. This would make Sherard Road a larger and more resilient practice, which is a key criterion of the CCG s Local Estates Strategy, which in turn supports the move towards larger and more resilient planning and operating units for primary care as set out in the Five Year Forward View. Criteria Access - Patient Choice Quality - Competition/ Performance Utilisation - Premises Finance - Cost Implications Option I : Sherard Road PMS Move into the Health Centre & Henley Cross patients are asked to register with another general practice No choice for patients resident in Kidbrooke Village. This is true in respect of the village; however there are a number of practices outside the village but within a two mile radius. Sherard Road has been successful in obtaining targeted recruitment funding which should increase capacity and choice of GP within the Surgery. No competition to drive improvement in performance. Elsewhere in Greenwich where practices are co- located, there is currently insufficient evidence in Greenwich that this serves to drive up performance. Likely to result in increased void space initially whilst practice registrations grow. This would be offset by the phased rental agreement discussed with The Royal Borough of Greenwich who will be the landlord. No increase in costs per capita due to patients currently registered with PMS practice. Greenwich PMS price per patient is currently New patients costs will be in line with PMS practices Results in a cost pressure for NHS England / Greenwich CCG which should be mitigated by CCG receiving funding for population increase. Sub Criterion Weighting 25% 25% 50% 50% Strategic Fit This would make Sherard Road a larger more resilient practice with a list above 10,000, as described in the CCG Estates strategy and in 75% 117

118 line with the GP Forward View and the STP s Community Based Care Programme. Patients' Views Based on concerns raised during the patient engagement process with Dr Guram's practice, this does not offer: 1. Patients a choice of provider which has been requested 2. Patients a new provider offering a high level of performance 3. Patient s additional capacity following concerns raised about the capacity of the current provider. Sherard Road has re organised Henley Cross and recruited new Doctors. They have also been approved for access to the Targeted Recruitment Funding stream so should be able to increase patient choice of GP on the site. 25% Total 45% 7. Option Two Option 2 Sherard Road PMS and a newly Procured APMS Practice are housed in the Health Centre. Option 2 would see Sherard Road PMS move into the new health centre. NHS England would procure a new APMS practice using the current Henley Cross patient list as a starting point - this would mean that there is no need to consider the more expensive option of procuring an APMS from a zero list start. Criteria Sherard Road & Procure a New APMS Practice Weighting Access - Patient Choice Quality - Competition/ Performance Offers choice for patients resident in Kidbrooke Village within Kidbrooke Village but does not offer choice of location within the village site which is large. Provides competition with potential to improve, Elsewhere in Greenwich where practices are co- located, there is insufficient evidence in Greenwich that this serves to drive up performance. The new PMS contract has been modelled on the APMS contract by NHS England. So the differences in the specifications and key performance indicators are becoming more marginal. 50% 50% Utilisation - Premises Requirement of practices to share space, which offers maximum use of premises in short term. However in practice and in other sites across Greenwich, this has seldom generated real advantages. Information governance requires separation of records and notes. Practices tend to want to use the shared rooms at the same time. 50% 118

119 Finance - Cost Implications Strategic Fit Negative The new London APMS contract price is per weighted patient, which is higher than the current Greenwich PMS price (price support supplement will be payable for any contract procured with a patient list of less than 6,000) This option results in a cost pressure for NHS England / Greenwich CCG which may be mitigated by CCG receiving funding for population increase but this will happen over time. There is an additional 5% management cost associated with lease arrangements for an APMS contract as opposed to PMS. Likely to result in 2 viable practices, 1 of which is in operation currently. Any new APMS contract may reach 10,000 patients and Sherard road may reach the London target practice list size of 6,000 patients using this site. However, this would only be possible if the new APMS was procured immediately and installed in the old Tudway Road premises. This could possibly happen within a year but the procurement process would need to start fairly soon. Approximately 4,000 of the 15,000 predicted residents have already moved in (information supplied by Berkeley homes in July 2016) and are probably already registered, limiting growth prospects for the new APMS. The Tudway Road site is currently in the middle of the Block D building site, which is unpleasant and carries risks for staff and patients. There is no other suitable accommodation to move them to. Putting more GPs and staff for the new APMS site into the building will increase those risks. Procuring an APMS contract would be a costly process and the 5 plus 5 year span of the contract would mean it would need reviewing at around the time the Health Centre is due to open. 0 50% Patients' Views Concerns were raised during the patient engagement process with Dr Guram's practice, that they should have a choice of provider with potentially improved performance, subject to the caveats on that improved performance, discussed elsewhere. 50% Total 37.5% 119

120 8. Conclusions and Preferred Option Category Kidbrooke Option 1 Option 2 Category weightin g (%) Sub Criterion Weightin g (%) Weighte d Score Sub Criterion Weightin g (%) Weighte d Score (a) (b) (a)*(b) (d) (a)*(d) Access patient Choice Quality / Competition / Performance Utilisation of Premises Finance / Cost Implications Strategic Fit Patient Views Using the weighted criteria and sub criteria adopted, Option 1 is the preferred option based on current facts. Recommendation The committee is asked to support Option 1 which would see Sherard Road PMS transfer into the Kidbrooke Village Health Centre once completed and Henley Cross PMS patients would be asked to register with a Practice of their choice at the end of Henley Cross caretaking period, taking into consideration views to be sought from: Further patient engagement Greenwich LMC Greenwich Overview & Scrutiny Committee. 120

121 Enc: I Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Primary Care Joint Committees (PCJC) Meetings DATE OF MEETING: 18 August 2016 AUTHOR: ENCLOSURE: I Title: Valentine Partnership Frances Street Branch Closure Gary Beard, Assistant Head of Primary Care Commissioning GP, NHS England (London) INTRODUCTION: Valentine Health Partnership provides primary care GP services from its main practice at the Ferryview Health Centre and from two branch sites: Holburne Road and Frances Street. On 3 June 2016 the Partnership submitted a Business Case to NHS England for the closure of the Frances Street branch surgery. The branch has been in operation since From 2000, when Ferryview (main site) opened, the use of the first floor of Frances Street was discontinued due to poor accessibility for patients. The Frances Street premises are owned by the Royal Borough of Greenwich (RBG) and consist of two converted flats. The current accommodation consists of one consulting room, one treatment room and a small reception area. The practice business case cited the poor condition of the building, under-utilisation of the location and improved use of resources. The proposed closure of the branch is supported by the Patient Participation Group. The original business case suggested branch closure should take effect from 1st September This timescale will not allow sufficient time for patient engagement post the Committee decision and NHS England has therefore proposed a date of 14th October. Premises The premises is quite run down and would be unlikely to meet current premises requirements. In 2011 a condition report was carried out by NIFES on behalf of NHS South East London Cluster, and the report described the accommodation as having significant functional suitability issues and that major capital investment would be required in virtually all of the elements reported against to raise standards to an acceptable level The five year 121

122 costs then stood at approximately 77k. Currently approximately 20k needs to be spent on the premises for essential maintenance. The practice believes that the CQC would undoubtedly raise concerns around the quality of accommodation particularly in comparison with the other two practice sites. Use of Premises The premises are available for appointments from 8.00 am to 1.00 pm Monday to Friday. All appointments are with a GP. Nurse appointments had previously been available but were moved to the Ferryview site due to poor uptake. In considering the options for the Frances Street branch, Valentine Partnership carried out a review of usage which indicated that whilst 1300 patients were registered at Frances Street only 34 patients have used solely this site (0.13% of the total registered list). Of these 34 patients only 5 regularly visit the branch surgery. Staffing and Range of Services Currently there is one GP surgery each morning with 16 appointments per clinic (80 appointments per week). One member of the practice reception team is present at Frances Street whilst the clinic is running and other than booked appointments on average 5 patients present in person during a four hour clinic. Should the business case to close the branch be accepted, staff would be redeployed to the remaining sites. This would improve flexibility in staffing at these sites. As Frances Street has only one clinician in attendance, it is staffed by senior doctors only. This staffing arrangement does provide continuity of care (the same senior GP provides the session each day) but at the same time limits direct peer support on site. The skill mix that is available at other sites is not available at Frances street and consequently patients are seen by a GP when they could perhaps be managed by a Health Care Assistant or Nurse. Conversely, patients using the main practice location have access to a wider range of services. Financial Considerations The premises are currently leased from RBG under a Tenancy at Will/rolling tenancy. NHS England currently reimburses approximately 11K in rent and rates. The premises lease is due to be signed and the practice has been advised that the rent is likely to increase from approximately 6k to 18K. The cost of premises improvements has already been mentioned above. From a practice point of view also, the under usage of the location means that it is relatively costly to run. Patient and Stakeholder Involvement The practice made a presentation to the Patient Participation Group (PPG) which, after discussion, supported the proposed closure. A senior GP practice partner has agreed to contact the small number of patients who regularly use the branch in order to support them in accessing one of the other sites if the closure proposal is accepted. Details of the 122

123 arrangements made will be fed back to the Joint Committee and will be included in a report to be provided to the RBG Overview and Scrutiny committee. Greenwich CCG supports the branch closure. The view of the local LMC is currently being sought. Alternative Practices It seems likely that the small number of patients who use solely the Frances Street site will move to the Ferryview main site which is approximately half a mile distant. However, there are a further two practices within the same distance and additionally 9 other practices within one mile. The Holburne branch practice is 2.1 miles from Frances Street. Patients do therefore have choice should they not wish to use the main practice site. OPTIONS CONSIDERED AND KEY ISSUES: The three options looked at by the Practice were: Option 1 Status Quo do nothing Option 2 Upgrade and maintain Frances Street Option 3 - Close Frances Street and consolidate services to the other two sites. A NIFES premises survey was carried out in 2011 which identified the premises as having significant functional suitability issues The practice believes that the CQC would undoubtedly raise issues around the quality of accommodation particularly in comparison with their other two sites. Premises improvements were estimated to be likely to cost in the region of 77K (2011 prices) The branch has limited opening hours, is poorly utilised by patients, expensive to operate and provides a more limited range of services as compared to the two other Valentine Health Partnership sites. The Valentine Health Partnership carried a review of branch surgery usage which indicated that only 5 patients out of a possible 1300 registered at Frances Street, regularly use this Branch Surgery as their sole site. Alternative primary care provision can be offered at the main Ferryview surgery (0.5 miles away) or Holburne Road Surgery (branch site) which would offer improved access and a wider range of services. The business case for branch closure is supported by the Patient Participation Group and by the CCG. 123

124 CONCLUSION AND RECOMMENDATION: Given the poor quality of the premises in question, the availability of alternative nearby primary care provision, and the access to opening hours and range of services available at the main practice site and branch site, the proposal would appear to constitute a sensible and cost effective solution to the issues raised. The PCJC is asked to endorse the Valentine Health Partnership s request to close their branch surgery at Frances Street on the basis of the reasons outlined above. CCG CONTACT: Name: Gary Beard gbeard@nhs.net AUTHOR CONTACT: Name: Denise Edwards denise.edwards6@nhs.net 124

125 Business Case for the Closure of the Frances Street Branch Surgery of Valentine Health Partnership and Consolidation of Services at Ferryview Health Centre and Holburne Road Surgery Version control: V0.1,0.2 Drafting versions V0.3 prepared for PPG consultation 13/05/16 V0.4 incorporated feedback from PPG and further consultation actions, submitted for approval to VHP Improvement Executive 20/05/16 Valentine Health Partnership Ferrview Health Centre Frances St Surgery Holburne Road Surgery 25 John Wilson St 184 Frances Street Holburne Road Woolwich Woolwich Greenwich SE18 6PZ SE18 5JS SE3 8HQ 125

126 1. Executive Summary The partners and staff at Valentine Health Partnership are aware of the need to deliver more with less and to do so equitably and safely. It is this twin motivation of quality of care and use of scarce resource that has prompted a review of operational sites. The continuance of delivery of primary medical services at 184 Frances Street will need investment to ensure adequate standards of health care accommodation. It is currently poorly utilised, expensive to operate and represents poorer quality compared to other Valentine Health Partnership sites. Investing in the upgrade of the premises would represent a poor use of scarce resource in that regardless of improvements to lighting, facilities and décor the premises would still be of lower quality than at its other sites. An option appraisal of remaining with the status quo, investing to improve the site and withdrawal of services from the Frances St site has been considered and supports the selection of option 3 consolidation of services on the Ferryview (FV) and Holburne Rd (HRd) sites as the best use of resources and the option most likely to secure consistent, equitable quality care. The PPG has assisted Practice Partners and managers in arriving at this recommendation. A very small proportion of patients registered with the practice choose to consult exclusively at Frances Street and these patients have been specifically consulted to understand their needs and preferences and to ensure that they continue to have appropriate access to care. 126

127 The proposal to close Frances Street will achieve a number of objectives: Improve the efficient use of public money by reducing spend on infrastructure and facilities upgrade and maintenance whilst maintaining spend on clinical care Provide a more equitable range of services offered on each remaining site Enable the development and use of skill mix within the staff group Secure an improvement in the working environment for staff Improve the resilience of the practice in responding to unplanned absence and surges of demand This Business Case has been prepared to enable the decision making of the Partners and to support their submission to NHS England for permission to proceed with this site closure and consolidation. 2. Background The premises in Frances Street have been used since 1984 when The Market Street Practice (later to become Valentine Health Partnership) took over a single handed practice that had lost all its records in a fire. The accommodation consisted of two flats comprising a ground floor reception and 2 consultation rooms and 1 st floor office space which between 1985 and 2000 functioned as the main office of the practice. With the opening of the Ferryview Building in 2000, administrative activity was concentrated on the main site and consequently the 1 st floor space became obsolete. Its poor accessibility made it unsuitable for extending clinical space and therefore the first floor was handed back to the Council. The current accommodation consists of a small reception area, one consulting room and a treatment room. An external review of the premises undertaken in 2011 describes the accommodation as having significant functional suitability issues and concluded that major capital investment is required in virtually all of the elements reported against to raise standards to an acceptable level. 5 year costs were then estimated at 77,200. Approximately 20,000 needs to be spent on the premises for essential maintenance The premises are currently rented from the Royal Borough of Greenwich with a Tenancy at Will/ rolling tenancy. A new tenancy agreement is due to be signed but RBG has indicated that the rent is likely to double to nearer 20,

