Personal Medical Services (PMS) Review 2016/17 Business Planning

Project name Programme Unique reference ID Lead Organisation Project sponsor Clinical lead Implementation lead Project category (S/M/L) Personal Medical Services (PMS) Review 2016/17 Business Planning Hounslow CCG Sue Jeffers Managing Director Dr Nicola Burbidge Clinical Lead Shelley Eugene Head of Primary Care Transformation PMS Review 2016/17 Business Planning Document [Date completed] Final decision Local Joint Co-Commissioning Committee (approve/reject) Date of decision 11 th February 2016 Decision made by Reason for decision Hounslow Local Joint Co-Commissioning Committee PMS Review QIPP Identified Not Applicable

Document Information Version v0.15 Status Draft Author Shelley Eugene Head of Primary Care Transformation Crispin Fu Project Manager Mandip Riyat Head of Financial and Management Accounts Date created 18.01.2016 Date last amended 9.02.2016 Version Control Version Release date Description of changes v0.2 Changes following meeting with Sue Jeffers, Managing Director v.0.3 Changes following meeting with Mandip Riyat, Head of Financial and Management Accounts v0.4 Further revisions from Crispin Fu and Shelley Eugene v0.5 Further revisions from Mandip Riyat, Head of Financial and Management Accounts v0.6 Further revisions from Mandip Riyat, Head of Financial and Management Accounts v0.7 Further revisions from Sue Jeffers, Managing Director v0.8 Further revisions from Sue Jeffers, Managing Director v0.9 Further revisions from Geralyn Wynne, Deputy Managing Director v0.10 Further revisions from Mandip Riyat, Head of Financial and Management Accounts v0.11 Further revisions from Mandip Riyat, Head of Financial and Management Accounts V0.12 Further revisions from Shelley Eugene, Head of Primary Care Transformation V0.13 Final revision from Sue Jeffers Managing Director V0.14 Further revision following NHSE amendments to mandatory KPIs and Saturday morning tariff V0.15 Further revision following non-conflicted Governing Body 9 th February 2016

Contents 1. Strategic objectives...1 2. Context and purpose of the Business Planning Document...1 3. Project objectives...2 4. Drivers for change Population, access and value for money...2 5. Proposed change (business option / solution)...7 6. Impact of doing nothing...8 7. Other options available...8 8. Expected benefits... 11 9. Other Resource implications... 11 10. Timescales, milestones and project plan... 12 11. Project team... 12 12. Project governance and controls... 13 13. Project costs and funding... 13 14. Funding & Budget... 13 15. Risks, issues, assumptions and decisions (RAID)... 14 16. Stakeholder engagement and communications... 17 17. Quality assurance... 17 18. Project Impact... 18 Appendix 1 Hounslow CCG Additional Technology KPI... 19 Appendix 2 KPIs for London Offer... 21 Appendix 3 Practice by Practice Aggregated Immunisation... 24 Appendix 4 On line appointment... 25 Appendix 5 Cancer Screening Rates for Hounslow General Practices... 26

1. Strategic objectives Indicate below which strategic objectives this proposed investment supports the delivery of; (1) Deliver Shaping a Healthier Future and the Out of Hospital Strategy Yes (2) Deliver improved quality of services to patients Yes (3) Deliver financial obligations and other statutory / legal duties Yes (4) Develop and maintain an effective organisation Yes Describe how the investment would support delivery of the strategic objective(s) indicated. The investment for commissioning the services from the London Strategic Commissioning Framework (SCF) will support the following: The delivery of preventative services in primary care Improve the quality of primary care services Improve the level of equality and access of care for patients The investment in out of hospital services that replaces the 2010 Premium services provides a higher specified service and more detailed contract monitoring, providing a better quality of service for patients. In undertaking the investment decisions and agreeing the programme for transitional relief the CCG is taking into consideration, the stability of practices, value for money and using an evidence base upon which to take its decisions. 2. Context and purpose of the Business Planning Document This Business Planning Document sets out the agreed scope, governance, plan and costs to deliver the PMS Review and investment in primary care. The document will include the objectives of the review and outline the governance process for agreeing the recommendations and decisions required for the PMS Review. The Business Case describes the financial costs required to support the implementation of the PMS Review and the subsequent investment to support the London Strategic Commissioning Framework under the Shaping the Healthier Future agenda. This Business Case will set out the options available to the CCG for this investment The objective of this Business Case is to: Recognise that the Premium (2010) PMS Services are provided in other services either within core GP contract, Quality Outcomes Framework (QOF), Out of Hospital services or other community providers Recognise that the decommissioning of the services will release funding to support the commissioning of new services/indicators 1

Support the decision making process on the investment to be made and an understanding of the financial implications for the different levels of investment 3. Project objectives 1) Decommission the existing PMS Premium Services and commission new services from the PMS and GMS Practices in Hounslow. The decommissioning of services will release funding that can then be used to commission a range of services from general practice to support the delivery of the London Strategic Commissioning Framework in Hounslow. 2) Demonstrate the sustainability of decommissioning services from the present PMS Premium Services (2010) and to assure Hounslow CCG (HCCG) that these services are provided using the Out of Hospital Services contract or services that are commissioned through the GMS/PMS core contract, QOF or other community services. 3) Understand the financial implications of commissioning the mandatory indicators, the optional indicators/services (PMS Premium Services 2016) 4. Drivers for change Population, access and value for money (4.1) Drivers for Change - Decommissioning 2010 premium services from PMS practices Since 2010 Hounslow PCT and from April 2013 HCCG have commissioned a range of primary and care services which now duplicates the 2010 premium services. In order to avoid double payment and ensure value for money it is recommended that these services are now decommissioned. A final due diligence is to be completed as outlined in next steps in the cover sheet. The PMS Premium (2010) that are being decommissioned and now provided through the Out of Hospital Services Contract are: Provision of care for patients with COPD and Spirometry Provision of care for all Type 2 Diabetes within the Practice Elderly Screening The Out of Hospital Strategy places the patient at the centre of their own care with the GP as the key provider and coordinator of services. With the services being decommissioned from PMS Premium services and commissioned via the Out of Hospital contract, this will ensure the delivery of the key strategic priority for HCCG, to improve quality, reduce variation in primary care and ensure all patients have equity of access to commissioned services which is supported through the Out of Hospital Services contract. The CCG has engaged with, and continues to engage with, patient and lay representatives throughout the development of the services/indicators which will include the on-going monitoring of services. In addition patients continue to be engaged in the out of hospital 2

