AGENDA A meeting of the Primary Care Commissioning Committee in public Date: 21 August 2018

AGENDA A meeting of the Primary Care Commissioning Committee in public Date: 21 August 2018 Time: 9.30-11.30 am Venue: Cantilever House, Eltham Road, London SE12 8RN Chair: Shelagh Kirkland Enquiries to: Lesley Aitken Telephone: 020 7206 3360 Email: lesley.aitken@nhs.net Members Diana Braithwaite Alison Browne Anne Hooper Shelagh Kirkland (Chair) Dr Faruk Majid David Maloney Dr Jacqueline McLeod Dr Marc Rowland Ray Warburton OBE Martin Wilkinson Director of Commissioning and Primary Care Registered Nurse Lay Member Lay Member Clinical Director Interim Chief Financial Officer Senior Clinical Director Chair Lay Member Managing Director Voting Members a. 3 x Lay Members o o o b. CCG Chair Chair: Lay Member for Primary Care Vice Chair: Lay Member responsible for Patient Public Engagement Lay Member: Chair of the Audit Committee and Conflicts of Interest Guardian c. 2 Governing Body GP Members d. Registered Nurse or Secondary Care Specialist (single member) e. CCG Managing Director f. CCG Chief Financial Officer g. Director of Commissioning & Primary Care Non-Voting Members a. Local Medical Committee Representative b. Healthwatch Representative c. Local Authority Representative of the Health and Wellbeing Board (Elected Member or Mandated Officer) d. Officers as required to undertake business of the committee e. NHS England Representative Chair: Dr Marc Rowland Accountable Officer: Andrew Bland Managing Director: Martin Wilkinson

Quorum 1. The quorum shall be a minimum of 4 members, of which 2 must be Lay Members. 2. Where a quorum cannot be convened from the membership, owing to arrangements for the management of conflicts of interest or potential conflicts of interest; the Chair of the meeting will comply with the conflicts of interest policy. 3. This may result in; a. The meeting being deferred b. A discussion being undertaken but the decision deferred until the next meeting c. Discussion being undertaken being deferred to the Governing Body Chair: Dr Marc Rowland Accountable Officer: Andrew Bland Managing Director: Martin Wilkinson

Order of Business Time Item Papers Presented by 1. 09:30 Welcome and Introductions Chair 2. Apologies for absence Chair 3. Declarations of Interest Chair Members should discuss any potential conflicts of interest with the Chair prior to the meeting. 4. 09:35 Minutes 1-12 Chair To approve the minutes of the PCCC meeting on 19th June 2018. To approve the minutes of the urgent planned PCCC meeting held on 17th July 2018 to consider CCG support for practice Improvement Grant applications 5. 09:45 Actions 13-20 Chair Review of actions Standing Items 6. 09:50 Finance Report - Month 3 21-24 Michael Cunningham Purpose: To note. 7. 10:00 Primary Care Operational Group: Chairs report Purpose: To note. 25-26 Dr Jacky McLeod 8. 10:10 GP Forward View (GPFV): Update 27-30 Noor Butt Purpose: To note. 9. 10:20 NHS Walk-in Centre, New Cross Closure: Monitoring Plans Purpose: To note. Verbal update Diana Braithwaite Chair: Dr Marc Rowland Accountable Officer: Andrew Bland Managing Director: Martin Wilkinson

Time Item Papers Presented by For Decision 10. 10:25 Medicines Optimisation Plan Local Improvement Scheme (LIS) 2018/19 31-40 Erfan Kidia Purpose: To approve. CoI: There is a conflict of interest for Clinical Directors in their role as General Practitioners as they will financially benefit from the scheme. Therefore, in order to mitigate any perceived/potential CoI and/or any undue influence; Clinical Directors on the committee will be excluded from taking part in any decisions. To note 11. 10:40 Merger: Rushey Green Group Practice / Baring Road Medical Centre - Update Purpose: To note. 41-44 Nick Langford 12. 10:55 AOB Chair 13. 11:00 Meeting Close Chair For information 14. None Foward Planner 15. Primary Care Quality Dashboard Refreshing PMS Commissioning Intentions Workshop Date of next meeting: Tuesday, 16 October 2018, 9.30 am Chair: Dr Marc Rowland Accountable Officer: Andrew Bland Managing Director: Martin Wilkinson

Managing Conflicts of Interest: Governing Body, committees, sub-committees and working groups 1. The chair of the Governing Body and chairs of committees, subcommittees and working groups will ensure that the relevant register of interest is reviewed at the beginning of every meeting, and updated as necessary. 2. The chair of the meeting has responsibility for deciding whether there is a conflict of interest and the appropriate course of corresponding action. In making such decisions, the chair may wish to consult the member of the governing body who has responsibility for issues relating to governance. 3. All decisions, and details of how any conflict of interest issue has been managed, should be recorded in the minutes of the meeting and published in the registers. 4. Where certain members of a decision-making body (be it the governing body, its committees or sub-committees, or a committee or sub-committee of the CCG) have a material interest, they should either be excluded from relevant parts of meetings, or join in the discussion but not participate in the decision-making itself (i.e., not have a vote). 5. In any meeting where an individual is aware of an interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, the individual concerned will bring this to the attention of the chair, together with details of arrangements which have been confirmed by the governing body for the management of the conflict of interests or potential conflict of interests. Where no arrangements have been confirmed, the chair may require the individual to withdraw from the meeting or part of it. The new declaration should be made at the beginning of the meeting when the Register of Interests is reviewed and again at the beginning of the agenda item. 6. Where the chair of any meeting of the CCG, including committees, sub-committees, or the governing body, has a personal interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, they must make a declaration and the deputy chair will act as chair for the relevant part of the meeting. Where arrangements have been confirmed with the governing body for the management of the conflict of interests or potential conflicts of interests in relation to the chair, the meeting must ensure these are followed. Where no arrangements have been confirmed, the deputy chair may require the chair to withdraw from the meeting or part of it. Where there is no deputy chair, the members of the meeting will select one. 7. Where significant numbers of members of the governing body, committees, sub committees and working groups are required to withdraw from a meeting or part of it, owing to the arrangements agreed by the Governing Body for the management of conflicts of interest or potential conflicts of interest, the remaining chair will determine whether or not the discussion can proceed. 8. In making this decision the chair will consider whether the meeting is quorate, in accordance with the number and balance of membership set out in the CCG s standing orders or the relevant terms of reference. Where the meeting is not quorate, owing to the absence of certain members, the discussion will be deferred until such time as a quorum can be convened. Where a quorum cannot be convened from the membership of the governing body, committees, sub committees and working groups owing to the arrangements for managing conflicts of interest or potential conflicts of interest, the chair may invite on a temporary basis one or more of the following to make up the quorum so that the CCG can progress the item of business: a. an individual GP or a non-gp partner from a member practice who is not conflicted b. a member of the Lewisham Health and Wellbeing Board; c. If quorum cannot be achieved by a) or b) (above) a member of a governing body of another clinical commissioning group. 9. These arrangements will be recorded in the minutes. Chair: Dr Marc Rowland Accountable Officer: Andrew Bland Managing Director: Martin Wilkinson