128 3. Who uses Frances St? There are currently approximately 1300 patients registered with the Frances St site. Of these 34 have only used Frances Street (.13% of the total list); of these only 7 patients (.03% of the toal list) are regular users of Frances St. The Senior Doctor has reviewed these 7 patients and found that 2 are now housebound and would therefore receive home visits, leaving 5 regular sole users of Frances St. 4. Who provides care at Frances St? Currently there is only one GP surgery each morning with 16 slots per clinic (80 appointments per week, (representing a very small proportion of Valentine contacts). The Practice Nurse session that previously operated from Frances St has been moved to Ferryview because of low take-up of nurse appointments at Frances Street. One member of the practice reception team is present at Francis Street whilst the clinic is running and other than booked appointments on average 5 patients present in person during a four hour clinic 5. Hours of operation Frances Street currently offers pre-bookable appointments only between the hours of 8am to 1 pm Monday to Friday 6. Associated costs and potential for savings There are no plans for linking any reductions in staff numbers with consolidation of sites. It is envisaged that staff would be redeployed within the remaining sites. Staffing costs of Frances St have therefore not been calculated for this Business Case. However a change in site utilisation would have implications for non- staff costs both for VHP and for NHS England. Appendix 2 includes a breakdown of the facilities costs that are directly related to Frances Street indicating a potentially saving of just under 20,000. There would be a further saving to NHS England of 11,000 in respect of rent and rates (at prices). (NB the Council has indicated that rents for the year will treble from 6000 to 18,000) 128

129 7. The challenges of delivering care at Frances Street Demand and capacity Valentine Health Partnership is currently implementing s service improvement programme that has the objective of improving patient access, improving the patient experience and improving the quality of staff members working lives. This includes working to reduce the waiting time to see a GP. The Walk In and Wait clinic introduced at Ferryview has had a significant impact, halving the waiting time for a bookable appointment. These quality improvements are being sought in the context of reducing and finite resources and it is therefore all the more important that the practice and our patients see maximum benefit from the money that is spent. Frances Street as it is currently used is under-utilised; it reduces the flexibility of staffing resource by having to maintain a separate rota for Doctors and Reception; spare capacity at times goes unused whilst demand at Ferryview remains consistently high. Staff isolation The relative isolation of Frances Street means that it is staffed by senior doctors only. The skill mix that is available on other sites is not available and consequently patients are seen by a GP when they could be managed by a Health Care Assistant or nurse and specialist opinion on managing long term conditions is not always available. The receptionist works alone for most of the session. Poor quality premises The inferior quality of the premises at Frances Street has been acknowledged since at least The premises have poor natural light and are difficult to heat and cool. The rooms are cramped, measuring 11.2 square mtrs. Although above minimum standard they nevertheless provide a poor working environment for delivering health care, particularly in relation to Ferryview and Holburne Road. There is no scope for extending the footprint of the surgery and therefore space will continue to be an issue regardless of any remedial action taken by the practice. The premises have no separate boiler or central heating system (these were located and controlled in the 1 st floor accommodation surrendered some years ago). Consequently the use of mobile heaters is expensive and inefficient. The quality of these premises is out of keeping with the values of the practice and the importance that the partnership gives to conducting care in an environment that is welcoming comfortable and respectful for users and the workforce. 129

130 Need for investment An external report commissioned in 2011 identified work likely to cost 77,000 (2011 prices). A minimum of 20,000 needs to be spent in the coming year to maintain minimum standards and to comply with infection control standards and CQC expectations. This money will have to be identified from other areas of service spend; there is no contingency to cover this amount and facilities budgets have been reduced to the minimum necessary to continue to operate. 8. Options considered Three possible ways forward were identified for Valentine Health Partnership. These included: 1. Do nothing continue as now 2. Continue to offer the same or better level of service at Frances St 3. Close Frances Street site and consolidate services on the remaining Ferryview and Holburne Road sites 130

131 9. Decision criteria 1. VHP aims to obtain the greatest health impact from the resources it has any decision should therefore be able to demonstrate that it represents the best use of resources 2. Service quality should be equitable for all patients in terms of the quality of care, the range of services available and access to services. any decision should have at least a neutral impact on equity and at best an improvement in equity 3. VHP staff should have access to a quality working environment that reflects their value to the practice - any decision should secure a safe, well-equipped working environment that is compliant with CQC and DDA standards 4. VHP staff need appropriate access to supervision and to be able draw on the skills of other members of the staff team any decision should as a minimum ensure that staff have access to supervision and second opinion from all sites 10. Option appraisal 10.1 Option 1 : Status quo do nothing Strengths Supports patient choice of where to consult particularly when demand is high at FV and HRd Supports patient choice for small number who consult only at Frances St Weaknesses Accommodation significantly poorer than other sites Inequity of quality and access between F St and other sites, contrary to vision and mission of practice Poor working environment for staff Limited range of services Staff isolated from colleagues Unlikely to recruit further to list from F St Limitations on staff deployment because of need to cover all sites Limits capacity to respond to demand and capacity at other sites Under-utilisation of FSt capacity continues Model of site utilisation out of step with 5 year forward view 131

132 Opportunities Threats none Risk that practice inspection might judge FSt facilities as inadequate with impact on whole practice (CQC, DDA) Inability to reduce facilities budget in line with reducing income Financial sustainability challenged by continuing with poorly utilised site List growth at practices to west of practice catchment area makes F St less valuable (eg Royal Arsenal) A very small proportion of patients consult at Frances Street but a further group use it as an alternative to Ferryview, especially when demand is high on the other sites. GP cover is provided by a small number of the practice staff and therefore continuity is likely to be high. Although the accommodation is poor quality it is cleaned to the same standards as the other sites. The proportion of facilities spend per contact is high because of the very small numbers using the site. The site needs 20k ofimmediate investment for maintenance and a further minimum spend of 50k has been recommended. This would not however be sufficient to bring it up to the standard of the other premises and coupled with the uncertainty of the leasing arrangement with the council could be viewed as a poor investment. It would still leave the practice open to criticism from CQC despite high quality accommodation on other sites and remains an isolated and cramped clinical space. The resources for any work would need to be deflected from other areas of spend which after several years of facilities budget reduction could only come from clinical salaries equivalent to 1.5 nursing posts or.8wte salaried GP Option 2: upgrade and maintain Frances St Strengths Equalises quality of accommodation for all patients regardless of choice of site Supports patient choice of where to consult particularly when demand is high at FV and HRd Supports patient choice for small number who consult only at Frances St Weaknesses Upgrade cannot address fundamental inadequacy of accommodation Space limitations prevents expansion of services No resources currently available for improvement in quality of premises external support would be needed to achieve this Limited range of services continues Staff isolated from colleagues Unlikely to recruit further to list from F St Limitations on staff deployment because of need to cover all sites 132

133 Opportunities Improvement in cosmetic features of premises may improve staff wellbeing and patient satisfaction Limits capacity to respond to demand and capacity at other sites Under-utilisation of FSt capacity continues Model of site utilisation out of step with 5 year forward view Threats Financial sustainability of practice is not ameliorated by reductions in facilities spending Resource for upgrade (either internally or externally sourced) would be deflected from other areas of essential maintenance Risk that practice inspection might judge FSt facilities as inadequate even after upgrade with impact on whole practice (CQC, DDA) Situation with RBG tenancy remains unresolved The quality of the built environment has been improved but it nevertheless represents poorer quality accommodation than other sites. Cosmetic improvements would not alter the fact that the rooms are cramped and services are limited and isolated. The uncertain nature of the tenancy means that investment in Frances Street would be at risk as the Partnership may be required to hand back the premises to the Council at short notice. Indications from the Council are that rental charges are likely to quadruple for the next year representing a further cost pressure to NHS England. The resources needed to bring the premises as near as possible to the other sites (minimum 77,000) do not exist in current budgets. Year on year reduction in facilities allocations means that this could only be funded through reduction in clinical sessions Option 3: Close Frances St and consolidate services at FV and HRd Strengths Improved equity of provision for VHP patients Strengthens practice position in compliance with DDA and CQC inspection with consequent impact on reputation Deployment of clinical resources more easily matched to meet demand over Weaknesses A small number of patients (% of list) would not be able to consult at their favoured site 133

134 2 sites Improved opportunities for skill mix responses to clinical need, supervision and access to second opinion Improved use of resources in terms of proportional spend of clinical and non-clinical Opportunities Consolidating resources at FV and HRd would create more opportunities to respond to Shooters Hill population growth 20,000 would be available to protect services against loss of income Threats Potential decrease in satisfaction for patients who previously consulted solely at F St The very limited operating hours and range of services offered at Frances St means that this is an expensive site to maintain. The planned clinical sessions are in response to patient utilisation; practice nursing sessions were withdrawn last year because of the very low levels of use. Closure of this site would release an additional 5 clinical sessions to the Ferryview where demand is high and Holburne Road sites. closure would save money from the non-clinical budgets and would also mean that service reductions to pay for premises improvements would not be necessary. This would contribute to VHP s financial sustainability and would support continuing improvements in access 11. Consultation with the PPG VHP have discussed the issue of Frances Street with its Patient Participation Group (PPG) before developing an option appraisal. A presentation was made to the PPG on 13/05/16 outlining the options considered and asked for their views on the partners position that closure of the site was the strongest option. The PPG agreed with Partners that option 3 was the way forward but they made a number of suggestions as to how the partnership might manage this change; As the numbers of solely Frances St users was so small, it would be helpful if a senior partner who knew those patients well could contact each of them and discuss how access to services could be supported eg through supporting patients with blue badge applications or use of dial-a-ride. Dr Kara Tanega will be undertaking this work. Individual letters explaining the changes should be sent to all registered patients. Patients should be made aware of other small practices in the immediate vicinity as an alternative but also continuity of care with their current clinician should be respected. 134

135 The PPG asked partners to look at ways in which they could support patients to access the most convenient site rather than the one they were registered with. This particularly applied to Ferryview registered patients accessing services at Holburne Road. Dr Tanega agreed to recommend this suggestion to the Partners meeting PPG members suggested that VHP could do more to promote the use of Holburne Road site; this has four well-equipped consulting rooms and could certainly increase the number of consultations and services on that site. VHP managers agreed to look at ways of promoting Holburne road to existing and potential patients 12. Conclusions Following internal review and full option appraisal and in consultation with the patient participation group, Partners are clear that the closure of Frances Street represents the best use of resources and the most equitable approach to service delivery. It protects expenditure on clinical time within the partnership and makes best use of the high quality accommodation available on the two remaining sites. It reduces the risk to the Partnership and NHS England of escalating premises costs and increases the likelihood that the premises used by VHP will be judged as safe and high quality by external inspectors. 13. Recommendation VHP requests permission from NHS England to cease delivering clinical services at the Frances St surgery and to consolidate patient services on its two other sites. It will make this change in close consultation with the small numbers of patients who only use Frances St. VHP would aim to give notice to the council at the earliest opportunity of their relinquishing their tenancy and would aim to cease operating from Frances Street by September 2016 at the latest 14. Timeline for implementation May June Consultation with patients and staff June Initial submission to NHS England July Notice to patients of planned relocation of service September Hand back Frances Street to RBG Time tolerance: +12 weeks 135

136 15. Change management arrangements Management responsibility for the relinquishing of Frances St will be led by Rok Ziherl Management responsibility for the change in registration of patients will be led by Laura Snow Clinical responsibility for patient care transition will be led by Dr Karta Tanega The change project will be overseen by the VHP Improvement Executive within its improvement programme Appendices Appendix 1 NIFES report February 2011 Appendix 2 Potential non-staff cost savings associated with Frances Street closure Appendix 3 text of letter to Frances St patients 136

137 Appendix 1 see separate report 137

138 FRANCES STREET: VARIABLE, FRANCES STREET DIRECTLY ATTRIBUTABLE RECCURING ANNUAL COST = POTENTIAL SAVING PER ANNUM BY CLOSING THE SURGERY Description: Amount: Comment: Rent , annual rent fully reimbursable (saving equals loss of income, net 0.00) Rates , annual rates fully reimbursable (saving equals loss of income, net 0.00) H&S Consultancy Fire, H&S, DDA, Legionella, Infection Control Audits Reliance Lone Worker Application Cleaning 3, per month Cleanig Consumables Sanitary Unit - Feminine Hygiene Drugs, Dressings and Consumables Tv Licence PRS Licence PPL Licence Courier FV-FS daily DRs Parking permit Water 1, Water Dispenser Electricity 1, Gas 1, LES 10 link 8, Fire Alarm maintennace and Certification Loss of those due to low usage - destroyed as out of date - aproximate average cost pa 138

139 Fire Extinguisher Maintenace and Certification General 1, Maintennace Equipment Calibration TOTAL: 20, Non- Reccurent estimated cost of required improvements needed - additional one off saving as closing the surgery 70,

140 Appendix 3 Dear Patient Proposed closure of Frances St Surgery The Partners at Valentine Health Partnership, who run the Frances St surgery, have been working with the Patient Participation Group to review the use of our three sites, Frances St, Holburne Road and Ferryview. The numbers of patients using only Frances Street have been very low and falling so only booked GP appointments are offered in the mornings. It has proved difficult to bring the buildings at Frances Street up to the standard of the other sites and rents are due to triple in Because of this we have decided to ask NHS England for permission to close Frances Street and concentrate our services on the other two sites. This will help us to control the costs of our buildings while protecting the money that we have to spend on nurses and doctors. It will also make things fairer for all patients in terms of the range of services available and the standard of the rooms where patients are seen and wait. We know that many of you want to see your usual doctor and we will do whatever we can to make this possible. We want to hear the views of patients about this proposal and we welcome suggestions about how we could make it easier for you to use the other two sites. Please write any comments you want to make on the back of this letter and post it back to us using the freepost address or leave it in the collection boxes in any of the surgeries by 30 th June We will continue to serve you as best we can at all of our sites. Thank you for your time and attention Dr Kara Tanega On behalf of Valentine Health Partnership 140

141 Enc: J Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Primary Care Joint Committees (PCJC) Meetings DATE OF MEETING: 18 August 2016 ENCLOSURE J Title: Proposal for the provision of a branch surgery in Horn Park AUTHOR: Jan Matthews NHS Greenwich CCG Harry Goldingay NHS England INTRODUCTION / BACKGROUND: The Middle Park area within which Horn Park lies, is within the top 10% most deprived on the national scale. (Appendix A) Employment levels fall within the lowest 20% in the country and in the barriers to housing and services domain, Horn Park falls within the 20% most deprived in the country. There is a high proportion of single person households, especially amongst older residents on the estate. 1 Over a third of households in the ward in which Horn Park sits, have no access to a car or van. There are unique geographical characteristics in Horn Park which mean that it is isolated from the wider Borough. It is entirely bounded to the North by the busy A205 South Circular road and to the East by the A20 dual carriageway. The Horn Park estate in the south west of the borough has a profile of residents with high levels of health need. The estate sits in a deprived area of the Borough, and has a high proportion of older residents and people living alone. The low levels of car or van ownership mean that many people, especially older people, rely on public transport to access other parts of the Borough and the services they need. The particular needs of this estate were recognised by the Royal Borough of Greenwich s SRB5 Regeneration Programme, which set out to regenerate deprived areas of South Greenwich between 1999 and This programme undertook detailed analysis of the challenges on the estate, including access to services such as health provision and primary care. The programme used walking distances, pram pushing distances and public transport analysis to assess access issues related to the needs of the specific populations on the estate. It identified that there were real barriers to access for a number of services, primary care being chief amongst these. This description of health need and status has been contributed by the Director of Public Health, Greenwich At the June 2016 meeting of the Health Overview and Scrutiny Committee it was agreed between the 1 Royal Borough of Greenwich ward profiles (Middle Park and Sutcliffe) 141

