Minutes of the Chester City Locality GP Network Meeting 9am 12pm on Thursday 13th March 2014 in Rooms A&B in the 1829 Building

Minutes of the Chester City Locality GP Network Meeting 9am 12pm on Thursday 13th March 2014 in Rooms A&B in the 1829 Building Present: Dr Claire Westmoreland (Chair), Dr Dave Nicholson, Dr Suzanne MacDonald, Dr Martin Allan, Dr Mike Lowrie, Dr Rowan Brookes, Dr Robin Davies, Dr Carole Holme, Dr Tim Saunders, Dr Tony Bland and Dr Robert Stewart. In Attendance: Alison Lee, Sarah Murray, Gary Howorth, Julia Bailey, Philip Smith, Trish Harrison, Carol McRae, Atiya Alam, Anna Coleman and Mandy Bates (minute taker). Apologies: Dr Laura Millard, Dr Steve Kaye, Dr Kate Bushell, Rob Nolan, Matthew Hebden, Hayley Pashley, Linda Bennett and Sue Dewhirst. All Practices Represented? There was no GP representative from Boughton Health Centre or City Walls Medical Centre. Key Points to Communicate to your Practice The project to provide diabetes care for housebound patients is progressing well. An initial viability assessment is being produced to obtain support for wider roll out of this scheme. Claire Westmoreland advised that it is unlikely that Park Medical Centre will receive retrospective funding for the storage of electronic records. The group felt that this penalised innovation and agreed to support Robert Stewart in appealing this decision. Alison Lee agreed to raise this with Huw Charles Jones. Post-Meeting Note: Huw Charles Jones has agreed that Park Medical Centre should receive retrospective funding for the digital storage of patient records. If the criteria for allocating the non-recurrent funding was strictly applied then this would not be funded, however it is recognised that this is a disincentive to innovation. Therefore, Huw has taken Chair s action and approved this payment The podiatry service is being redesigned to allow it to focus on patients with a high clinical need. From July, patients with a low clinical need will start to be discharged from the podiatry service. The next meeting will focus completely on the work of the vanguard practices. Therefore, the group agreed that the actions plans for the Access Local Enhanced Service could be ratified virtually beforehand via email. These plans will be discussed at the meeting in May. Laura Millard will no longer be attending this meeting. Claire Westmoreland thanked Laura Millard for her hard work and contribution to the group as both a member and chair. Carol McCrae is also leaving her current role and Claire Westmoreland thanked her for her contributions too. City Locality GP Network Minutes - 13 th March 2014 1

Summary of Actions Item Action Person 1 Raise the issue about retrospective funding of the digital storage of patient records storage with Huw Charles Jones. 4 Communicate information about strength and balance classes in the community in the weekly bulletin. Alison Lee Julie Jones 5 Clarify the different referral pathways for biomechanics. Stephen Price 5 Provide information about podiatry services available. Stephen Price 8 Resend the Prime Minister s Challenge Fund proposal to the group. Sarah Murray 8 The next meeting will focus on the vanguard scheme and Claire Westmoreland and Laura Millard will develop the agenda for this session. 8 Invite a representative from the community interest company to the next meeting. 8 Share the actions plans for the Access Local Enhanced Service so that these can be ratified. 9 Inform the 3 requestors of future agenda items of the decisions made. Claire W / Laura Millard /Mandy B Claire W / Mandy B Sarah M Mandy B 11 Investigate the issue with referral for dexa scans. Claire W City Locality GP Network Minutes - 13 th March 2014 2

Minutes No Item Action 1 Welcome and Apologies Claire Westmoreland welcomed the group to the meeting. Apologies were received from Dr Laura Millard, Dr Steve Kaye, Dr Kate Bushell, Rob Nolan, Matthew Hebden, Hayley Pashley, Linda Bennett and Sue Dewhirst Approval of the Minutes of the Last Meeting The minutes of the last meeting held on 13th February were approved by the group. Actions Update Paper 2 sent with the agenda provided an update on the actions from the last meeting. Claire Westmoreland added that an initial viability assessment had been completed for medical photographic equipment at dermatology intermediate service. Helen Ashcroft reported that this proposal has been approved and non-recurrent funding will be used for this. Conflicts of Interest: No conflicts of interest were declared. Chair s Update Claire Westmoreland provided an update in paper 3 and also gave the following information: There was a meeting last week about the project to provide diabetes care to housebound patients which is progressing well. A pilot phase is being conducted at City Walls Medical Centre. A template has been produced for the district nurses to use on the initial assessment and another template has been produced for the second visit to support care planning. An initial viability assessment is being produced to obtain support for wider roll out of this scheme. It is unlikely that Park Medical Centre will receive retrospective funding for the digital storage of patient records. The group felt that this penalised innovation and agreed to support Robert Stewart in appealing this decision. Alison Lee agreed to raise this with Huw Charles Jones. Alison L Post-Meeting Note: Huw Charles Jones has agreed that Park Medical Centre should receive retrospective funding for the digital storage of patient records. If the criteria for allocating the non-recurrent funding was strictly applied then this would not be funded, however it is recognised that this is a disincentive to innovation. Therefore, Huw has taken Chair s action and approved this payment. 2 Clinical Commissioning Group s Operational and Strategic Planning Helen Ashcroft (Head of Commissioning, Clinical Commissioning Group) explained that she would highlight the main points from paper 4 (Setting Out on the West Cheshire Way) and would like feedback on the plans. The plan reflects national and local perspectives and is aligned with other plans and local organisations. The plans are based on 5 programmes: starting well, being well, developing primary care, mental health and ageing well/end of life. In addition, the Clinical Commissioning Group will deliver against the urgent care agenda. Helen Ashcroft described the aims and projects in each programme. The group were asked for their opinions on the plan. In response to a question from Philip Smith, it was confirmed that only practices can record the number of appointments City Locality GP Network Minutes - 13 th March 2014 3

provided by primary care. Alison Lee advised that this could be investigated by practices as a vanguard practice initiative. Philip Smith commented that these data were available from Emis LV but not from Emisweb and Sarah Murray recommended raising this with Kerry Winsland. Robert Stewart remarked that it was important to empower patients to manage their health conditions. There was a discussion about the services available for families with multiple issues. Alison Lee advised that Cheshire West and Chester have a service with a multidisciplinary team to support such families. GPs can refer into the troubled families service. It was suggested that Alison Stathers-Tracey could be invited to a future membership council to discuss the service for vulnerable families including the health visiting service. The use of a risk profiling tool to identify vulnerable families was discussed. Vulnerable families could be considered as part of the vanguard practice initiative. In response to a question from Robin Davies, Sarah Murray explained that Education North West (part of NHS England) is undertaking some work around workforce modelling and the education of staff in primary care. Alison Lee added that there is also ongoing work around workforce planning to identify the number of doctors and nurses required across all care settings. Practices will receive an executive summary of this plan in the next few weeks. 3 Developing the Older Persons Frailty Pathway Dr Tim Webster (Consultant Physician in Stroke & Geriatric Medicine, Countess of Chester Hospital) and Amanda Lonsdale (Head of Partnerships, Clinical Commissioning Group) attended for this item. Tim explained that the aim was for him to verbally present his ideas for a community geriatrics service and obtain feedback from the group. Tim explained that 2 community geriatricians have recently been appointed and the service will have the following aims: Provide a prompt and responsive service: see the frail elderly at the front door and perform same-day diagnostics. Adopt a multidisciplinary approach and use a rapid response team to support patients at home to avoid a hospital admission. Provide a telephone advice service for GPs. Improve communication and relationships between primary and secondary care. Carole Holme said that this service seemed appropriate but stated that more resources are needed in the community to manage these patients as GPs have no spare capacity. Tim would like primary care and secondary care to work together in a more integrated way. It is anticipated that there will be a co-ordinator who will facilitate communication and will have information about the virtual ward of patients and the plans for follow-up. Robin Davies highlighted that patients may not be ambulatory and that supporting patients at home requires substantial resources including social care input. Amanda Lonsdale advised that social care is involved with developing this service. Tim Webster commented that changes in mobility or cognisance would be identified quickly to provide early access to services. Carole Holme remarked that families/neighbours and the voluntary sector can also support patients. Amanda Lonsdale advised that the Housing Trust is committed to supporting this service and it s recognised that community equipment (e.g., commodes) should be provided promptly. Carole Holme stated that the clinician who requests a test should communicate the results to the patient and this could be done by telephone as well as in person. City Locality GP Network Minutes - 13 th March 2014 4