services contract supporting improvement in the delivery of local services so that the services are receptive to all patient groups Services to be decommissioned from the PMS Premium (2010) that are covered by GP Extended Hours, and the CCG review of Primary Care Access Urgent Care in General Practice Additional Hours 52 hour opening As part of the on-going review, the CCG is reviewing the access to GP primary care in relation to routine opening times and extending opening hours. By decommissioning the urgent care and additional hours in general practice as part of the PMS Review, the CCG will be able to reinvest in commissioning extended opening hours (both routine and urgent) across Hounslow in order for patients to be given a choice of access options for a service that best meet their needs. The 52 hour opening is part of the new PMS core contract (2016). Any GMS practice the CCG contracts with to provide the additional services from the London Strategic Commissioning Framework will also be expected to deliver the core contract including the 52 hours opening. The CCG is currently reviewing feedback from patients on patient access and opening hours Services to be decommissioned from the PMS Premium (2010) that are provided through the Core contract Neonate checks The Neonate check is performed when the baby is eight weeks when the first set of immunisations are due. This check is part of the NHSE Newborn and Infant Physical Examination (NIPE) and includes: A physical examination A review of development An opportunity to give health promotion advice An opportunity for the parent to express any concerns Services to be decommissioned from the PMS Premium (2010) that are provided through QOF Osteoporosis Prevention QOF was introduced, developed and designed to drive measurable quality improvements. The Osteoporosis Prevention QOF Indicator has similar quality measurements as the PMS Premium Services (2010). By decommissioning this service, the CCG could avoid the duplication of payment to a practice for undertaking both QOF Osteoporosis Prevention and the PMS Premium Osteoporosis Service thus ensuring value for money for the provision of care Services to be decommissioned from the PMS Premium (2010) that are provided by 3

other providers Alcohol Misuse Teenage Support and Sexual Health Management Dermatology The Alcohol misuse service is delivered by the Integrated Drug and Alcohol Dependence Service and provided by the ihear Partnership. This service provides information, advice and treatment for Hounslow residents with regards to drug and alcohol misuse. Teenage Support and Sexual Health Management (Sexual Health Hounslow) This service is provided by Chelsea and Westminster NHS Trust and provides contraception, family planning and sexual health services based at West Middlesex Hospital ( acute sexual health with doctors available at every walk in session and providing infection diagnosis and treatment provided on the same day). Teenage sexual health clinics (the KISS clinic) are held at Heart of Hounslow and Feltham. These clinics have a specialist teenage sexual health advisor. The main contraception clinic in Hounslow is provided from the Heart of Hounslow. This service provides a range of contraceptive and specialist reproductive services Monday to Friday, with specialist clinics for long term contraception such as Intrauterine System (IUS) or IUDs (Intrauterine Device). A nurse led contraception and sexual health service providing walk in contraception 3 days a week and STI testing 4 days a week is provided from Feltham Health Centre. A nurse led contraception and sexual health service provision is provided at Chiswick Health Centre one evening a week. Dermatology The community dermatology service has been commissioned by the CCG and is provided by Concordia. The service is for the Hounslow GP registered population and GPs refer to the service via the Referral Facilitation Service (RFS). This is a consultant led service and manages all Tier 2 and Tier 3 skin conditions in the community from three locations across the Borough. The above demonstrates that service provision under the PMS Premium (2010) services is also commissioned by other providers. The CCG feels assured that despite the decommissioning of the PMS Premium Services (2010), patients will continue to receive these services via other contracts. Continuing to commission these services will continue to duplicate service provision which does not represent value for money for the CCG. Equality Impact Assessments are currently being undertaken on each of these decommissioned services and will be presented at the Governing Body meeting on the 9th February 2016 4 (4.2) Further Drivers for Change - Expected strategic outcomes In February 2014 National guidance set out a requirement to review all PMS contracts by March 2016. The purpose of the review was to secure best value from future investment of the premium element of PMS funding.

As a result of the review, the outcome would be that any additional investment in general practice services that go beyond core national requirements (whether this is deployed through PMS or through other routes) should: reflect joint NHS England /CCG strategic plans for primary care; secure services or outcomes that go beyond what is expected of core general practice or improve primary care premises; help reduce health inequalities; give equality of opportunity to all GP practices, PMS, General Medical Services (GMS) and Alternative Providers Medical Services (AMPS) (provided they are able to satisfy the locally determined requirements); support fairer distribution of funding at a locality level. In London, NHSE, the London Regional Office set a list of mandatory and optional services/indicators included in the London Strategic Commissioning Framework. These services are to be the offer that London general practice provides to its patients, irrespective of the contract type (GMS, PMS or APMS) See Appendix 2 (4.3) Driver for Change GP Wraparound Contract The CCG is currently developing plans for a new model of care for general practice (the GP wraparound contract) which is planned to come into place from the 1 st October 2016. The CCG is investigating opportunities to commission primary care services from a network of GPs. The CCG envisages letting a contract to GP network (locality-level) for providing services in addition to those currently commissioned from individual practices, i.e. through GMS/PMS contracts. The GP wraparound contract will be subject to a future business case for the CCG to consider and the cost of Saturday opening from 8.30am to 1pm for routine and urgent care from all GMS and PMS practices will be considered in this. The decision around Saturday morning opening has therefore been removed from the PMS Review so that there is not duplication or conflicts with commissioning weekend access. (4.4) Further Driver for Change Improvement in Public Health indicators Hounslow CCG has reviewed its performance against the outcomes of the new services set out in PMS Mandatory and Premium Services (2016). This has revealed a number of areas for improvement which commissioning these services could support. Please see Appendix 2 for the KPI achievement by practice. Mandatory - Cancer Screenings In 2015 Public Health England, Hounslow rated as significantly worse than the England average in 2015 across all three of the cancer screening services two of which are mandatory in the new PMS Premium Services (2016) 1. Hounslow CCG would like to include bowel screening as an additional indicator. Screening Rates England Average Service Indicator Hounslow value (%) Value (%) Breast Screening 69.3 75.4 Optional Cervical Screening 67.7 74.2 Mandatory 1 http://www.nepho.org.uk/pdfs/public-health-outcomes-framework/e09000018.pdf 5