142 Royal Borough of Greenwich and Greenwich CCG, to explore with NHS England the potential to offer local Greenwich practices the opportunity to open a branch surgery in Horn Park, utilising the premises at 65 Sibthorpe Road and offering ease of access to general medical services in the isolated Horn Park area. The premises are currently utlised by a service (The Source) which the CCG s Financial Recovery Board will make a decision about continuing to fund, on the 24 th September 2016, following public engagement. The CCG is committed to reviewing this opportunity given its view that the most effective and appropriate response to this population in health terms, is access to General Medical Services. The population of Horn Park which is approximately 3,400 is not large enough to sustain a new GP Practice. Appendix B shows the distribution of GP practices and pharmacies in the area. There are 12 proximate GP Practices across Greenwich and 5 in lewisham. NHS England, which currently commissions general medical services to Horn Park, has no formal definition of an acceptable distance to a GP Practice; the current number of 4 Greenwich practices which are situated at 1.12 miles away, is considered acceptable. There are also 3 Lewisham practices situated within 1 mile. Whilst these distances are a useful guide, the very particular physical constraints of the area, described above, mean that patients experience difficulties out of proportion to the distances in question. Recent public engagement at the Community Centre on the Horn Park estate, demonstrated that whilst there are a number of surgeries situated in the general area, the position of the Horn Park estate sandwiched between the extremely busy South circular and A20, makes travelling to these surgeries by public transport difficult and time consuming. The reality is that travel by public transport makes it actually nearer 2.2 miles to the nearest Greenwich surgeries at the Eltham Community Hospital. If a branch surgery were to be put in place, there is no doubt that isolated and vulnerable residents would choose to access this service with consequent health benefits and potentially improved continuity of care. KEY ISSUES: The opening of a new branch surgery is not in alignment with the GP Five Year Forward View or The Greenwich CCG Estates Strategy (2016), with their direction of travel towards larger and more sustainable general practices. This is not sufficient reason to set aside the inaccessibility of general medical services for this deprived community, isolated as it is by its unique geographical location, provided an affordable and proportionate solution can be found (Appendix C). Horn Park must be considered as an exceptional case. There are limits both to the resources available to fund provision and to the viability of the proposition. It is likely that if a branch surgery opens here, the list will grow very quickly as the local population will have the ability to access the full range of general medical services at accessible premises which are already adapted for carrying out such services, as the existing service is CQC registered. 142

143 The Specification and Qualification It is proposed that the attached specification (Appendix D) is offered to all qualifying Greenwich GP practices to provide medical services at the existing premises in Sibthorpe Road, based on their existing Contract type (APMS, PMS or GMS). The level of access will be commensurate with the size of the local population in Horn Park. Practices will be required to provide the full range of GP, Practice Nurse and reception services at the premises in Sibthorpe Road during those hours, with full core hours access (8am to 6.30pm Mon to Fri) being available from the successful practice s main surgery. This will require the latter to be located within a reasonable travelling distance from the Horn Park estate. The offer will be restricted to all practices whose quality indicators, as measured by NHS England, meet or exceed the Greenwich average, in order to facilitate an offer of good quality services to this deprived cohort of patients. Should more than one eligible practice apply, an assessment of applications will be undertaken and an interview conducted, prior to which the scoring criteria will be shared with qualifying applicants/bidders. The applicant/bidder with the highest score will be invited to establish the branch surgery. Viability of the Proposal As described above the population of Horn Park is modest at 3,400. The Royal Borough of Greenwich has offered to partner NHS England and Greenwich CCG in offering the premises at 65 Sibthorpe Road to any successful applicant practice at a peppercorn rent with no charge for a licence. The Royal Borough of Greenwich has confirmed that this will continue for the foreseeable future and that it would look favourably on financially supporting any requests to ensure the premises meets CQC requirements, should any issues be identified. Greenwich CCG and NHS England acknowledge that demand is untested and therefore propose to offer the branch surgery as a trial for 12 months in order to test demand for services, by this cohort of patients. Other than funding for core IT requirements, there will be no additional funding associated with this offer. Funding will be via the capitation fees on registration of patients as part of the provision of Medical Services. Should there be CQC required changes to the proposed premises, the local NHS expect that these will be financially supported by the local authority. CONCLUSION AND RECOMMENDATION: The health and deprivation status of Horn Park and its unique geographical characteristics, together represent a substantial case that Horn Park should be treated as an exception to the current direction of travel towards larger practices. There is little doubt that the population would benefit from easy access to a full range of general medical services. The Primary Care Joint Committee is asked: 143

144 To endorse the Greenwich CCG and NHS England s plan to offer the site at 65 Sibthorpe Road to qualifying GP practices in Greenwich as a branch surgery. NHS England CONTACT: Name: Gary Beard gbeard@nhs.net AUTHOR CONTACT: Name: Jan Matthews Jan.matthews@nhs.net 144

145 Appendix A 145

146 Map of Surgeries and Pharmacies Appendix B 146

147 147

148 Appendix DPMS Review Greenwich CCG Lung Cancer Early Detection KPI. Appendix D Proposed Specification for the provision of a branch Surgery on The Horn Park Estate Why this area was chosen for provision of a branch Surgery At the June 2016 meeting of the Health Overview and Scrutiny Committee it was agreed between the Royal Borough of Greenwich and Greenwich CCG, to explore with NHS England the potential to offer local Greenwich practices the opportunity to open a branch surgery in Horn Park, utilising the premises at 65 Sibthorpe Road and offering ease of access to general medical services in the isolated Horn Park area. The premises at 65 Sibthorpe Road are currently utlised by a service (The Source) which the CCG s Financial Recovery Board will make a decision about continuing to fund, on the 24 th September 2016, following public engagement. The CCG is committed to reviewing this opportunity given its view that the most effective and appropriate response to this population in health terms, is access to General Medical Services.The Horn Park estate in the south west of the borough has a profile of residents with high levels of health need. The estate sits in a deprived area of the Borough, and has a high proportion of older residents and people living alone. The low levels of car or van ownership mean that many people, especially older people, rely on public transport to access other parts of the Borough and the services they need. Recent public engagement at the Community Centre on the Horn Park estate, demonstrated that whilst there are a number of surgeries situated in the general area, the position of the Horn Park estate sandwiched between the extremely busy South circular and A20, makes travelling to these surgeries by public transport difficult and time consuming. The reality is that travel by public transport makes it actually nearer 2.2 miles to the nearest Greenwich surgeries at the Eltham Community Hospital. If a branch surgery were to be put in place, there is no doubt that isolated and vulnerable residents would choose to access this service with consequent health benefits and potentially improved continuity of care. 148

149 Appendix DPMS Review Greenwich CCG Lung Cancer Early Detection KPI. Purpose The purpose of this specification is to set out the criteria for the provision of a branch Surgery at 65 Sibthorpe Road, Horn Park. Outline specification of Service. The successful Practice must provide Primary Care medical Services based on their existing contract type. (APMS, PMS or GMS). A full GP, Practice Nurse and Reception service should be supplied during opening hours. The Practice will be asked to negotiate opening hours with the CCG and NHS England based on the demographics of the 3,400 population and service needs. Hours should include, as a starting minimum, three mornings and two afternoons a week. A Licence will be granted by the Royal borough of Greenwich to the successful practice for the usage of the premises at 65 Sibthorpe Road at a peppercorn rent. The Borough has indicated that they would be supportive of any interior changes that may need to be made to the premises. Core IT will be supplied and funded by the CCG. The successful Practice will be responsible for any legal costs, furniture, equipment and telephony but the borough have also indicated their willingness to provide practical support for the premises licence, signage, equipment and removals as they are very keen to support an alternative to the service currently provided at that location by 'The Source'. Qualifying criteria Practices must have their main surgery in Greenwich in an area that is within 30 minutes travelling time on public transport, from the Horn Park estate. Patients on the estate must be able to use the main premises when the branch surgery is not open. In order to ensure quality, qualifying Practices must be: At or above the Greenwich average of 82% on the indicator Overall Experience of GP Surgery as taken from the latest ISOS Mori Survey on Patient satisfaction. Must be either an achieving Practice or approaching review on the Primary care Web tool 149

150 Appendix DPMS Review Greenwich CCG Lung Cancer Early Detection KPI. Payment Payment will be based on capitation payments derived from registering patients on the estate and any enhanced services provided under the core contract. There is no additional funding. Application process Practices meeting the qualifying criteria who wish to apply should submit an expression of interest to NHSE by.. The expression of interest should include statements on: Reasons for applying Plans to grow the list in the area What workforce will be put in place to provide the service How the workforce will be recruited (if applicable) Applications will be assessed by: NHSE Gary Beard, Assistant Head of Primary Care Harry Goldingay, Senior Primary Care Commissioning Support CCG Gina Shakespeare, Turnaround Director Jan Matthews, Primary Care Transformation Manager Public health CCG non conflicted clinical lead R.B.G Councillor. Steve Whiteman, Director of Public Health Dr Ellen Wright David Gardner 150

151 Enc: K Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Primary Care Joint Committees (PCJC) Meetings DATE OF MEETING: 18 August 2016 ENCLOSURE: K Request for practice merger between Crown Dale Medical Centre and The Norwood Surgery AUTHOR: Nick Langford, Senior Commissioning Manager, Lambeth & Southwark NHS England (London) SUMMARY: The Committee is asked to consider whether it wishes to support the merger between Crown Dale Medical Centre & The Norwood Surgery, based on the attached NHS England (London) analysis of the business case presented by the practices. The main reason for the practices decision is based on the need for Norwood Surgery to not operate as a single handed practice, to be part of larger team to manage the workload, improve services to patients and to ensure the financial viability of the practices & services to patients going forward. The practices are requesting to merge The Norwood Surgery on to the existing PMS contract for Crown Dale and will provide services from both sites from 1 October Owing to the timelines for the outcome of the PMS review being delayed, the practices have been advised that it is likely that NHS England (London) will vary the existing PMS contract for Crown Dale in order to allow the practices to continue with the merger and then move on to the new PMS contract once it has been finalised. The practices are content with this approach. Both practices currently hold separate PMS Contracts with NHS England and are located less than 1 mile between sites. The merged practice would have a combined list size of in excess of 14,000 patients. The future list size is likely to increase owing to trends in population growth in London and the merger will mitigate the minor downward trend in both practices lists by increasing capacity at Crown Dale (through funding being sought to increase the premises m²) and a greater pool of female GP s for Norwood Surgery. Both practices have indicated, as part of the business case, that there is surplus space within Norwood Surgery to allow for growth. Both practices are well served by public transport routes, allowing patients to easily access services at either site for their convenience. 151

152 Crown Dale has had a full inspection by the CQC and received a Good rating in all areas. Norwood Surgery is yet to be inspected. By combining work forces the practices feel confident that their shared knowledge, both clinical and non-clinical experiences, and shared determination to move forward would allow them to offer the patients an improved combination and wider selection of services including longer opening hours and Saturday opening, which are currently unavailable to Norwood Surgery patients. Both practices need to reduce costs and overheads to ensure their future viability, and feel that combining workforces, and reducing overheads will future proof the practices over the long term to ensure that they are able to continue to deliver services to the existing registered patients, and potential future patients that will come about as a result of the current trend in growth. The practices have identified circa 10k per annum in economy of scale savings relating to staff cost, duplication of costs for insurance, accountancy fees, consumables, etc. The practices have identified a number of areas of difference in performance between them for flu & childhood immunisations, triggers and patient experience, and have provided an action plan that details how these will be addressed to deliver improvements and equality in health care across the whole practice population. The practices have already undertaken some patient engagement events and a short survey to gauge patient responses. This has shown that patients are in favour of the proposal. The practice has included a wider patient and stakeholder engagement and implementation plan, which will be enacted should their merger be approved in principle. This in principle agreement will also enable NHS England to engage with Lambeth HOSC, Lambeth HealthWatch & Lambeth LMC to take in to account their views. The practices have spoken to and obtained initial support to the proposal from Lambeth CCG, Londonwide LMC and the Federation. KEY ISSUES: The Norwood Surgery wishes to merge with Crown Dale Medical Centre to ensure the future viability of the practice and to continue better serving the population in Lambeth. The practices are requesting to merge under a variation of the existing Crown Dale PMS contract, and then move on to the new PMS contract. The merger will enable a workforce restructure with associated cost savings of 10k, which includes other identified savings relating to reduced costs and overheads by merging functions. The merger will release running cost savings by managing one PMS contract. The merged practice will be able to offer a wider variety of services to their joint 152

153 patient list as outlined in their business case. As a merged practice they will offer longer opening hours to benefit their proposed joint patient list. Joining the workforce will provide an excellent skill mix offering a more efficient and broader spectrum of services to patients. The practices have indicated that financial support may be welcomed in the form of an advance payment to help support the merged practice through the first couple of months of merging and the associated costs, but this will be assessed and confirmed nearer the time. RECOMMENDATIONS: The PCJC is asked to endorse the following: 1. Agreement in principle to merge The Norwood Surgery on to the existing Crown Dale PMS contract, since 2. NHS England reviews the practice's implementation of its Improvement Plan and Communications & engagement Plan, to ensure the actions identified are delivered. 3. Views of Lambeth LMC, Healthwatch & Overview & Scrutiny Committee to be considered 4. Agreement to provide financial assistance as follows: Actual cost of full usual mail out 5,191 Actual costs associated with the merge of IT TBC Financially support the practice by means of an advance payment, if required, through the merger period 5. That the commissioners reserve the right to review the options for location of services in the Norwood area, in the context of work being undertaken to consider estates capacity CCG CONTACT: Name: Andrew Parker andrew.parker6@nhs.net AUTHOR CONTACT: Name: Nick Langford nick.langford@nhs.net 153