There was a discussion about the geographical remit of the community geriatricians and the role of the frailty co-ordinator in terms of the new integrated teams. Amanda Lonsdale assured the group that the aim was to avoid complexity and duplication. Claire Westmoreland stated that it is not just about increasing numbers of GPs in primary care but that secondary care need to be brought into the community as part of the primary care team. Claire Westmoreland recommended that the community geriatricians shadow a GP in primary care to understand the level of support provided to patients in the community. Amanda Lonsdale explained that Dr Chatterjee reviewed 10 patients admitted to hospital to understand what could have been done differently which has provided useful intelligence. It was suggested that a similar exercise could be done with a practice as part of the vanguard initiative. Practices should contact Amanda Lonsdale if they are interested in undertaking this exercise (email: Amanda.lonsdale@nhsn.net). Tony Bland said that it is important that research is done before the service is developed to ensure it meets requirements from the offset. In terms of the next steps, the team are reviewing patient journeys, developing information about the service and setting up frailty clinics at Ellesmere Port Hospital, Tarporley Hospital and the Countess of Chester Hospital. It was suggested that the clinics should be in non-hospital settings. The frailty service will be launched in April. Tim reassured the group that he did not want to increase workloads in primary care and Amanda Lonsdale added that the use of technology (e.g., Skype) is being investigated. Amanda explained that the frailty service has been funded by the Countess of Chester Hospital. Carole Holme recommended providing an email advice service for less urgent cases and Tim Webster agreed to consider this. 4 Consultation on the Falls Pathway Julie Jones (Clinical Specialist Physiotherapist, Cheshire & Wirral Partnership), Anna Rees (Specialist Physiotherapist, Ellesmere Port Hospital) and Lesley Hilton (Joint Commissioning Project Manager, Clinical Commissioning Group) attended for this item. Anna explained how the new pathway differs from the one produced in 2009. The new pathway is expected to be launched in June and the general public will be informed so that they know what to expect from the service. Anna provided background information about the number of patients who fall locally and how this may increase because of the ageing population. Anna outlined the guidance from the National Institute for Health and Care Excellence (NICE) for patients aged over 65 years of age and the role of GPs. The Falls Risk Assessment Tool (FRAT) and the Timed Up and Go tools are used to triage patients but clinical judgement is a critical part of the assessment too. The care coordinator in the integrated teams will manage the referrals. In response to a question from Alison Lee, Julie Jones replied that the aim is to increase the number of appropriate referrals to the service. There was a discussion about selfreferral and the management of patients in Accident & Emergency. Tim Saunders advised that the assessment and referral process should not be too onerous for GPs. Julie Jones clarified that there isn t a formal falls service, rather she is a community physiotherapist with an interest in falls. Carole Holme suggested that Julie Jones should focus on patients who have fallen previously and that organisations like Age Concern could support patients who are wobbly but have not yet fallen. Julie Jones acknowledged that it may be necessary to refine the referral criteria. Lesley Hilton interjected to explain that the aim was to simplify the current pathway but that the brief had expanded to prevention as well as the treatment of falls. Julie Jones clarified that there isn t a leaflet about strength and balance exercises that City Locality GP Network Minutes - 13 th March 2014 5

can be given to patients as patients need support in-person. There was a discussion about strength and balance classes in the community and Julie Jones will provide more information so that this can be included in the weekly bulletin. Julie Jones 5 Consultation on Redesign of Podiatry Service Stephen Price (Podiatry Team Leader) and John Hilton (Operational Development Manager) attended for this item. Stephen stated that the redesign aims to allow the service to focus on patients with a high clinical need and optimise the use of resources. From July, patients with a low clinical need will start to be discharged from the podiatry service and the process for discharge was explained. Stephen explained that patients scoring 70 or above in an assessment have a high clinical need. Currently the service has 3,000 patients with a low clinical need and 2,000 patients with a high clinical need. Patients with conditions such as diabetes and peripheral vascular disease are classed as having a high clinical need. There will be an option for some patients (e.g., diabetics) to self-refer themselves back into the podiatry service if required and they can attend the drop-in service. Patients newly diagnosed with diabetes can attend for a one-off advice session. There was a general discussion about the services available and Stephen Price clarified that children remain with the biomechanical service until they stop growing. Stephen agreed to clarify the different referral pathways for biomechanics. Stephen Price Carole Holme highlighted that GPs need to understand what can be referred and advised that if GPs refer a patient then patient expectations will need to be managed carefully Claire Westmoreland highlighted that GPs need to be informed about the alternative services available as patients are likely to ask them for help. Stephen Price agreed to provide a range of information about what services are available with the minutes. Stephen Price advised that the consultation process will involve patient groups. Stephen Price 6 Local Medical Committee Update No update was provided as Steve Kaye was absent. 7 Clinical Commissioning Group Update Vanguard Practices Sarah Murray (Programme Lead Primary Care Development and Membership Engagement) reported that 31 practices are part of the vanguard scheme. The proposal for the Prime Minister s Challenge Fund was submitted on the 14 th February and Malpas is the lead practice for the bid so they may be informed of the decision first. The vanguard practice scheme will be funded by the Clinical Commissioning Group even if the bid is unsuccessful. Therefore, progress needs to continue and leads for each cluster need to be identified. There is one cluster for the city locality and practices will need to decide on their approach including what they wish to focus on, producing project plans and agreeing the governance arrangements. It may be difficult to organise a meeting that all practices can attend to discuss this. Dr Laura Millard is the lead GP and the lead practice manager is yet to be confirmed. Sarah clarified that the Clinical Commissioning Group is funding backfill for the lead GP from each practice for 1 session per week and for the lead GP from each cluster to be funded for 2 sessions per week at the current rates. Sarah Murray agreed to resend the Prime Minister s Challenge Fund proposal to the group. Alison Lee emphasised the need to proceed quickly and suggested that the next City GP Sarah M Claire W/ City Locality GP Network Minutes - 13 th March 2014 6

Locality Network meeting in April could focus completely on the vanguard scheme. The group agreed with this suggestion and Claire Westmoreland and Laura Millard will develop the agenda for this session. Tony Bland requested that a representative from the community interest company also attend the next meeting to provide information and it was agreed that this would be useful. Laura M/ Mandy B Claire W/ Mandy B Therefore, the group agreed that the actions plans for the Access Local Enhanced Service could be ratified virtually beforehand via email. These plans will be discussed at the meeting in May to share best practice. Sarah M Membership Council: Future topics Sarah Murray reported that positive feedback was received about the last membership council where mental health services were discussed. This format will be used for the next meeting and Sarah asked for topic suggestions. The rural network has suggested health visiting, school nursing and vulnerable families. The Ellesmere Port and Neston network has suggested hospital discharge letters but as Paula Wedd is currently undertaking some work on this matter then it would be useful to have this topic at the subsequent meeting in September 2014. The group will feedback ideas to Sarah Murray. Tim Saunders suggested focusing on one of the priorities from the Clinical Commissioning Group s plan, such as starting well which would encompass the suggestion from the rural network too. Julia Bailey suggested focusing on the integrated teams. 8 Items for Future Meetings Paediatric Hospital at Home: The group approved this request. Emis Web Data Sharing: The group declined this request because it is training. It was suggested that it would be useful for Kerry Winsland to produce a podcast about the training for practice staff. Sarah Murray advised that the Information and Communication Technology (ICT) Operational Group could also provide an update at the practice managers meeting. It was also suggested that the minutes and updates from the Information and Communication Technology (ICT) Operational Group should be shared more widely (e.g., via the website) and Sarah Murray will look into this. Mandy B Community pain service: The group declined this request but suggested that the information could be communicated by the relevant clinical programme link instead as well as the weekly bulletin. 9 Clinical Programme Links Update Urgent Care Martin Allan recently attended the Winter Review meeting and gave the following update: The acute visiting service run by the Out Of Hours service has worked well. A total of 179 visits were made and only 13 patients were taken to Accident and Emergency. Thus, this has reduced the number of attendances at Accident and Emergency. In response to a question from Tony Bland, Alison Lee replied that a cost-benefit analysis of this service will be undertaken. Carole Holme suggested that if GPs could refer into this service then it may reduce demand at the Countess of Chester Hospital. Martin Allan will feedback these comments. Areas that could be improved were also identified such as the pathway between Out Of Hours and Accident and Emergency. There is ongoing work to understand the demand at the Countess of Chester Hospital. This may be related to increasing numbers of complex patients as well as patients from North Wales. It is anticipated that robust plans for next Winter will be completed by July. City Locality GP Network Minutes - 13 th March 2014 7

Information Technology John Glover (Director of Information Management and Technology, Countess of Chester Hospital) and Jackie Millar (project manager) attended to present the West Cheshire Integrated Health and Social Care Record. It is expected that this project will improve integration, self-care and support people in the community. The system will be live from the 1st April. This project is focused on supporting direct patient care and expert advice has been obtained around governance issues. The project board has met with the Local Medical Committee. Jackie Millar, project manager, will engage with practices to ensure they are comfortable signing up to the sharing agreements. 10 Any Other Business Claire Westmoreland reported that Laura Millard will no longer be attending this meeting. Claire thanked Laura for her hard work and contribution to the group as both a member and former chair. Carol McCrae is also leaving her current role and Claire Westmoreland thanked her for her contributions too. Dexa scans: Martin Allan reported that an osteoporosis nurse at the Countess of Chester Hospital is asking GPs to refer patients for dexa scans and it was queried if the hospital could do this instead. Claire Westmoreland agreed to look in to this matter. Claire W Format of the papers: Following a change in the way the agenda and papers were provided this month, Mandy asked the group if they preferred for the papers to be combined into a single document or provided separately. There was a mixed response to this change but approximately 60% of people expressed a preference for individual documents. 11 Close Next Meeting: Thursday 10th April 2014 in the 1829 Building City Locality GP Network Minutes - 13 th March 2014 8