Bowel Screening 46.9 57.1 Hounslow Mandatory - Immunisations The national target for childhood immunisations is 95% for each of the six vaccines of the under-fives childhood immunisation schedule. Overall, Hounslow s 2013-14 childhood immunisation rates, published in the 2014/15 JSNA, were below the 95% target (herd immunity) levels. This was generally comparable to other London rates and falls short of the England average rates overall. Appendix 3 provides 2015/16 aggregated data by practice that shows most practices are achieving the NHSE 70% minimum target. Immunisations 2013/14 Performance 2 DTaP/IPV/Hib Hounslow: 93.3% Diphtheria, tetanus, pertussis, poliomyelitis, Region: 93.1% Haemophilus influenza type B (HiB) 2 years old England: 96.1% MMR 2 years old Hounslow: 87.8% Region: 87.5% England: 92.7% Hib / Men C Booster 2 years old Hounslow: 87.0% Region: 86.8% England: 92.5% Hounslow is also behind England in terms of the two flu vaccination measures which are included in the new PMS Premium Services (2016). Immunisations Population Vaccination Coverage 2014/15 3 Flu imms for 65+ Hounslow: 66.4% England: 72.7% Flu imms for -65 at risk Hounslow: 45.6% England: 50.3% Patient Voice The GP Patient Survey (2016) has shown that Hounslow is behind the national average on all survey questions across a range of topics, including overall experience, telephone access and convenience. In addition, the results show minimal improvements since 2013. Question Dec 2013 Jan 2015 Latest England Overall, how would you describe your 79% good 79% good 80% good 85% good experience of your GP surgery? 7% poor 7% poor 7% poor 5% poor Generally, how easy is it to get through to someone at your GP surgery on the phone? How convenient was the appointment you were able to get? Overall, how would you describe your experience of making an appointment? 70% easy 69% easy 69% easy 70% easy 26% not easy 26% not easy 26% not easy 26% not easy 87% 87% 88% 92% convenient convenient convenient convenient 13% not 13% not 12% not 8% not convenient convenient convenient convenient 70% good 69% good 68% good 73% good 13% poor 13% poor 13% poor 12% poor 2 http://www.phoutcomes.info/public-health-outcomesframework#gid/1000043/pat/6/ati/102/page/1/par/e12000007/are/e09000018 3 http://www.nepho.org.uk/pdfs/public-health-outcomes-framework/e09000018.pdf 6

In addition, there are substantial differences in the performance of GP practices across Hounslow, resulting in patients receiving highly inconsistent experience because this depends on which GP practice they are registered with. Patients feedback on the patient voice indicators was that the indicators were not easily measurable or specific enough. The local Hounslow Healthwatch has agreed to develop local monitoring measures against the five patient voice indciators and report on them as part of their quarterly patient experience reports. Question Overall, how would you describe your experience of your GP surgery? Generally, how easy is it to get through to someone at your GP surgery on the phone? How convenient was the appointment you were able to get? Overall, how would you describe your experience of making an appointment? Lowest Practice Score Highest Practice Score 59% good 97% good 27% easy 95% easy 61% convenient 98% convenient 39% good 93% good Additional Technology Hounslow has made significant progress in ensuring the availability of online appointments, online repeat prescriptions and online access to summary records. Please see Appendix 4. Whilst there is almost complete availability for booking of on-line appointments and repeat prescriptions on line only 14.2% of the practice population in Hounslow has an online account. This figure is indicative of the percentage of people who book their appointments on line. While this figure is significantly higher than the CWHHE average of 9.27%, there is more that can be done to increase the utilisation of these services as well as increasing the level of service, for example allowing online booking of nurse appointments as well as with a GP. Utilisation of online services varies significantly from practice to practice so there is an opportunity to encourage an uptake in services. Initial patient feedback indicates that they would use technology as long as it works efficiently and access by phone and on line services need to be easy and convenient to use. The London Offer for additional technology KPIs are just two; 50% of people who book appointment on line by April 17 and the practice to offer electronic consultations. Hounslow CCG has developed 7 stretch targets which will support the take up of digital technology and make the assessment of the achievement of the targets more measurable. Please see Appendix 4. In order to commission these more specific stretch targets the CCG will need to develop its own specification in line with the NHSE PMS Premium Service Specification and agree it with the local LMC. 5. Proposed change (business option / solution) The proposed investment will deliver equity of services to patients and improve patient outcomes. 7

In making a decision to commission optional services/indicators from PMS practices the CCG decided at the Governing Body meeting 12 th January 2016 to commission the equivalent services from the GMS practices. In preparation for the PMS review the CCG has planned for a recurrent sum of 1m from April 2016-2017 onwards to support the commissioning of these services. The CCG has carried out various financial modelling of different options which includes the funding to support transitional relief and the likely impact on the additional investment required. To achieve these strategic outcomes/indicators, the CCG s non conflicted Governing Body sub group made a recommendation to the Local Joint Co Commissioning Group for the new services and indicators to be commissioned from General Practice. 6. Impact of doing nothing As NHSE is undertaking a PMS review, the core contract for the PMS contract will change and the current Premium Services as they stand will not form part of the PMS contract. The CCG has no option but to decommission Local Premium Services (2010) in their current format. The CCG is committed to working towards the London Strategic Commissioning Framework. If some of the services are not commissioned via the PMS review, then the CCG will have to find another mechanism (both contractual and financial) to deliver the SCF. The CCG have identified, through the JSNA 2014 that the uptake on cancer screening needs to be improved in Hounslow as cancer screening rates are substantially below the English average for CCGs. In addition, the other issues set out in the Drivers Section of this document will not be improved upon unless the CCG commissions these additional services 7. Other options available 8 In developing this business case, various options have been identified for commissioning new primary care services as do nothing is not an option NHSE will commission the mandatory services/indicators from the London Strategic