154 CRITERIA FOR CONSIDERING A REQUEST FOR PRACTICE MERGER London Region Practice Name & Address (1) Practice Name & Address(2) Crown Dale Medical Centre (G85022) 61 Crown Dale, Upper Norwood, London, SE19 3NY PMS List Size Lambeth CCG The Norwood Surgery (G85113) 483 Norwood Road, West Norwood, London, SE27 9DJ PMS 3874 List Size Lambeth CCG Date Application made: 01 August 2016 Region: London Report template completed by Nick Langford Date completed 02 August 2016 Assessment Criteria Attachments Presentation of Case Background in respect of each of the practices Business Case - Appendix 1 This paper is to consider the request made to NHS England following the submission of a Business Case from Crown Dale Medical Centre & The Norwood Surgery. Both practices are requesting to merge Norwood Surgery PMS contract on to the existing PMS contract for Crown Dale with NHS England with effect from 01 October The main reason for the practices decision is based on the need for Norwood Surgery to not operate as a single handed practice, to be part of larger team to manage the workload, improve services to patients and to ensure the financial viability of the practices & services to patients going forward. The Norwood Surgery has operated from a circa 1900 s converted shop on Norwood Road for many years. Dr Fernandes is the sole contractor and is supported by 1 salaried GP and 2 practice nurses. Crown Dale is located 1 mile away in a purpose built premises, leased from NHSPS. The premises were modern and fit for purpose at the time it was built 26 years ago, however this is no longer the case and the practice is operating from 4 porta cabins as it has outgrown the premises. The practice has made an application to NHS England, in collaboration with Lambeth CCG, to access funding through the Primary Care Transformation and Technology Fund to resume the modernisation, refurbishment and expansion of the premises. 154

155 Both practices currently hold separate PMS Contracts with NHS England and are located 1 mile between sites. The merged practice would have a combined list size of in excess of 14,000 patients and the future list size is likely to increase owing to projected population growth within South East London and the proposal mitigating the issues the practices have encountered with staffing and capacity. Information about local demography 1) Business Case 2) Scatter graphs of patient distribution (Pages of the Business Case) Lambeth is the 8th most deprived borough in London and 22nd most deprived in England. The most deprived places in the borough are mostly in Brixton and Stockwell, with some in Norwood. Crown Dale sits at the bottom of the Borough on the boundary with Croydon Boundary in Knights Hill Ward. Norwood Surgery is north in relation to Crown Dale, at a distance of 1 mile and sits within the Thurlow Park ward. West Norwood & Tulse Hill is currently undergoing a programme of change from street and park improvements to research and development around key business and industrial areas. Over recent years and across the next few years the area will have benefited from a total of around 30 million pounds worth of capital investment. There is expected to be continual population growth in the borough generally which is expected to increase over the medium and long terms. The practices have highlighted that there are a high number of first/only language being Sri Lankan, Indian, Portuguese and Polish. Practice specific demographics include high levels of alcohol use, high incidence of diabetes, hypertension, stroke and serious mental illness in addition to high levels of unsupported migrants/families, which impacts on managing health outcomes due to the additional support from both reception front line staff and administrative services in order to access services for these patients. The demography of the patients registered with both practices are categorised as having average social deprivation in respect of Index of Multiple Deprivation, Employment and Skills, Healthcare Education and Skills, Crime, Deprivation affecting older persons and above average deprivation in relation to Living Environment, Deprivation affecting Children Barriers to Housing and Income. The patient list for Norwood has remained fairly stable but has seen a minor decrease of 200 patients (5.6%) over the last 4 years to The patient list for Crown Dale has also remained stable and has experienced a small decrease over the last 4 years by 481 patients (4.5%) to In the case of Crown Dale this reduction has been a result of capacity issues at the premises, and Norwood Surgery feedback has shown to be around the lack of a female GP. As both of these areas 155

156 will be addressed as a result of the proposed merger, the practices do not expect to see a further downward trend. When the two practice boundaries are overlaid, the boundary for Norwood Surgery is contained within the boundary for Crown Dale. It is proposed that the boundary for Crown Dale will remain as the boundary for both sites, which is to be formally agreed with NHS England in consultation with the LMC. Should both practice s patients choose to remain registered with their existing practices following the merge, they would benefit from the combined services offered, have access a broader range of GP and Nurse and more extended hours available to them including Saturday morning opening & Thursday evening appointments. A full range of services will be available to all patients, and information regarding the different services offered by both practices is fully described within the business case on pages 21. Existing patients will not need to do anything as they will be transferred onto the registered list of the newly merged practice. With regard to patient choice, patients will be able to choose to continue to receive services from the merged practice across both sites, or register with any of the other practices located within one mile if they prefer. Both practices have begun preliminary discussions with their PPG s and through a brief patient survey they have demonstrated support for the proposal owing to the improvements to services, opening hours and access from more than one location. Subject to NHS England (London) approval to this Business Case, the two Practices will commence their formal meetings and consultations with both sets of patients via their respective PPG forums, a wider patient consultation to capture any patient feedback via a patient survey for a period of one month and publication of an information leaflet/q&a to patients within the practices and online. A formal patient engagement event will be arranged once the merger is approved in principle to further understand the views of the patients with regard to services and improvements they would like to see as a result of the merger. What are the strategic benefits of agreeing a merger and do they meet the criteria set out above Demonstrated in Business Case The strategic drivers that support this scheme are : Ensure the long term viability of the merged practice and give financial stability Enable a workforce restructure to ensure the new practice is operating as efficiently as possible, reducing its expenditure and becoming more sustainable in the long term. Enable the practices to expand clinical and specialist services including minor surgery, Dedicated clinics for chronic disease management i.e. Diabetes, Asthma and COPD, Health Check, In house Phlebotomy Services Improved access to all patients offering a broader range of extended hours including Saturday 156

157 opening and late evenings on Thursday s (Saturday appointments are currently unavailable to Norwood Surgery patients and Thursday appointments for Crown Dale) Wider choice of GP and nurse appointments. Better access to male/female mix of GP s. Support the NHS England and CCG strategy for larger practices delivering a wider range of services to a larger patient population. Eliminate the requirement for one practice to continue operating as a solo contractor. Revenue Implication/ Capital Requirements Business Case (Pages 23) The Practice merger will make financial savings to the practice and NHS England (London). The Practices have estimated that the saving to themselves will be in the order of 10,000 per annum through economies of scale efficiencies in staffing costs particularly in relation to administration and management costs. Efficiency savings to NHS England will realised through running cost savings in managing two PMS contracts. Financial implications to NHS England relate to costs associated with the mail out to patients in the order of 5,191. The associated IT costs of merging the clinical systems is unknown at this stage. The practice recognises that it will be required to pick up the associated costs HR Advice, Accountancy, Business Case and the practice information sheet to be sent with the mail out. To support this, the practice has indicated through discussions with NHS England (London) that it may consider requesting support in the form of an advance on its PMS payments, but this is to be confirmed nearer the time. Performance of the individual Contractors within each practice The Medical Directorate has confirmed that there are no known issues of concern relating to any of the performers at either of the practices. Practice performance QOF (Page 9 of the Business Case) The following has been listed by year, % achievement and national average difference Crown Dale Medical Centre The Norwood Surgery 2013/ /900 = 88.6% (-4.9%) /900 = 99.1% (+5.6%) 2014/ /559 = 97.2% (+2.5%) /559 = 97.8% (+3.1%) 2015/ /559 = 98.8% (%TBA) /559 = 97.9% (%TBA) 157

158 Performance Primary Care Webtool (Page 8 of the Business Case) The above indicates that both practices are achieving higher than the national average for 2014/ /16 data has not yet been populated, but the practices are already achieving similar high QOF scores for 2015/16. The merger will create further opportunity to improve the level of care to all patients through shared learning and best practice as well as enhanced practice management and scrutiny. Further details of this are included in the action plan at Appendix 1 of the Business Case. Crown Dale Medical Centre The Norwood Surgery 10 Level 1 Triggers 6 Level 1 Triggers 0 Level 2 Triggers 0 Level 2 Triggers Performance - GPOS Contractual Issues Both practices currently do not have any Level 2 Triggers. Both practices have the same Level 1 triggers for; 6a) AF Est Diag Rate 9) COPD Est Diag Rate 18) Satisfaction Overall 20) Patient Experience The GP Outcome Standards are generated for all practices from the Primary Care Web Tool. The triggers are based on how far a practice is away from the National mean average for each indicator and is described as either Level 1 or Level 2 depending on the individual practices achievement. The average score across London is 11. Therefore, any practice with a score of below 11 points is rated above average, between 12 and 15 below average, and above 16 in the bottom 5%. The latest data available is for 2016 and shows Crown Dale and Norwood Surgery performance is rated as above average, each scoring a 10. Neither practice has been issued with a breach notice. NHS Choices Crown Dale 1.5 Stars The practice scores 74.4% (In the middle range) for Would recommend the surgery Norwood Surgery 4.5 Stars The practice scores 71.6% (In the middle range) for Would recommend this surgery National Patient Survey 158

159 July 2016 (Page 12 & 13 of the Business Case) Crown Dale % of patients whose overall experience of this surgery as good = 84% (Lambeth average 85%) % of patients who would recommend this surgery to someone new in the area = 74% (Lambeth average 80%) Norwood Surgery % of patient whose overall experience of this surgery as good = 79% (Lambeth average 85%) % of patients who would recommend this surgery to someone new in the area = 79% (Lambeth average 80%) Crown Dale scored 43% for ease of getting through to GP surgery on the phone (Lambeth average 75%) and appears in the bottom 3 for the borough. The practice has included a section in their improvement plan which addresses this as part of the longer term plans for improving access via their ETTF bid by refurbishing the site to a standard that will allow them to have a better telephony system. Crown Dale scored 59% for success in getting an appointment (Lambeth average 80%) and 57% for overall experience of making an appointment (Lambeth average 74%), resulting in the practice appearing in the bottom three for the borough. Again, the practice has included actions in their business case to mitigate this going forward under the new partnership through an appointed patient services manager, review of appointment systems to allow patients better access to preferred clinician and greater number and choice of Patient Access (on-line) appointments and by undertaking a review extended hours access across both sites. The practices recognise the need to improve the performance in areas where there is disparity between practices and has developed an action plan (Appendix A of the business case) which addresses these issues by having combined leadership which will bring about the changes required by having better governance and improving quality. Will the merger result in services being provided from premises that are fit for purpose in accordance with minimum standards set out in 2013 GMS Premises Costs Shown in Practice s Business Plan (Appendix A) While the premises in the premises at Crown Dale is well located in a 26 year old, bespoke premises. The practice has now outgrown the premises and owing to these capacity issues, the CCG has supported the practice to make a bid to the NHS England Estates and Technology Transformation Fund to make improvements to their existing premises owned by NHS Property Services, including a new extension of the building. Historically, this project had been aligned with the former Strategic Service Development Plans and now the local estates strategy for approximately 13 years. Whilst the project has been classified as essential on a number of previous occasions, it has not yet been delivered. The preferred option is the refurbishment of the existing building, circa 430m² and a new extension of 159

160 Directions, or that have a Business Plan to achieve within no more than 12 months about 470m². The proposal will increase the m² of the building to about 900m² and will enable the removal of the temporary portacabins that have been on site for 10 years. The refurbishment plus extension would enable the centre to accommodate its entire staff in one composite, permanent building and provide improved access to our current patient list in an adequate building. The Practice is a training practice and the additional accommodation will assist it to develop its training provision. By re-developing and extending the current site, it will relieve pressure on the extremely cramped existing facilities as well as offer better facilities and access to patients registered and not registered with the Practice to the borough wide services it delivers. Furthermore, it will allow the practice to extend the provision of out of hours service and it will permit the Practice to take on additional patients as the circumstances arise and to better manage and deliver core primary medical care needs in their current premises. The practice has indicated that the proposed timescales for works to be completed is 17/18. The NIFES premises report of 2012 stated that Crown Dale Medical Centre, although purpose built, is dramatically under sized for current service demands. Administration function has been located to external temporary buildings due to a lack of space. Rooms within the medical centre are often small and there is a shortage of consulting room provision, storage and sanitary facilities. Further issues highlighted in the report were non-compliances of infection control standards, security concerns and the required updating of Fire Safety and DDA Statutory Compliance risk assessments. Extensive reconfiguration/refurbishment/relocation was recommended at the time of writing and the estimated costs highlighted in the report were 169,950 in There were seven red flag and twenty three amber flag issues and whilst the practice has taken actions to mitigate risk on the red areas, the practice has made limited progress on the wider shortcomings, owing to the capacity issues with the premises. Crown Dale had a comprehensive CQC inspection in March 2015 where the CQC rated the practice as Good in all five domains relating to the practice being Safe, Effective, Caring, Responsive and Wellled. The CQC also rated it as Good for the care provided to all six population groups, including older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia). The NIFES premises report of 2012 stated that The Norwood Surgery occupies three floors of a terraced building constructed circa early 1900s. At that time, the report stated that the facility was 160

161 Has specified a clear plan of service improvements that will arise as a result of the merger Business Case & Appendices maintained to a reasonable standard although flooring and decor was aged. The surgery did not fully comply with CQC requirements with regards to flooring and sanitary fittings. Most of the required statutory risk assessments were in place and documented with the exception of Disability access, COSHH or legionella assessments. Total costs at that time were estimated at 47,287 and there were ten red and nine amber areas. The practice provided an action plan that detailed the steps taken to mitigate risks detailed in the report. Norwood Surgery received funding through improvements grant to update the general aesthetics of the interior, which will be carried out and completed by end of August Norwood Surgery was inspected by the CQC in June 2013 under the old style visit, and met the standards for Respecting and involving people who use, services, Care and welfare of people who use services, Cooperating with other providers, Cleanliness and infection control, Safety and suitability of premise, Requirements relating to workers and Assessing and monitoring the quality of service provision. It should be noted that commissioners are currently reviewing the options for location of services in the context of estates capacity in the Norwood area. The practice recognises a difference in performance on a number of indicators and has included an action plan to address these as part of the merger. Patients will benefit from the increased choice of GP and access through extended opening hours and flexible clinic types including a range of routine bookable, walk-in, and telephone consultations available across both sites. Extended Hours would result, following merger, of an additional 5 hours per week for Norwood Surgery patients, including Saturday mornings for 3 hours. Patients at Crown Dale will benefit from an addition 1.5 hours on a Thursday. Patients from both Practices will be able to access the full range of specialist services offered by the Practices including sexual health and LARC, minor surgery, acupuncture, community dietician and bi/multi-lingual clinicians and reception staff. Due to the different closing times across both practices patients will have greater choice across the week in accessing these services. Phlebotomy will be made available to Norwood Surgery patients at the Crown Dale site. Patients, particularly older patients and those with long term conditions will benefit from continuity of care by remaining under the care of their usual GP. Increased choice of GPs and Nurses, improved range of services being offered to both sets of patients. Both practices will be financially robust to deliver services in the future. 161