Minutes of the Chester City Locality GP Network Meeting 9am 12pm on Thursday 10th April 2014 in Rooms A&B in the 1829 Building Present: Dr Claire Westmoreland (Chair), Dr Steve Kaye, Dr Ian Minshall, Dr Dave Nicholson, Dr Suzanne MacDonald, Dr Martin Allan, Dr Mike Lowrie, Dr David Inchley, Dr Carole Holme, Dr Tim Saunders, Dr Tony Bland, Dr Robert Stewart and Dr Raj Avula In Attendance: Huw Charles Jones, Rob Nolan, Matt Powls, Dr Laura Millard, Hayley Pashley, Linda Bennett, Sue Dewhirst, Trish Harrison, Sheila Hardy and Mandy Bates (minute taker). Apologies: Dr Robin Davies, Dr Kate Bushell, Dr Rowan Brookes, Sarah Murray, Philip Smith, Julia Bailey, Gary Howorth, Atiya Alam-Jones and Helen Whyte. All Practices Represented? Yes Key Points to Communicate to your Practice Matthew Hebden (practice manager) has left City Walls Medical Centre. Jan Huxley is currently the acting practice manager. GP attendance at child protection conferences has decreased. The number of reports provided and GP attendance is likely to be an indicator on the quality dashboard. This matter will be discussed at the Quality meeting and Claire asked the group to consider if they or a colleague would take on the role of quality lead for the City locality. Vanguard Workshop Claire Westmoreland explained that the workshop would comprise 2 sections. The first half will focus on how practices want to be involved and potential projects and the second half will involve a discussion about the community interest company. Matt Powls (Interim Project Manager Cheshire Primary Care Provider) is providing management support to the community interest company. Matt stated that it s important to agree the purpose of the community interest company so results can be delivered quickly. The group would like to explore the following suggestions: Social prescribing and self-care. Human resources and other back office functions. Delivery of the service to residential homes and nursing homes. Dr Jonathan Gregson (GP Helsby and Elton Practice and Chair of the Federation) advised that the organisation is now being referred to as a federation to reflect that it is a co-operative of practices although it is still a social enterprise (community interest company). The Annual General Meeting will be delayed until 7.30pm on the 14 th May 2014 at Cheshire View. There was a discussion about the role of the GP and practice manager leads from each practice and clarification about this will be sent to the group. A lead GP and practice manager are still required to support the vanguard scheme for the City locality cluster. These posts are both funded for 2 sessions per week. Please let Claire know if you are interested in either of these roles by 14 th April. City Locality GP Network Minutes - 10 th April 2014 1

Summary of Actions Item Action Person 1 Consider if you or a colleague would be interested in taking on the role of quality lead for the City locality. 2 Highlight the issue of GPs being assigned the role of houseman in the community. 3 There was a discussion about the role of the GP and practice manager leads from each practice in the vanguard project and clarification about this will be sent to the group. 3 Claire Westmoreland reminded the group that a lead GP and practice manager are still required to support the vanguard scheme for the City locality cluster. These posts are both funded for 2 sessions per week. Please let Claire know if you are interested in either of these roles by Monday 14 th April All GPs Claire W Mandy B All practices 4 Obtain an update on the Med3 letters issue. Mandy B 4 Tony Bland requested that the hospital should be asked to send the Do Not Attempt Cardio Pulmonary Resuscitation (DNA CPR) form when patients are discharged too and Claire Westmoreland agreed to discuss this with Dr Andy McAlavey 4 Ask the Area Team how practices should sign up to the directed enhanced service. 4 It was highlighted that some practices cannot grant access to records to other healthcare professionals. Mandy agreed to investigate this matter. Claire W Mandy B Mandy B City Locality GP Network Minutes - 10 th April 2014 2

Minutes No Item Action 1 Welcome and Apologies Claire Westmoreland welcomed the group to the meeting. Apologies were received from Dr Robin Davies, Dr Kate Bushell, Dr Rowan Brookes, Sarah Murray, Philip Smith, Julia Bailey, Gary Howorth, Atiya Alam-Jones and Helen Whyte. Claire advised that Matthew Hebden (practice manager) has left City Walls Medical Centre. Jan Huxley is currently the acting practice manager and she will attend the Practice Manager s meeting from May. Claire explained that Dr Laura Millard was attending in her capacity as provisional GP cluster lead for vanguard. Approval of the Minutes of the Last Meeting The minutes of the last meeting held on the 13th March were approved by the group. Actions Update Paper 2 sent with the agenda provided an update on the actions from the last meeting. Claire highlighted that Park Medical Centre has been awarded retrospective funding for the digital storage of electronic records. Robert Stewart thanked the group for their support. Conflicts of Interest Dr Raj Avula stated that he is an advisor to Cheshire and Wirral Partnership Foundation Trust. Chair s Update Claire Westmoreland provided an update in paper 3. Claire also highlighted that GP attendance at child protection conferences has decreased and emphasised the importance of these meetings. The number of reports provided and GP attendance is likely to be an indicator on the quality dashboard. This will be discussed at the Quality meeting and Claire asked the group to reconsider if they or a colleague would be interested in taking on the role of quality lead for the City locality. All GPs 2 Workshop: Vanguard Practices (part 1) Claire Westmoreland explained that the workshop would comprise 2 sections. The first half will focus on how practices want to be involved and potential projects and the second half will involve a discussion about the community interest company. Claire gave a Powerpoint presentation which covered the vision and principles in West Cheshire, the blueprint written by Huw Charles Jones, case studies and the application for the Prime Minister s Challenge fund. Laura Millard is the provisional GP lead for the City cluster and the role of cluster practice manager lead is currently vacant. Huw Charles Jones explained that practices need to work together to transform to respond to the challenges faced. Practices also need to work collaboratively with other providers including the voluntary sector. A community interest company is a potential vehicle for implementing changes. Matt Powls (Interim Project Manager Cheshire Primary Care Provider) is providing management support to the community interest company. Matt stated that it s important to agree the purpose of the community interest company in terms of relieving the pressure on primary care so that results can be delivered quickly. The vanguard scheme provides an ideal situation for the community interest company to progress, City Locality GP Network Minutes - 10 th April 2014 3

deliver results and establish a good reputation. Ian Minshall asked how the community interest company could relieve pressure on primary care. Steve Kaye remarked that the community interest company could be a vehicle for moving funding streams from secondary care to primary care. Laura Millard commented that it could encourage self care among patients. Carole Holme explained that social prescribing is a means of enabling primary care to refer patients to non-clinical services (e.g., Men in Sheds, coffee mornings, buddying, walking clubs, debt advice) in the voluntary sector that can provide emotional and social support and reduce the patient s need for primary care services. Carole suggested that primary care staff could recommend a service to a patient and then arrange for the relevant organisation to contact the patient. Suzanne Macdonald felt that this was a good idea and said that the community interest company could act as a single point of access and signpost to the wide range of organisations. Carole added that there are a lot of third sector organisations offering professional and impressive services that can help people. Claire Westmoreland stated that the community interest company could match patient demand to the local supply of health and community building premises. Suzanne Macdonald asked how this would be funded and it was suggested that the Clinical Commissioning Group could commission this service from the community interest company. Tim Saunders asked if there was evidence that this type of service could reduce demand for primary care. Matt Powls is aware that a buddying service for people with diabetes has improved self management and reduced demand for acute services. Huw added that a tool from NHS England indicates that West Cheshire would benefit from encouraging self care. Carole Holme commented that there is a wealth of evidence about how these schemes can reduce the demand for primary care. Huw reiterated that making a number of small changes, like introducing this service, will have a cumulative and beneficial effect but it will take time and everyone needs to participate to address this challenge. Steve Kaye remarked that 7 day working would reduce the continuity of care. Huw acknowledged that the local Out of Hours service is very good and it is important to build on these strengths. Tony Bland commented that the GP would still be the hub of the patient s care if the relationship changes from being a provider of care to an integrated manager of care and ensuring continuity. The options for changing the traditional 10 minute consultation with a GP and the use of email and Skype were considered. Claire Westmoreland emphasised that it was for members to decide on the format and function of their service. There was a discussion about why demand for GP appointments has increased and how other staff in the primary care team can support patients. Dave Nicholson explained the importance of improving the outlet to influence patient demand. Dave suggested that hospital discharge could be improved if the patient had an interview with the doctor who explained the condition, what to expect and the next steps. This would reduce the need for patients to visit the GP multiple times for information. Alternatively, this information could be provided by a relevant voluntary organisation (e.g., a stroke charity). Suzanne Macdonald commented that it would be better for secondary care to obtain and explain the results of their tests to the patients, rather than asking GPs to do it, assigning them the role of houseman in the community. Several members agreed that this is an issue and Steve Kaye advised that the Local Medical Committee is pursuing this matter. This would necessitate a change in culture and Robert Stewart felt that this should be City Locality GP Network Minutes - 10 th April 2014 4

part of the induction training for secondary care doctors. Claire Westmoreland agreed to take forward this issue. Claire W In response to a question from Claire Westmoreland about the changes the group would like to make, Ian Minshall described a project in which he manages some patients with epilepsy. Ian proposed applying this model to other conditions and training GPs and nurses to develop specialist interests. There was a discussion about how the workload of GPs could change in the next 5 years and it was acknowledged that this evolves constantly although the traditional format of surgeries and visits remains. It was felt that 30 minute appointments with complex frail elderly patients and a multidisciplinary team would be useful. The need to manage capacity and demand was reiterated. The issue of decreased funding in primary care was highlighted but it was emphasised that primary care and secondary care need to work together as if they have a shared budget with which to deliver care. Rob Nolan explained that the community interest company could ensure funding follows the patient. Tim Saunders felt that the crux of the issue is that primary care can t do things differently without additional resource. Rob Nolan clarified that there is significant funding available to support the vanguard scheme. Carole Holme added that secondary care has benefitted from increasing resources. Laura Millard commented that it seemed there were barriers to progress but the group felt that there was enthusiasm for projects like social prescribing that could deliver results quickly. Laura assured the group that projects would be piloted before roll-out. In response to a question from Martin Allan, Claire Westmoreland advised that there is information about the types of services other community interest companies (e.g., Vitality) have developed. Dave Nicholson commented that establishing St Werburgh s practice had benefited both practices and the homeless patients that it serves and this model could be applied elsewhere. For example, 1 practice could manage all residential homes and nursing homes. The practice could create a multi-disciplinary team (including occupational therapists and physiotherapists) which would proactively improve the overall quality of life of the patients (e.g., all issues affecting a person who has experienced a stroke), rather than just reactively managing the condition that requires attention (e.g., chest infection in a stroke patient). This could reduce the number of hospital admissions and prescriptions required as well as improving the service. This would reduce the number of visits that other practices would need to do. The group felt that the impact of taking this local enhanced service from practices should be considered carefully. Laura Millard suggested that practices could share back-office functions like human resources and finance. Hayley Pashley agreed that outsourcing the human resource function would save a lot of time. Matt Powls added that primary care transformation is not just about clinical services. A vehicle, like the community interest company, could provide a high quality service that relieves the pressure on primary care and saves money too. Claire Westmoreland summarised that the group would like to explore the following: 1. Social prescribing and self-care. 2. Human resources and other back office functions. 3. Delivery of services to residential homes and nursing homes. Tim Saunders added that the community interest company could develop a service to provide practices with advanced nurse practitioners in order to relieve the pressure on GPs. A paramedic/expanded acute visiting service and an expanded community matron service (with enhanced levels of care) could also be beneficial. City Locality GP Network Minutes - 10 th April 2014 5