Commissioning Framework (the London offer). The CCG has considered the range of optional indicators and services, and has engaged with patients in making a recommendation for commissioning. Appendix 2 for the list of mandatory and optional services/indicators. The table below sets out the full current London Offer, and the Hounslow offer of bowel screening the additional KPI for Hounslow. This table sets out the maximum potential cost to the CCG, total 2,327k; 599k for PMS practices and 1,728k for GMS practices. Full cost of London offer & CCG optional for Hounslow CCG Weighted List Size Actual List Size KPIs Mandatory KPI Optional Sat opening Use of tech Total London Offer Cost Additional CCG Option - Bowel Screening Grand Total 3.04 0.96 4.00 1.00 9.00 0.40 9.40 PMS No of practices 12 12 as at Apr 15 62,542 65,367 190,127 60,040 261,468 62,542 574,177 25,017 599,193 GMS No of practices 33 33 as at Apr 15 179,610 189,501 546,014 172,426 758,004 179,610 1,656,054 71,844 1,727,898 Grand total 242,152 254,868 736,141 232,466 1,019,472 242,152 2,230,231 96,861 2,327,091 Note - 1. KPI's mandatory - please note breast screening has been removed from mandatory KPIs, resulting in the fee reducing by 0.40 from 3.44 to 3.04. 2. Sat opening is now based on actual list size and has increased by 1.53 from 2.47 to 4.00. 9 Recommendation The CCG s non-conflicted subgroup has made the following recommendation; to commission the mandatory and optional indicators including the HCCG bowel screening but excluding Saturday opening. With regard to Saturday opening a decision to commission Saturday opening would need to be taken in line with a value for money, effectiveness and patient engagement assessment. The GB sub group confirmed that NHSE have commissioned the mandatory KPIs which will be funded through the released PMS funding. The CCG recommended the commissioning of the additional technology in line with local Hounslow current achievement and local targets. The CCG recommends using the London offer on additional technology as below; The practice will be required to make at least 50% of all appointments available on line for booking and cancellation by the 1 st April 2017 The contractor is required to offer electronic consultations (for example video conferencing) The CCG recommended the commissioning of additional local technology indictors as attached at Appendix 1 The CCG recommended the commissioning of the (London offer) mandatory and the optional (local) clinical indicators, including bowel screening The CCG recommended the commissioning of the five patient voice indicators. The Patient and Carer Reference Group having received feedback from the patient engagement programme recommended that the two patient voice indicators to be included in the mandatory offer are;

Generally how easy is it to get through to someone at your GP surgery on the phone How convenient was the appointment you were able to get The commissioning intentions for Saturday opening is that the CCG will undertake a review of the current weekend working and the options available to the CCG through the London offer of Saturday opening, and the Out of Hospital GP extended hours. The review will take into consideration value for money of all the options, the effectiveness in terms of uptake and the patient engagement outcomes. The timeline for the commissioning intentions is 1 st July 2016 for the mandatory indicators, contingent upon the completion of the NHSE and LMC negotiations on baseline financial information and transitional relief. The commissioning of the optional local indicators will be subject to affordability within the HCCG financial plan. The table below shows the full cost of the commissioning recommendation - GMS PMS Total Year 1 GMS PMS Total Year 2 KPIs Mandatory 409,511 142,595 552,106 546,014 190,127 736,141 KPI Optional 129,319 45,030 174,349 172,426 60,040 232,466 Sat opening 0 0 0 0 0 0 Use of tech 134,708 46,906 181,614 179,610 62,542 242,152 Additional CCG Option - Bowel Screening 53,883 18,763 72,646 71,844 25,017 96,861 Investment - no price change or list a 727,421 253,294 980,715 969,894 337,725 1,307,619 Funding for commissioning services from GMS practices could come from the 1m funding set aside for this purpose. At present, the CCG commissions a GP weekend opening service at weekends and Bank Holidays to see patients redirected from the UCC and NHS111. There are 5 such hubs open each weekend, one in each locality. In addition the Out of Hospital services portfolio provides the CCG with an option of commissioning GP extended hours service. This service would provide both routine and urgent patient appointments for the weekend and in the evening. The New Model of Care Programme will incorporate weekend working and as part of the review, the CCG is reviewing how an extended hours service can be delivered for the population of Hounslow. Whilst this review is being undertaken, the CCG is making the recommendation not to include the commissioning of Saturday mornings, but does include the financial impact within Table above for information. The CCG has recurrent budget lines for the Out of Hospital services and the GP weekend working. Transitional Relief 10 In year 1 total investment of 0.981m will be required. From Year 2 onwards 1.308m will be required. Assumptions - Start date 1 July 2016. Costing assume full achievements of KPIs. The costs are based on weighted population as @ Apr 15 and at current prices. No adjustment has been made for activity or price increases. The costs above does not include investment for the 8 APMS practices

NHSE and the LMC are in current negotiations on transitional relief for practices. Once agreed the CCG will update its financial models accordingly 8. Expected benefits Description Decommissioning of PMS Premium Services Cervical screening Childhood, flu and Pneumococcal immunisation and patient voice 2 mandatory indicators Type (financial / nonfinancial, direct / indirect) Owner When? (full year)* Financial NHSE July 2016 Public health improvement and improved patient experience 3 optional patient voice indicators Improved patient experience Bowel Screening Additional Technology Use Public health improvement improved patient access NHSE July 2016 NHSE July 2016 NHSE July 2016 NHSE July 2016 9. Other Resource implications Outline any internal management resources involved in delivery of the investment and any other delivery costs that may not be captured in investment details Following the review of weekend working the CCG will need to build in the financial impact of extended hours, and Saturday opening, within its overall financial plan. Following the potential increase in cancer screening, the CCG is in the process of undertaking a capacity review to cost the potential increase in pathology requests together with discussions with the Trusts providing pathology to ensure there is enough capacity to deal with an increase in activity. There will be an increase in the management resource of the CCG in the joint performance monitoring of the KPIs with NHSE 11