162 What is the CCG s view of the proposed merger? Crown Dale Medical Centre and The Norwood Surgery have informed the CCG of the proposed merger, which has been acknowledged and agreed in principle. Region recommendation to the Panel (will be subject to patient engagement) Crown Dale & Norwood Surgery have requested the following approvals from the PCJC 1. NHS England to give approval for the practice contracts to be merged onto the new, or a variation of the existing PMS contract from 1 October NHS England to provide the Practice with short-term financial assistance, if required, through advance of their PMS payments, towards meeting the non-recurring costs associated with the organisational merger and restructure. NHS England recommends support as follows: 1. Agreement in principle to the proposed merger to take place from 1 October 2016 under a variation of the existing PMS contract 2. NHS England to review the practice's implementation of their Improvement Plan and Communications & engagement Plan to ensure the actions identified are delivered. 3. Views of Lambeth LMC, OSC & HealthWatch to be considered 4. Agreement to contribute financial assistance as follows: Actual cost of full usual mail out costs at 5191 Actual costs associated with the merge of IT TBC Financially support the practice by means of an advance payment, if required by the practice. 5. That the commissioners reserve the right to review the options for location of services in the Norwood area, in the context of work being undertaken to consider estates capacity Date of the Joint Committee) 18 August 2016 Outcome: Please delete as appropriate Feedback from the Joint Committee Please insert Approved / Approved with Conditions/ Rejected Panel Members: Please insert 162

163 BUSINESS CASE Project Name: Crown Dale / Norwood Merger Author: Arif Ladha Practice Manager Crown Dale Medical Centre DATE: August 2016 Practice Name Address Key Contact Contact Details Crown Dale Medical Centre 61 Crown Dale Upper Norwood London SE19 3NY Arif Ladha arifladha@nhs.net The Norwood Surgery 483 Norwood Road West Norwood London SE27 9DJ Michelle Barros michelle.barros@nhs.net Version FINAL 1/8/16 CDMC-N Merger Business Case vfinal 1/8/16 163

164 Contents Page No. 1 Executive Summary 3 2 Proposal 5 3 Practice/s Information 8 4 Case for Change 21 5 Financial Costs of the Proposal Recurrent and Fixed 23 6 Options i) Options appraisal ii) Preferred option 23 7 Comments / Issues 24 8 Appendices 24 CDMC-N Merger Business Case vfinal 1/8/16 164

165 1. EXECUTIVE SUMMARY The Norwood surgery The Norwood Surgery is situated in the southern half of the London Borough of Lambeth within two miles of Brixton Town Centre and generally has a very large ethnic Afro Caribbean population. It is a general medical/surgical establishment located on a main road shopping area, serviced by buses and two railway stations within walking distance. The premises have been converted to a GP surgery utilising three floors with a lift to the second floor. With both the front automated sliding door and the lift within the building the premises are DDA compliant as much as possible. The last CQC inspection (2013) concluded the surgery was CQC compliant with all the outcomes / standards. This PMS Practice currently has a patient list of Dr. Neville Fernandes succeeded Dr. William Doa upon his retirement on 30 th June 1998 and is the sole Partner of the Practice, supported by 1 salaried GP (currently undergoing recruitment) and two Practice Nurses. The Norwood Surgery has been designated as a Family Planning Training Centre. This accreditation was following an assessment by an independent assessor, representing The Faculty of Family Planning & Human Reproduction. Dr Fernandes has identified the need to be a part of a larger team to deal with the ever increasing work load and so wishes to merge with a neighbouring practice so that he can continue to work in the area and serve his patients along with the members of his existing team. Crown Dale Medical Centre Crown Dale Medical Centre opened at the current site on 1 st April The purpose built premises, which the Practice rents from NHS Properties Services, was modern and fit for purpose at the time. However, with the growth of the list size and increase in services the practice now looks very dated, is no longer fit for purpose and many aspects including clinical / consulting areas are not CQC compliant. The Practice has installed a ramp to allow access to the building for the purposes of DDA compliance. The two-storey building primarily delivers patient services on the ground floor although on many occasions it does have the need to utilise a converted clinical room on the first floor. The practice has made an application to NHS England in collaboration with Lambeth CCG to modernise, update and make the premises CQC compliant through the Primary Care Transformation and Technology Fund This PMS Practice currently has a patient list of over 10,300 and is located on the road that borders Lambeth and Croydon. As at April 2016, 71% of the patients resided in Lambeth and 29% in Croydon. The Practice has four GP Partners, four salaried GP and three Practice Nurses. In addition to its PMS contract, the Practice has contracts to provide sexual health services to the locality through its Public Health contract and also provides a CCG commissioned diabetes service to the whole of Lambeth. It is also a training practice and currently has 3 ST3 trainees and 1 F2 trainee. Both practices are members of the South East London Healthcare Partnership (SELHP) Federation. Following discussions, the practices are proposing to merge to further improve and extend the offer of Primary Care services including Minor Surgery and Family Planning / Sexual Health services to a larger patient population which would continue to be delivered from the two current geographical locations. CDMC-N Merger Business Case vfinal 1/8/16 165

166 Crown Dale and The Norwood Surgery are therefore seeking permission from NHS England (London) to merge their respective PMS contracts on 1 st October The benefits of the merger are explained in detail in the business case, however the key benefits are: 1. Patients will benefit by having greater choice and access to primary care services thereby further enhancing the patient experience. The merged practices will benefit by having access to a wider pool of resources including workforce and suppliers resulting in appreciable cost savings. 2. Benefits to patients will include being able to book for doctor, nursing and phlebotomy appointments at either site resulting in shorter waiting times for these appointments. This will include a wider pool of Patient Access appointments as well as other services like repeat prescriptions. 3. Patients will benefit from a wider resource of clinical skills and expertise such as minor surgery, family planning, sexual health and diabetes services and appointments across more days of the week. Patients, specifically those from The Norwood Surgery, will have greater choice in requesting a female GP for an appointment due to the wider pool of female GPs that will become available across both sites. 4. Savings made through consolidation of suppliers and accountancy costs will help release financial resources which can be reinvested in recruitment of further clinical and non-clinical staff. 5. Patients at The Norwood Surgery will benefit greatly from the wider pool of GP resource postmerger as the practice is currently struggling to recruit to fill a salaried GP post which is proving to be challenging. Furthermore, by sharing this resource across both practices The Norwood Surgery will benefit from consistency in service delivery from employed GPs rather than an over use of locum GPs. 6. NHS England & Lambeth CCG commissioners will benefit this merger as this aligns with the strategic direction for Primary Care services as outlined in the General Practice Forward View paper ensuring sustainability in general practice, supporting management of demand, diversion of unnecessary work, an overall reduction in bureaucracy and practice infrastructure and premises developments. 7. By both practices merging there will be great chance of sustainability resulting in a positive impact to patients. 8. SELHP Federation will benefit from the merger through improvements in engagement and service provision when undertaken through a single organisation. The General Practice Forward View paper outlines support to dovetail CCGs and Federations / Networks to work collaboratively to commission care redesign and deliver new / existing services to their local populations. CDMC-N Merger Business Case vfinal 1/8/16 166

167 To support this proposal, the practices have developed an Improvement Plan which addresses any areas of underperformance. This is included as Appendix A. In addition to this, the practices have agreed an Overview Work Plan which addresses the requirements and timelines of the proposal, such as engagement and communications, contracting, regulatory (including CQC), IM&T, HR & Finance. As part of this, the practices have agreed a separate patient and stakeholder engagement plan (Appendix B), which will allow us to strengthen our service going forward, help design the service around patient needs and proactively address patient needs and concerns. We will have a clear message that together, we can provide better primary care services to the combined patient population and patients will experience greater access to appointments and services as part of the new partnership. Crown Dale Medical Centre and The Norwood Surgery are fully embraced with this exciting opportunity to make tangible and real benefits to the healthcare needs for its patient populations. 2. PROPOSAL Crown Dale Medical Centre Crown Dale Medical Centre is currently a Partnership of 4 GPs the details of which are as follows: Name Date Joined Partnership Dr Mark Chamley (Senior Partner) August 1991 Dr Colin Gatward October 1991 Dr Carley Hennah July 2011 Dr Nicoletta Scaravilli July 2011 There are no indications from any of the Partners of any retirement plans in the foreseeable future. The Practice opened at the current site on 1 st April The purpose built premises which was modern and fit for purpose at the time is no longer the case 26 years later. With the growth of the list size and increase in services the practice now looks very dated, is no longer fit for purpose as it uses four portakabins external to the main building and does not reflect the ethos or standards of the Practice. There had been plans about ten years ago to address these issues but unfortunately these got shelved due to NHS strategic changes at the time. However, due to the implementation of the Primary Care Transformation and Technology Fund, the practice has made an application to NHS England in collaboration with Lambeth CCG to resume the modernisation, refurbishment and expansion of the premises This PMS Practice currently has a patient list of over 10,300 and is located on the road that borders Lambeth and Croydon. As at April 2016, 71% of the patients resided in Lambeth and 29% in Croydon. The Practice, in addition to the four GP Partners, has four salaried GPs and three Practice Nurses. In addition to its PMS contract, the Practice has contracts to provide sexual health services to the locality through its Public Health contract and also provides a CCG commissioned diabetes service to the whole of Lambeth. It is a reputable training practice and currently has 3 ST3 trainees and 1 F2 trainee. Crown Dale Medical Centre has identified the need to work collaboratively with neighbouring practices to improve outcomes and efficiencies in the provision of healthcare services to the local population. Both Crown Dale Medical Centre and The Norwood Surgery have always worked closely with each other due to their proximity and geographical location as they are in the same Lambeth locality and CDMC-N Merger Business Case vfinal 1/8/16 167

168 Federation. The fact they both deliver similar primary care services and the same type of enhanced services namely minor surgery and family planning / sexual health services aligns them well to combine and merge their resources as there is a significant degree of overlap between the two practice boundaries. The merger of the two practices is the preferred option as this addresses many of the challenges facing Primary Care at this current time in the NHS. Crown Dale Medical Centre has engaged with its PPG by meeting with them to discuss the proposal. The initial feedback from patients demonstrated that patients are in favour of the merger. Initial feedback from the patients include that it is generally a good idea as it will give a wider range of appointments, more appointments outside of the normal core hours, generally easier and more convenient as there will be a choice of two sites now. Furthermore, the practice has engaged with patients by carrying out a survey from 14 th July 2016 to 26 th July 2016, informing patients of the potential merger. The survey results show 93% of patients are in support of the merger. The Norwood Surgery The Norwood Surgery is owned and managed by a sole GP Partner, Dr. Neville Fernandes. Dr. Neville Fernandes succeeded Dr. William Doa upon his retirement on 30 th June The Norwood Surgery is situated in the southern half of the London Borough of Lambeth within two miles of Brixton Town Centre and generally has a very large ethnic Afro Caribbean population. It is a general medical/surgical establishment located on a main road shopping area, serviced by buses and two railway stations within walking distance. The premises have been converted to a GP surgery utilising three floors with a lift to the first and second floors. The premises has 6 clinical rooms and a minor surgery/family planning unit on the ground floor as well as a couple of clinical rooms on the first floor. Whilst the premises are generally fit for purpose it is somewhat dated in its appearance. There have been recent upgrades to the front of the premises as well as signage. Furthermore the practice has some funding from the improvements grant to update the general aesthetics of the interior, which will be carried out and completed over by end of August This PMS Practice currently has a patient list of As well as the sole Partner, the Practice is supported by 1 salaried GP whose post is currently vacant for which the practice is undergoing recruitment. In addition to this, the practice has two Practice Nurses as well as a small group of administrative staff. The Norwood Surgery has been designated as a Family Planning Training Centre. This accreditation was following an assessment by an independent assessor, representing The Faculty of Family Planning & Human Reproduction. Family planning and minor surgery services are delivered in the surgical suite on the ground floor. The Norwood Surgery has always allied with Crown Dale Medical Centre and both practices have a good working relationship. The proximity and geographical location of the two practices is within less than a mile and they are in the same Lambeth locality and Federation (SELHP). As detailed above both practices deliver similar primary care services and the same type of enhanced services namely minor surgery and family planning / sexual health services which naturally aligns them well to combine and merge their resources as there is a significant degree of overlap between the two practice boundaries. Dr Fernandes, as the sole Partner of The Norwood Surgery, has identified the need to be a part of a larger team to deal with the ever increasing work load and so wishes to merge with Crown Dale Medical Centre so that he can continue to work in the area and serve his patients along with the members of his existing team. This preferred option addresses many of the challenges facing smaller, CDMC-N Merger Business Case vfinal 1/8/16 168

169 single-partnered practices in General Practice at this current time in the NHS. The Norwood Surgery has engaged with its PPG whose initial feedback has been that they are in favour of the merger. In much the same feedback received at Crown Dale Medical Centre the initial thoughts from patients included overall a good idea as it will give a wider range of appointments, greater access to evening and weekend appointments, access to a female GP and again greater convenient due to a choice of two sites. Furthermore, the practice has engaged with patients by carrying out a survey informing patients of the potential merger. The survey results show 94% of patients are in support of the merger. The practice is proposing to deliver services from both sites by migrating the individual clinical systems (EMIS Web) into a single patient list for Crown Dale Medical Centre (G85022). It will also migrate and combine administrative functions which will be managed by the Crown Dale Medical Centre senior management team and share the combined clinical workforce across both locations. In addition, it is proposed to integrate the IT and telephony infrastructure as both practices have the same telephony provider. It is envisaged that both practices will keep their respective practice contact details / numbers for patients to contact them to avoid confusion or disruption to patients and services. However, it is envisaged the telephony systems will be updated at both sites to allow transfer of calls from one practice to another without the need for patients to redial thereby minimising any inconvenience. Crown Dale Medical Centre has started initial discussions with the telephony provider in this matter. In conclusion, the initial response to date from various patients and also both Practices PPG s is supportive of the merger and service delivery from both locations. Feedback from the 7% and 6% of patients from Crown Dale Medical Centre and The Norwood Surgery practice respectively who were not in support of the proposal included concerns about no longer being able to see their preferred GP, losing the personal touch or and dealing with staff they are not familiar with. The practices have incorporated this feedback in the patient engagement plan and will endeavour to address these concerns, where practicable. Subject to NHS England (London) approval of the Business Case, the two Practices will commence a series of formal meetings and consultations with both sets of patients via their respective PPG forum and a mail shot will be sent to all patients advising them of the outcome of the Business Case and the practice will keep patients informed of what is planned and what they can expect via posters, leaflets etc. at the practices and updates on the Practices websites. Both sets of patients will be fully consulted and kept informed at all stages of the merger. The wider patient/stakeholder consultation and engagement plan is included as Appendix B 3. PRACTICE/S INFORMATION Crown Dale Medical Centre and The Norwood Surgery have worked in partnership to produce this Business Case. Both partnerships are long standing and well established. They are successful and deliver safe high quality services with high levels of patient satisfaction. A summary of each of the Practices is provided below: Crown Dale Medical Centre (Contract: PMS) The Norwood Surgery (Contract: PMS) Registered list size (1/4/16) CDMC-N Merger Business Case vfinal 1/8/16 169