3 Workshop: Vanguard Practices (part 2) Dr Jonathan Gregson (GP Helsby and Elton Practice and Chair of the Federation) advised that the organisation is now being referred to as a federation to reflect that it is a co-operative of practices although it is still a social enterprise (community interest company). At the forthcoming Annual General Meeting members will be asked to vote in a new board including chair, chief operating office, governance/quality officer and secretary/finance officer. They will also be asked to ratify the post of medical director and if ratified then an interim appointment will be made whilst the post is formally recruited to. Members are invited to apply for these roles and there will be a vote at the Annual General Meeting. Job descriptions and application details will be circulated shortly. Practices were asked to discuss their voting preferences prior to attendance at the Annual General Meeting. Jonathan confirmed that there will be 1 vote per practice for each role. The Annual General Meeting was due to take place on the 30 th April, however, the group felt this provided insufficient time for members to apply for the roles and for practices to consider the candidates beforehand. Therefore, it has been agreed that the Annual General Meeting will be delayed until7.30pm on the 14 th May 2014 at Cheshire View. This change will be communicated to members immediately. Jonathan explained that there have been a number of developments in recent weeks which have affected the direction of the community interest company including the provision of management support from Matt Powls. Currently, 34 practices are members and the federation has the following priorities: 1. To support the transformation of primary care. 2. To support practices (e.g., with human resource and training needs). 3. To protect member practices. Matt Powls emphasised that the federation will listen to the member practices. Jonathan advised that the federation will be sending practices a questionnaire to ask about premises. Jonathan explained that the federation is looking at the service for frail elderly patients and the use of step up/step down beds in the community. He clarified that the federation would need to work flexibly. On some projects the federation would be the lead organisation which subcontracts to other providers whereas on some projects the federation would work in partnership with other providers. It is anticipated that the federation will provide economies of scale whilst retaining the local identities of the practice clusters. The working group comprises Dr Jonathan Gregson, Dr Branwen Martin, Dr Chris Ritchieson, Dr Annabel Jones, Dr Tahir Awan, Gary Howorth, Brian Yorke and Trish Harrison. There was a discussion about the role of the GP and practice manager leads from each practice in the vanguard project and clarification about this will be sent to the group. Post Meeting Note: Please find below clarification about the time that will be funded for the GP and practice manager leads at practice and cluster level. Role Required Lead GP from each practice Lead Practice Manager from each practice Lead GP/link for each cluster Lead Practice Manager/link for each cluster Time commitment 1 session a week 1 session a week 1 day a week 1 day a week Mandy B City Locality GP Network Minutes - 10 th April 2014 6

Claire Westmoreland reminded the group that a lead GP and practice manager are still required to support the vanguard scheme for the City locality cluster. These posts are both funded for 2 sessions per week. Laura Millard is provisional GP lead for the cluster at present. Please let Claire know if you are interested in either of these roles by Monday 14 th April. All practices Matt Powls clarified that the federation could support a range of projects such as employing advanced nurse practitioners that can be seconded into practices and employing paramedics for an acute visiting service. Huw thanked Jonathan on behalf of the Clinical Commissioning Group for his hard work on this project. 4 Any Other Business Electrocardiograms (ECGs) for housebound patients Claire Westmoreland raised this matter on behalf of Dr Robin Davies who reported that district nurses have stopped doing community ECGs because they need ongoing training. This may cause a problem for housebound patients. The group reported that the district nurses were not performing electrocardiograms for many of their practices either. Claire Westmoreland is working on a project to improve the care of housebound patients. Issues with district nurses certifying death were raised and Claire advised that there is variation in the way district nurses are interpreting the guidance which is leading to variations in service. The group felt that Cheshire and Wirral Partnership Foundation Trust should inform practices directly about policy changes to avoid misinterpretation and Claire advised that there is work ongoing around this. Med3 Letters A draft communication about Med3 letters has been prepared by the Ellesmere Port and Neston Locality GP Network and this was sent to group as an additional paper. The Ellesmere Port and Neston Locality GP network has asked if the City Locality GP Network wish for the letter sent on their behalf too. Claire Westmoreland advised that there have been evolving discussions around this which she agreed to follow up with Dr Andy McAlavey. If following that, the letter still needs to be sent, then the group agreed that the letter should be revised. The group requested feedback on this next month. Mandy B Post Meeting Note: Claire Westmoreland has discussed this matter with Dr Andy McAlavey and it has been agreed that the letter should not be sent as the process should be for current negotiations to continue through Dr McAlavey. Tony Bland requested that the hospital should be asked to send the Do Not Attempt Cardio Pulmonary Resuscitation (DNA CPR) form when patients are discharged too and Claire Westmoreland agreed to discuss this with Dr Andy McAlavey. Claire W Directed Enhanced Service for Avoiding Unplanned Admissions Carole Holme explained that the supporting guidance about this service is useful and that funding previously associated with the Quality and Outcomes Framework has been transferred to it. It is worth approximately 20,000 per practice and there is some overlap with schemes such as named GPs for patients aged over 75 years, the West Cheshire Way and the Vanguard scheme. Suzanne Macdonald felt that practices had to work harder to earn this funding although Carole advised that it wasn t necessary for GPs to complete all of the documentation. City Locality GP Network Minutes - 10 th April 2014 7

Mandy will ask the Area Team how practices should sign up to this directed enhanced service. Mandy B Epilepsy The group agreed that Ian Minshall could audit the epilepsy patients from their practices that he has managed over the past 9 years. Ian will contact practice managers to obtain access to the information required. Ian will feedback the results at a future meeting. It was highlighted that some practices cannot grant access to records to other healthcare professionals. Mandy agreed to investigate this matter. Mandy B 5 Close Next Meeting: Thursday 8th May 2014 in the 1829 Building City Locality GP Network Minutes - 10 th April 2014 8

Rural Locality Meeting Minutes of the meeting held on Tuesday 11 th March 2014 Cheshire View, Plough Lane, Christleton 2.00pm 5.00pm Key Points to Communicate to your Practice Phase one of the Community Ultrasound project will start at Frodsham Princeway on 26th March. Posters advertising the service will be sent to practices shortly. The application for the Prime Minister s Fund was submitted on 14 February, and the outcome would be announced at the end of March 2014. The Vanguard Programme will proceed regardless of the outcome, funded by the clinical commissioning group. The new Pain Pathway is to be in place from June 2014. Action List RN178 RN179 RN180 RN181 RN182 RN183 RN184 RN185 RN186 RN187 RN188 Action WCCCG to create a poster advertising the community ultrasound project. Investigate possibility of formal launch event for community ultrasound project. Colin to review referrals with Podiatry team, as patients from Bunbury were not currently accepted for referral for Podiatry. Podiatry to review rural requirements and Stephen Price to report back to the group with suggested amendments to the proposed podiatry redesign. Investigate if GP practices can charge to do nail cutting service etc. All to decide how they want to proceed with the Vanguard Project and who will lead from the clusters. Group to respond to Sarah Murray/Colin McGuffie by Friday 21 March 2014. Colin to progress on agreed topic for membership council select committee meeting. Lynne Keenaghan to take away feedback from meeting for action. Colin to investigate complex imaging as a possible topic for RHD. Brian Yorke to e-mail Helen McCairn with information about challenges with travellers (e.g. no immunisations). Helen to investigate once information received. DVT Referrals to Leighton Item to be added to agenda for next meeting. Alistair to e-mail Colin with information. Owner Colin McGuffie Colin McGuffie (with assistance from local GP) Colin McGuffie & CWP Stephen Price, CWP Colin McGuffie All practices Colin McGuffie Lynne Keenaghan, Public Health Colin McGuffie Brian Yorke/Helen McCairn Colin McGuffie/Alistair Adey Rural GP Network Minutes 11/03/2014 1