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Item Number 4 Primary Care Commissioning Committee Tuesday 20 th June 2018 Present Shelagh Kirkland (SKi) Chair Magna Aidoo (MA) Lay Member Healthwatch Representative Alison Browne (AB) Governing Body Registered Nurse Member Diana Braithwaite (DB) Director of Commissioning & Primary Care Anne Hooper (AH) Lay Member Public Engagement David Maloney (DM) Chief Financial Officer, Lewisham and Greenwich CCGs Dr Jacqueline McLeod (JM) Clinical Director Ashley O Shaughnessy (AOS) Deputy Director of Primary Care Simon Parton (SP) Chair, Local Medical Committee Dr Marc Rowland (MR) Chair, Lewisham Clinical Commissioning Group Jill Webb (JW) South East London Primary Care Contracting Team Martin Wilkinson (MW) Managing Director Attending Lesley Aitken (LA) Noor Butt (NB) Russell Cartwright (RC) Colin Paget (CP) Apologies Nick Langford (NL) Dr Faruk Majid (FM) Dr Danny Ruta (DR) Folake Segun (FS) Ray Warburton (RW) Board Secretary (Minutes) Commissioning Manager Head of Communications and Engagement Lewisham CEPN South East London Primary Care Contracting Team Clinical Director Director of Public Health, LBL Director, Healthwatch Lewisham Lay Member, Chair of the Audit Committee and Conflicts of Interest Guardian 1. Welcome and Introductions 1.1 The Chair welcomed everyone to the meeting. Introductions were made. RW, due to being unable to attend the meeting, had provided comments on agenda reports. 2. Declarations of Interest 1.2 In addition to the declarations recorded on the NHS Lewisham Clinical Commissioning declarations of interest register, it is noted that for agenda items; 9 Supporting Practice Engagement in Clinical Commissioning LIS 2018/19: there is a conflict of interest for Clinical Directors in their role as GPs. The Clinical Directors will be excluded from taking part in any decisions. 10 PMS: Patient Voice Evaluation: there is a conflict of interest for Clinical Directors in their roles as GPs as will financial benefit from the premium and a conflict of interest for Dr Simon Parton as Chair of the LMC and as a GP will benefit from the premium. Clinical Directors and Dr Simon Parton will not partake in any decisions related to the item. 11 Healthwatch Accessible Information Standards: There is a conflict of interest for PCCC members whose practices are specifically mentioned in the report. The conflict for Dr Simon Parton is noted. Dr Marc Rowland and Dr Faruk Majid are absent from the meeting. 13 Business Merger: South Lewisham Group Practice, Bellingham Green Surgery, Jenner Health Centre and the Modality super-partnership; there is a conflict of 1 P age PCCCAUG2018 Page 1

interest for Dr Simon Parton who will not take part in any discussions on the item. Dr Marc Rowland is absent from the meeting. 14 Single Hander Status Vale Medical Centre: there is a conflict of interest for Dr Jacky McLeod as a salaried GP at the Vale Medical Centre, she will not take part in any discussions on this item. 1.3 DM declared that he is a PCCC member for Greenwich CCG. 3. Minutes of the previous meeting 1.4 The minutes of the meeting held on Tuesday 17 April 2018 were agreed as an accurate record. 4. Review of action log 1.5 The committee reviewed the outstanding actions and the log was updated. 5. Financial Report 2017/18 Outturn and 2018/19 Budget 5.1 DM reported that there would be a Q1 Finance report brought to the next meeting. The old year had been closed down with a small overspend for Primary Care Commissioning of 42k. The 2018/19 budget is 42.87m. ACTION: DM to circulate to Committee members a breakdown of the budget and movement from 2018/19. The Committee noted the financial outturn for 2017/18 and the budget for 2018/19. 6. Primary Care Operation Group: Chairs Report 5.2 JM gave the report from the Primary Care Operation Group (PCOG) meeting held on 10 May. 5.3 The CCG along with One Health Lewisham has made a bid against Transformation Fund for: Supporting Neighbourhood Delivery; to support advancement in the use of Population Health and a more systematic approach to quality improvement, and; System Partnership; to support development of formal relationships with partner organisations. 5.4 An update was received on the PMS contract which included the removal of the patient voice specification. A summary of the practice responses to the patient voice selfassessment template was reviewed. 5.5 The Primary Care Quality Dashboard will be updated at least twice a year and would be brought to the October PCCC meeting. 5.6 A Primary Care Development Event had been held on 1 May from which the outcomes would be shared with all practices. There would be a follow up event in July with a focus on workforce development. 5.7 There was funding available across London for the Quality Premium with bids to be put forward on areas; core infrastructure, quality Improvement and system partnership with a focus on the latter two. ACTION: The Self-Assessment Maturity Matrix would be brought to the August PCCC meeting. The Committee noted the report. 7. GP forward View (GPFV): Update 5.8 AOS explained that the update would now focus on any changes since the last report given. The following was highlighted: Admin and clerical training; there had been Medical Assistant training for six practices in May with subsequent follow up sessions planned to ensure that learning is embedded. 2 P age PCCCAUG2018 Page 2

Further funding was expected for Care Navigator and Medical Assistant training for 2018/19. GP Extended Access (GPEA); in April 2018 there was 3000 appointments available with a DNA rate of 16%. Work was ongoing with the Federation looking at how to bring this rate down, including ringing and texting patients before their appointments. A London School of Economics student was working with the CCG on reviewing the first year of the GPEA service; this will support commissioning the service for 2019/20. It was confirmed that the 299 appointments not booked were paid for as part of the service. This would be looked into. There is a good utilisation of GP practice and Urgent Care appointments. The evaluation will be reviewed at the contract management meeting with the provider. 5.9 AOS explained that the Medical Assistant training was for non-clinical staff to support clinicians and that the Care Navigator Training was for front line staff. 5.10 GP Development Programme: An econsultations app had been developed which was currently being trialled in one practice which will be rolled out to all practices in the summer, with all patient contacts being traced to ensure that the outcomes are clinically correct. ACTION: AOS to check where the responsibility would lie if there was a problem with the app. 5.11 3 a head transformation funding: 50p per head is available to practices to support working at scale. 57,891.50 funding has been allocated so far which will include cover for legal costs, HR support and external facilitation. Practice mergers were also supported by the funding. The second phase of funding was being released to those practices that are merging or recently merged. 5.12 AOS informed the Committee that the legal advice was procured direct by the practices. DB advised that it would not be appropriate for the CCG to recommend any particular legal support as if there were issues with the support provided, the CCG could be liable. It was suggested that practices should look at advice at scale to ensure value for money. AGREED: SK, DM and AOS will review all applications. 5.13 Referring to econsultations, AOS stated that there was funding of 111k for the second year of the programme and it was expected all practices would be on board by September 2018. JM added that econsultations was just part of what local practices should offer as part of a package of care. Communication was important to promote the service to younger patients. The Committee noted the update on the implementation of the GP Forward View. 8. NHS Walk-in Centre, New Cross Closure: Monitoring Plans 8.1 DB reminded the Committee that the NHS Walk in Centre (WiC), New Cross closed on 31 st March 2018 and that the PCCC had been charged by the Governing Body with monitoring of the assurance and mitigation plans following the closure. It was highlighted: The Clinical Streaming & Redirection Service provide by nurses, was supporting the UCC, redirecting patients to the right service. The Rough Sleepers pilot was launched in April. The pilot would be evaluated at the end of the year and is commissioned from the Amersham Vale Training Practice and is located at two sites; (i) Deptford 999 Club; and (ii) Amersham Vale. The design, 3 P age PCCCAUG2018 Page 3

engagement, development of this pi8lot has been recognised as an exemplar by the Healthy London Partnership (HLP). The PALS team offered support through the redirection if requested. It was noted that the most frequent reason for attending the WiC was for sexual health services. There would be a full review on the impact of the closure, which would be submitted to the PCCC before being presented to the Healthier Communities Select Committee in October 2018. There is no evidence that the closure of the WiC has impacted on the volume of attendances to A&E, the UCC or ED at University Hospital Lewisham and monitoring would continue. The CCG had commissioned the Pharmacist located at the Waldron Health Centre to open over the Bank Holidays in May. 8.2 JM thanked all the team involved for all their hard work. Recognising that the expenditure for the WiC is now finished, what was the expenditure now for the small group of patients? DB responded that there was ongoing investment in areas such as the Rough Sleepers service. The GP Extended Access Service is a mandated service and funded centrally. The main engagement with local communities and stakeholders had ceased - although there would be continued engagement with some groups. The Use the Right Service had been a successful campaign and would be considered for use during winter. 8.3 It was not possible to collect data on potential rough sleepers who may have attended the WiC. The information used was provided by the local authority, which includes their regular street count. 8.4 The Committee praised the excellent work undertaken and in particular with the networks developed. The Committee noted the report. 9. Supporting Practice Engagement in Clinical Commissioning Local Improvement Scheme (LIS) 2017/18: Evaluation 10.1 There is a conflict of interest (CoI) for Clinical Directors for this item in their role as General Practitioners as either they or the practices will financially benefit from the scheme. Therefore, in order to mitigate any perceived/potential CoI and/or any undue influence; Clinical Directors on the committee will be excluded from taking part in any decisions. 10.2 Russell Cartwright (RC) explained that the purpose of the LIS was to support Lewisham GP practices engagement in commissioning and service redesign by financially compensating practices for their input. The total paid to each practice in 2017/18 was 3,600 in two parts, A and B. 10.3 Part A consisted of: Neighbourhood commissioning meetings CCG- Led Protected Learning Time (PLT) events Surveys Practice Contacts 10.4 Part B consisted of: Pathway Redesign 10.5 In response to the Committee s query on the cost to fund locum cover, Dr Simon Parton (SP) advised that the cost was low and that 2k covered all practices, the cover was hours 12:30 18:30. The GP Extended Access Service is also additional capacity. 4 P age PCCCAUG2018 Page 4