170 Partners Staff Dr Mark Chamley 1WTE (male) Dr Colin Gatward 0.88WTE (male) Dr Carley Hennah 1WTE (female) Dr Nicoletta Scaravilli 0.75WTE (female) 4 Salaried GPs 2.63WTE (2 male & 2 female) 3 Practice Nurses 1.96WTE 1 Practice Manager 1WTE Admin staff (9.37WTE) Dr Neville Fernandes 1WTE (male) 1 Locum GP 0.05 WTE (female) 1 Practice Nurse 0.35 WTE 1 Practice Nurse 0.48 WTE 1 Practice Manager 0.68 WTE Admin staff (2 WTE) Specialities Languages spoken : English, Italian, Tamil, Sinhalese, Urdu and Hindi Sexual health and family planning Minor surgery Diabetes Practice Nurse Specialist Asthma Practice Nurse Specialist COPD Practice Nurse Specialist Languages spoken: English, Swahili, Hindi, Konkani & Creole Sexual health and family planning Minor Surgery Diabetes Asthma COPD Population profile Patient catchment areas Clinical achievement / QOF Locality working High number of first/only language not English Sri Lankan and Indian High levels of deprivation High levels of alcohol High incidence of diabetes, hypertension, stroke and serious mental illness High levels of unsupported migrants/families SE19, SE20, SE21, SE23, SE24, SE 25, SE27, CR0, CR2, CR6 & CR7 - see attached map Consistently high performer in QOF and national DESs Member practice of South East Locality in Lambeth Member of the South East London Healthcare Partnership (SELHP) Federation High number of first/only language not English Portuguese & Polish High levels of deprivation High levels of alcohol High incidence of diabetes, hypertension, stroke and serious mental illness High levels of unsupported migrants/families SE27, SE21, SE25, SW16, SW2 & CR0 - see attached map Consistent high performer in QOF and national DESs Member practice of South East Locality in Lambeth Member of the South East London Healthcare Partnership (SELHP) Federation LIST SIZES As is the case with many London Practices, patient turnover is comparatively high. Crown Dale Norwood Surgery 01/04/ /04/ /04/ /04/ Net increase/decrease over 4 year - 4.8% - 5.6% CDMC-N Merger Business Case vfinal 1/8/16 170

171 Both Crown Dale Medical Centre and The Norwood Surgery have seen a slight reduction in their patient list over the last 4 years. In the case of Crown Dale this has been as a result of Access issues and in the case of Norwood Surgery feedback has shown to be around the lack of a female GP. As both these areas will be addressed as a result of the proposed merger, we do not expect to see a further trend of this nature. AGE DISTRIBUTION Crown Dale Medical Centre The Norwood Surgery QOF ACHIEVEMENT Crown Dale Medical Centre The Norwood Surgery 2013/ /900 = 88.6% /900 = 99.1% 2014/ /559 = 97.2% /559 = 97.8% 2015/ /559 = 98.8% /559 = 97.9% CDMC-N Merger Business Case vfinal 1/8/16 171

172 The above indicates that both Crown Dale Medical Practice and The Norwood Surgery are achieving high QOF scores. The merger will create the opportunity to continue improving the levels of care to the combined list of patients and thereby further increase our achievement percentage. This is detailed in the practice Improvement Plan (Appendix A) PERFORMANCE PRIMARY CARE WEBTOOL Crown Dale Medical Centre 10 Level 1 Triggers 0 Level 2 Triggers The Norwood Surgery 6 Level 1 Triggers 0 Level 2 Triggers Both practices currently do not have any Level 2 Triggers. Both practices have the same Level 1 triggers for; 6a) AF Est Diag Rate 9) COPD Est Diag Rate 18) Satisfaction Overall 20) Patient Experience The practices have developed an Improvement Plan (Appendix A) which addresses these issues by appointing new AF and COPD Leads under the new Partnership and pooling knowledge and experience to achieve the national average standards. Furthermore, the practice will address Overall Satisfaction & Patient Experience through appointment of a Patient Services Manager to develop better engagement and feedback mechanisms with patients, continued development of the amalgamated PPG and tackling operational and infrastructural issues. AF - This will be done through engagement with clinical staff (clinical meetings), implementation of new / reviewed operational processes and using templates on the clinical system (EMIS Web). COPD This will be done through engagement with clinical staff (clinical meetings), review of patients with COPD-related type symptoms e.g. coughs and READ coding accordingly and reviewing those patients issued inhalers but have no coding of COPD diagnosis. Satisfaction Overall and Patient Experience This will be done through the appointed Patient Services Manager who will work across both sites to develop better engagement and feedback mechanisms such as Friends and Family Test, MJOG text messaging services and use of the website feedback system. Operational and infrastructural changes will entail upgrading the telephone system to ensure patients have an improved experiencing contact the practice as well as reviewing the appointment systems to ensure patients are able to see their preferred GP. The practices have also developed a plan to address the other areas. FLU & CHILDHOOD IMMUNISATIONS ACHIEVEMENT As part of the PMS Contract, both practices are required to deliver and demonstrate an active engagement in providing childhood immunisations to its patients under the age of 5 years. In addition to this, both practices are contractually required to actively engage to deliver, as a minimum, the Lambeth average for the following: CDMC-N Merger Business Case vfinal 1/8/16 172

173 Immunisation Diphtheria, tetanus, polio, pertussis, Haemophilusinfluenzae type b (Hib) (i.e. All 3 doses of dtap/ipv/hib Pneumococcal infection (i.e. Received pneumococcal booster) (pcv) Haemophilus influenza type b (Hib), meningitis C (menc) - (ie received Hib/menc booster) Measles, mumps and rubella (MMR) - (i.e. 1 dose of MMR) Diphtheria, tetanus, polio, pertussis (dtap/ipv) (i.e. All 4 doses) Measles, mumps and rubella (MMR) (i.e. 2 doses of MMR) % of minimum cover 93% (the current Lambeth Average) of all patients by their first birthday 84% (the current Lambeth average) of all patients by their second birthday 85% (the current Lambeth Average) of all patients by their second birthday 86% (the current Lambeth Average) of all patients by their second birthday 75% (the current Lambeth Average) of all patients by their fifth birthday 80% (the current Lambeth Average) of all patients by their fifth birthday As part of the contract, both practices are required to demonstrate an active engagement in providing influenza vaccinations to no less than 60% of patients aged 65 years and over; and 50% of patients in the at risk groups, excluding carers. Crown Dale Medical Centre Flu Immunisation Uptake Year 65 and Over (%) Under 65 (at-risk only) (%) 2013 / / / Childhood Immunisation Uptake Immunisations (Age 2) Boosters (Age 5) MMR (%) 5 in 1 (%) Men C (%) (%) 2013 / / / The Norwood Surgery Flu Immunisation Uptake Year 65 and Over (%) Under 65 (at-risk only) (%) 2013 / / / CDMC-N Merger Business Case vfinal 1/8/16 173

174 Childhood Immunisation Uptake Immunisations (Age 2) Boosters (Age 5) MMR (%) 5 in 1 (%) Men C (%) (%) 2013 / / / The merger of both practices will give an opportunity for improving flu uptake and other immunisation achievements by implementing shared learning and good practice from both practices. Examples of this include the ability for patients to access walk in services at either site improving convenience as detailed in Appendix A Improvement Plan Childhood immunisation uptake at both practices is overall very good and this will be closely monitored post-merger. Any specific immunisation areas that need addressing will be monitored and actioned as a priority. PATIENT EXPERIENCE Crown Dale Medical Centre The Norwood Surgery CCG National % of patients who say the last appointment they got was convenient % of patients who say the last GP they saw or spoke to was good at giving them enough time % of patients who say the last GP they saw or spoke to was good at explaining tests and treatments % of patients who had confidence and trust in the last GP they saw or spoke to % of patients who describe their overall experience of this surgery as good % of patients who find it easy to get through to this surgery by phone CDMC-N Merger Business Case vfinal 1/8/16 174

175 % of patients who usually get to see or speak to their preferred GP % of patients who describe their experience of making an appointment as good % of patients who usually wait 15 minutes or less after their appointment time to be seen Both practices believe the merger will enable them to pool their resources and allow greater peer review / shared learning providing a support network amongst clinical (and non-clinical staff) to improve and further drive standards higher. It is envisaged this will lead to greater improvements in patient experience and overall satisfaction. As can be seen from the above data there are some indicators for which the Norwood Surgery performs better at than Crown Dale Medical Centre. The shared learning will be paramount in raising standards and driving up quality. Also changes in operational and infrastructural changes will help improve areas where both practices fall short of CCG and national standards. See Appendix A Improvement Plan. Furthermore, overall access will continue to improve through greater choice and utilisation of services across both locations offering even more convenience for patients. PERFORMANCE CONTRACTUAL KPI S & ANNUAL DECLARATION Both practices are fully compliant with KPI s. One of the important benefits of the merger would be shared ownership and combined leadership which will bring about the changes required by having better governance and improving quality. APPOINTMENTS PER PATIENT PER ANNUM Both practices are contractually required to achieve 3.5 appointments per weighted patient, per annum. Both Practices currently achieve a minimum of 3.84 appointments/attendances per patient per annum. Once merged we will aspire to achieve 4.05 appointments/attendances per patient per annum by March This is detailed in the Improvement Plan (Appendix A). POPULATION GROWTH IN THE AREA Crown Dale Medical Centre The building at Crown Dale Medical Centre has now outgrown its capacity since its development in 1990 due to its increasing patient list size. The practice with the support of Lambeth CCG has submitted an application for funding to extend the premises under the Estates and Technology Transformation Fund 2016/17. This application was submitted to NHS England in June 2016 and is currently being reviewed by the relevant committee. The proposal of the refurbishment of the existing building, circa 430m2, and a new extension of about 470m2 will increase the m2 of the building to about 900m2 and also remove the temporary portacabins that have been on site for 10 years. The refurbishment plus extension would enable the CDMC-N Merger Business Case vfinal 1/8/16 175

176 practice to accommodate its entire staff in one composite, permanent building and provide improved access to its current patient list in an adequate building. This extended building will also enable patients from The Norwood Surgery to be seen at the Crown Dale Medical Centre site as and when required opening up patient choice and improving convenience for patients. The extended building would also cater for any increase in list size due to local population growth in the area. The Norwood Surgery The building at The Norwood Surgery currently has consulting rooms on the ground, first and second floor. For the current list size the practice is under-utilised. However, following the merger this building will also enable patients from Crown Dale Medical Centre patients to be seen at that site again opening up patient choice and improving convenience for patients. The building would still have the capacity to cater for any increase in list size due to local population growth in the area. PRACTICE CURRENT LOCATIONS Crown Dale Medical Centre (28) The Norwood Surgery (24) CDMC-N Merger Business Case vfinal 1/8/16 176

177 Other Practices situated in the South East Locality are as indicated in the key above PRACTICE BOUNDARIES Crown Dale Medical Centre covers the following postcodes as indicated on the maps below: SE19, SE20, SE21, SE23, SE24, SE 25, SE27, CR0, CR2, CR6 & CR7 The Norwood Surgery covers the following post codes as indicated on the maps below: SE27, SE21, SE25, SW16, SW2 & CR0 When the two boundary maps are overlaid the area covered by both will be the merged practices patient boundary. CROWN DALE MEDICAL CENTRE BOUNDARY (MAP) CDMC-N Merger Business Case vfinal 1/8/16 177

178 THE NORWOOD SURGERY BOUNDARY (MAP) CDMC-N Merger Business Case vfinal 1/8/16 178

179 CURRENT BOUNDARIES AND PROPOSED PRACTICE BOUNDARY CDMC-N Merger Business Case vfinal 1/8/16 179

180 HEAT MAP SHOWING CROWN DALE PATIENT SPREAD MAP SHOWING NORWOOD SURGERY PATIENTS At the time of writing this business case, it was not possible to obtain the information required to produce a map for Norwood Surgery. IMAGES OF CURRENT PREMISES Crown Dale Medical Centre Front View CDMC-N Merger Business Case vfinal 1/8/16 180

181 Side View Back View CDMC-N Merger Business Case vfinal 1/8/16 181

182 The Norwood Surgery Front view CARE QUALITY COMMISSION Crown Dale Medical Centre The Care Quality Commission carried out an inspection in November A Good rating was given in all categories and areas. The Norwood Surgery The Care Quality Commission carried out an inspection in June The practice was rated as being compliant under all the outcomes. The practice is due to have re- inspection which will be rated under the updated process. This visit was due in June but had to be cancelled and is being rescheduled. CDMC-N Merger Business Case vfinal 1/8/16 182

183 4. CASE FOR CHANGE The Practices believe that the preferred option is to have both practices merge and operate and continue serving the population from both sites as one practice. A summary of the anticipated benefits is provided below: BENEFITS TO PATIENTS Continuity of care the current GP Partners will remain and continue to serve their patients Patients will benefit from the increased choice of GP (e.g. The Norwood Surgery gaining access to a female GP) and access through additional extended opening hours and flexible clinic types including a range of routine bookable, walk-in and telephone consultations resulting in shorter waiting times for these appointments. This will include a wider pool of Patient Access appointments as well as other services like repeat prescriptions. Both cohort of patients will be able to access appointments at times they were previously unable to e.g. The Norwood Surgery patients would have access to services on a Saturday and likewise Crown Dale Medical Centre patients would have access to Thursday evenings. The current / planned opening hours at both sites are : Current Crown Dale Medical Centre The Norwood Surgery Monday 8.00am 6.30pm 8.00am 6.30pm Tuesday 8.00am 6.30pm 8.00am 6.30pm Wednesday 8.00am 8.30pm 8.00am 6.30pm Thursday 8.00am 6.30pm 8.00am 8.00pm Friday 8.00am 6.30pm 8.00am 6.30pm Saturday 9.00am 12.00pm CLOSED Planned Monday Tuesday Wednesday Thursday Friday Saturday 8.00am 6.30pm 8.00am 6.30pm 8.00am 8.30pm 8.00am 8.00pm 8.00am 6.30pm 9.00am 12.00pm Patients from both Practices will be able to access the full range of specialist services offered by the Practices including sexual health and LARC, minor surgery, acupuncture, community dietician and bi/multi-lingual clinicians and reception staff. Due to the different closing times across both practices patients will have greater choice across the week in accessing these services. Additional services planned include offering phlebotomy at Crown Dale Medical Centre to all current The Norwood Surgery patients Patients will be consulted on the re-design of services prior to the merger in order to ensure that the newly merged Practice is responsive to patient need. Patients, particularly older patients and those with long term conditions will benefit from continuity of care by remaining under the care of their usual GP. All patients will also continue to see familiar reception, nursing and GP staff in a familiar location. Patients will retain access to high quality patient-centred care. Both Practices have evidence of strong patient support, high quality patient experience and confidence in services. Home visits there will be the opportunity for the combined clinical team to overlap and share this responsibility Savings made through consolidation of suppliers and accountancy costs will help release financial resources which can be reinvested in recruitment of further clinical and non-clinical staff. CDMC-N Merger Business Case vfinal 1/8/16 183