10. Timescales, milestones and project plan It is the responsibility of the Governing Body s non-conflicted sub-group to approve Hounslow CCG s investment and to make a recommendation on the services to be commissioned. Once the Hounslow Joint Co Commissioning Body has made the final decision on the agreed set of services to commission, NHS England will be responsible for contract negotiations with individual practices. 11. Project team Role Who Key Responsibilities Project manager Shelley Has overall responsibility for the Eugene successful execution of the project Develops the papers for CCG s internal processes and manages the CCG s project tasks with other CCG staff Status reporting Risk management Finance Manager Mandip Riyat Has overall responsibility for the financial assumptions and workings of the project Develops the financial papers for CCG s internal meetings Status reporting on financial management 12

12. Project governance and controls 12.1 Project governance The Terms of Reference for the Hounslow Joint Co Commissioning Group were approved at the November 2015 Governing Body Meeting 12.2 Interdependencies Hounslow s New Model of Primary Care programme will incorporate weekend working explanation is included in the Drivers Section. The new model of Primary Care programme is scoping out a new arrangement for access to primary care at the weekend. Completing this work will place the CCG in a better position to decide on what sort of weekend access it needs to commission. 13. Project costs and funding These are covered under section 7, Other options available. 14. Funding & Budget This project will be funded using a combination of the premium value released from the PMS review and new investment. The CCG has built in an additional 1m recurrent investment in primary care in its 16/17 plans. The level of investment will be dependent upon the outcome of discussion between NHSE and the LMC on transitional relief. As outlined above this has been accounted for within the financial planning for the next planning round. This is however subject to Governing Body sign off of the whole CCG financial plan for 16/17 and the subsequent four years. 13

15. Risks, issues, assumptions and decisions (RAID) Risks Risk ID Description of risk Inability to complete the PMS review within the timescales of March 2016 Financial sustainability of PMS Practices Conflicts of interest Date raised December GB seminar Raised by Shelley Eugene Shelley Eugene Governing Body Likelihood (1 low 5 high) Impact (1 low 5 high) Mitigation plan 3 2 Project management to ensure timescales are achieved for the PMS review 2 4 Transitional relief funding will be available and impact on individual practices has been set out in the Business Case 5 2 GB agreed to convene a non-conflicted sub group of the GB to decide on the CCG investment and make a recommendation to the local joint co-commissioning committee on the services to be commissioned from Hounslow practices Owner Shelley Eugene Sue Jeffers Ben Westmancott Issues Issue ID Description of issue There is on-going work to determine the opportunities for Date raised Raised by Shelley Eugene Issue type Priority Impact Actions to resolve issue Owner Dependency Medium Low Decision on weekend working not included in the PMS Business Case and will be looked at in the wider context Shelley Eugene 14

weekend primary care which does fit with PMS timescales Assumptions Assumption ID Description of assumption NHSE will be able to negotiate contracts with practices within the timescales Date raised Raised by Owner Actions to validate Validation due date Shelley Shelley Eugene Discussions with NHSE Team Eugene Discussion at the Hounslow Joint Co Commissioning Group Decisions Decision ID 15 Description of decision Date Reason for decision Agreed by Link to supporting documentation Governing Body approved governance process, delegated authority to nonconflicted sub-group and requested business case to be reviewed by F&P 12/01/2016 Approval of governance process and delegated subgroup to ensure that the CCG can make a recommendation to the Joint Co Commissioning Group. Governing Body Governing Body Paper PMS Review 2016

Governance Process to be developed to mitigate conflicts of interest F&P and non-conflicted group to review the Business Case to understand the financial implications and approve CCG investment. 08/12/2015 The CCG needs to make a recommendation on the services to commission but members of the Governing Body have a conflict of interest on GMS/PMS contracts. Governing Body (Seminar) 16

16. Stakeholder engagement and communications Stakeholder (group)* Patient & Carer Reference Group Locality Patient Participation Groups Healthwatch and Adult Health and Social Care Councillor GPs/Local LMC CCG Commissioners Governing Body Finance and Performance Committee NHSE Communication approach Frequency Lead Discussing overview of the PMS Review, approach to engaging with patients and listening to patient views on the service options, including the patient voice KPIs. Explaining the PMS Review and listening to patient views on the service options, including the patient voice KPIs Explaining the PMS Review and listening to patient views on the service options, including the patient voice KPIs Discuss decommissioning services to ensure coverage and new services to commission to ensure alignment to other HCCG activities. Papers brought to the GB to set out the process, issues and decisions. Papers brought to F&P to set out the financial implications to the CCG of the different service options. Regular meetings at a CWHHE level as well as Hounslow specific discussion on a range of topics. *Should also include patient and carer engagement Discussed 19/01/16 All 5 locality groups during Jan/Feb Sue Jeffers Sue Jeffers 1 st February Clive Chalk and Sue Jeffers Regularly with individual commissioners from December. Monthly Monthly Regular discussions and meetings Nicola Burbidge/Sue Jeffers Sue Jeffers Nicola Burbidge Sue Jeffers Julie Sands 17. Quality assurance All formal and final deliverables from the project will be reviewed by appropriate stakeholders and approved by the Operational Group of the CCG and NHSE The main quality measures are as outlined in the Key Performance Indicators 17

18. Project Impact As a result of commissioning new services for Hounslow patient, the CCG will ensure equity of services to all residents. In addition, the KPIs have clear outcomes which are measurable and will form part of a joint performance management approach with NHSE and the CCG. Once the project becomes business as usual, the long term impact will be contract monitoring and financial payments which will all be managed by NHSE. The CCG will report on quality and patient engagement 18

