Delegated Commissioning of Primary Medical Services Briefing Paper

Appendix One Delegated Commissioning of Primary Medical Services Briefing Paper 1.0 Introduction Swindon CCG has been jointly commissioning Primary Medical Services with NHS England under co-commissioning arrangements since April 2015. During this time the CCG have worked closely with NHS England to be involved in commissioning discussions, liaison with practices and to ensure that commissioning outcomes are aligned with the needs for the local population in Swindon and Shrivenham. A monthly Primary Care Operational Group (PCOG) has been in place between the CCG and NHS England, reporting to a quarterly Joint Primary Care Committee (JPCC) with responsibility for decision making, held in public and a formal sub-group of the CCG s Governing Body. An application to develop these commissioning arrangements by Swindon CCG taking on delegated responsibility was accepted by the Governing Body in September 2016 following a successful ballot of the membership practices. In order to develop these plans, and in line with national timeframes, Swindon CCG applied to NHS England to take on delegated responsibility on 5th December 2016. NHS England confirmed that the Swindon CCGs application for fully delegated commissioning was successful on 9th February 2017. In line with recommendations discussed at Governing Body in September 2016 it is planned that Swindon CCG will take on delegated responsibility for Swindon and Shrivenham primary medical care services within existing resources and without any resource transfer from NHS England from 1 st April 2017. It is expected that 2017/18 is a transition year, during which the CCG and NHS England work closely together to transfer resource and capability with the CCG leading actions where possible. Delegated commissioning offers an opportunity for CCGs to assume full responsibility for commissioning general practice services. Legally, NHS England retains the liability for the performance of primary medical care commissioning so will expect assurance that its statutory functions are being discharged effectively. 2.0 Implementation NHS England have been revising the Memorandum of Understanding (MOU) for Primary Care Medical Services support for Delegated CCGs. This details the offer of transitional support available to the CCG during 2017/18, the first year, of delegated commissioning. This will ensure that the NHS England team is able to provide support

from the integrated core Primary Care Medical Commissioning Team (covering commissioning, finance, nursing and quality) as the CCG build capability in this regard. The CCG and NHS England have been working on a transition plan (see Appendix 1) to agree and phase how responsibilities will transfer by function during 2017/18 and in order to ensure that capability is shared. There is a central team employed by NHS England who will continue to provide support to CCGs on the technical elements of primate care contracting. The resource is being aligned to the STP footprint. The transition plan has been built splitting functions into 3 main categories. These are:- Payment related functions Contracting related functions Estates related functions Payment related functions: These are broadly similar to functions already carried out by Swindon CCG for Contracts and Local Enhanced Services. Resource will be required to monitor, review against contracts and authorise. Contracting related functions: These have been grouped for Quarter 3 transition transfer. The resource will be required to contract manage the GMS, PMS and APMS contracts. The Primary Care team within the CCG currently manage the LES contracts. Estates related functions: These functions will cover ongoing premises issues, such as rent reviews, any National initiatives as well as the Estates and Technology Transformation Fund (ETTF). 3.0 CCG responsibilities for delegated commissioning The functions CCGs with delegated authority cover are: a) decisions in relation to the commissioning, procurement and management of Primary Medical Services Contracts, including but not limited to the following activities: i) decisions in relation to Enhanced Services; ii) decisions in relation to Local Incentive Schemes (including the design of such schemes); iii) decisions in relation to the establishment of new GP practices (including branch surgeries) and closure of GP practices; iv) decisions about discretionary payments; v) decisions about commissioning urgent care (including home visits as required) for out of area registered patients; b) the approval of practice mergers;

c) planning primary medical care services in the Area, including carrying out needs assessments; d) undertaking reviews of primary medical care services in the Area; e) decisions in relation to the management of poorly performing GP practices and including, without limitation, decisions and liaison with the CQC where the CQC has reported non-compliance with standards (but excluding any decisions in relation to the performers list); f) management of the Delegated Funds in the Area; g) Premises Costs Directions functions; h) co-ordinating a common approach to the commissioning of primary care services with other commissioners in the Area where appropriate; and i) such other ancillary activities as are necessary in order to exercise the Delegated Functions These are the same functions that the JPCC has responsibility for in the joint cocommissioning model. The main difference here is that the responsibility and decision making for these functions lies solely with the CCG, as opposed to jointly with the NHS England regional teams. This means that primary care investment decisions that fall within the functions above will not require approval by the NHS England. 4.0 Responsibilities remaining with NHS England (Reserved Functions) The following detailed information has been taken from the Delegated Agreement to assist with the understanding of the function (see Appendix 2) for more information. a) management of the national performers list; b) management of the revalidation and appraisal process; c) administration of payments in circumstances where a performer is suspended and related performers list management activities; d) Capital Expenditure functions, decision making; e) section 7A functions under the NHS Act (public health programmes/services); f) functions in relation to complaints management; h) such other ancillary activities that are necessary in order to exercise the Reserved Functions; 5.0 Proposed Governance Structure