184 BENEFITS TO NHS ENGLAND (LONDON) AND LAMBETH CCG NHS England (London) and NHS Lambeth CCG will retain well established safe, high quality Practices ensuring continuity of care for patients. NHS England (London) and Lambeth CCG will retain well qualified and experienced primary care staff and well established teaching and training opportunities essential to the sustainability of the local workforce. Practice merger will support the national direction of travel towards upsizing general Practices to become more cost efficient and offering consistent quality of care as outlined in the General Practice Forward View paper. The Practices are committed to developing an approach to access and service delivery that will support national priorities to provide care closer to patients homes and reduce secondary care costs again as outlined in the General Practice Forward View paper. NHS England (London) and Lambeth CCG will retain the confidence of the local health community. BENEFITS TO PRACTICE Economy of scale savings in staff costs of circa 10,000 per annum The Practice will be able to gain the benefits of economy of scale that a single practice with a larger list size will provide. This will include efficiencies in staffing costs particularly in relation to administration and management costs. In addition the Practice will benefit from a reduction in the duplication of costs of running two contracts separately such as accountant s fees, insurance, subscriptions etc. and more cost efficient procurement of consumables through increased volume. The Practice will be able to take advantage of opportunities to maximize income by ensuring consistent delivery of enhanced services, including locally enhanced services such as the GP Delivery Scheme, across the full patient list as well as QOF achievement and income. With a larger workforce, a merged Practice will benefit from the diversity in skills of staff and flexible working arrangements in order to deliver extended opening hours. All clinical staff will benefit from a supportive culture of teaching and personal development. The Practice will be able to build a competitive edge by using the increased workforce to deliver more choice, specialist services and extended access to attract and retain patients. CCG SUPPORT Crown Dale Medical Centre and The Norwood Surgery have informed the CCG of the proposed merger. They have acknowledged the proposal and look forward to seeing this business case. SOUTH EAST LAMBETH HEALTH PARTNERSHIP- SELHP (Federation) SUPPORT Crown Dale Medical Centre and The Norwood Surgery have informed SELHP of the proposed merger who have acknowledged the proposal. They have given their support to this proposed merger. LONDONWIDE LMC SUPPORT Crown Dale Medical Centre and The Norwood Surgery have informed Londonwide LMC of the proposed merger. They have acknowledged the proposal and they are supporting both practices through this proposed merger process. CDMC-N Merger Business Case vfinal 1/8/16 184

185 5. FINANCIAL COSTS OF THE PROPOSAL RECURRENT AND FIXED (where applicable) Crown Dale Medical Centre and The Norwood Surgery are seeking the following financial support from NHS England in regards to this proposed merger: - IT - Mail out to both practice patient lists (NHSE and Practice split cost) Crown Dale Medical Centre and The Norwood Surgery will be seeking financial support from the Practice Resilience Scheme/Vulnerable Practice Scheme when it becomes available and the details have been finalised by the Health London Partnership team at NHS England (London) in regards to this proposed merger. Crown Dale Medical Centre and The Norwood Surgery recognise the following financial costs must be met by them in regards to this proposed merger: - Project Management - Marketing including Rebranding - Telephony - Legal (LMC Law Partnership Agreement) - HR including TUPE arrangements 6. OPTIONS i) OPTIONS APPRAISAL A) Do nothing This option entails both practices continuing to operate as they currently do i.e. separate organisations. B) The Norwood Surgery to merge with Crown Dale Medical Centre This option entails the merger of both practices resulting in greater operating efficiencies and generating cost savings ensuring sustainability of service delivery for the combined cohort of patients. The merger will benefit patients by giving greater access to primary care and enhanced services improving choice and convenience for patients. C) Share resources This option considers the sharing of resources across both practices. The key point with this option entails the workforce being utilised across either practice depending on the needs of that practice. The practices would negotiate the recharge costs accordingly. ii) PREFERRED OPTION The preferred option expressed by both practices would be: B) The Norwood Surgery to merge with Crown Dale Medical Centre. A merger as outlined in this proposal demonstrates maximum benefits to all stakeholders. To continue operating as two separate organisations will no doubt challenge the sustainability of The Norwood Surgery as a single-partner general practice and the continued delivery of primary care and enhanced services to its current cohort of patients. CDMC-N Merger Business Case vfinal 1/8/16 185

186 To share resources would only seek to address a small element of the sustainability challenges faced by, primarily, The Norwood Surgery due to its size and infrastructure. This option would yield little benefit to either patients or the practice compared to a full merger. 7. COMMENTS / ISSUES: IT As both practices use EMIS Web as the clinical system, the merging of both systems will be a much easier process. Lambeth CCG has been contacted, who will authorise the process for a joint clinical system on EMIS via GPSoC for the proposed merge 8. APPENDICES APPENDIX A IMPROVEMENT PLAN Appendix A_CDMC-N_Merger_I APPENDIX B PATIENT & STAKEHOLDER ENGAGEMENT PLAN (Updated 08/08/2016) Appendix B_CDMC-N_Merger_P CDMC-N Merger Business Case vfinal 1/8/16 186

187 Improvement Plan The merger of Crown Dale Medical Centre and The Norwood Surgery gives an opportunity to review and improve / update some key areas in the practice through benefit of shared learning. As outlined in the Business Case there are some areas that one practice exceeds above the other and there are some similar areas where both practices can improve on. No. Improvement Area Action Due Action Status Person Responsible Action by 1 Quality and Outcomes Framework (QOF) achievement > Review processes on how QOF is managed at each practice > Standardise processes and implement at each site > Update all staff (clinical and non-clinical) To be started Dr Carley Hennah (QOF Lead) Arif Ladha 01/11/2016 2a Level 2 Trigger - AF Est Diag Rate > Appoint new AF Lead under new partnership > Review clinical practice / shared learning at clinical and peer review meetings > Update clinical system templates and implement retraining where necessary To be started GP Partners Ladha Arif 01/11/2016 2b Level 2 Trigger - COPD Est Diag Rate > Appoint new COPD Lead under new partnership > Review clinical practice / shared learning at clinical and peer review meetings > Review patients with COPD related/type symtoms e.g. coughs and READ code accordingly > Review READ coding for patients being issued inhalers but have no COPD diagnosis > Implement COPD screening on patients who present for smoking cessation services To be started GP Partners Ladha Arif 01/11/2016 2c Level 2 Trigger - Satisfaction Overall To action in conjunction with Patient and Stakeholder Engagement Plan > Appoint Patient Services Manager under new partnership > Review and update appointment system to allow patients better access to preferred clinician > Review and update appointment system to allow greater number and choice of Patient Access (on-line) appointments > Review extended hours access across both sites To be started Arif Ladha Barros Michelle Sheila Ryan 31/12/2016 2d Level 2 Trigger - Patient Experience To action in conjunction with Patient and Stakeholder Engagement Plan > Appoint Patient Services Manager under new partnership > Review, update and implement standardised patient feedback systems such as Friends & Family Test, MJOG text messaging, website online survey To be started Arif Ladha Barros Michelle Sheila Ryan 01/11/2016 3a Flu immunisation Uptake - 65 and over Although both practices achieve the 60% target uptake, levels could be improved > Review and update recall mechanism > Review and update marketing and communications campaign > Implement walk in clinic at both sites To be started Arif Ladha Barros Michelle Sheila Ryan 01/10/2016 3b Flu Immunisation Uptake - At Risk (< 65years) > Review and update recall mechanism > Review and update marketing and communications campaign > Implement walk in clinic at both sites > Review access outside of core hours for working patients To be started Arif Ladha Barros Michelle Sheila Ryan 01/10/ Childhood Immunisations Although both practices overall achieve the target uptake, levels could be improved > Review and update recall mechanism > Review and update communications campaign > Review access times within core hours to further improve convenience for parents To be started Arif Ladha Barros Michelle Sheila Ryan 01/10/

188 5 Appointments per patient per annum Currently combined level exceeds contractual requirement but GP contacts could be improved > Review and update patient contact levels on GP template > Continue implementing GP recruitment programme > Review and update scheduling process to implement shared clinical resource across both sites To be started Arif Ladha Barros GP Partners Michelle Sheila Ryan 31/12/ Upgrade telephony system > Continue telephony upgrade and implementation programme at Crown Dale site > Review and update telephony system at Norwood site > Standardise processes and implement system changes so both sites can communicate effectively > Update all staff (clinical and non-clinical) To be started Arif Ladha Barros Michelle Sheila Ryan 01/11/

189 Patient and Stakeholder Engagement Plan Patient & Stakeholder engagement is fundamental to the process of the merger and future as this will allow us to strengthen our service going forward, help design the service around patient needs and proactively address patient needs and concerns. We will have a clear message that together, we can provide better primary care services to the combined patient population and patients will experience greater access to appointments and services as part of the new partnership. No. Required Action Action Taken 1 Engagement with patients prior to the merger proposal - informal 2 Regular PPG meetings/consultations are held to address the following: - Concerns about the proposed merger - Suggestions as to how you can deliver services in a better way in the future as a merged organisation. Clinicians / Reception staff from both practices have been informally discussing the merger opportunistically with patients to obtain their views. Patients views have also been discussed at meetings for the practice to be aware of their hopes and fears and general concerns. Regular PPG meetings/consultations are held to address concerns from both practices and minutes of meetings/consultations with FAQs raised are published on the website. Action Status completed Remaining Action Person Responsible Action by Collate all responses from short survey Arif Ladha 25/07/2016 Continue collating information Arif Ladha Michelle Barros Sheila Ryan > Review & update Patient communication materials: 26/08/16 > PPG consultation meeting: 09/09/16 Patients can also give feed back by doing the following: - completing the online survey via the website or completing a form at the surgery - Send messages and feedback by accessing the messaging system on the website - Use the suggestion box at the reception desk Ongoing 3 Ensuring that all patients are made aware of the merger and the date of commencement Information has been made available in various formats such as patient surveys (both online and offline), information (like Q&A's) published on the website and on the surgery notice boards. Leaflets are also available at the surgery reception desk. Need to include adding information to repeat Rx, recall letters and other general correspondence Ongoing Arif Ladha Michelle Barros Sheila Ryan 16/09/ Organised Q&A session for patients from both Organise a date and time in September in practices prior to leading up to the merger colaboration with PPG and GP Partners from both practices Ongoing The feedback and comments will be analysed and fed back to partners and PPGs before sharing this with NHSE & CCG. The results will also be made available via our websites and vulnerable patients, and will be incorporated into the service design where practical and improvement plans during and after transition. Arif Ladha Michelle Barros Sheila Ryan > Arrange date by: 23/08/2016 > Q&A session date: w/c 19/09/16 6 Mitigation of disruptions caused to the care of vulnerable patient groups Patients falling under this group will be contacted to inform them of the merger. Whilst it is anticipated they will not encounter any possible disruptions as both sites will remain open as before we will conduct an identification of risks/disruptions and allow for mitigating measures to be put in place early on to prevent any reduction in the list size. To be started Michelle Barros Sheila Ryan 30/09/ Risk assessment to be carried out regarding the related risks of those patients who want Currently in the process of informing all patients in this group. All information gained their care continued under the new partnership from these conversations to be collated. 8 Investigating the effects caused to all patient groups from both practices Discussions have taken place with the PPG whereby their views expressed were noted and recorded on information media for all to be able to access (e.g. surgery website and notice board). To be started Ongoing Risk Assessment Register will be compiled as and when patients are identified as belonging to this group and practical mitigation measures will be implemented Feed back will continuously be obtained from patients. This will be analysed and distributed to patients regularly before and after the merger. Michelle Barros Sheila Ryan Arif Ladha Michelle Barros Sheila Ryan 30/09/2016 No fixed end date 9 Close monitoring of the removal requests from the clinical system. 10 Active engagement with local GP's, pharmacies, ward councillors and support organisations & other key stakeholders* Estimations at this stage only Local GPs and pharmacies will be informed of the merger by telephone and other available methods e.g. Practice manager meetings, locality meetings. Any of the PPG members that can support in diseminating information about the merger will do so at any community functions / events. To be started Ongoing Weekly monitoring of the removal requests through EMIS and subsequent communication with said patient as to why they left and what measures can/could have been taken to prevent this. PPG lead/practice to organise a meeting with the ward councillor to inform of the merger. Arif Ladha Michelle Barros Sheila Ryan No fixed end date Arif Ladha 30/09/ Proposal to be shared with CCG,LMC, federation and NHS England & their views be incorporated 12 Ensuring staff are TUPED over to the new partnership (legal requirement). Business case has been sent to these organisations mentioned and feed back from the individual organisations have been actioned and fed back to NHS England. General staff discussions and updates have been carried out with all staff to explain the merger. These meetings and individual consultions will continue and reassurance will be given that they will be transferred in the new partnership. It is anticipated all clinicians and admin staff will be happy to be TUPED to the new partnership. Ongoing Ongoing N/A Arif Ladha 30/09/2016 Organisational restructure will take place 3 months after the merger Arif Ladha 31/12/ * Other Key Stakeholders we will communicate with as part of our comms and engagement plan SELDOC Local practices Local acute and community care providers (KCH and GSTT) SLAM 111 Lambeth Council & Overview & Scrutiny Committe (OSC) Lambeth Health and Wellbeing Board Southwark, Lewisham & Croydon CCGs Local MPs Local Councillors Local Medical Committees in both Southwark, Lewisham & Croydon This list is not exhaustive and some of the key stakeholders will have already been consulated and engaged with as part of the proposal, as detailed above, however all stakeholders will be formally notified of the outcome once the actions for the agreement in principle given on 18th August 2016 have been concluded To be started Arif Ladha 23/08/ Update Report Post Merger As part of our overall strategy for comms and engagement and to ensure that patients views are addressed, we will complete and submit a report (post merger) to NHS England and NHS Lambeth CCG on progress and key issues that were highlighted, have been rectified and addressed (and if not then why), including timelines. Arif Ladha No fixed end date 189

