PRIMARY CARE COMMISSIONING COMMITTEE MEETING Date of meeting Title of report 20 th June 2017 Agenda item number Unscheduled Primary Care Services for the Fylde Coast 7 Paper Presented by: Alison Kerfoot, Director of Strategic Procurement & Commissioning Support, John Gaskin, Deputy Chief Finance Officer Paper prepared by: Chris Gough, Senior Procurement Manager CCG strategic objective supported by this paper: (please tick ) Purpose of report Develop and maintain an effective organisation Commission high quality, safe and cost effective services which reduce health inequalities and improve access to healthcare Effectively engage patients and the public in decision making Develop excellent partnerships which lead to improved health outcomes Make the best use of resources The purpose of this report is to provide the Primary Care Co-commissioning Committee with an update in respect of the next steps of the procurement. Recommendation The Primary Care Commissioning Committee is requested to accept and approve the recommendation noted in the report, to proceed with the direct contract award for the provision of Unscheduled Primary Care Services for the Fylde Coast. This will enable the completion of Contracts to be signed based on high level parameters above with a provision for collaborative contract and performance management agreement, to maximise the quality and efficiency opportunities throughout the life of the contract and therefore the new contract for Unscheduled Primary Care Services to be in place by 1 st July 2017. Please indicate which Group this has been discussed with (please tick ) Executive Management Team Clinical Commissioning Committee Audit Committee Council of Members Other/Not Applicable Patient and Public Engagement: Equality Impact Assessment: Quality Improvement and Governance Cttee Finance and Performance Committee Remuneration Committee Primary Care Commissioning Committee Not applicable Not applicable Resource Implication(s): For further information please contact: Barbara McKeowen
Unscheduled Primary Care Services for the Fylde Coast Outcome Report Version: 2 Date: 16 th June 2017 1. Introduction The contract award for the Provision of Unscheduled Primary Care Services for the Fylde Coast (the Services) was agreed in principle in 2016 following a robust direct contract award process which demonstrated that the incumbent Providers were the most capable of providing the services. The direct award is subject to satisfactory conclusion of due diligence, VFM and service delivery sign off against the four checkpoints referenced below which were agreed by the NHS Fylde and Wyre Primary Care Co-commissioning Committee. The process met the requirements of the Public Contract Regulations 2006 and The National Health Service (Procurement, Patient Choice and Competition (No.2)) Regulations 2013 and will enable improved quality, value for money and integration of the services. The process was assured through engagement with NHS Improvement as well as legal review by Capsticks and independent review by two GPs with interest and experience in Unscheduled Care. The decision to award a contract to the incumbent Providers (listed below) was approved by the Governing Body of NHS Blackpool CCG and the Primary Care Co-Commissioning Committee of NHS Fylde and Wyre CCG (the CCGs) in August and September. Fylde Coast Medical Services (NW) Ltd PDS (Medical) Ltd Bloomfield Medical Centre (in partnership with Blackpool Teaching Hospital) In addition to the above listed Providers, Fleetwood Community Care (Fleetwood Federation) will continue to deliver the Extended Access to General Practice element of the service specification across Fleetwood (whilst the other providers will deliver Extended Access to General Practice to the rest of the Fylde Coast). In doing so, they will act as a sub-contractor to FCMS, please see further information below (on page 2) regarding organisational form/the completion of checkpoint 1. The Providers were then informed of the decision in October and following a standstill period, a due diligence process (working towards enabling service mobilisation) began in December after no challenges were received. 2. Due Diligence and Mobilisation Work to Date A joint Provider and Commissioner Mobilisation Board was formed, including representatives from: 1
NHS Blackpool Clinical Commissioning Group NHS Fylde and Wyre Clinical Commissioning Group NHS Shared Business Services Fylde Coast Medical Services (NW) Ltd PDS (Medical) Ltd Bloomfield Medical Centre Blackpool Teaching Hospital The primary objectives of the Mobilisation Board are listed below with responsibility for their achievement also identified. Objective Refine the CCGs service specification. Develop and agree the Providers joint proposal for service delivery. Enable joint management of the mobilisation and contracting. Oversee and manage the mobilisation activities required to enable successful service delivery. Responsibility Commissioner Responsibility Joint Provider and Commissioner responsibility - The Providers are responsible for defining their service delivery plans - The Commissioners then responsible for reviewing those plans - The Providers and Commissioners are jointly responsible for agreeing a final version of those plans which will form part of the contract document Joint Provider and Commissioner responsibility Joint Provider and Commissioner responsibility As agreed, the following checkpoints were established which were used to monitor progress against these objectives, including:- Checkpoint 1 Develop and agree the form of contract e.g. aligned bilateral contracts with an overarching alliance agreement or lead provider model and potential capitated budget. Checkpoint 2 Completion of the open book financial assessment and satisfactory conclusion of value for money by the CCGs CFO and mutual agreement to an affordable maximum contract price, which will be reduced where efficiency is identified and realised over the life of the contract. Checkpoint 3 Due diligence on workforce plan to deliver the integrated service model with long term joint workforce strategy driven by clinical excellence, sustainability and operational efficiency. Checkpoint 4 Contracts to be signed based on high level parameters above with a provision for collaborative contract and performance management agreement to maximise the quality and efficiency opportunities throughout the life of the contract. 2