Swindon CCG currently has in place a quarterly JPCC held in public supported by the monthly PCOG for joint co-commissioning responsibilities. It is proposed that the following committee structures are put in place for delegated commissioning arrangements; Governing Body Primary Care Commissioning Committee Primary Care Operational Group In effect this means the existing Joint Primary Care Committee is replaced with the Primary Care Commissioning Committee (PCCC). In line with national and conflict of interest guidance the PCCC membership will need to have a majority of members who are not GPs. The membership of the Primary Care Operational Group is recommended to change to include greater GP membership with the Clinical Chair and two other Governing Body GPs on the committee. It is proposed that the chair is the CCGs Accountable Officer (AO), and vice-chair Chief Operating Officer (COO). Draft TORs for the 2 committees will be developed and taken to the April Joint Primary Care Committee for consideration before being presented to Governing Body for approval. 6.0 Ongoing considerations PCOG will closely monitor any risks associated with implementing delegated commissioning arrangements, reporting to the risk management panel where appropriate. Lessons learnt from other areas, suggest to ensure a smooth transition between NHS England and CCG any due diligence needs to cover all key aspects of primary care

commissioning, such as finance, premises, commissioning and contracting. Areas to consider include: 6.1 Governance: To ensure conflict of interest and decision making is clearly understood and implemented, in line with national guidance. 6.2 Finance: To ensure that transactional processes and any legacy issues are understood. Smooth transition of budgets to CCG To understand timescale for rent reviews To put in place process for consideration of discretionary payments. 6.3 Contracting: To ensure that documentation is transferred to CCGs and updated To receive clearly documented records of any current issues with providers Future procurements are set out clearly. As a part of the overall process the CCG needs to ensure that it maintains a productive and engaged relationship with its membership practices, the public and other local stakeholder organisations in respect of primary care commissioning. 7.0 Next Steps It is proposed that; 7.1 The CCG (primary care, finance, quality and contracting teams) will continue to meet fortnightly with NHS England to progress and implement to transition plan during 2017/18. 7.2 Draft Terms of Reference for JPCC transitioning to PCCC will be presented at the April 2017 JPCC meeting. 7.3 Draft Terms of Reference for PCOG will be presented at the April 2017 PCOG meeting. 7.4 Both draft Terms of Reference will be Presented to Governing Body in April for approval. 7.5 PCOG will monitor progress on implementation of the transition plan, reporting by exception on progress to PCCC.

Appendix 1 TRANSITION PLAN - DELEGATED CCGS - version 3 Transition (QTR 1, 2,3 & 4) Quarter 1 Area Function/Tasks Annual Payment Schedule - PMS, APMS and ES's Review and set up of annual bugets on the Exeter system Payment processing - DES Receipt of claims - manual or CQRS, approval - Payment queries - DES Payment processing - QOF Receipt of claims - manual or CQRS, approval Payment queries- QOF Payment processing - ad hoc Receipt of claims - manual or CQRS, approval Payment queries - ad hoc QOF review: achievement, activity, prevalence rates & exception rates QOF process Rent payments (including reviews) Practice mergers/federations CQRS system - in year support for practices and year end review an sign off Process in line with SOM Quarter 2 Agree opt-outs from the GMS contract Payment processing - drugs Payment queries - drugs Payment processing - core contract Payment queries - core contract Directed Enhanced Services - nationally defined - Learning Disabilities - Avoiding Unplanned Admissions - Extended Hours - Minor Surgery - Out of area agreement Contract variations GP minimum workforce dataset Completion of E-Dec returns Dispensing Services Quality Scheme (DSQS) Retainer approvals Processing of the drugs payment on the Exeter system PMS - annual review of the practices budgets GMS - quarterly review of Exeter payment calculations and monthly payments APMS - annual review of practice budgets and monthly payments All paid via the Exeter system (manual set up for APMS and PMS) Management of Enhanced Services Implementation of national contract variations Via primary care web tool Via primary care web tool Annual review and payment process Process adhoc payment claims Locum reimbursement approvals Practice list size reviews Application for closed lists Identify changes in list sizes and liaise with CCGs Process applicationin line with SOM Branch surgery closures Process applicationin line with SOM Breeches / Remedial / Termination notices Boundary changes Process in line with SOM Quarter 3 GMS and PMS contract reviews APMS contact reviews PMS premium usage Bank holiday planning Emergency Planning Follow up of CQC visits Secxtion 96 applications Annual Contract reviews ES's and core contract Quarterly contact review - Finance, activity, KPI's etc. Agree year 2 funding Obtain information from contractors and share with stakeholders Quarter 4 Agreement of revenue funding for premises development Acting as first point of contact for practices concerning contractual issues LMC liaison regarding CCGs role in primary care Termination of contracts (Initiated by CCG or Practice) APMS contract development of service specification and scope APMS contract procurement process Interpreter & Translating services Violent Patients Process applicationin line with SOM Liaise with practice Development of service specification Development and running of a procurement process Procurement, contact management and associated payments Clinical waste contract Primary Care Support England