The cover created time for GPs to discuss quality improvement issues and development for practices. There is generally good attendance across all practices for Neighbourhood meetings. DB added that commissioning issues such as the dashboard are discussed at meetings. The Committee noted the report. 10. Personal Medical Services: Patient Voice Specification Evaluation 13.1 There is a conflict of interest (CoI) for Clinical Directors in their role as General Practitioners either they or their practices will financially benefit from the premium. Therefore, in order to mitigate any perceived/potential CoI and/or any undue influence; Clinical Directors on the committee will not partake in any decisions related to this item. There is also a conflict of interest for Dr Simon Parton as Chair of the LMC and as GP who practice will benefit from the premium. Therefore, in order to mitigate any perceived/potential CoI and/or any undue influence; Dr Parton will not partake in any decisions related to this item. 13.2 AOS reminded the Committee that it had been agreed the April 2018 meeting that a report would be complied to provide assurance of delivery against the Patient Voice specification. 13.3 It is proposed to hold a PCCC workshop to discuss the impact of the MPIG adjustment for 2019/20 and 2020/21. 13.4 Practices conducted a one off self-assessment against a number of questions related to patient experience of making an appointment and developed action plans. As part of the template, practices had provided narrative which would be collated with learning shared across practices. Actions included reception training and an intensive deep dive on practice s websites. Most practices welcome the action plans as a way of improving patient experience. 13.5 AOS explained that it had been confirmed that the impact of the MPIG adjustment for 2018/19 was 0.41p per weighted patient. Through the removal of the Patient Voice specification this left an unallocated amount of 0.09 per weighted patient. This equates to 630 for an average practice. Through the PMS contract and Improvement Groups it had been recommended to use the funding with the PPGs to focus on FFT with analysing data as a specific piece of work. SP added that this may generate valuable questions. ACTION: AOS to bring a headline report back to the PCCC for the February 2019 meeting on the premium which would include Commissioning Intentions. 13.6 The Committee noted the evaluation of delivery against PMS contract Patient Voice specification and noted the proposal to use the remaining 0.09p per weighted patient resulting from the MPIG adjustment for 2018/19. AGREED: To convene a PCCC workshop to discuss the proposals to manage the impact of the MPIG adjustment for 2019/20 and 2020/21. 11. Healthwatch: Accessible Information Standards 17.1 There is a conflict of interest (CoI) for PCCC members, whose practices are specifically mentioned in the Healthwatch report, which should be noted; Dr Marc Rowland, Dr Simon Parton and Dr Faruk Majid. 17.2 AOS informed the Committee that Healthwatch had carried out a project to evaluate the implementation of the Accessible Information Standard (AIS) in 12 GP practices. The report highlighted good practice, areas that require improvement and had made 5 P age PCCCAUG2018 Page 5

some recommendations. The report has been shared with the CCG and practices. The CCG will formally respond to the recommendations before a formal action planned is developed. It is noted that the CCG has produced an initial response to the report. 17.3 Healthwatch were thanked for the useful report. ACTION: AOS to recirculate the 2016 AIS GP Practice Guide to GP practices. 17.4 MA informed the Committee that there would be a discussion with PRGs on how to collect the information. A video produced by Healthwatch, which could be used for staff training, would be sent to all practices. 17.5 RW provided feedback to SK (in his absence), that the Healthwatch recommendations were good, good practice should be shared and that the CQC s response was proactive. 17.6 The Committee commented whether GPs were conforming with the IAS should be reviewed by CQC, that the PCCC needs assurance that all the practices are conforming to the IAS and that compliance to the PMS contract should be monitored. 17.7 DB added that we should be pragmatic on what we can do, consider targeting from what we know and use levers such as CQC, the LMC and what is in the contract. The CCG and LMC can help practices on how to deliver the IAS. 12. Primary Care Equalities Objectives: Developing a pragmatic approach to cultural awareness training 18.1 DB informed the Committee that this was the final year of the delivery of the Primary Care Equalities Objectives, which looked specifically at two cohorts; ethnicity and cultural awareness in primary care. 18.2 Colin Paget (CP) added that the initial brief had been to develop a training programme on improving the experience of feeling supported to manage Long Term Conditions for the BME population. Feedback on the care they received for conditions including diabetes and breast and prostate cancer raised issues on the lack of engagement, feeling misrepresented and not feeling positive with western medicine. CP concluded that there needed to be a continued system change; every patient should be seen as an individual. Change should not just be directed at primary care and the BME network in Lewisham should be utilised. 18.3 The report would be submitted to the CCG Equality & Diversity Group to consider how this could be taken forward and the potential implications. The report would then be presented to the Public Engagement & Equalities Forum (PEEF). It was acknowledged that this work was part of a larger piece of work. 18.4 It was acknowledged that more peer representation was needed on developing the training. 18.5 In response to the Committee on that this was about delivery and impact on integrated health and social care, MW said that the Health and Wellbeing Board had an interest with work undertaken across all workstreams. 18.6 It was proposed that following the Equality and Diversity Group meeting the report would go to a Strategy and Development Workshop. 18.7 It was noted that the committee suggested that the Diabetes Champion Scheme should be revisited. 6 P age PCCCAUG2018 Page 6

The Committee noted the final report on Phase 4 of delivering the Primary Care Equalities objectives. 13. Business Merger: South Lewisham Group Practice, Bellingham Green Surgery, Jenner Health Centre and the Modality super-partnership 19.1 There is a conflict of interest (CoI) for Dr Marc Rowland and Dr Simon Parton as GP partners within the referenced practices. Therefore, in order to mitigate any perceived/potential CoI and/or any undue influence; Dr Rowland was absent from the meeting but Dr Parton will not take part in any discussions on this item. 19.2 JW provided an update on the proposed business merger. The report was only for noting as no decision was required and there were no contractual changes being proposed. The proposal reflected a different way of working at scale for GPs including changes to back office functions and support for transformation. All staff would be TUPE d over under an umbrella contract. The merger would take place from 1 st July 2018. The employment rights were not a CCG responsibility. 19.3 AOS added that no changes to estates were planned and that there was an expectation of a bid against the 50p per weighted patient resource. There will still be local practices delivering local services. The Committee noted the report. 14. Single Hander Status: Vale Medical Centre 20.1 There is a conflict of interest (CoI) for Dr Jacky McLeod as a Salaried GP at the Vale Medical Centre. Therefore, in order to mitigate any perceived/potential CoI and/or any undue influence; Dr McLeod will not take part in any in discussions on this item. 20.2 JW reported that the briefing regarding a contractual variation discrepancy with the Vale Medical Centre was for information only at this stage. JW described how officers had not been made aware of the death of a GP, which resulted in a provider reducing from a partnership to a single hander which resulted in a variation of contract. As the provider has been operating as a single hander since January 2015, a review of practice performance on the Primary Care Quality dashboard had been undertaken with no performance concerns identified. 20.3 Internal processes will be reviewed to understand any lessons learned. To avoid any similar occurrences in the future practices on an annual basis practices will be required to undertake a workforce data report, which will be shared with the CCG on an exception basis. The Committee noted the briefing paper. 15. Any other business No other business at this point of the meeting. For Information. 16. Primary Care Support England (PCSE) National Audit Office Report 22.1 Referring to the NHSE Management of primary care support services contract with Capita, the Committee queried who was responsible for service failures across areas including payments and pensions for primary care and the delay in new pharmacies being approved and how could concerns be escalated? Officers responded that the SE London Audit Chairs were looking at the issues with Capita acknowledging that the CCG 7 P age PCCCAUG2018 Page 7

does not have direct responsibility for the service. It is a national contract. NHSE will formally respond and would report back, with recommendations to the SE London PCC Board and then to local PCCCs. The Committee noted the report for information 17. Notification of urgent planned meeting to consider Improvement Grant applications 23.1 The Committee were informed that an urgent planned decision will be required before the next PCCC in August to consider whether the CCG supports 2019/20 Improvement Grant applications made by practices, the applications need to be submitted before 20 July 2018. 23.2 The notice was in line with the PCCC terms of reference which states: as a committee of the Governing Body, the Committee will operate in accordance with the CCG s Standing Orders (in line with NHS England Standard Operating Procedures). This includes the capacity to manage urgent matters outside the normal arrangements. The Committee noted the report for information. 18. Forward Planner Primary Care Quality Dashboard October 2018 Merger: Rushey Green Group Practice/Baring Road Medical Centre August 2018 Refreshing PMS Commissioning Intentions Workshop July 2018 Headline Report on the Premium Commissioning Intentions February 2019 The next meeting will be 21 st August 2018 The Chair closed the meeting. 8 P age PCCCAUG2018 Page 8