3. Checkpoint 1 Form of Contract Checkpoint 1 has been completed and it has been agreed that FCMS (NW) Ltd will act as the Lead Provider, with PDS (Medical) Ltd, Bloomfield Medical in partnership with Blackpool Teaching Hospitals NHS Foundation Trust and Fleetwood Community Care Limited delivering services as subcontractors to FCMS. The advantages of this model being that: The CCGs will be able to manage the service provision through a single contract The contracting model gives the Providers the flexibility to work together to improve the efficiency of the Unscheduled Primary Care Services All provider staff will continue to have access to NHS pensions Separately from the Mobilisation Board meetings, Commissioner Only Mobilisation meetings have been held in order to address actions that are specific to the CCGs. 4. Checkpoints 2 & 3 Due Diligence, Service Delivery Plan and Finance Assessment In order to enable completion of mobilisation checkpoints 2, 3 and 4, a Due Diligence and Service Delivery Plan Assessment process has been undertaken using a similar methodology to a tender process. In parallel to this an open book assessment of the Providers financial model has also been undertaken. The assessment was based upon the Providers responses to: 1. A Due Diligence Questionnaire 2. A Service Delivery Plan and Finance Questionnaire The Providers submitted their responses to these questionnaires on 13 th April and presented their service delivery plans to the CCGs at a Mobilisation Board meeting held on 20 th April. The Commissioner Group then undertook a detailed evaluation of the information submitted along the following timeline: Activity Detailed review of due diligence information, service delivery and mobilisation plans. Open Book Finance Meeting First Commissioner only review meeting First Provider feedback meeting Further information and clarifications requested Provider responses to further information request and clarifications questions received Second Commissioner only review meeting Further information and clarifications requested Date 13 th and 25 th April 24 th April 26 th April 28 th April 8 th May 23 rd May 3
Provider responses to further information request and clarifications questions received Second Provider feedback meeting 31 st May 14 th June 4.1. Due Diligence The Due Diligence Questionnaire was used to confirm the Providers suitability to deliver the Services by assessing their capability, capacity, economic and financial standing. The Providers response to the due diligence questionnaire has been reviewed by relevant subject matter experts from both CCGs. The questionnaire was assessed on a pass/fail basis and the Providers achieved a pass for all sections of the questionnaire which included: 1. Economic and Financial Standing o Analysis of providers financial accounts 2. Technical and Professional Ability o Evidence of providers records of delivering similar services 3. Grounds for Mandatory Exclusion o Provides self-declaration of compliance with the law (i.e. bribery; fraud) 4. Grounds for Discretionary Exclusion o Provides self-declaration of compliance (i.e. misconduct; distorting competition) 4.2. Service Delivery Plan Assessment The Service Delivery Plan Questionnaire was used to assess the Providers service delivery proposals, focussing on the following areas:- Principles of Service Delivery Clinical Outcome Requirements Patient pathway, access and communication Efficiency and Integration Referral / Appointment Management Patient Education Workforce IM&T Quality and Safety Contract Management and Mobilisation Social Value Finance New Locations (Fylde and Wyre CCG only) Subject matter experts from both CCGs reviewed the responses to the Service Delivery Plan Questionnaire in order to assess how well the Providers responses met the requirements and desired outcomes of the service specification. Following the CCGs review of the Providers responses to this questionnaire a number of areas where more information was required were identified. This information was provided firstly on 8 th May and then on 31 st May. 4
On 14 th June, representatives of both CCGs met with the Providers in order to enable further discussion of the issues raised for clarification and to give Commissioners the further assurance required in order to enable them to recommend that the CCGs award the contract. A key outcome of the service delivery plan assessment is to ensure that the due diligence on the workforce plan to deliver the integrated service model is undertaken. This is one subject area where further information was requested through the assessment process in order to ensure the appropriate level of scrutiny. During the meeting on 14 th June, the Commissioners agreed that they were satisfied with the information provided and therefore that Checkpoint 3 had been completed. However it was also agreed that the appropriateness of the workforce (i.e. total staff numbers and skill mix) would be monitored through the contract management process. 4.3. Finance An open book finance meeting took place on 24 th April, a number of clarification questions were asked at that meeting which have now been satisfactorily answered. Given that the Clinical Staffing costs represent circa 74% of the total annual contract price, it was also essential that Checkpoint 3 could be completed prior to the completion of Checkpoint 2. This has been achieved, therefore enabling mutual agreement to an affordable contract price and pass through Checkpoint 2. 4.4. Outcome The outcome of the due diligence, service delivery plan and finance assessment process is therefore that Checkpoints 2 and 3 have been completed and that the Commissioner Group recommends that the CCGs proceed with the contract award, progressing towards contract sign-off. 5. Checkpoint 4 Prior to contract sign-off, both CCGs are in the process of refining and agreeing the key performance indicators. In addition a mobilisation group has been established in order to agree timelines, aligning all stakeholders priorities against the Providers initial proposal. As part of the contract management process various risks and issues have been identified which are described below. 5.1. Contract Form and KPIs The contract payment will be based on a 70% assured and 30% incentivised split. There will be 8 KPIs that are incentivised related to the following subject areas: - Extended Access (2 KPIs) 5