Appendix 2 Responsibilities remaining with NHS England (Reserved Functions) include the following; a) management of the national performers list; NHS England will continue to perform its primary medical care functions under the National Health Service (Performers Lists) (England) Regulations 2013. NHS England s functions in relation to the management of the national performers list include: 1.1.1. considering applications and decision-making in relation to inclusion on the national performers list, inclusion with conditions and refusals; 1.1.2. identifying, managing and supporting primary care performers where concerns arise; and 1.1.3. managing suspension, imposition of conditions and removal from the national performers list. NHS England may hold local Performance Advisory Group ( PAG ) meetings to consider all complaints or concerns that are reported to NHS England in relation to a named performer and NHS England will determine whether an initial investigation is to be carried out. NHS England may notify the CCG of all relevant PAG meetings at least seven (7) days in advance of such meetings. NHS England may require a representative of the CCG to attend such meetings to discuss any performer concerns and/or quality issues that may impact on individual performer cases. The CCG must develop a mechanism to ensure that all complaints regarding any named performer are escalated to the Local NHS England Team for review. The CCG will comply with any Guidance issued by NHS England in relation to the escalation of complaints about a named performer. b) management of the revalidation and appraisal process; NHS England will continue to perform its functions under the Medical Profession (Responsible Officers) Regulations 2010 (as amended by the Medical Profession (Responsible Officers) (Amendment) Regulations 2013). All functions in relation to GP appraisal and revalidation will remain the responsibility of NHS England, including: 1.1.1. the funding of GP appraisers; 1.1.2. quality assurance of the GP appraisal process; and 1.1.3. the responsible officer network. Funding to support the GP appraisal is incorporated within the global sum payment to GP practices.

The CCG must not remove or restrict the payments made to GP practices in respect of GP appraisal. c) administration of payments in circumstances where a performer is suspended and related performers list management activities; NHS England reserves its functions in relation to the administration of payments to individual performers and related performers list management activities under the National Health Service (Performers Lists) (England) Regulations 2013 and other relevant legislation. NHS England may continue to pay GPs who are suspended from the national performers list under the Secretary of State s Determination: Payments to Medical Practitioners Suspended from the Medical Performers List (1 April 2013). For the avoidance of doubt, the CCG is responsible for any ad hoc or discretionary payments to GP practices (including those under section 96 of the NHS Act) in accordance with clause 6.2.1.4 and Schedule 2 (Delegated Functions) Part 1 paragraphs 2.13 and 2.14 of this Agreement, including where such payments may be considered a consequence of actions taken under the National Health Service (Performers Lists) (England) Regulations 2013. d) Capital Expenditure functions; In accordance with clauses 13.13 to 13.16, NHS England retains the Capital Expenditure Functions and will be responsible for taking decisions in relation to the Capital Expenditure Functions. e) section 7A functions under the NHS Act; In accordance with clauses 13.17 to 13.20, NHS England retains the Section 7A Functions and will be responsible for taking decisions in relation to the Section 7A Functions. In accordance with clauses 13.17 to 13.20, the CCG will provide certain management and/or administrative services to NHS England in relation to the Section 7A Functions. f) functions in relation to complaints management; NHS England retains its functions in relation to complaints management and will be responsible for taking decisions in relation to the management of complaints. Such complaints include (but are not limited to): 1.1. complaints about GP practices and individual named performers; 1.2. controlled drugs; and 1.3. whistleblowing in relation to a GP practice or individual performer. The CCG must immediately notify the Local NHS England Team of all complaints received by or notified to the CCG and must send to the Local NHS England Team copies of any relevant correspondence.

The CCG must co-operate fully with NHS England in relation to any complaint and any response to such complaint. In accordance with clauses 13.21 to 13.23, NHS England may ask the CCG to provide certain management and/or administrative services to NHS England (from a date to be notified by NHS England to the CCG) in relation to the handling and consideration of complaints. h) such other ancillary activities that are necessary in order to exercise the Reserved Functions; NHS England will carry out such other ancillary activities that are necessary in order for NHS England to exercise the Reserved Functions. NHS England will continue to comply with its obligations under the Controlled Drugs (Supervision of Management and Use) Regulations 2013. The CCG must assist NHS England s controlled drug accountable officer ( CDAO ) to carry out its functions under the Controlled Drugs (Supervision of Management and Use) Regulations 2013. The CCG must nominate a relevant senior individual within the CCG (the CCG CD Lead ) to liaise with and assist NHS England to carry out its functions under the Controlled Drugs (Supervision of Management and Use) Regulations 2013. The CCG CD Lead must, in relation to the Delegated Functions: 1. on request provide NHS England s CDAO with all reasonable assistance in any investigation involving primary medical care services; 2. report all complaints involving controlled drugs to NHS England s CDAO; 3. report all incidents or other concerns involving the safe use and management of controlled drugs to NHS England s CDAO; 4. analyse the controlled drug prescribing data available; and 5. on request supply (or ensure organisations from whom the CCG commissions services involving the regular use of controlled drugs supply) periodic self declaration and/or self-assessments to NHS England s CDAO.