Urgent Planned Primary Care Commissioning Committee Tuesday 17 th July 2018 Present Shelagh Kirkland (SKi) Chair Anne Hooper (AH) Lay Member Public Engagement Dr Faruk Majid (FM) Clinical Director Dr Jacqueline McLeod (JM) Clinical Director Ashley O Shaughnessy (AOS) Deputy Director of Primary Care Dr Marc Rowland (MR) Chair, Lewisham Clinical Commissioning Group Martin Wilkinson (MW) Chief Officer Ray Warburton (RW) Lay Member, Chair of the Audit Committee and Conflicts of Interest Guardian Attending Lesley Aitken (LA) Jackie Malone (JMa) Apologies Diana Braithwaite (DB) Alison Browne (AB) Board Secretary (Minutes) Estates Programme and Project Manager Director of Commissioning and Primary Care Governing Body Registered Nurse Member 1. Welcome and Introductions 1.1 The Chair welcomed everyone to the meeting. Ski, AH, FM, JM, and RW joined the meeting by phone. 2. Apologies for absence 2.1 Apologies for absence were recorded. 3. Declarations of Interest 3.1 There were no other declarations other than those recorded on the Lewisham Clinical Commissioning Group declaration of interest register. 4. London STP s Improvement Grant Programme 2019/20 CCG support for practice applications 4.1 The Committee were informed that the CCG, in their role as Level 3 Commissioners, are required to give their support for Improvement Grant applications from practices. The deadline for submissions to the London team, with the letter of support from the CCG, is 20 th July 2018. It is recommended that support should be conditional on any revenue consequences that may arise from these applications. 4.2 JMa explained that following due diligence in September 2018 the District Valuer will advise NHSE if there is an increase rent value to the property. JMa confirmed that if the CCG think that in future the revenue costs were too high then the application could be declined. The one site which had a recommended CCG unconditional support would only add disabled access therefore would incur no revenue increase. 4.3 It was confirmed that this was a Part I meeting being held as an urgent planned meeting, as agreed at the PCCC held on 17 th June 2018 and in line with the Terms of Reference. Minutes of today s meeting will be brought to the August 2018 PCCC. 1 P age PCCCAUG2018 Page 9

4.4 The Committee commented that it would have been useful to have an indicative value of the applications, AOS said that this was part of a London wide scrutiny process; this was the first stage of the process for which CCG strategic support was required. There is no guarantee that any of the funding for schemes will be granted. A prioritisation process may be required. 4.5 Funding is for schemes for the 2019/20 financial year and successful applications will be awarded funds at 66% of the cost of eligible works with the remainder being funded by the practice. Practices were aware of this. Due diligence will completed by end of September 2018 with the CCG being informed by October 2018 if there will be a potential revenue impact. Unconditional support at this stage does not need to be given. The practices know that there is the possibility that the CCG will not support the scheme. 4.6 Responding to the Committee that revenue consequences should not be agreed without looking at other priorities and developing a process, MW said that this matter would be picked up by the Finance and Investment Committee. 4.7 DM added that work will commence in September 2018 on the financial plan for 2019/20 which will include how the schemes fit in with the estates strategy, transformation work and demonstrated value for money. 4.8 JMa outlined the schemes for submission all of which have a works total value of over 7,500, each site has been visited; Deptford Medical Centre: unconditional support Is a small site which is not fit for purpose, and is affected by population growth. There had been problems with DDA access There are concerns over security of the site An electronic patient call display is to be installed 4.9 Wells Park; conditional support subject to revenue consequences; To convert the unused seminar room into two clinical rooms which have been released due to records digitalisation. Disabled access is required. 4.10 Lee Road; conditional support subject to revenue consequences; Their own site within a conservation area There is a growth in list size To convert the staff room into a clinical room. Looking at self-funding a conservatory to house a new staff room. 4.11 Woodlands Health Centre: conditional support subject to revenue consequences Their own site List size growth Need a further three clinical rooms Good quality building N2 area needs to be addressed due to population increase Proposal will result in increased revenue consequences to the CCG. 4.12 AOS explained that all applications do not need to meet all of the five criteria for support to be submitted. The Committee queried the lack of proposals for patients with protected characteristics in the Lee Road surgery application. 2 P age PCCCAUG2018 Page 10

ACTION: Lee Road to include enhancement works for patients with the protected characteristics in their bid. ACTION: JMa to work with the finance team on quantifying any revenue costs. RESOLVED: The Committee agreed to offer conditional support for all four schemes; Deptford Medical Centre, Wells Park Practice, Lee Road Surgery and Woodlands Health Surgery in line with the CCG s recommendations subject revenue cost being quantified. ACTION: The four practices to be written to with CCG conditional support letters. ACTION: Feedback of the Urgent Planned meeting to be taken to the PCCC meeting in public on 21 August 2018 along with the minutes of the meeting. 5. Any other business 5.1 No other business reported at this stage of the meeting. The next meeting will be 21 st August 2018 The Chair closed the meeting. 3 P age PCCCAUG2018 Page 11

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Enclosure 2 ACTION TRACKER: Live Date Reference Action Description Due Date Lead Status 20.06.2018 5.1 20.06.2018 7.3 20.06.2018 17.3 DM to circulate to Committee members a breakdown of the budget and movement from 2018/19. AOS to check where the responsibility would lie if there was a problem with the app. AOS to recirculate the 2016 AIS GP Practice Guide to GP practices 21.08.2018 David Maloney 14.08.2018: Included in the finance report for the 21.08.2018. 21.08.2018 Ashley O Shaughnessy 21.08.2018 Ashley O Shaughnessy 14.08.2018: Completed. Page 13 17.04.2018 6.7 JW to request for Lambeth CCG CFO to represent Lewisham at the meeting with the NHSE Counter Fraud Service 21.08.2018 Jill Webb 19.06.2018: A meeting to be held in July with TIAA. An update will be circulated before the August PCCC meeting OPEN 17.04.2018 6.8 Headlines from SEL Primary Care Executive Board to be taken to subsequent PCCCs for information 21.08.2018 Ashley O Shaughnessy 19.06.2018: A headline summary of the 19 June SEL PCCC Executive Board meeting to be circulated to Committee members. 15.05.2018: Agreed at SEL Primary Care Executive Board for key messages to be shared with PCCC first update to be prepared for August 2018 meeting OPEN Item Number 5 1 P age PCCCAUG2018

20.06.2018 6.6 The Self-Assessment Maturity Matrix would be brought to the August PCCC meeting. 21.08.2018 Ashley O Shaughnessy 17.08.2018: See below. SCF Transformation Funding in SEL: Self-Assessment Maturity Matrix SCF framework elements Framework Elements Sub Elements Baseline rating (a) Large enough to support economies of scale Complete Page 14 1. Comprehensive population-based care 1. Scale 2. core medical provision 3. Proactive care (b) Alignment with boundaries of local care system (c )Arranged into primary care networks groupings of practices with combined 30-50,000 registered lists (a) Responsibility for the delivery of core medical services, patient outcomes and continuous improvement across all practices (a) Assess population needs and design services based on segmentation and risk stratification, using range of data sources (a) Demonstrably expand the skill mix of practice workforce, both clinical and non-clinical Complete Some 4. Accessible care (b) Develop breadth of methods by which patients can equitably access services, including online and mobile 2 P age PCCCAUG2018