Appendix 1 Hounslow CCG Additional Technology KPI 1 3 4 PMS Review Suggested KPIs on IT Enablers and Patient Access Description Tiered targets Weightings Title Numerator Denominator Percentag Target 2 - Target 1 - Target 3 - e medium Target 1 Target 2 low (min high (min weighting (min Weighting Weighting value) value) across all value) IT KPIs Percentage of patients with online accounts Percentage of patients with 2 or more repeat prescriptions that have a recorded nominated community pharmacy for EPS2 Percentage of patients with recorded mobile phone number Total number of registered patients at the end of the reporting that have an online account Total number of patients with two or more repeat prescriptions at the end of the reporting period with a nominated pharmacy for EPS2 Total number of registered patients at the end of the reporting period that have a recorded mobile number Total number of registered patients at the end of the reporting period Total number of patients with two or more repeat prescriptions at the end of the reporting period Total number of registered patients at the end of the reporting period Target 3 Weighting 15% 25% 40% 15% 50% 80% 100% 25% 50% 80% 15% 50% 80% 100% 40% 60% 80% 15% 50% 80% 100% 5 Percentage of patients with a recorded email address Total number of registered patients at the end of the reporting period that have a recorded email address Total number of registered patients at the end of the reporting period 20% 35% 40% 10% 50% 80% 100% 19

6 Percentage of patients with a recorded preferred method of communication being via texting or emailing Total number of registered patients at the end of the reporting period that have a recorded preferred method of communication that is either texting or emailing Total number of registered patients at the end of the reporting period 35% 50% 70% 5% 50% 80% 100% 7 Percentage of patients with an appointment that have received a text or email notification Total number of appointments where the patient received a text or email notification at the end of the reporting period Total number of appointments at the end of the repotting period 20% 30% 40% 20% 50% 80% 100% 8 Percentage of patients that have a recorded explicit consent on whether to share their medical record Total number of registered patients at the end of the reporting period that have expressed an explicit preference about the sharing of their medical record Total number of registered patients at the end of the reporting period 5% 10% 15% 10% 50% 80% 100% 20

Appendix 2 KPIs for London Offer NHS England Standard PMS Contract - Schedule No13 No. 1 2 3 Screening Description of Key Performance Indicator Breast Screening percentage of females in relevant age cohort during reporting period registered with the practice that have responded to invitation to screening Cervical Screening percentage of females in relevant age cohort during reporting period registered with the practice that have had cervical screening LONDON STANDARD KPIs: MANDATORY Band A - Optimal Performance level Greater than 80% of eligible patients have been screened Greater than 80% of eligible patients have been screened Band B- Acceptable Performance Level More than 70% and less than 79% of eligible patients have been screened More than 70% and less than 79% of eligible patients have been screened Band C- Minimum Performance Level More than 60% and less than 69% of eligible patients have been screened More than 60% and less than 69% of eligible patients have been screened Band D- KPI Failure Less than 69% of eligible patients have been screened Less than 60% of eligible patients have been screened 0.40 Subtotal for section 0.80 Childhood Immunisation - 5-in-1 Vaccine by 1 Year Percentage of children aged 1 whose notes More than Less than record the hep B immunisation programme More than 80% 70% and less 70% of comprising four doses of the vaccine given to and less than than 79% of Vaccination & Greater than 90% of eligible eligible infants at birth (routinely in hospital), aged one 89% of eligible eligible Immunisations patients have been immunised patients have month, two months (four weeks after dose patients have patients have been one) at any time up to their FIRST birthday, in been immunised been screened accordance with the BMA Vaccination and immunised Immunisations Programme 2015/16, Guidance and Audit Requirements March 2015 0.40 Adjusted costing 0.40 21

4 5 6 7 Childhood Immunisation - aged 5 years and over. Percentage of patients in its area (i) who have attained the age of 2 years but who are not yet 3 years are able to benefit from the recommended immunisation courses (that is those that have been recommended in England and by the World Health Organisation for protection against (aa) diphtheria, tetanus, poliomyelitis, pertussis and Haemophilus influenzae type B (HiB), (bb) measles/mumps/rubella, and (cc) Meningitis C, or (ii) who have attained the age of 5 years but who are not yet 6 years are able to benefit from the recommended reinforcing doses (that is those that have been recommended in England and by the World Health Organisation) for protection against diphtheria, tetanus, pertussis and poliomyelitis; Flu Immunisation 65+ Percentage of patients aged 65 and over whose notes record that the influenza immunisation has been given Flu Immunisation Under 65 at risk Percentage of patients aged under 65, with clinical conditions placing them in the 'At Risk' category whose notes record that the influenza immunisation has been given (including pregnant women) Pneumococcal Immunisation 65+ Percentage of patients over 65 and 'At Risk' groups aged two years or over whose notes record that pneumococcal immunisation has Greater than 90% of eligible patients have been immunised Greater than 75% of eligible patients have been immunised Greater than 75% of eligible patients have been immunised Greater than 75% of eligible patients have been immunised More than 80% and less than 89% of eligible patients have been immunised More than 70% and less than 74% of eligible patients have been immunised More than 70% and less than 74% of eligible patients have been immunised More than 70% and less than 74% of eligible patients have More than 70% and less than 79% of eligible patients have been immunised More than 60% and less than 69% of eligible patients have been immunised More than 60% and less than 69% of eligible patients have been immunised More than 60% and less than 69% of eligible Less than 70% of eligible patients have been screened Less than 60% of eligible patients have been screened 0.40 0.40 Less than 60% of eligible patients have been screened 0.40 Less than 60% of eligible patients have 0.40 22

8a 8b been given been immunised patients have been immunised been screened Subtotal for section 2.00 Patient Voice The practice The practice is The practice is is more than between 1 and between 0 and 1 2 standard Two indicators on patient voice need to be 2 standard As band B, with greater than standard deviations included. These can be taken from the list of deviations 0.32 10% improvement from the deviations from from the optional indicators in this workbook, or from from the previous year the average of average of elsewhere in the GP Patient Survey. average of the the benchmark the benchmark group benchmark group group 0.32 Subtotal for section 0.64 Grand total 3.44 23