Present: Steve Pomfret, Brian Yorke, Louise Davies, Jonathan Gregson, Trevor Ferrigno, Helen Black, Andy Campbell, Paul Smith, Alistair Adey, Lynn Suckley, Linda Duffin, Philip Milner, Sam Jeffrey, Debbie Bailey, Debbie Taylor and Christine Kenyon, Jim Hinds. In attendance: Sarah Murray, Nicola Daniels Alison Lee. Practices not clinically represented: n/a NO. ITEM ACTION 1. WELCOME AND INTRODUCTIONS Steve Pomfret opened the meeting and welcomed the group. 2. APOLOGIES Apologies were received from Colin McGuffie, Rajesh Rajan and Chris Ashbrook 3. DECLARATION OF INTEREST Andy Campbell declared an interest in item 4 - the Community Ultrasound Project. Andy is a trustee of Tarporley Memorial Hospital and is working to develop ultrasound capacity at the hospital. Helen Black also declared an interest as Andy s spouse. 4. COMMUNITY ULTRASOUND UPDATE Louise Davies updated the group on the latest progress towards implementing the Community Ultrasound Project. The main points of the update were: Phase one of the project was due to commence in Frodsham by 26 March. Louise reported that she would send out flow charts to all practices of dates for the roll out of the project. Louise reported that Tarporley would begin the process on 1 May and Malpas on 1 June. Steve Pomfret suggested that it would be beneficial for all practices to advise patients when making the referral, that if the ultrasound could not be carried out locally that it would be done in Chester. Louise also reported that a press release would go out to local media regarding the project and that she would liaise with the parish councils to inform rural patients. The group agreed that it would be beneficial for the clinical commissioning group to create a poster advertising the project. ACTION - Colin McGuffie to investigate. CM It was also agreed that a formal launch event would be useful. Rural GP Network Minutes 11/03/2014 2

NO. ITEM ACTION ACTION Colin McGuffie (with assistance from local GP) CM Steve asked if there were questions from the countess to go with the form to pass to patients for information. All agreed this would be beneficial. Paul Smith advising that there would be training held during this week. 5. PROPOSED PODIATRY REDESIGN Stephen Price and Jean Pace (CWP) presented on the proposed redesign of the podiatry service. ReadOnlyCopy of Pod redesign present Points raised following the presentation were: Lynne Suckley requested clarification on the new patient scoring: 0-60 - not eligible 70-90 - high clinical need, moderate risk above 90 - high clinical need, high risk and Stephen Price (CWP) advised that scores went up in 10. Alistair Adey asked what type of patients, were classed as low level risk. Stephen advised that this would be elderly patients, arthritic patients, patients with corns etc. Stephen also advised that there were domiciliary drop in clinics running on various days, across the rural areas. Philip Milner asked how the service and skill-mix would be redesigned. Stephen Price explained that there would be a restructure, reassessing band 6 roles, diagnostic clinics, more dopplers and equipment would be purchased, enabling early referrals, and that more assistants would be hired to man emergency clinics. Stephen also confirmed that current low risk/patients no longer eligible would be discharged safely. Steve Pomfret asked how patient expectation would be met and if there was engagement with private providers, to give patients the information they needed if they wished to pay for treatment. Stephen Price confirmed that the Healthy Living Centres were a mobile unit and could travel to rural locations and that there would be information for patients containing lists of all registered practitioners. It was agreed that it would be beneficial if a signposting booklet were developed and also that the new referral form should provide clear criteria for referral eligibility. Lynne Suckley asked what GPs would be able to do for patients who were no longer eligible for referral. Stephen Price reported that the Healthy Living Centres would provide services at a cost of between 10-25. Helen Black advised that she could not currently refer patients as had been advised that Bunbury was not classed as West Cheshire. ACTION Colin McGuffie to review with Podiatry. Alison Lee asked for confirmation of agreed timeframe for the changes. Stephen Price reported that the proposal had been to scrutiny committee, and was being CM Rural GP Network Minutes 11/03/2014 3

NO. ITEM ACTION reviewed by stakeholders and should be complete by July 2014 with an expected 12 months process to review current patient needs and safe discharge of low risk patients. Philip Milner suggested that the rural requirements needed to be reviewed and requested that Stephen Price report back to the group with suggested amendments to the proposed redesign. Stephen Price (CWP) Steve Pomfret also suggested that it be investigated if GP practices can charge to do nail cutting service etc. ACTION Colin McGuffie to investigate. CM 6. VANGUARD PRACTICES Sarah Murray provided an update to the group on progress: Application for funding for Prime Minister s Fund had been submitted on 4 February, and the outcome would be decided in March 2014. Sarah reported that the funding from the Prime Minister s Fund was for 1.75 million and that the clinical commissioning group had allocated a further 1 million for the project. The money from the clinical commissioning group is to be used for the project even if the bid for funding is unsuccessful. Sarah confirmed that 31 practices in total had signed up to the project. Helen Black asked if it was possible to sign up to project at a later date. Sarah advised that if we were unsuccessful in obtaining the Prime Minister funding then yes, however she did not yet know the rules around the funding. Sarah also reported that governance structure for the development of the Primary Care Programme were being developed and are due to go live on 01 April 2014. Sarah asked the group how they wanted to proceed with the Vanguard Project and who will lead from the clusters. Sarah asked the group to consider the best way forward and get back to her by Friday 21 March 2014. It was agreed by all that they needed to discuss how to engage and the best way forward. ACTION all due 21/03/2014 All practices 7. QUALITY Jonathan Gregson gave an update on Quality data. He informed the group that the following areas were progressing: - Cancer - COPD Jonathan reported that the referral activity for Q1 was due out on 31 March 2014 and was due to be reviewed by the end of April 2014 for the returns to be submitted. Rural GP Network Minutes 11/03/2014 4

NO. ITEM ACTION He advised that the update on COPD had not been received. ACTION Sarah Murray to check with Sarah Vickers. SM 8. HEALTH VISITOR SERVICES The group discussed the current issues surrounding the above service. The main points were: There has been very little communication with GPs or patients. There has been no consultation regarding the changes to the service. Cross boundary issues were arising. Although patients had been transferred out onto different health visitor lists, GPs had not received a revised list to advise who was transferring in to their area. Safeguarding concerns. All agreed that the best way forward at present, would be to contact the practice health visitor with any concerns, who would then communicate with the relevant health visitor for the child. There is a duty of care to patients, which needs to be addressed. All agreed that clarity was needed on how CWP were communicating and that the commissioner needed to be advised of the concerns raised. ACTION - Colin McGuffie to investigate with CWP. Colin Mc 9. FUTURE MEMBERSHIP COUNCIL SELECT COMMITTEE TOPICS Sarah Murray reported that the reviews received from the last meeting were very positive and that the format would be used going forward. Sarah asked the group what topics they would like to discuss at the meetings, and the following topics were listed: - Health visitors and school nursing services - Cancer - Orthopaedics - Respiratory - Discharge from Hospitals - AMAMS - Social Care - Child Immunisations on line Rural GP Network Minutes 11/03/2014 5

NO. ITEM ACTION It was agreed that the topic for the next meeting would be Starting Well to focus on health visiting and school nursing. The group agreed that they would like representation from as many of the following as possible to be present at the meeting: - School Nurse - Local Authority - Public Health As well as: - Sheena Kiminski - Val Surgess - Avril Divani, Director of Nursing - Director of Children s Services ACTION Colin to progress 10. NHS HEALTH CHECKS CM Lynne Keenaghan (Public Health) presented on HS Health Checks, with the following points arising: Lynne to send the data/evidence to the group, detailing the outcomes of the west Cheshire health checks against other areas, including breakdown of performance and cost envelope. LK (Public Health) Lynne to send information about the higher achieving areas to the group for information. It was stated by the group that they felt the current process was restrictive and that it would be beneficial to be able to invite people for a health check that were not on the current lists provided. The group asked Lynne if it was possible for them to be paid for outreach checks. Lynne confirmed that support for hard reaching areas will be put in place. It was reported that there were cross border issues due to the council being responsible for resident populations. It was suggested that cross boundary funding should be received from local authority (reciprocal agreement).action Lynne Keenaghan to take feedback away for action. The group also enquired about other changes within Public Health and Lynne Lynne Keenagha Rural GP Network Minutes 11/03/2014 6

NO. ITEM ACTION reported that with regards to Sexual Health that the Local Authority has responsibility but does not hold contracts. Lynne reported that Public Health will notify GPs of contracts and payment changes this week. The group confirmed that they had not received notice of changes to payments. ACTION Lynne Keenaghan to investigate. Lynne also reported that the go live date for the new Smoking Cessation Service was planned for 1 December 2014. n Lynne Keenagha n 11. COMMISSIONING LEAD UPDATES FROM CLINICAL LEADS Key issues discussed were: Pain pathways to be implemented in June DVT LES should this be managed in primary care? The views from the group were as follows: - It is not unsafe to screen patients and refer to clinic for scan where necessary - the new service is more patient centred - previous queries raised have not yet been answered (CM to investigate) Complex Imaging - the group discussed the growth in CT/MRI scans. It was agreed that better interrogation of information was needed and pathways needed to be developed. It was also agreed that it would be beneficial to improve dialog with radiologists regarding the need for scans. The group agreed that this would be a good topic for a RHD. ACTION Colin McGuffie to investigate for RHD topic. CM 12. RHEUMATOLOGY UPDATE This update was to be presented by Rajesh Rajan and as Rajesh was unable to attend the meeting, this item will be carried forward to the next meeting. 13. CLINICAL COMMISSIONING GROUP: OPERATIONAL AND STRATEGIC PLANNING UPDATE THE NETWORKS ON THE TWO YEAR OPERATIONAL AND FIVE YEAR STRATEGIC PLANS Helen McCairn provided an update on the above and reported that the plan would be submitted on 04 April 2014. Helen reported that the focus was: Starting Well Being Well Developing Primary Care Mental Health Ageing Well/End of Life Rural GP Network Minutes 11/03/2014 7