(c ) Range of appointment types and lengths to reflect variation in patient need (a) Develop consistent clinical and non-clinical processes and pathways 5. co-ordinated Care (b) Single point of access to shared services across practices (where appropriate) (c )Multi-disciplinary workforce arranged into teams with responsibility for particular cohorts of patients Page 15 2. Systems, information & Quality improvement 1. Service planning & delivery 2. Adminstrative & operational efficiency (d) Shared decision-making between patients, carers and clinicians for care delivery, outcomes and service design (a) Data sharing arrangements in place across all practices (b) Consistent appointment booking and electronic records systems in place, with visibility of capacity across whole organisation (c ) Organisation-wide activity and patient-related data, both real-time and historic, available and presented in accessible format (a) Capacity and demand forecasting used to plan workforce requirements, for both operational and for recruitment purposes (b) Review variation of productivity between services and practices (e.g. DNAs and frequent attenders) (c ) Implement new technology to improve administrative efficiency (e.g. e-prescribing, online appointment booking) Complete 3.Effective and Efficent patient care (a) Read-write access of patient record to partner providers to support care management outside of general practice 3 P age PCCCAUG2018

(b) Online triage, referral and service navigation tools available to both care professionals and patients as appropriate 4. Quality improvement & clinical governance (c ) Promotion of self-care through symptom checking (e.g. via NHS Choices) (a) Adopt an evidenced approach to quality improvement, informed by data, and train staff with either internal or external resources (b) Promote a culture of transparency, collaboration and continuous improvement at a senior leadership level (c ) Carve out dedicated time for clinical leaders to participate in and lead quality improvement efforts Page 16 (d) Access/develop dedicated clinical governance resource to manage incidents, risks, complaints and clinical audit (e ) Demonstrate learning from clinical governance and feed into quality improvement (f) Share processes, protocols and policies once across all practices None None None 3. Organsitional capabilities 1. Business development 2. workforce wellbeing & resilence (a) Undertake robust business case for service and operational change development (b) Draw on advice and guidance in developing inhouse services or contracting externally (c )Engage with staff, patients, community and partners in business developments (a) Specialist HR expertise available to all practice staff (b) Consistent contracts, policies and procedures Some Some None None 4 P age PCCCAUG2018

(c ) Workforce planning and recruitment strategy, including skill mix reviews and design of portfolio roles (d ) Development of student placements None (e ) Training, development and support programmes for staff (a) Access to qualified financial and legal advice at all levels for business development and organisational decisions 3.Finance and contracting (b) Base executive decisions upon robust financial information and legal advice, regularly provided to budget holders and leadership Some (c )Coordinate procurement and systems across practices to lower unit costs None Page 17 4. Effective governance and stewardship 1. Accountability (a) Multi-disciplinary executive leadership team, including rep from each network of practices and non-clinical expertise (b) Independent/non-executive, patient and partner organisation representation at 'board' level (c )Sub-board-level groups (e.g. steering groups/committees) with responsibility for key operational areas (e.g. finance) (d) Multi-professional clinical leadership at lower organisational levels (both of bodies such as practices and staff groups) (e ) Assurance internally that organisation is acting in best interest of staff and in accordance with mandate (f) Assurance externally to patients, partners, commissioners and regulators that commitments to quality are met Some Some 5 P age PCCCAUG2018

Page 18 5. Building collaborative system partnerships 2. Strategy (a) Establish a strategy that is clinically-led, informed by system engagement and includes SMART objectives where appropriate (b) Strategy is available and understood throughout the organisation (a) Articulate a commitment to a culture based on NHS values, trust, sharing of risk and patient safety 3. Culture (b) Demonstrable processes to ensure culture is embedded throughout practices at all levels (a ) Data is benchmarked internally and external for variation 4. Intelligence (b) Information is transparently shared and made available to inform decision making and quality improvement 5.Engagement 6. Context (a) Involve staff and external stakeholders in the development of, decisions relating to service redesign (b) Seek approval of internal and external stakeholders as appropriate for any changes to strategy (a)demonstrable understanding of local, regional and national policies and funding arrangements (a)leadership team empowered to act for and represent the whole organisation 1. Leading an at scale provider (b) Demonstrable engagement with wider care system to share responsibility for whole population outcomes 2. Leading systems of care (a )Take a central role locally in each aspect of patient care through partnerships with all relevant providers (b) Take collective decisions with partners for outcome measures, models of care and management of resources (c ) Pool incentive payments and take collective ownership for shadow whole population budgets Some Some Some Some Some None None 6 P age PCCCAUG2018

3. A lead provider In a system of care (a)demonstrate participation in and leadership of networks of providers within an Integrated Care System (b) Take shared responsibility for whole population budgets and outcomes-based payments (c) Represent the interests of constituent practices by providing a collective voice None Page 19 7 P age PCCCAUG2018

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Item Number 6 PCCC Primary Care Commissioning Committee Tuesday 21 st August 2018 ENCLOSURE 3 NHS England: London Region Financial Report 2017/18 Outturn and 2018/19 Budget South East London Primary Medical Services CLINICAL LEAD: Dr Jacky McLeod, Clinical Director Primary Care Lead MANAGERIAL LEAD: David Maloney, Chief Finance Officer AUTHOR: Michael Cunningham, Head of Finance RECOMMENDATIONS: The Primary Care Commissioning Committee is asked to note; 1) An on plan financial position YTD and forecast outturn at month 3 2018/19. 2) The movement explained below in the annual budget for 2018/19. 3) The comparison of 2017/18 annual outturn compared to the 2018/19 annual budget. 4) The cost pressure of 158k relating to the GP, and GP practice staff pay ward, which has emerged since month 3 reporting. KEY ISSUES: The Committee requested to see a breakdown of the budget for 2018/19, and the movement from 2017/18 outturn to the 2018/19 budget. A detailed budget statement is presented at Appendix A to this report. The table below shows the movement between 2017/18 outturn and 2018/19 start budget. 000 Outturn 2017/18 41,950 Movement to 2018/19 start budget 920 2018/19 Start budget 42,870 It should be noted that the annual budget has changed since that which was reported in the paper to this committee on the 19 th June 2018. The changes are summarised in the table below. 2018/19 Budget 000 Presented to Primary Care Commissioning Committee 19 th June 2018 42,870 Population Growth Reserve omitted in CCG consolidation of budgets 221 GP Forward NHSE guidance to hold as reserve (335) Revised Budget included in this paper 42,756 1 P age PCCC JUNE 2018 Page 21

There are no identified cost pressures at month 3. However since reporting the financial position at month 3, the GP and GP practice pay award has been confirmed, as a further award of 1% in addition to the 1% already included in budget setting. The award is backdated to April 1 st 2018. The consequence of the pay award is a cost pressure of 158k for 2018/19 for Lewisham CCG. This pressure impacts upon all CCGs and representations have been made to NHSE to request a funding allocation in relation to this cost pressure. CORPORATE AND STRATEGIC OBJECTIVES: Contract Management: To manage effectively the CCG s contract portfolio to ensure that the CCG s Operating Plan s commitments are met in 2017/18. This includes ensuring our financial targets are met and value for money is achieved. CONFLICT OF INTEREST (CoI): No conflicts of interest are identified to the Primary Care Commissioning Committee in relation to this item. CONSULTATION HISTORY: Not applicable for this briefing. PUBLIC ENGAGEMENT: Not applicable for this briefing. HEALTH INEQUALITY & PUBLIC SECTOR EQUALITY DUTIES: No adverse impacts identified. RESPONSIBLE MANAGERIAL LEAD CONTACT: Name: David Maloney; E-mail: d.maloney@nhs.net 2 P age PCCC JUNE 2018 Page 22