THORNBURY ALBANY PRACTICE ST.MARGARETS HOUNSLOW DR SOOD'S CARLTON CHISWICK MOUNT MEDICAL WEST4 GPS THE 303 BATH TWICKENHAM CRANFORD ST DAVIDS BLUE WING CHESTNUT KINGFISHER FIRSTCARE CLIFFORD REDWOOD CROSSLANDS PENTELOW COLE PARK GREEN PRACTICE WILLOW PRACTICE BRENTFORD CHISWICK HOLLY ROAD JERSEY PRACTICE GLEBE STREET WELLESLEY GROVE PARK CLIFFORD ROAD GREENBROOK GROVE VILLAGE MANOR HOUSE SKYWAYS GILL MEDICAL HOUNSLOW BATH ROAD HATTON HIBERNIA HOUSE GREENBROOK GREENBROOK QUEENS PARK BRENTFORD LITTLE PARK GREENBROOK GREENBROOK GROVE PARK SPRING GROVE NORTH HYDE THE PRACTICE THE PRACTICE THORNBURY ALBANY ST.MARGARETS HOUNSLOW DR SOOD'S CARLTON CHISWICK MOUNT WEST4 GPS THE 303 BATH TWICKENHAM CRANFORD ST DAVIDS BLUE WING CHESTNUT KINGFISHER FIRSTCARE CLIFFORD REDWOOD CROSSLANDS PENTELOW COLE PARK GREEN PRACTICE WILLOW BRENTFORD CHISWICK HOLLY ROAD JERSEY GLEBE STREET WELLESLEY GROVE PARK CLIFFORD GREENBROOK GROVE MANOR HOUSE SKYWAYS GILL MEDICAL HOUNSLOW BATH ROAD HATTON HIBERNIA GREENBROOK GREENBROOK QUEENS PARK BRENTFORD LITTLE PARK GREENBROOK GREENBROOK GROVE PARK SPRING GROVE NORTH HYDE THE PRACTICE THE PRACTICE Appendix 3 Practice by Practice Aggregated Immunisation 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 12 Month Childhood Immunisation 5-in-1 Vaccination Rate Number of children in cohort not immunised Number of children in cohort immunised 70% Baseline 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 60 month Childhood Immunisation Rate Number of children in cohort not immunised Number of children in cohort immunised 70% Target 24

Appendix 4 On line appointment Practice Practice Code Clinical System Patient List 05-Oct-15 Online Appointments Available Online Repeat Prescriptions Available Online Access to Summary Record Number of Patients with Active Online Accounts % of Practice Population with Online accounts (Target 10%) Carlton Surgery E85024 TPP 5,300 Yes Yes Yes 25 0.47% Clifford House Medical Centre E85071 TPP 1,836 Yes Yes Yes 126 6.86% Gill Medical Practice E85708 TPP 4,498 Yes Yes Yes 368 8.18% Greenbrook Bedfont E85697 TPP 5,358 Yes Yes Yes 793 14.80% Grove Village Medical Centre E85699 TPP 5,118 Yes Yes Yes 31 0.61% Hatton Medical Practice E85718 TPP 4,695 Yes Yes Yes 48 1.02% Little Park Surgery E85736 TPP 6,139 Yes Yes Yes 535 8.71% Manor House Practice E85700 TPP 2,147 Yes Yes Yes 12 0.56% Mount Medical Centre E85035 TPP 4,534 Yes Yes Yes 386 8.51% Pentelow Practice E85115 TPP 3,009 Yes Yes Yes 364 12.10% Queens Park Medical Practice E85734 TPP 5,293 Yes Yes Yes 487 9.20% St David's Practice E85056 TPP 7,524 Yes Yes Yes 874 11.62% The Practice Feltham Centre For Health Y02672 TPP 8,021 Yes Yes Yes 786 9.80% Twickenham Park Medical Centre E85045 TPP 3,761 Yes Yes Yes 190 5.05% NHS Hounslow CCG 54 305,947 98% 98% 94% 43,671 14.27% CWHHE 253 1,408,972 96% 96% 95% 130,544 9.27% 25

Appendix 5 Cancer Screening Rates for Hounslow General Practices Bowel Cancer Screening Rates for Hounslow General Practice 26 2009/1 0 (%) 2010/1 1 (%) 2011/1 2 (%) 2012/1 3 (%) 2013/1 4 (%) Persons, 60-69, screened for bowel cancer within 6 months of invitation 45.3 45.4 43.6 46.5 44.0 44.6 (Uptake, ) 303 BATH ROAD SURGERY 29.9 37.5 30.6 36.6 29.2 36.0 ALBANY PRACTICE 44.7 45.9 40.3 43.9 42.6 40.2 BATH ROAD SURGERY 26.6 37.1 33.3 37.1 33.7 36.8 BLUE WING FAMILY DOCTOR UNIT 51.7 41.5 47.3 46.8 43.1 40.2 BRENTFORD FAMILY PRACTICE 36.5 37.7 43.5 39.0 46.2 43.2 BRENTFORD GROUP PRACTICE 54.5 55.3 45.8 55.7 47.6 52.5 CARLTON SURGERY 49.2 50.7 43.2 52.3 44.5 56.9 CHESTNUT PRACTICE 39.6 34.3 40.7 35.4 38.2 33.3 CHISWICK FAMILY DRS PRACTICE 40.4 48.6 41.0 54.2 40.4 51.7 CHISWICK HEALTH PRACTICE 49.1 56.4 47.6 52.7 50.0 58.1 CLIFFORD HOUSE MEDICAL CENTRE 53.8 51.4 50.4 56.3 49.1 55.1 CLIFFORD ROAD SURGERY 23.7 32.9 21.8 28.6 25.2 29.0 COLE PARK SURGERY 39.2 40.2 35.9 47.2 37.0 39.3 CRANFORD MEDICAL CENTRE 36.0 44.5 36.2 43.9 38.2 42.9 CROSSLANDS SURGERY 40.3 45.4 38.0 46.6 41.1 44.2 DR SOOD'S PRACTICE 51.2 42.0 42.1 41.8 41.2 34.4 FELTHAM CENTRE 37.5 34.9 33.8 33.7 42.9 31.7 FIRST CARE PRACTICE 33.9 44.3 38.8 48.6 35.8 41.3 GILL MEDICAL PRACTICE 45.0 42.4 39.6 44.0 42.1 33.3 GLEBE STREET SURGERY 49.6 48.5 49.2 46.0 44.0 50.9 GREEN PRACTICE 37.7 41.9 36.2 41.8 34.2 40.6 GREENBROOK BEDFONT 42.4 37.2 32.9 38.5 35.7 42.5 GREENBROOK CHINCHILLA 30.2 25.0 29.9 43.2 28.2 36.1 2014/1 5 (%)