190 Enc: L Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Primary Care Joint Committees (PCJC) Meetings DATE OF MEETING: 18 August 2016 ENCLOSURE: L Title: The Vauxhall Surgery Lambeth Review of need for contractual action following Inspection by the CQC AUTHOR: Stella Babudoh, Commissioning Manager, NHS England (London) Nick Langford, Senior Commissioning Manager, NHS England (London) SUMMARY: The Care Quality Commission (CQC) carried out a comprehensive inspection of Vauxhall Surgery on 3 February The practice was rated as Good for Are services caring? and Are services responsive to people s needs? The practice was rated as Requires improvement for Are services safe?, Are services effective? and Are services well-led? They received an overall rating of Requires improvement for the Quality of care provided by the practice. The Lambeth PCJC approved at its last meeting the London region Standard Operating Procedure for Primary Medical contracts: A consistent approach to responding to Care Quality Commission Requires Improvement ratings. The considerations within this have been used to determine what formal contractual actions, if any, may be recommended to the Lambeth PCJC, as a result of The Vauxhall Surgery receiving a Requires improvement notice. The considerations have included: 1. Should contractual action be considered? When a practice is in receipt of a CQC report indicating that they Require improvement, they have immediately breached their contract The Contractor shall comply with all relevant legislation and have regard to all relevant guidance issued by the Board or the Secretary of State or Local Authorities in respect of the exercise of their functions under the 2006 Act. it is therefore proportionate for NHS England to consider further contractual action. 2. Should a breach/remedial notice be issued based on CQC visit report evidence? NHS England concludes that the report findings, on which the practice has had the opportunity to comment, provide sufficient evidence of specified contractual compliance issues, and that it is therefore able to issue a breach and remedial notice 190

191 based on the evidence contained within. 3. Is it a proportionate response to issue a breach/remedial notice? NHS England concludes that given the background to this case, it is not proportionate to issue a breach/remedial notice, but to issue an action plan instead as the practice has mitigated some of the adverse findings during and after the inspection. NHS England will write to the contractor to set out what has occurred, and confirm that formal contractual action will not be pursued on this occasion, based on the contractor s response to the outcome of their inspection. In addition, it will confirm that the CCG will arrange to offer advice and support, which is appropriate for issues that need resolving that are not matters of patient safety and where there is no history of wider contractual concerns. 4. What is the Practice s track record/contractual history? NHS England concludes that taking into account the full contractual history of this practice, further contractual sanctions are not deemed reasonable. NHS England therefore recommends the issue of an action plan as a proportionate response to the inspection published report - covering the following areas: Policies are not up to date and relevant Health and safety issues Lack of employment references Medicines Management issues No Safeguarding training KEY ISSUES: The practice was inspected on 3 February They practice s overall rating was Requires improvement for the Quality of care provided by the practice. The practice will be issued with an action plan by NHS England to complete within 28 days. The practice will be revisited within 12 months of the initial visit by the CQC. Whilst the practice is in breach of the following regulations, NHS England (London) has concluded that it is not proportionate on this occasion to issue a breach and remedial notice 1. Requirement to abide by all legislation 2. Part 19 of the Contract and Regulations 121 (1), (2), (3) and (4), Schedule 6, Part 9 of the GMS Regulations 2004 (as amended). Requirement to have an effective system 191

192 of Clinical Governance 3. Part 14, clause 359 of the practice PMS contract. Requirement to ensure that the persons providing care or treatment had the necessary qualifications, competence, skills and experience. 4. Part 7 of the Contract and Regulations 2004 (as amended). Requirement to provide essential services within core hours, as are appropriate to meet the reasonable needs of its patients. RECOMMENDATIONS: The regional team recommends that the PCJC members approve that the practice be formally required to complete an action plan in response their failure to meet the following requirements: 1. Abide by all legislation. 2. Have an effective system of Clinical Governance. 3. Ensure that the persons providing care or treatment had the necessary qualifications, competence, skills and experience. 4. Provide essential services within core hours, as are appropriate to meet the reasonable needs of its patients. The regional team also recommends that the CCG offers support and advice the practice on how to remedy matters that do not relate to patient safety and where there is no history of wider contractual concerns. AUTHOR CONTACT: Name: Stella Babudoh, Commissioning Manager - NHS England (London Region) stellababudoh@nhs.net 192

193 Enc: M Co-commissioning of Primary Care South East London s CCGs and NHS England Primary Care Joint Committees Primary Care Joint Committees (PCJC) Meetings DATE OF MEETING: 18 August 2016 ENCLOSURE: M Title: Nunhead Surgery Southwark - Request to Change Catchment Area AUTHOR: Stella Babudoh Commissioning Manager, NHS England (London) Nick Langford - Senior Commissioning Manager, NHS England (London) Jean Young - Head of Primary, Community and Children s Commissioning NHS Southwark Clinical Commissioning Group SUMMARY: Introduction and Purpose The Nunhead Surgery has submitted an application on 26 April 2016 to reduce the practice s catchment area. See Annex 1 for the practice application and Annex 2 current and proposed new catchment areas. The practice seeks the agreement of the Southwark Primary Care Joint Committee to reduce their catchment area as the practice premises does not have the current physical capacity to deliver full PMS contract to the significantly increased registered list in their current premises. The practice states in the application that: It has registered 2,000 new patients in 18 months and is struggling to maintain good quality patient access, care, clinical, administrative and service delivery The list size has increased disproportionately compared to previous years Vast numbers of patients have switched to its practice as they are unhappy with their existing surgeries, or they are unable to get appointments of their choice. The current catchment area overlaps with that of neighbouring practices. Four new building developments for new homes will be completed within 12 months of the application, which will further impact on the increasing list size. It is currently providing appointments over and above the contractual requirements The practice has confirmed it has fully engaged with their PPG who supports this application. 193

194 Background The Nunhead Surgery is a PMS practice located in south Southwark and, based on NHS England s established performance indicators, is identified as a good and achieving practice. The practice previously applied to NHS England (London) in May 2015 to close its list for 6 months but its application was not supported for the following reasons: Limited evidence of business continuity planning, and it was considered that a robust business continuity plan would have allowed the surgery to proactively take actions to recruit extra staff as required. The increase in patient list size had been gradual over the past year. The request for list closure was a reactive measure. There was a lack of evidence, that the practice had absorbed a large number of patients following list dispersal one year prior. NHS England, Southwark CCG and Londonwide LMC did not support the list closure for the reasons provided above. Following the outcome of the Primary Care Joint Committee in July 2015, the practice was advised on further measures that it could take to improve capacity, including the LMC s advice that the practice could consider reducing its catchment area as one of the alternatives. The LMC offered to support the practice progress this application. Capacity and Premises To address the issue of practice capacity, the practice applied for 2015/16 London Improvement Grant. The practice application was refused as the items for which they sought funding were not eligible in accordance with the requirements set out in the NHS (General Medical Services Premises Costs) Directions 2013, with which all approved bids must comply. Therefore the practice recently applied for Estates Technology Transformation Fund (ETTF) and their scheme has been supported by the CCG submitted for funding. The practice is proposing to reduce its catchment area will: Minimise the amount of overlap with other local practices, yet retaining the existing patients currently registered within its existing catchment area. Ensure that the local population close to the practice will be able to register with the practice. Retain all of the existing patients regardless of whether they fall outside of, or within the new catchment area. Register new patients moving in with existing patient s e.g. new partner, children, regardless of whether they fall outside of, or within the new catchment area. 194

195 KEY ISSUES: List size The practice indicated that its list size increased by 2,000 in last 18 months NHS England has analysed the list size growth and after the FP69 deductions have been taken into account, the actual list size increase in 24 months (01/04/14 to 01/06/16) is 1,338 patients. Annex 3a-3f illustrates the changes in the list size at the practice and comparison to local practices. The disproportionate growth in the list size could be attributed to Dr Sarma s practice closure on 31 July 2014 and subsequent list dispersal. Dr Sarma s practice was within 1.2 miles (23 minutes walk) of the Nunhead Surgery but the majority of Dr Sarma s patients were not located in the vicinity of Nunhead and not in its catchment area. Within one year of the closure 1,673 new patients registered with the practice. At the time of closure Dr Sarma s list size was 1894 patients. Whilst it is expected that the practice would have absorbed some of these patients, the growth compared to the previous 2 years shows that Dr Sarma s practice closure is likely to have had an impact on the increased list size. The practice list size growth in 2012/13 was 22 new patients; it increased to 149 new patients in 2013/14; it further increased in 2014/15 to 638 new patients; and then slightly declined to 615 new patients in 15/16. (see Annex 3C) The aggregate list size change, including patient deductions, from 01/04/14 to 01/04/16 demonstrates that, of the 10 practices within 0.8 miles radius of the Nunhead practice, the largest growth increase occurred at Queens Road Surgery with 22.14% increase in new registration followed by Nunhead Practice with 14.59%. Some practices during the period had a decline in growth. (see Annex 3D) The practice has stated that a number of patients have switched to the Nunhead Surgery as they were unhappy with their existing surgeries, or they were unable to get appointments of their choice. Whilst there is currently no evidence to substantiate this claim, NHS England and Southwark CCG will review the patient experience results of the local practices and consider opening discussions with them to look at ways to improve. Catchment area and local practices Annex 2 shows the current catchment area and proposed catchment area.10 practices are within 0.8 miles (between 12 to 21 minutes walk) of Nunhead practice and there are 12 practices in Southwark and Lewisham with overlapping boundaries. Developments and further impact on list size The practice confirmed that there are 4 housing developments providing new homes that are due to be completed within 12 months. The new homes are within their new reduced catchment area. One of the developments is opposite the practice and will consist of 1,500 homes. By reducing the catchment area, the practice will be able to absorb any additional 195

196 patients that choose to register with them from the new developments close by. The practice has confirmed that its premises were purpose built approximately 20 years ago at the time for a list size of 6000 patient with the potential to grow to a list size of The practice stated that it has no further room for growth as its list size has now grown beyond the capacity. The practice has also confirmed that it has 8 clinical rooms, 1 meeting room and 3 administrative rooms, and that its clinical rooms are used at full capacity during opening hours for either face to face patient contact, telephone consultations, or for clinicians administrative work. The administrative rooms are at 100% capacity. The room usage rota is prepared weekly and the practice will continue to review capacity on a monthly basis to ensure that clinical capacity is maximised in order to deliver GP services. Their list size as at 01/04/16 is 9168 patients. The practice advised that Southwark Council rejected the first application to extend the front of the practice which is currently a two bedroom flat owned by the practice. It has now submitted another application with the support of the CCG to extend again. If this application is rejected the practice plans to extend to the car park which is to the side of their building. This is the least preferred option as it will require building works. This application is in line with their ETTF bid. Appointments The practice currently offers 450 GP appointments each week during core hours. In line with their contract, the practice should be offering 441 appointments (Monday to Friday 8am - 6:30pm). The practice is currently offering 9 appointments more per week. (see Annex 3E) Workforce NHS England PMS contract does not include guidance regarding a GP: patient ratio. The Department of Health (DH) average for GP provision is 1,800 patients per Whole Time Equivalent (WTE) GP. Using the DH guidance the practice has sufficient WTE GPs for its 9,168 patients. (Annex 3F list the practice workforce) NHS Southwark CCG Following a review of the application the following issues were identified by the CCG, and the specified assurance was subsequently provided by the practice: 1. Full use of the Extended Primary Care Service (EPCS) Nunhead practice during quarter 1 of 2016/17 was a relatively low user of the CCG commissioned EPCS, the latter of which provides additional primary care appointments at the Lister Primary Care Centre. The practice has demonstrated full cooperation with the EPCS including adjusting their own access model to align with the EPCS model. The practice has indicated that many patients prefer to have appointments with their own registered GP and therefore the reason their use of the EPCS has decreased. The practice has confirmed they will continue to work with EPCS, Improving Health Limited (the GP federation that provides EPCS) and their PPG to increase use of the EPCS as appropriate and reduce 196

197 pressure on the use of their clinical space at Nunhead Surgery Site including for routine appointments. Furthermore the practice is working with the EPCS to develop the service model and increase further capacity within the service for use by the GP practices e.g. provision of routine nurse appointments and will pilot technology to increase alternate access to GP services to patients. 2. West boundary area The proposed reduction of the catchment boundary area includes the triangle to the west of the map. It is noted that patients living close to the practice will not be able to register. The practice has reviewed the area and notes the neighbourhood in the west boundary area have just as easy access to several neighbouring practices, as there is to Nunhead Practice. 3. Clinical Capacity The practice has confirmed that it has recruited and has sufficient clinical and admiration capacity to deliver the full PMS contract (evidenced by its good rating ). The practice is able and willing to recruit additional staff for the increased list size but is unable to accommodate within the current premises. Southwark LMC The LMC fully supports the practice in its application to reduce the practice boundary. The LMC states the level of detail that has gone into ensuring that the areas it will no longer cover by the current practice boundary is covered by other practices. As stated earlier in this paper, there is a significant amount of building work going on in the area immediately adjacent to the practice which will have an impact on the number of patient registrations, and the practice obviously wants to serve the practice population in the immediate vicinity. The LMC has also have been supporting the practice in meetings with Southwark Council to get their planning application approved. Annexes Annex 1A Practice application to reduce catchment area Note: Co-commissioners have received further information to complete this paper on request further to this application. Annex 2 Current catchment area with proposed reduced catchment area map Annex 3A F Registered list size changes summary and comparison to local practices 197

198 RECOMMENDATIONS: The Committee Members are requested to approve the reduction in the catchment area to enable the practice to manage patient registrations in the short term following engagement with the following conditions: o This is time limited and should be reviewed on a 6 monthly basis in line with premise capacity including the outcome of its planning permission application and Estates & Technology Transformation Fund (ETTF) bid is known o That the practice continues to engage with their PPG on the catchment reduction and clearly communicates the reasons for the reduction with their patients and local stakeholders o That the practice increases the use of the EPCS and continues to fully work with service model o The practice pilots alternative ways of patients accessing GP services working with the GP federation and the CCG The Committee Members note that NHS England and the CCG will monitor progress to revert to the original boundary area including progress to improve indicated access and quality of neighbouring practices and capacity for primary care services for the local population. Members will be updated as appropriate CCG CONTACT: Name: Jean Young jean.young4@nhs.net AUTHOR CONTACT: Name: Jill Webb Head of Primary Care, NHS England (London) jill.webb3@nhs.net 198

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202 Current and proposed Catchment Map overlap Nunhead Surgery Current Catchment Proposed Catchment 202