- Prescribing (2 KPIs) - Workforce - ED attendances - IUCS diversions/discharge (2 KPIs) In addition, there will be a robust process for reviewing actual activity against modelled activity, with the contract value being adjusted should there be significant variances. 5.2. Mobilisation As part of the service delivery plan assessment, the Providers have submitted a mobilisation plan which will be refined by a mobilisation group comprising appropriate members of both CCGs and Providers. The mobilisation group will meet on a weekly basis from 23 rd June. The mobilisation group will routinely report progress to the Primary Care Co-commissioning Committee. 5.3. Risks/Issues Identified The following risks and issues have been identified and will be managed through the mobilisation and/or contract management process. Risk/Issue There is a risk that further (or inappropriate) activity is diverted to the Blackpool Teaching Hospital Combined Assessment and Treatment (CAT) service which should be dealt with through the Unscheduled Primary Care Services. The CAT Service is paid for on a tariff basis whilst the Unscheduled Primary Care Services will be paid for on a block basis therefore an increase in activity for the CAT service would potentially increase PbR costs in that area but a corresponding decrease in activity for the Unscheduled Primary Care Services would not lead to a decrease in costs. Therefore the risk is that the overall cost to the CCGs would increase. A potential issue was identified with regards to FCMS approach to management of clinical audits. Audits are undertaken by local GPs who are paid to undertake the audit by FCMS. The GPs who undertake the audit can be split into two categories: Mitigation Actions This risk can be mitigated by ensuring that the Acute UCC Gateway and all other triage points are working effectively and directing patients to the most appropriate place. This will be addressed during mobilisation and through robust contract management. Furthermore, ongoing assessment of staff numbers and skill mix will identify whether or not any area of the Unscheduled Primary Care Services is being underutilised and adjustment of staff numbers and skill mix as well as the contract cost can be agreed through a contract variation. Any increase in ACS activity will be monitored and discussed with providers. The mitigation actions are therefore: 1. CCG representatives to observe the audit process and seek to amend should it be deemed necessary. 6
1. GPs who only undertake audit 2. GPs who undertake audit as well as providing GP clinical sessions on behalf of FCMS 2. CCG representatives to review the process for managing the auditors conflicts of interest. The issue identified therefore relates to the management of the auditors conflicts of interest. There is a risk that some of the key milestones for service transformation may not be achieved by the proposed completion date. The completion dates proposed by FCMS are to be agreed with Commissioners through a separate mobilisation work stream which is due to begin on 23 rd June and continue on a weekly basis. Mobilisation work will commence once the contract award decision is confirmed. The providers have undertaken a gap analysis to show the difference between the current and future workforce. Due to the workforce market conditions, there is a risk that the Providers will not be able to recruit to fill all posts required. The Providers will commence recruitment as soon as the contract award is confirmed. The workforce gaps primarily relate to the GP extended access service in Blackpool. The Providers have experience of running the Fylde and Wyre GP extended access service which is currently working well and will implement recruitment lessons learnt. The providers also highlighted the co-location with the walk-incentre as an opportunity to share staff. In addition, a KPI (linked to finance) has been agreed which relates to the Providers rota fill rate. 6. New Locations for Fylde and Wyre CCG As part of the service delivery plan assessment process the providers undertook a review of available sites in the South of the Fylde and Wyre CCG area. Three options were identified in the Lytham area but with only one of those sites providing the required clinical space. The site identified that best meets the CCG s requirement is located at Lytham Primary Care Centre, Warton Street, Lytham St. Anne s, Lancashire, FY8 5EE. Future plans for the utilisation of the building are to be confirmed and further work to identify additional funding requirements is underway. 7
In addition to the North and South proposed locations, further discussions were held with the providers to enable extended access provision to be provided from Wyre Integrated Neighbourhood and also Kirkham and Wesham Neighbourhood. Options for future provision are noted below: Option 1 - North and South based Provision (included in the existing model) Option 2 Full Neighbourhood based Extended Access Provision Option 3 - North and South Hub Based Provision with 2 Additional Extended Access Spokes Option 4 Spoke Based Neighbourhood Extended Access Provision providing 7 days across CCG The options were discussed with the Clinical Leads who recommend Option 3 as the preferred choice. 7. Action Requested It is requested that the Primary Care Co-commissioning Committee accepts and approves this recommendation to proceed with the contract award for the provision of Unscheduled Primary Care Services for the Fylde Coast. This will enable the completion of Checkpoint 4 and therefore the new contract to be signed and to commence on 1 st July 2017. 8