NO. ITEM ACTION Which fell into the following areas: Primary Care - Education training & development - How the over 75s care is managed - Structured education programmes and training - Ambulatory care: reducing hospital admissions - Young children & childcare - End of life Maternity Services - Being well - Integrated models of care - Patient education - Pathways of care in the community Mental Health & Learning Disabilities Ageing Well Brian Yorke asked Helen who it is in the clinical commissioning group who deals with the challenges such as travellers (e.g. no immunisations). Brian to e-mail Helen with further information. ACTION Helen McCairn to investigate. BY/HM 14. MINUTES OF THE LAST MEETING The minutes of the last meeting were agreed as an accurate record of the meeting. Updated action list: RN168 - The Great Sutton medical centre data quality check found no issues with data quality and extraction. Therefore, following Medical Director and Quality Lead agreement the Q2 and Q3 data will be shared shortly. Practices should still expect to undertake the work and receive payment. RN170 - Colin McGuffie has chased with Gavin Butler awaiting details from his colleague in the training arm of the council. RN171 - This will be completed week commencing 10 March, alongside some other changes to the clinical commissioning group website. RN172 - Ongoing: Colin has asked Gavin to send the details but has received nothing as yet. Colin will continue to chase. RN173 - Awaiting confirmation RN174 - Completed sent with the minutes. RN175 - Completed sent after the last meeting. RN176 - Sioned Brown has confirmed that Carewatch covers the clinical commissioning group area, including Bunbury. If there are continuing problems Rural GP Network Minutes 11/03/2014 8

NO. ITEM ACTION please contact Colin and Sioned so that they can speak to the council again. NB there is a meeting at the end of March to look at this kind of provision and see if we want to re-commission them, particularly with t the same providers, so please feed back any problems. RN177 I have reminded the Contracts team about the issue. I am hopeful that we will have some further clarity shortly. 15. FUTURE AGENDA ITEMS Invite Local Authority and NHS England to discuss the increased population resulting from successful planning applications. Falls Pathway Paediatric Hospital at Home Services EMIS web data sharing Pain Clinic (June agenda) DVT Referrals 16. ANY OTHER BUSINESS DVT Referrals to Leighton Helen Black reported that she is no longer able to refer to Leighton and is concerned that she does not have access to these services. It was agreed that this item should be added to the agenda for the next meeting. ACTION Alistair to e-mail Colin with information. ACTION - Colin to invite the relevant people to the next meeting. New homes in Tarporley Alistair Adey raised his concerns that 500 new homes were being built in Tarporley, which was potentially 1000 patients moving into the area. He asked how we should communicate with the local authority regarding these concerns. Helen McCairn advised that the Estates Groups should take the strategic view on all planning applications in the West Cheshire Area. It was agreed that this should be a future agenda item, to invite the Local Authority ad NHS England to discuss these concerns. ACTION Colin McGuffie DATE AND TIME OF NEXT MEETING AA CM CM The next meeting will be held on 8 April 2014, 2.00-5.00pm, in the Lewis Room at Cheshire View, Plough Lane, Christleton, Chester Rural GP Network Minutes 11/03/2014 9

Rural Locality Meeting Minutes of the meeting held on Tuesday 8 th April 2014 Cheshire View, Plough Lane, Christleton 2.00pm 5.00pm Key Points to Communicate to your Practice Phases two and three of the Integrated Health and Social Care project will run from April- June 2014 and involve the roll out to all practices during that period. The new LUTS service for male patients was launched on the 1st of April 2014. This completes the range of services of the Adult Community Based Urinary Continence Service following on from the Female LUTS service, already delivered by CWP across West Cheshire since January 2014. The next Membership Council meeting on 21 May will give over the second session to the Rural Network to allow them to challenge the clinical commissioning group and wider partners on commissioning decisions. Health Visiting and School Nurses have been chosen as the priorities to discuss at the meeting. The Community Ultrasound service has started at Princeway and patient feedback has been very positive. Roll out to Tarporley Hospital and Malpas surgery will begin as soon as possible. The Vanguard Programme will form take up the first part of the next Network meeting to discuss priorities and timetable for the three rural clusters. Action List RN189 RN190 Action Dan Jones and John Glover to be invited to the July Network meeting Liaise with Tarporley War Memorial Hospital and the Countess of Chester Hospital to facilitate a compromise over starting the Community Ultrasound Service as soon as possible. Owner Colin McGuffie Colin McGuffie RN191 Send PDF versions of the Community Ultrasound posters Colin McGuffie to Paul Smith RN192 Allocate half of the May Network meeting to discuss the Colin McGuffie Vanguard Programme RN193 Clarify the status of CQUIN payments Sarah Vickers RN194 Forward feedback to Ellesmere Port & Neston Network on proposed letter to hospitals who fail to issue correct sick notes to patients Colin McGuffie Rural GP Network Minutes 08/04/14 1

Present: Steve Pomfret, Brian Yorke, Louise Davies, Jonathan Gregson, Trevor Ferrigno, Helen Black, Andy Campbell, Paul Smith, Alistair Adey, Lynn Suckley, Linda Duffin, Philip Milner, Sam Jeffrey, Debbie Taylor. In attendance: Sarah Murray, Colin McGuffie, Alison Lee, Huw Charles-Jones. Practices not clinically represented: Kelsall NO. ITEM ACTION 1. WELCOME AND INTRODUCTIONS Steve Pomfret opened the meeting and welcomed the group. 2. APOLOGIES Apologies were received from Sarah Murray, Debbie Bailey, Jim Hinds, Christine Kenyon. 3. DECLARATION OF INTEREST Andy Campbell declared an interest in item 4 - the Community Ultrasound Project. Andy is a trustee of Tarporley Memorial Hospital and is working to develop ultrasound capacity at the hospital. Helen Black also declared an interest as Andy s spouse. 4. WEST CHESHIRE INTEGRATED HEALTH AND SOCIAL CARE RECORD UPDATE Dan Jones, Clinical Lead for Information Communication Technology and GP at City Walls Medical Centre and John Glover, Director of IM&T at the Countess of Chester Hospital gave an update on the Integrated Health and Social Care record. The work on the Integrated Health and Social Care record fits in with the wider remit of the West Cheshire Way. It helps join up work being done by West Cheshire Clinical Commissioning Group, Countess of Chester Hospital, Cheshire and Wirral Partnership and Cheshire West and Chester Council to integrate Health and Social Care. The system will also help to support integrated teams working in primary care. Electronic record sharing already exists in West Cheshire, for example between GPs and the hospitals and between CWP and Cheshire West and Chester Council. In the future this is set to increase to allow record sharing between GPs, the Countess of Chester Hospital, mental health, community services, social care, cancer care (Clatterbridge) and the GP out of hours service. Steve Pomfret asked if there was an electronic connection for sharing data between the Countess of Chester Hospital and Clatterbridge Hospital. John Glover explained that no direct link was available at the moment. There are links to some services but there is no joined up link. The overarching aims of the project are: Improved patient experience Quicker patient pathway Reduction of duplicate testing Reduction of admissions from A&E, as full meds history Patient safety know what has already been prescribed/don t re-prescribe. Earlier discharge, quicker diagnosis and treatment and access to community care packages Reduction in phone calls between GPs and Consultants Rural GP Network Minutes 08/04/14 2

NO. ITEM ACTION Explicit consent is required if a health professional needs to access the social care element of a patient s records. This can be collected by a GP or social care professional at the point of contact with the patient. Consent options include setting a limit on that consent. This might be set at three months, one year or indefinitely. Information governance was discussed and it was felt that greater communication with patients will be needed to inform them of what will happen with their data. Many Practices have this information on their websites; we need to check if the same information is in the Practice Leaflets. Steve Pomfret asked how information on medications would be aggregated from all of the different prescribing organisations and clinicians. John Glover said that the team was looking at the best way to do that, but that there are a number of options to pull together that information and present it in an appropriate way. There followed some discussion on how the system might highlight or identify certain types of patients to different clinicians or teams. John explained that the risk stratification of patients was already done by other tools used within the Clinical Commissioning Group. However, the system could include a flag on some patients to highlight them. It was suggested that the current process for highlighting patients who are subject to child protection issues could be expanded to allow other patients to be highlighted to the integrated teams. This could remove the need for those patients to see their GP simply to be referred on to the integrated teams. Helen Black asked how the integrated health record would pick up patients who access services across clinical commissioning group borders. John and Dan explained that at the moment that would not happen. This is not a perfect system and it will not address all GP concerns and issues. However, the system was designed in such a way as to allow it to be scaled up across existing boundaries. John said that there had already been interest expressed by other organisations in the work that the team were doing. He cited the example of Hampshire Clinical Commissioning Group who had implemented a similar system and rolled it out across a number of neighbouring clinical commissioning groups. The timetable for implementation was set out and phase one, the technical sign off has already been completed. Phases two and three will run from April-June 2014 and involve the roll out to all practices (phase two) and analysis of the benefits that are realise (phase three). Phase four, the patient portal was beyond scope at the moment. Dan expressed the team s desire to test the quality of the data alerts and the communication processes before moving on to the next phases. Steve Pomfret thanked Dan and John on behalf of the group and suggested that they be invited back to update the group again in July. Action: Invite Dan Jones and John Glover to the July Network meeting. 5. Falls Pathway CMc Julie Jones (Clinical Specialist Physiotherapist, CWP) introduced the proposed new falls pathway. She explained that because people fall in very different places, in different ways and for various reasons, the falls pathway remains very complex. However the team has tried to make better links between services and highlight them on the pathway. Rural GP Network Minutes 08/04/14 3