Appendix A Primary Care Co-Commissioning Financial Summary 2018-19 Description Annual Budget YTD Budget YTD Reported Spend YTD Variance 000 000 000 000 PMS Essential and Additional Services 26,600 6,650 6,649 (1) PMS Premium Services 3,156 789 789 (0) GMS Global Sum & MPIG 1,811 453 453 0 GMS Premium Services 210 53 53 0 APMS Essential and Additional Services 0 0 0 0 APMS Premium Services 0 0 0 0 Caretaking - Management Fee 0 0 0 0 Subtotal Core contract 31,777 7,944 7,943 (1) Population/List Growth ear-marked fund 750 187 187 0 Total Core contract 32,527 8,132 8,131 (1) QOF aspiration 2,232 558 558 0 QOF achievement 925 231 231 0 Total QOF 3,157 789 789 0 Minor Surgery DES 46 11 11 0 Extended Hours DES 623 156 156 0 Learn Dsblty Hlth Chk DES 82 20 20 0 SAS/Violent patients scheme 22 5 5 0 Out of area registration DES 6 1 1 0 Total enhanced services 777 194 194 0 Rent 2,801 700 700 (0) Rent - CHP/NHS PS 1,226 307 307 0 In-year revaluation budget 116 29 29 0 Business Rates 643 161 161 0 Business Rates - CHP/NHS PS 148 37 37 0 Service Charges 0 0 0 0 Other Premises 178 44 45 0 Total Premises Reimbursements 5,113 1,278 1,278 (0) Seniority 298 74 74 0 Locum reimbursements 400 100 100 0 PADM Prescribing Fees Admin 147 37 37 0 CQC Fees reimbursement 206 52 52 0 Total PCO administered 1,051 263 263 0 Other 44 11 11 0 Indemnity - transfered to GPFV Mth 3 0 0 0 0 Clinical waste 87 22 22 0 MOU costs 0 0 0 0 Prior Year 17/18 0 0 0 0 Prior Year - pre April 17 0 0 0 0 Contingency 0 0 0 0 Savings Target 0 0 0 0 Total Other Medical Services 131 33 33 0 Total Primary Care Medical Services 42,756 10,689 10,688 (1) 3 P age PCCC JUNE 2018 Page 23

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Item Number 7 ENCLOSURE: 5 Primary Care Commissioning Committee (PCCC) on Tuesday 14 th August 2018 Report from Dr Jacky McLeod, Clinical Director, Primary Care lead and Chair of Primary Care Operational Group (PCOG) Date of Meeting reported: Thursday 5 th July 2018 Author: Noor Jhan Butt, Commissioning Project Manager 1. National Consultations PCOG received on update on the national consultation which reinforced the focus on better patient care once released from the hospital and; GP contract payments; input required from STP and LMC QOF report; encourage local conversation 2. PMS Contract PCOG received on update on the PMS/ GMS open practice meeting that took place on 20 th June 2018 at Cantilever House. The meeting was well received and attended by 28 people. Practices had the opportunity to understand and ask any questions on the PMS/GMS specification and contract monitoring arrangements. Presentation slides, PMS/GMS Performance Dashboard and Contract monitoring schedule was emailed across to all practice managers and GP Leads. PCOG received an update on the Commissioning Intentions for MPIG 2018/2019. Following discussion at CIOG/PCCC the remaining 9p per weighted patient will be used to support practices to continue strengthening the patient voice and specifically for a targeted, one off piece of work with their PPGs to focus on the Family & Friends Test (FFT). CCG officers have been working closely with LMC to define this requirement and practices will be formally notified of arrangements. 3. Primary Care Quality Dashboard PCOG received an update stating that the GP Patient survey data has been delayed to August 2018. The Primary Care Quality Dashboard will be updated and shared with the PCCC and PCOG post September 2018. CCG officers are planning to send a Friends & Family Test (FFT)reminder to all practices as some practices have submitted no data. The email referred to the core contract mandatory requirements, latest published FFT data and guidance. 4. GP Forward View PCOG received a verbal update on the local implementation of the GP Forward View. 5. Working at Scale QI funding PCOG discussed current QI approaches in primary care and options for taking this forward. PCOG were updated on plans across London where 10M of the 2018/2019 GPFV Access funding will be used as a Transformation fund (approx. 2M per STP). This funding is available as London has fully delivered on GPEA in 2017/18, in advance of the additional national funding available in 2018/19. The funding is to support transformation work and the acceleration of collaborative working and new models of working at scale, as outlined in the Next Steps to the Strategic Commissioning Framework: A vision for strengthening general practice collaboration across London (yet to be published). The Transformation fund is intended to directly support the development of general practice working at scale. 1 Page Page 25

The CCG, working with One Health Lewisham (GP Federation) has bid against this fund and been indicatively allocated 291k to support the following areas: Supporting Neighbourhood delivery To support advancement in use of population health and performance data to drive a more systematic approach to QI and delivery at a neighbourhood level. System partnerships To support development of formal relationships with partner organisations to realise wider benefits. Discussed of the options to how Quality Improvement can be implemented. Conversations concluded to discussing this matter with the Federation and asking them to lead on this matter. 6. Primary Care Community Practice follow-up PCOG agreed to reschedule the follow-up event date to October 2018, as the CCG are exploring development ideas. 7. Care Navigation Evaluation Lewisham CCG commissioned Lewisham CEPN to deliver Care Navigation Skills Training for Frontline Staff. Part of the GP Forward View drive to test new ways of working which could relieve clinicians of tasks that could be effectively undertaken by appropriately trained and supported nonclinical staff. The training focused on identifying opportunities and challenges in each trainee s role to use enhanced communication skills to appropriately solicit a patient s needs at every interaction. This would support directing to the most appropriate caregiver or information resource at the first point of contact. 93 GP practice frontline staff (90% receptionists, 10% other, including administrators and practice managers) underwent the training, delivered by Sheffield Hallam University, across four sessions, two at the end of November 2017 and two in early February 2018. The evaluation stated;- Despite very clear narrative about what the training comprised and was designed to achieve, there was some expectation that it was about something different i.e. the roll-out of a directory. This may be because care navigation as a term has been widely used in workforce discussions. Hence the training clarified what care navigating meant and sought to emphasise that it is about skills and local service knowledge. Some attendees fed back that they felt that some of the content had been covered in other training provided for non-clinical staff in the previous year, for example motivational interviewing or having the confidence to manage difficult conversations training etc. Repeating these skills may be frustrating for some, but they require constant nurturing in order to consistently improve; as well as encouraging new talent into the NHS, it is imperative that we keep reinforcing core communication skills at every opportunity. 8. Conflicts of Interest (CoI) No conflicts of interest are identified to the Primary Care Commissioning Committee in relation to this item. 9. Next meeting The next scheduled meeting of the Primary Care Operational Group is the 7 th September 2018. 2 P age Page 26

Item Number 8 PCCC Primary Care Commissioning Committee Tuesday 21 st August 2018 ENCLOSURE: 6 GP Forward View Implementation Update CLINICAL LEAD/S: Dr Jacky McLeod, Clinical Director lead for Primary Care MANAGERIAL LEAD: Ashley O'Shaughnessy, Deputy Director of Primary Care AUTHOR: Ashley O'Shaughnessy, Deputy Director of Primary Care RECOMMENDATIONS: The Primary Care Commissioning Committee is asked to note the update on the implementation of the GP Forward View. SUMMARY: NHS England set out its ambitions for the transformation of general practice services in the GP Forward View (GPFV), published in April 2016 (https://www.england.nhs.uk/wpcontent/uploads/2016/04/gpfv.pdf) This paper provides a high level update on the local implementation of the GP FV in Lewisham highlighting key updates since the last report. KEY UPDATES SINCE LAST REPORT: GPFV area Update GP Extended access (GPEA) Validated activity data for June 2018 is as follows: Number of appointments available 2626 Number of appointments booked 2438 Number of DNAs 414 Overall utilisation (%) 77% OHL Ltd have enacted a number of actions to address reducing the DNA rate as part of the contract management of this contract, which includes reminder calls to patients in advance of their appointments, booking appointments in advance appointments and released to practices in a phased manner over the course of each day. Early unvalidated review of the July returns suggests a drop in DNAs to 374 and a dramatic reduction in the number of DNAs in August to 89 (3%). 1 P age PCCC August 2018 Page 27