27 GREENBROOK HESTON 41.1 32.1 37.6 34.3 38.5 33.7 GREENBROOK ISLEWORTH 39.5 35.8 41.9 45.2 43.0 50.0 GREENBROOK MANOR 43.9 45.6 39.3 43.5 46.1 33.3 GROVE MEDICAL CENTRE 44.3 46.4 42.9 42.8 39.2 41.2 GROVE PARK SURGERY 48.0 50.2 50.8 55.0 49.6 51.0 GROVE PARK TERRACE SURGERY 46.6 33.8 50.0 46.1 57.9 44.4 GROVE VILLAGE MEDICAL CENTRE 48.7 45.5 46.8 48.3 45.5 44.3 HATTON MEDICAL PRACTICE 29.9 45.8 32.8 44.4 38.4 37.7 HEART OF HOUNSLOW PRACTICE 61.5 22.9 31.9 31.4 38.3 33.5 HIBERNIA HOUSE SURGERY 39.4 36.3 44.6 37.6 41.1 38.6 HOLLY ROAD MEDICAL CENTRE 44.9 52.5 44.7 49.5 45.5 50.3 HOUNSLOW FAMILY PRACTICE 37.2 42.1 36.4 46.3 33.6 45.9 HOUNSLOW MEDICAL CENTRE 33.3 37.7 44.6 40.4 41.3 34.4 JERSEY PRACTICE 38.3 35.4 37.8 40.5 34.8 36.6 KINGFISHER PRACTICE 53.7 57.1 50.9 55.8 52.6 51.9 LITTLE PARK SURGERY 53.3 48.3 46.4 52.5 46.7 45.5 MANOR HOUSE PRACTICE 33.8 42.5 38.2 48.6 0.0 40.8 MOUNT MEDICAL CENTRE 43.8 45.9 39.3 50.5 46.4 47.5 NORTH HYDE MEDICAL PRACTICE 25.6 38.1 34.5 41.4 31.0 31.7 PENTELOW PRACTICE 53.2 48.5 54.4 60.7 59.6 56.0 QUEENS PARK MEDICAL PRACTICE 45.6 50.0 30.5 35.0 37.1 41.3 REDWOOD PRACTICE 44.8 51.3 51.5 51.0 51.9 48.6 SKYWAYS MEDICAL CENTRE 43.8 41.9 42.0 41.0 36.6 38.0 SPRING GROVE MEDICAL PRACTICE 42.0 32.8 38.4 37.6 43.1 34.6 ST DAVIDS PRACTICE 55.5 46.9 50.0 47.1 43.4 45.7 ST.MARGARETS PRACTICE 53.8 51.5 53.7 51.6 57.4 52.2 THORNBURY ROAD CENTRE FOR HEALTH 47.5 53.7 47.9 50.8 45.7 52.7 TWICKENHAM PARK MEDICAL CENTRE 48.9 42.2 45.2 50.5 51.2 47.5 WELLESLEY ROAD PRACTICE 56.9 55.7 54.1 52.3 54.1 55.8 WEST4 GPS 52.3 50.9 52.4 54.8 53.6 52.0 WILLOW PRACTICE 60.3 54.5 58.2 52.8 54.3 52.4

Cervical Screening Rates for Hounslow General Practice 28 2009/10 (%) 2010/11 (%) 2011/12 (%) 2012/13 (%) 2013/14 (%) 2014/15 (%) Females, 25-64, attending cervical screening within target period (3.5 or 5.5 year coverage, ) 69.6 67.7 66.8 66.3 67.6 65.6 303 BATH ROAD SURGERY 67.8 65.0 62.9 61.4 65.7 65.6 ALBANY PRACTICE 67.6 67.5 65.5 64.1 66.1 64.3 BATH ROAD SURGERY 70.5 64.3 67.7 70.5 72.3 70.3 BLUE WING FAMILY DOCTOR UNIT 68.1 70.1 70.9 71.3 68.1 66.7 BRENTFORD FAMILY PRACTICE 69.6 69.4 72.3 70.3 71.4 68.1 BRENTFORD GROUP PRACTICE 73.6 73.3 75.1 75.6 77.4 73.8 CARLTON SURGERY 78.9 77.9 77.8 75.4 76.0 74.5 CHESTNUT PRACTICE 57.9 55.4 59.8 65.9 71.8 70.3 CHISWICK FAMILY DRS PRACTICE 70.8 69.4 67.7 69.6 68.3 65.4 CHISWICK HEALTH PRACTICE 68.3 66.0 62.2 59.6 66.3 61.2 CLIFFORD HOUSE MEDICAL CENTRE 79.9 79.8 75.4 80.0 76.0 75.9 CLIFFORD ROAD SURGERY 57.7 52.4 55.2 52.5 53.7 56.4 COLE PARK SURGERY 70.4 71.7 76.4 76.1 76.5 75.3 CRANFORD MEDICAL CENTRE 75.8 77.4 78.9 77.7 74.9 72.0 CROSSLANDS SURGERY 72.3 72.0 73.0 70.4 70.2 68.4 DR SOOD'S PRACTICE 67.7 72.3 72.6 76.7 69.3 71.2 FELTHAM CENTRE 55.1 56.5 60.7 61.5 62.6 57.8 FIRST CARE PRACTICE 57.6 55.0 52.2 52.1 55.0 54.1 GILL MEDICAL PRACTICE 70.9 70.3 77.3 75.7 73.3 71.2 GLEBE STREET SURGERY 77.8 76.6 76.3 76.4 78.4 77.6 GREEN PRACTICE 61.2 59.7 58.1 60.7 59.9 56.0 GREENBROOK BEDFONT 67.7 70.4 69.5 64.8 70.1 69.3 GREENBROOK CHINCHILLA 66.0 65.7 64.6 57.3 61.9 59.1 GREENBROOK HESTON 61.8 62.9 59.9 58.5 61.2 57.5 GREENBROOK ISLEWORTH 71.3 68.0 66.5 66.8 65.9 62.8 GREENBROOK MANOR 70.9 69.7 67.2 66.3 65.3 65.7 GROVE MEDICAL CENTRE 63.6 64.2 63.2 64.5 63.5 65.8