NO. ITEM ACTION The new pathway looks at the whole patient journey and ensures that all patients have the same, consistent service no matter which route they enter the pathway. The main points of the presentation were: All over 65s should be asked the falls question. National Institute for Health and Care Excellence (NICE) guidance recommends that these patients are asked about falling no matter what they are contacting their GP for. The team recognises that this could be an issue for GPs, given the limited time they have with patients. It was suggested that a poster or other publicity material be used to highlight the importance of falling to patients. The Falls Campaign in June aims to raise awareness. There are two assessment tools that are used to stratify patients and their risk of falling. The first is the Falls Rick of Falling Tool (FRAT), the other is the Timed Up and Go Tool. Julie explained that the same interventions were in place as under the old pathway. The new one seeks to improve communications between service providers via integrated teams or the falls clinic. The referral process is the same for all patients. There is one form that is completed by GPs and then triaged by the care coordinator within the integrated team. The patient is then referred to the appropriate element of the pathway. Direct referrals to the falls clinic are done via a GP letter to the consultants at the Countess of Chester Hospital. However, the team are looking to smooth this process and move to using the same form for every referral. This will speed up the process and make it much more consistent for patients and clinicians. If GPs do not have an integrated team at the moment, they should use the old referral process for now. A leaflet is available to practices which gives further information for carers and patients. The Falls Week will take place in June, the new pathway will be launched then. Further comments should be emailed to: anna.rees@nhs.net or juliejones2@nhs.net 6. MEMBERSHIP COUNCIL The next Membership Council meeting on 21 May will give over the second session to the Rural Network to allow them to challenge the clinical commissioning group and wider partners on commissioning decisions. It is an opportunity to address the Rural Locality s priority areas for commissioning of existing services. It was agreed that Health visitor provision should be discussed as a priority. School nurses and Community Matron provision were also suggested as topics to be covered. It was suggested that representatives from Public Health, Cheshire West and Cheshire Council and the providers of Health Visiting services in the neighbouring clinical commissioning groups, such as East Cheshire should be invited. Rural GP Network Minutes 08/04/14 4

NO. ITEM ACTION Phillip Milner said that it would be helpful to tease out of the organisations how the landscape for Health Visitor provision looks, and how do we make sure it works in an integrated way. Paul Smith said that his concern was that as The Knoll accessed Health visitors from East Cheshire, they had no communication with them at all about how the changes were being implemented and what the implications for practices are. Lynn Suckley expressed her concern that the Health Visitor service for new mums in the Malpas area was non-existent. Lynn felt that this left an at-risk population being disenfranchised. Lynn wanted this concern addressed through the Membership Council session. Steve Pomfret agreed that having a representative who could explain how the communications were supposed to work would be helpful. It was suggested that as a minimum the panel should consist of: Anne Eccles and Sue O Dell (West Cheshire Clinical Commissioning Group); Gerald Meehan (Director of Children s Service at Cheshire West & Chester Council); Val Sturgess (Cheshire and Wirral Partnership) Service managers from the Health Visiting Team Representatives from the Local Area Team (NHS England) 7. COMMUNITY ULTRASOUND UPDATE Louise Davies updated the group on the latest progress of the Community Ultrasound Project. The main points of the update were: Phase one of the project was had started in Frodsham, Princeway on 26 th March. Steve Pomfret and Paul Smith echoed Louise s suggestion that it had gone well. Louise explained that the Countess of Chester Hospital staff had reported that they would have to delay the start date for the clinic at Tarporley because of renovations at the hospital. Colin McGuffie agreed to investigate whether alternative arrangements could be put in place to keep the Tarporley clinic on track to start as soon as possible. Action: Colin McGuffie to liaise with Tony Gorman and Linda Williams to facilitate a compromise. CMc Pau Smith asked if PDF versions of the publicity material could be provided for The Knoll. Action: Colin McGuffie agreed to investigate and reply to Paul Smith. CMc Paul Smith said that patient feedback from the first clinic had been very positive and he thanked Louise Davies on behalf of the group for all of her hard work getting the service redesigned and implemented. 8. BREAST SCREENING REVIEW Paula Taylor (Commissioning Manager, West Cheshire Clinical Commissioning Group) and Jackie Lewis (Healthwatch) presented the findings of the Breast Rural GP Network Minutes 08/04/14 5

NO. ITEM ACTION Screening Review and asked for comment on the proposed changes. The main discussion points were: It has been recommended that the Chester and Wirral programmes come together to form one service. There is concern that this will have a significant impact on rural patients. The major concern is that patients will have to travel further and wait longer for their appointments. One option involves switching the screening of Frodsham, Helsby and Bunbury women to Chester. Currently women are screened in a mobile unit, which Chester and Wirral do not have at the present time. The potential deterioration in service caused significant concern. Rajesh Rajan made the point that removing access to the mobile unit was contrary to the clinical commissioning group s plans to have patients access services as close to their homes as possible. Johnathan Gregson also expressed his concern that these changes may impact on the number of patients who access the service, as the turnout from Helsby patients at the moment is very high. These numbers would probably drop if they had to travel much further for their appointments. Paula Taylor thanked the group for their input and said that their concerns would be fed back to NHS England. Any other comments could be emailed to her or Rachel Warner: paula.taylor17@nhs.net; rachaelwarner@nhs.net 9. COMMUNITY RHEUMATOLOGY Rajesh Rajan fed back to the group on the latest progress. The team had visited a community rheumatology service in Telford. The visit highlighted the difference in understanding of what a community service might look like. The significant findings from the visit were that although the patients loved the service, as it provided a one stop shop clinic, the staff were less enthusiastic. The staff felt isolated from secondary care, but feel even more isolated from primary care. They had no communication with GPs at all. Rajesh said that the visit had given them some issues that they would need to think carefully about. The plan now is to design a service that would reduce referrals to secondary care. The next steps are to: Look at all of the current pathways this will include GP feedback; Create a single point of access for these pathways (possibly Sharepoint or Map of Medicine); Seek GP feedback once all the pathways are uploaded It was felt that there should be a focus on education and training for clinicians in terms of rheumatology. There appears to be a lack of provision delivered through the Rolling Half Day training events, and it was suggested that his be fed back to the clinical commissioning group team. Rajesh also pointed out that there was an issue with GP use of Choose and Book when referring in to Rheumatology clinics. GPs need to be selecting the correct clinic when accessing the system. Rural GP Network Minutes 08/04/14 6

NO. ITEM ACTION Rajesh asked for the group s opinion on the proposal to have some form of rheumatology triage service run by a GP With Specialist Interest (GPWSI). Inflammatory rheumatology patients excluded from that, and remain as direct referrals to the hospital. However, this service would act as a first screening to help speed up appointment times. Rajesh suggested that this would need to be piloted first before deciding to roll it out wider or not. There was some further discussion about how a community service might be structured. Jonathan Gregson expressed a view that he would prefer to retain some secondary care input, if only to confirm diagnoses. Rajesh Rajan said that consultants in secondary care had made it clear that stable review appointments could be done in a community setting as long as at least one review in every 12 months was then seen in secondary care. Jonathan suggested that these reviews could very well be done by specialist nurses and GPs With a Specialist Interest (GPWSI), outside of the tariff payment, in a community setting. This would dramatically reduce the cost for these patients. However, the money would need to follow the patient and not be retained in secondary care. Rajesh agreed that this was a possible model for a community service, and it might allow one clinic to be based in each of the three localities. Alison Lee pointed out the need to consider the longer term move towards embedding self-care for patients. The team should consider how these patients are empowered to look after themselves and better manage their conditions. Rajesh agreed to build that in to the community service specification, and ensure that self-care it promoted and appropriately signposted. 10. VANGUARD PRACTICE Steve Pomfret introduced the agenda item and suggested that the group use the allotted time to start thinking about how they engage in the vanguard Programme, and what the timescales might be. He stressed the importance of taking the opportunity that the programme provided to look at how they develop services to meet the demands generated by seven day working for integrated teams. Jonathan Gregson said that the M56 cluster had been exploring the possibility of employing a GP to back fill GPs involved in their cluster. However, he wanted to clarify the back fill funding arrangements. Brian Yorke suggested that this topic be a standing agenda item from now on. It was agreed that half of the next meeting would be given over to discuss the Vanguard Programme. This would be reviewed after that to see if every meeting had the same time allotted to it. It was agreed that at the May meeting the group would look at the cluster applications alongside each other to identify areas of similarity, and to inform each clusters priorities. Matt Powls said that the Federation would be looking at the bids to identify clinical commissioning group wide similarities and drive efficiencies that could be made by working across more than one cluster. He would also be looking at the bids on a locality level to see if further efficiencies could be made within the rural locality. Rural GP Network Minutes 08/04/14 7

NO. ITEM ACTION Louise Davies expressed her concern that this kind of approach could mean that the local flavour of each bid is lost if a one size fits all approach is taken. This point was supported by the whole group. Colin McGuffie confirmed that the intention was to develop local priorities as set out in the bids. Equally, it makes sense to consider how sharing good practice or simply working together to deliver economy of scale might improve services for all clusters. Alison Lee supported this approach and highlighted to the group the need to mindful of any possible conflict of interest. The clinical commissioning group needs to be able to justify why it is funding the Federation to redevelop Primary Care. Part of that justification will come through collective bargaining and sharing of services and contracts. Action: First half of the May meeting to be given over to discuss the Vanguard Programme. CMc 11. COMMISSIONING UPDATES FROM CLINICAL LEADS Lower Urinary Tract Symptoms Service Phillip Milner updated the group on the launch of the new LUTS service for male patients, as of the 1st of April 2014. This completes the range of services of the Adult Community Based Urinary Continence Service following on from the Female LUTS service, already delivered by CWP across West Cheshire since January 2014. This has been the result of a long standing service redesign project of integrating continence care in a collaborative approach with existing suppliers of these services; Cheshire and Wirral Partnership and Countess of Chester NHS Foundation Trust, based on consultation with local GPs, Consultants and Patients and in line with NICE guidance and best practice. 12. MINUTES OF THE LAST MEETING The minutes of the last meeting were agreed as an accurate record of the meeting. 13. FUTURE AGENDA ITEMS There were no items presented for consideration. 14. ANY OTHER BUSINESS CQUINS Helen Black asked about the current status of the CQUINs, and the CQUIN payments. Action: Sarah Vickers to clarify the position Hospital letter from Ellesmere Port and Neston Locality The Ellesmere Port and Neston Locality had drafted a letter for comment from the other localities. The letter is in response to GP concerns about hospitals issuing incorrect medical certificates to patients. Rural GP Network Minutes 08/04/14 8