Broken down by day: Number of appointments available Number of appointments booked Number of DNAs Monday 388 371 56 Tuesday 325 299 56 Wednesday 396 374 65 Thursday 289 255 32 Friday 466 444 66 Saturday 461 430 79 Sunday 301 265 60 Clinical Pharmacists in General Practice An update on key milestones is as below: Milestone 1. Funding model agreed - Split posts with pharmacists working in GP practices (with continuity) and Lewisham and Greenwich NHS Trust (LGT) LIMOS team 2. Contract development and agreement between individual practices and LGT 3. NHSE agreeing their ES with individual practices Update This was agreed May 2017 Completed December 2017. Amended March 2018 to mirror model of Enhanced Service (ES) contracting between NHSE and individual practices NHSE delayed release of GP practice pharmacist ES - APMS contracts finally agreed in June 2018 4. Recruitment LGT proceeded at risk ahead of ES agreement with NHSE to minimise further delays to project 5, Registration on CPPE training scheme 3 WTE (4 clinical pharmacists headcount) already recruited, last pharmacist into post July 2018 Completed and 3 pharmacists have attended the initial 2 day residential ahead of even starting with practices. 4th pharmacist will attend the next round of courses which starts in September 2018 6. Service launch First practice went live May 2018, with subsequent roll out over June and July 2018. 9 practices scheduled to have gone live by 1st August 2018. 10th practice expected to be live by mid-august 2018 2 P age PCCC August 2018 Page 28

General Practice Resilience Programme The national GP Forward View Resilience Programme for 2018/19 has now been announced and the CCG have invited all practices to apply for funding through self-nomination. The exact allocation for Lewisham is still to be confirmed but is anticipated to be within the region of 30-40k. Practices have been asked to submit applications by midnight on 12th August 2018. Applications will be assessed by the CCG with peer review of the process by the LMC and the SEL STP and initial feedback will be provided to practices by 14th September 2018. CORPORATE AND STRATEGIC OBJECTIVES: Primary Care: Implementation of GP Forward View CONFLICT OF INTEREST (CoI): The Primary Care Commissioning Committee is asked to note this high level update on the local implementation of the GP FV in Lewisham. However, it is recognised that Clinical Directors in their role as General Practitioners may benefit from the funding and support provided through the GPFV. Therefore, in order to mitigate perceived/potential CoI and/or any undue influence; All decisions on how GPFV monies are committed will be taken through the appropriate governance structures with any CoIs managed as necessary. Funding levels stated in this update are already available in the public domain. The update does not contain any practice specific information. CONSULTATION HISTORY: Primary Care Operational Group PUBLIC ENGAGEMENT: Not applicable for this update HEALTH INEQUALITY & PUBLIC SECTOR EQUALITY DUTIES: No specific adverse impacts identified. RESPONSIBLE MANAGERIAL LEAD CONTACT: Name: Ashley O Shaughnessy; Email: ashley.oshaughnessy@nhs.net AUTHOR CONTACT: Name: Ashley O Shaughnessy; Email: ashley.oshaughnessy@nhs.net 3 P age PCCC August 2018 Page 29

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Item Number 10 PCCC Primary Care Commissioning Committee Tuesday 21 st August 2018 ENCLOSURE 7 Supporting Medicines Optimisation through the implementation of the Medicines Optimisation Plan (2018/19) MANAGERIAL LEAD: Alison Browne, Director of Nursing & Quality AUTHOR: Erfan Kidia, Deputy Head of Medicines Management RECOMMENDATIONS: The Primary Care Commissioning Committee are asked to; Approve the Lewisham CCG Medicines Optimisation Plan 2018/19. SUMMARY: The purpose of the 2018/19 Medicines Optimisation Plan (MOP) is to support Lewisham GP Practices and their neighbourhoods to actively achieve high quality, evidence-based and cost effective prescribing within locally available resources. Medicines management workstreams with measurable outcomes are set in different clinical areas to promote medicines optimisation. The medicines optimisation plan is specifically seeking to support collaborative working and engagement between practices within neighbourhoods particularly to meet local and national high risk priority areas such as in asthma as a collective approach across the borough. Lewisham CCG Medicines Optimisation Plan (MOP) 2017/18 Evaluation: The 2017/18 MOP concluded in March 2018 with the following outcomes: 100% of practices achieved at least 1 part and associated targets set in each of the 3 areas of the MOP. It is important to note that work initiated in 2017/18 continues to have an effect in 2018/19. As with many QIPP related workstreams implementation and subsequent realisation of savings may span more than one financial year. The entire QIPP achievements/savings as a result of MOP 2017/18: 46% (147 patients) of patients who were identified as at risk of stroke reviewed and appropriately actioned, thereby possible stoke averted.* from data available from 24 practices 2017/18 MOP related QIPP savings to date: 1,018,639 *data to May 2018 KEY ISSUES: The full MOP specification is enclosed, which details the prescribing workstream requirements, funding, and monitoring arrangements. The value of this scheme is aligned to improvement in medicines optimisation to ensure high quality prescribing with overall funding from an already agreed prescribing incentive scheme 1 P age PCCC August 2018 Page 31

budget. If the MOP were not to be implemented 2 major QIPP projects i.e. respiratory and wound care ordering would be more challenging to implement due the complex nature of these projects and the commitment required from the practices to enable them. QIPP schemes included in the MOP are: Respiratory: 500k QIPP. Assuming practices take part in the specialist pharmacist asthma reviews Repeat prescribing: 125k. Practices required to spare receptionist staff to attend training Rosuvastatin: 91k. Practices encouraged to switch to chaper generic alternative Wound care: 100k Practices asked to not order wound care items on FP10s. but to use the NHS Supply Chain. For the investment made from the MOP and the QIPP we have the potential of 800k of savings for the CCG. The MOP schemes are not policy/guideline nor contractually driven. They are either an additional enhanced service (i.e. asthma reviews) or a change in the way of working (i.e. repeat prescribing and wound care). We aim to ensure the following year s MOP starts earlier in the financial year. Again, this partly due to capacity issues, which has been addressed this FY with the recruitment into vacancies in the team. And also due to the 2 months delay we have for prescribing data to be available i.e. April s data becomes available in June. With additional team capacity we aim to release MOP earlier next year, towards the start of the FY. With regard to this year s MOP schemes such as the woundcare ordering and respiratory were not due to be live at the start of the financial year and there are schemes that will span more than 1 Financial years once started. Hence investment via MOP this year has a continued effect. Practices are required to submit work has been detailed in the scheme (worksheets and review summary sheets). This will be monitored by the CCG using EPACT2 (prescribing data) and reports received from NHS Supply Chain. CORPORATE AND STRATEGIC OBJECTIVES: Contract Management: To manage effectively the CCG s contract portfolio to ensure that the CCG s Operating Plan s commitments are met in 2018/19. This includes ensuring our financial targets are met and value for money is achieved. CONFLICT OF INTEREST (CoI): The Primary Care Commissioning Committee is asked to approve of the Lewisham CCG Medicines Optimisation Plan (MOP) 2018/19. However, it is recognised Clinical Directors in their role as General Practitioners or their practices will financially benefit from this scheme and the financial payments have changed for 2018/19. Therefore, in order to mitigate any perceived/potential Col and/or any undue influence Clinical Directors as members of the Committee will not be able to vote on the scheme. CONSULTATION HISTORY: Builds on Engagement of Medicines Optimisation Plans (Formerly Prescribing Incentive Schemes) of previous years; Draft MOP has been shared with LMC for comment and endorsement. Draft MOP has also been to all Lewisham CCG neighbourhoods (twice) for comment and feedback and has been approved 2 P age PCCC August 2018 Page 32

by the Lewisham CCG Prescribing and Medicines Optimisation Group (PMOG). PUBLIC ENGAGEMENT: Both Healthwatch and lay member representatives on the CCG Prescribing and Medicines Management Committee have contributed to the development and advised on patient impact. HEALTH INEQUALITY DUTY & PUBLIC SECTOR EQUALITY DUTY: Ensuring that all service redesign complies with CCG policies and the commissioning cycle will ensure that any service that is ultimately commissioned will have due regard to; (i) eliminate unlawful, harassment, victimisation and any other conduct prohibited by the Equality Act 2010; (ii) discrimination advance equality of opportunity between people who share a protected characteristic and people who do not share it; and (iii) foster good relations between people who share a protected characteristic and people who do not share it. RESPONSIBLE MANAGERIAL LEAD CONTACT: Name: Alison Browne, Director of Nursing and Quality AUTHOR CONTACT: Name: Erfan Kidia, Deputy Head of Medicines Management; Email: erfan.kidia@nhs.net 3 P age PCCC August 2018 Page 33