NO. ITEM ACTION The group appreciated the sentiment of the letter, but felt that further work was needed to soften the tone of the text. It was also suggested that other options should be taken up to correct the problem rather than issuing the proposed letter. It was felt that the issue could be addressed through the monthly contract meetings between the clinical commissioning group and provider organisations. Action: Colin McGuffie to feed these comments back to the Ellesmere Port and Neston Network Chairperson. CMc DATE AND TIME OF NEXT MEETING The next meeting will be held on 13 May 2014, 2.00-5.00pm, in the Lewis Room at Cheshire View, Plough Lane, Christleton, Chester Rural GP Network Minutes 08/04/14 9

Minutes - Ellesmere Port and Neston GP Network Meeting 8.30am - 11.30am on Thursday, 3 rd April 2014 at Ellesmere Port Civic Hall, 4 Civic Way, Ellesmere Port, CH65 0BE. GP Attendants: Jeremy Perkins: Neston Surgery. Marc England: Whitby Group Practice (England) Alison Daly: Whitby Group Practice (Warren) Jon Stringer: Whitby Group Practice (Stringer) Chris Ritchieson: Great Sutton (Wearne) Nigel Wood: Great Sutton Medical Centre (Wood) David Thorburn: Great Sutton Medical Centre (McAlavey) Sally Shaw: Old Hall Surgery Chris Macdonald: York Road Geff Meyer: Willaston Surgery Simon Powell: Hope Farm Medical Centre Chris Steere: Neston Medical Centre Practice Manager Attendants: Claire Wightman, Westminster In attendance: Laura Jones: Locality Manager, West Cheshire Clinical Commissioning Group Helen McCairn: Director of Partnerships, West Cheshire Clinical Commissioning Group Sarah Murray: Primary Care Development & Membership Engagement, West Cheshire Clinical Commissioning Group Helen Wormold: Designated Nurse, Adults Safeguarding, West Cheshire Clinical Commissioning Group Apologies received: Mark Adams: Westminster Surgery Practices not represented by a GP: Westminster 1

Key points to communicate to your practice: Practice staff should follow the Adult Abuse Flowchart if there is concern, allegation, disclosure or suspicion of Adult Abuse. The number for the Adult Social Care Advice team was confirmed as 0300 123 8 123 or out of hours 01244 977 277. GPs were also advised they could email Helen Wormold direct if they wanted advise over whether they should make a referral h.wormold@nhs.net Cheshire ICT (Information Communications and Technology) are working towards allowing practices, via Emis Web, to access records that are held by Cheshire & Wirral Partnership Trust. The Integrated Health Care record will allow sharing of summary patient records across organisations via Single Sign On tab within the practice s clinical system to support direct patient care. The draft Commissioning Plan is now available and has been shared with practices. A detailed discussion around Vangaurd will be on the agenda for the next Ellesmere Port & Neston GP Network meeting. Practice Managers are encouraged to attend. The LMC (Local Medical Committee) have given feedback that the funding for the proposed new DVT (Deep Vein Thrombosis) service is not sufficient. The Local Medical Committee are also is discussion regarding the payments for the sexual health checks and health checks (CHD) which are now commissioned by Public Health. Actions: Laura Jones to email a copy of the Adult Abuse flowchart to the Network. Data Sharing and Emis Web: Kerry Winsland and Rachel Lewis to take back the suggestion made by GPs that rather than having consent prompt a box appears which notifies the GP who obtained the consent (named person) and the date that this was done. Laura Marsh to provide clarity on the group that is the Clinical Commissioning Group Estates Forum as it appeared the GPs in the room had not heard of this forum. Laura Jones to share the draft letter written by Marc England, regarding the issuing of medical certificates by the hospitals with the City and Rural Networks for their feedback and to ask if they would be willing to add their support to it. 2

1.Introductions and apologies for absence Apologies/introductions: Mark Adams sent his apologies, Claire Wightman, the Practice Manager attended on behalf of Westminster. Jeremy Perkins Declarations of interest: None declared. 2. Previous minutes and matters arising Previous minutes: The previous minutes were agreed as being an accurate record with one exception; Sally Shaw referred to page 8, item 7, which referred to suggestions for future membership council topics, which read as follows: Jeremy Perkins Panel to include clinicians and managers from Urology, GMI investigations, Liver mets services Sally clarified that the message should have been that the suggestion was for all cancers of unknown origin, not just liver metastases. Matters Arising: 1. Laura Jones has already sent an invite to the new Community Geriatrician at the Countess of Chester to attend a Network, but has been advised that there will be two new Community Geriatricians, the second of whom is not yet in post. Both of the new Community Geriatricians will be invited to attend a future Network. 2. Rob Nolan to seek clarification of how winter funding for transitional beds was spent by the Countess of Chester Hospital this is being followed up. 3. Dan Jones has been invited to attend the meeting today. 4. Rob Nolan to investigate when the next national opportunity to bid for Any Qualified Provider status is and feed back to the group this is being followed up. 5. Sarah Murray has now sent an email to practices to kick-start the Vanguard meetings. 6. Marc England has shared a letter for feedback regarding hospitals issuing patients with the correct medical certificate. 3

3. Vale Court Helen introduced herself as the Designated Nurse for Adult Safeguarding at the clinical commissioning group and added that she has been in post since February 2013. Helen advised that she had been asked to attend this meeting to give an update on situation at Vale Court. Helen Wormold Helen discussed the standard of care issues that have arisen at Vale Court. The concerns related to the level of basic nursing care that was being provided which was sub-standard, for example residents who had a grade 2 pressure ulcer that deteriorated to a grade 4. The GPs in the room were concerned that they had not previously been informed about the issues that had arisen in relation to the care provided at Vale Court. Helen confirmed that in the future if significant concerns arise about the standard of care within a local care home then all GP practices who have patients registered at that Home will receive a letter outlining the details. The letter will be sent to the senior partner of the practice. No agreement was reached regarding the validity of notifying practices about issues with Care Homes out of area, Helen to look into this and feedback to Jeremy Perkins. Vale Court is now under voluntary suspension, this means that Vale Court is not accepting any new residents, whether that is NHS funded, self-funders or out of area residents. There was a discussion around the process if a member of staff has adult safeguarding concerns. Helen referred GPs to the Inter-agency Safeguarding Adults in Cheshire West and Chester Break the Silence Document which has previously been sent to all practices in West Cheshire. A flow chart (Appendix 5, page 22) was referred to, which provides all of the necessary information including a telephone number for referrals to the Adult Social Care Advice and contact team. (In hours: 0300 128 8 123 Out of Hours: 01244 977277) Helen advised all GPs in the room that if they wished to seek advice over whether they should make a referral they can email her at h.wormald@nhs.net Action: Laura Jones to email a copy of the flowchart to the Network. 4. EMIS Web Kerry Winsland, Relationship Manager and Rachel Lewis, Emis Web Applications Manager were introduced. Kerry Winsland/ Rachel Lewis In January 2014 data sharing was enabled between the Emis Web GP practices and the Emis system used at Cheshire & Wirral Partnership for Nursing and Therapies. Dr Claire Baker requested that the CMCSU (Cheshire & Merseyside Commissioning Support Unit) provide an overview session on Emis Web data sharing at each of the GP Network meetings. 4

The aim of the presentation was to provide an overview on the use of Emis Web data sharing. Rachel s presentation (attached) demonstrated how clinicians can access clinical data held within the community Emis Web system. After the presentation, discussion focused on slide six, which requests that the GP confirm they have permission to view the patient s shared care record, prompting them to click on yes or no. Nigel Wood raised concerns about GPs answering yes to this prompt in instances where no evidence is available that the patient has actually consented. There was a consensus amongst other GPs in the room. It was felt that it would be more appropriate if the prompt that came up on the screen provided details of the name of the person who had received the patient s consent and the date. Rachel explained the process by which consent is gained and clarified that consent is gained either verbally or via patient data sharing form. The patient s signature is obtained by the member of staff seeing the patient e.g. District Nurse or Community Matron and then sent to the Practice Manager for them to record on the clinical system Action: Kerry and Rachel investigate changing the system so that rather than having consent prompt, instead a box will appear which notifies the GP who obtained the consent (named person) and the date that this was done. 5. Integrated Health & Social Care Record Dan Jones, Clinical Lead for Information Communication Technology and GP at City Walls Medical Centre and John Glover, Director of Information Technology at the Countess of Chester Hospital provided an update on the Integrated Health and Social Care record. Dan Jones/ John Glover The West Cheshire Way describes how our local health and care system will work together in Chester, Ellesmere Port and the surrounding rural areas. It is a partnership between the West Cheshire Clinical Commissioning Group, Countess of Chester Hospital NHS Trust, Cheshire and Wirral Partnership NHS Trust and Cheshire West and Chester Council to respond to the challenges outlined. The work around the Integrated Health and Social Care record fits in with the wider remit of the West Cheshire Way in that it looks to: improve self-care support people in the community 5