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Local Improvement Scheme: Assessment Template Area Assessment Title of scheme Medicines Optimisation Plan LIS 2018/19 Has the CCG consulted with the LMC? NB. NHS England cannot approve schemes unless the LMC has reviewed and commented What was the outcome of LMC engagement? Yes The LMC support the proposals Page 35 Does the Scheme fit strategic and/or commissioning priorities of CCG? CCGs need to specify the link to their primary care strategic priorities. Yes Scheme supports CCG priorities: QIPP Medicines related asthma exacerbations Medicines related hospital admission avoidance. Does the scheme support improvements in the quality of primary medical care services under the following categories? 1. Reducing variation in quality 2. Improving quality 3. Undertaking clinical audit 4. Peer review 5. Other 1. Reducing variation in quality - Yes 2. Improving quality - Yes 3. Undertaking clinical audit - Yes 4. Peer review - Yes 5. Other Through optimising medicine use by primary care clinician engagement within the CCG, practices can improve the quality of their medicines management services particularly through the use of comparative prescribing EPACT2 data. 1

Page 36 Does the scheme have clear, measurable processes and/or clinical outcomes? NB. These need to be articulated clearly and process outcomes should show how progress will be tracked against milestones throughout the year in order to demonstrate how the expected outcomes will be achieved. Is the scheme rewarding outcomes? NB. NHS England cannot approve schemes that do not reward outcomes. Is there any overlap with what is paid for under the Primary Medical Care Contract, DES, QOF? NB NHS England cannot approve duplicate payments but there will be situations where a LIS scheme is paying for work in excess of existing arrangements What are the proposed Contractual arrangements? e.g. SLA, Letters of Intent, National Contract (not mandated) What is the total financial value of the scheme? What is the payment structure? NB. It is expected that there will be a payment that is only realised on achievement of key deliverables. i.e. not all of the payment will be made up front What are the arrangements if outcomes are not achieved? e.g. Clawbacks or no achievement payment released Is participation in the scheme optional or mandatory for CCG member practices? If other scenarios apply, please specify Yes, clear requirements are detailed in the Medicines Optimisation Plan for 2018-19. Yes, clear requirements are detailed in the service specification. No Signed practice specific local improvement plan 90,000 across 37 practices 100% payment will be made in June 2019 against performance achievement criteria outlined in the MOP document requirements Practices will not receive payments for unachieved targets. Optional, but it is anticipated that all practices will partake as in all previous years. Assessment undertaken by: Erfan Kidia - Deputy Head of Medicines Management Date: 21 st August 2018 2

NHS Lewisham CCG Medicines Optimisation Plan September 2018 to March 2019 The Lewisham Prescribing Incentive Quality Scheme has been in place for many years to encourage high quality cost-effective prescribing in areas of priority in the CCG. The scheme has recently been renamed as the Lewisham Medicines Optimisation Plan (MOP) in line with the nationally introduced concept of medicines optimisation to support the principles of medicines use and outcomes: evidence based choice of medicines ensure medicines use is as safe as possible make medicines optimisation part of routine practice understand the patient experience Scheme details: Practices will continue to receive an indicative amount of money to meet prescribing costs which will be held at CCG level. However, while practices will still be expected to be vigilant about prescribing costs and take steps to ensure that unnecessary waste and non-evidence base practice is eliminated in preparation of taking full accountability. All practices participating in the scheme are required to complete all action areas and will be measured using baseline performance data in each area with an achievement target to be reached by Q4 2018/19. A named practice clinical lead for each area will be agreed and responsible for ensuring delivery. Summary of MOP prescribing areas: Area 1 Respiratory 1. Prevention of asthma exacerbation (GP Clinic): Review management of asthma patients who have received 2+ courses of oral steroids in the past 12 months 2. Asthma Review: >12 SABAs in previous 12 months 3. Optimising inhaler therapy: Seretide review 4. Attendance to accredited respiratory education events. Area 2 Repeat prescribing Repeat prescribing accounts for approximately 66% of prescriptions generated in primary care which represents approximately 80% of medicines costs. It is therefore important that a safe, efficient and effective repeat prescribing service is in place. There will be targeted training to nominated practice staff, involved directly in generating/managing repeat prescriptions. The trained member of staff is then to disseminate the learning within the practice, to encourage better management of repeat prescriptions. Area 3 Prescribing Guideline Implementation 1. Adherence to SEL Area Prescribing Committee RAG list 2. Adherence to the new Lewisham CCG Wound care formulary 3. Rosuvastatin switch 4. Summary sheet of 17/18 MOP schemes Practice Date of Visit (if applicable) / / Email: LEWCCG.medicinesoptimisationteam@nhs.net Page 37 Telephone number: 020 7206 3200

Glossary of Abbreviated Terms: ACQ6: Asthma Control Questionnaire. A simple questionnaire to measure the adequacy of asthma control and change in asthma control which occurs either spontaneously or as a result of treatment. APC: Area Prescribing Committee ASTRO PU: Age, sex, and temporary resident originated prescribing unit BD: Twice daily BDP: Beclometasone dipropionate BDR: Bronchodilator response BNF: British National Formulary BTS: British Thoracic Society CCG: Clinical Commissioning Group COPD: Chronic Obstructive Pulmonary Disease DPI: Dry powder inhaler DoH: Department of Health EMIS: EMIS Health, formerly known as Egton Medical Information Systems, supplies electronic patient record systems and software used in primary care in England. epact: Online application developed by NHS Business Services Authority providing information on prescribing (cost and volume) in primary care. Decommissioned in June 2018 and replaced by epact 2. FeNO: Fractional exhaled nitric oxide, measured in parts per billion (ppb) FP10HNC: forms issued by hospital outpatient clinics for dispensing by community pharmacists. Fingertips: A rich source of indicators across a range of health and wellbeing themes that has been designed by PHE to support Joint Strategic Needs Assessment (JSNA) and commissioning to improve health and wellbeing, and reduce inequalities. Indicators are browsable by geographical areas and comparable to regional or England average. FY: Financial year GORD: Gastro oesophageal reflux disease GSTT: Guy s and St. Thomas Hospital ICS: Inhaled Corticosteroid (inhaler) ICU: Intensive Care Unit ISO: International Organisation for Standardisation JSNA: Joint Strategic Needs Assessment LABA: Long acting beta₂ agonist (inhaler) LAMA: Long acting anti-muscarinic (inhaler) MDI: Metered dose inhaler MHRA: Medicines and Healthcare products Regulatory Agency MOP: Medicines Optimisation Plan formerly known as the prescribing incentive quality scheme (PIQS) NHS: National Health Service NICE TA: National Institute for Health and Care Excellence Technology Appraisal NRAD: National Review of Asthma Deaths report (2015), run by a consortium of asthma professional and patient bodies led by the Royal College of Physicians (RCP), looked into the circumstances surrounding deaths from asthma from 1 February 2012 to 30 January 2013. NSAIDs: Non-steroidal anti-inflammatories OD: Once daily PAAP: Personal asthma action plan PEFR: Peak expiratory flow rate PHE: Public Health England PIQS: Prescribing Incentive Quality Scheme PPB: Parts per billion PrescQIPP: A programme that supports quality, optimised prescribing for patients by producing evidence-based resources and tools for primary care commissioners, and providing a platform to share innovation across the NHS. QEH: Queen Elizabeth Hospital QIPP: Quality, innovation, productivity and prevention challenge Email: LEWCCG.medicinesoptimisationteam@nhs.net Page 38 Telephone number: 020 7206 3200

QOF: Quality and Outcomes Framework, a voluntary annual reward and incentive programme for all GP surgeries in England, detailing practice achievement results based on resourcing and then rewarding good practice. RAG: Red, Amber, Green, Grey List. Drugs that require additional knowledge, experience, monitoring or review are listed on the on the RAG list. This is to promote safe, effective prescribing within the most appropriate setting by the most appropriate person and ensure that each party in the management plan knows what their role is in the management of the patient. The RAG list is updated with new recommendations quarterly. RCP: Royal College of Physicians Right Care: A national NHS England supported programme committed to delivering the best care to patients, making the NHS s money go as far as possible and improving patient outcomes. Its focus is to expose and tackle geographical variation with a view to securing value. SABA: Short acting beta₂ agonist (inhaler) SEL: South East London VCD: Vocal Chord dysfunction Email: LEWCCG.medicinesoptimisationteam@nhs.net Page 39 Telephone number: 020 7206 3200

Page 40 Email: LEWCCG.medicinesoptimisationteam@nhs.net Telephone number: 020 7206 3200