Papers for the West Kent Primary Care Commissioning Committee (Improving Access) on Tuesday 21 st August at 4 4:30 pm at Hadlow Suite, Hadlow Manor Hotel Hadlow, TN11 0JH 1 of 23
Primary Care Commissioning Committee (PCCC) Improved Access Direct Award: Conflicts of Interest Assessment This paper is for: Approval Recommendation: With assurances on process received from Federation and the management of decision making at WK CCG Governing Body, the committee is asked to approve the proposed Direct Award using the agreed procurement approach. For further information or for any enquiries relating to this report please contact: Adam Wickings (Chief Operating Officer); adamwickings@nhs.net Date: 21/08/2018 Reporting Officer: Ian Ayres Agenda Item: 1 Lead Director: Gail Arnold Version: 1.0 Report Summary: In accordance with the national commitment to deliver 7 day NHS services, NHS West Kent CCG is required to commission and fund additional capacity, so that by 2020 everyone has improved access to GP services. This report outlines the context, the Proposed Direct Award (West Kent Health ltd.), the CCG decision making and respective recommendations put to the committee for approval. This will allow the implementation of a 12-18 month pilot in response to an accelerated NHS England timetable. FOI status: This paper is disclosable under the FOI Act Strategic objectives links: Board Assurance Framework links: Identified risks & risk management actions: Resource implications: All Risk registers underpin the board assurance framework and all major changes to risks are subject to bi-monthly review. None identified None identified 2 of 23
Legal implications including equality and diversity assessment Equality and diversity assessment Management of Conflicts of Interest Public and Patient Engagement/Impact on patient services The Policy Book for Primary Medical Services (https://www.england.nhs.uk/commissioning/wpcontent/uploads/sites/12/2016/01/policy-book-pms.pdf ) aims to support a consistent and compliant approach to primary care commissioning across England. It is essential that any decisions relating to primary care confirm to this guide and other statutory regulations and standard operating procedures that are in force. Has an equality assessment been undertaken? Yes Not applicable Data (both qualitative and quantitative) from the pilot will be used to inform EIA as part of full procurement. - GP members of WK CCG governing Body excluded from decision regards procurement approach - PCCC decision made in accordance with CCG Conflict of Interest policy. Engagement activities undertaken to date include: West Kent Practice Cluster Meeting (member GP practices) West Kent Practice Manager Meeting (member GP Practices Managers) Presentation at Patient Participation Group Chairs meeting Patient Survey to be completed. Report history: Appendices: Procurement approach agreed 31 st July 2018 Governing Body A) NHS E Improving Access national slide deck B) Extract from National Planning Guidance 2017-2019 Next steps: Pending approval, procurement and implementation led by NHS WK CCG Primary Care team. 3 of 23
Improved Access Direct Award: Conflicts of Interest Assessment August 2018 Patient focused, providing quality, improving outcomes 4 of 23
Document Version Control Document Title Improved Access Direct Award: Conflicts of Issue Assessment Version Final Author Adam Wickings, Chief Operating Officer Date 15 August 2018 5 of 23
1. Introduction & Context 1.1 The GP Forward View published in April 2016 set out plans to enable clinical commissioning groups (CCGs) to commission and fund additional capacity across England to ensure that by 2020 everyone has improved access to GP services. This must include sufficient routine appointments at evenings and weekends to meet genuine locally determined demand, alongside effective access to out of hours and urgent care services. The NHS Operational Planning and Contracting Guidance 2017 19 set out the funding trajectory for this work as well as a number of core requirements. 1.2 Refreshed planning guidance published in February 2018 then required all CCGs to provide improved access to GP services, including at evenings and weekends, for 100% of their population by 1 October 2018, a challenging and much accelerated timetable. This must include ensuring access is available during peak times of demand including bank holidays and across the Easter, Christmas and New Year periods. 1.3 National procurement advice was then issued which implied that CCGs should proceed with formal tendering for Improved Access provision even though this prescribed timeline makes that impractical. So WK CCG then sought and received endorsement from NHS England for a direct award on a pilot basis to the local GP Federation, without resource to tendering, on the basis that a formal tender exercise would proceed after the pilot phase. 1.4 The CCG Governing Body then agreed to proceed with that direct award (on a 12-18 months pilot basis) subject to agreement by the Primary Care Commissioning Committee (PCCC) that such an award could and would be managed in a way consistent with the CCG s Conflicts of Interest policy and associated mitigations. 1.5 The purpose of this paper is to seek approval from the Committee that the procurement approach agreed, the assurances on process received from the Federation and the management of decision making at the Governing Body together confirm that the proposed direct award can be so endorsed. 1. The Proposed Direct Award 1.1 The CCG has not negotiated pricing arrangements with the Federation because of the national specification (attached). 1.2 The CCG has worked with the Federation to secure detailed assurance on how the Federation will deliver to the specification within the prescribed funding. The requirement has been set down nationally and the CCG is meeting fortnightly with NHSE to provide assurance to them that it is on track with delivery plans and that these plans will meet the national requirement from October 18. 1.3 The Federation has agreed to work in partnership with the CCG to co-design the delivery model at cluster level to allow the recognition in the final service specification of population need and usage particularly around the way in which capacity is used. This will allow the development of a suitable specification with which to test the market in due course. Furthermore the Federation and CCG will use an open book approach to enable learning to be gleaned from the costing of service 6 of 23
delivery across the different days of the week (ie the differing costs between delivering on weekdays to delivering at weekends and public holidays) and the level of challenge experienced in identifying workforce within West Kent able to deliver on the national requirements. 1.4 The CCG is further working with the Federation and its member practices to test a dynamic scheduling, monitoring and billing took which will allow comprehensive and detailed datasets to be produced which will further influence the detail of the final service specification. 2. CCG Decision Making 2.1 The CCG has been cognisant throughout the programme of the need to manage the contractual discussions with the Federation with due attention to any real or perceived conflicts of interest. The following key measures have been taken to ensure appropriate process. 2.2 Chief Operating Officer Leadership and Oversight: this programme has been overseen by the COO Delivery, who has not worked anywhere on behalf of the Federation, and all recommendations to CCG committees for this programme have been in the COO (Delivery s) name and have been reviewed by the COO (Delivery). 2.3 The CCG s Governing Body, when making the procurement decision in August, excluded from the GB meeting all GPs including the CCG Chair. This has been noted in the GB minutes. This is in accordance with the CCG Conflicts of Interest Policy (attached). 3. Recommendations 3.1 The Primary Care Commissioning Committee is asked to agree that the details of the contract and associated terms and conditions, because nationally prescribed, have not been and could not have been in any way set by the CCG so as to be advantageous to the Federation (in the context of a direct award) the CCG s decision making and executive leadership have been appropriately managed so as to avoid any real or perceived conflicts of issue with regard to the Federation the CCG s Governing Body decision making has been in line with the CCG Conflict of issues policy and has appropriately ensured that any real or perceived conflicts of issue cannot influence the GB decision. 7 of 23
Improving Access to General Practice National slidepack October 2017 NHS England Publications Gateway Reference 07286 www.england.nhs.uk 8 of 23
Why do we need to improve access? GP Patient Survey Good overall experience of making an appointment declined from 79.1% in 2011-12 to 72.7% in 2016-17. 11% (1 in 10) reported not being able to get appointment. Likelihood of getting convenient appointment lower if you are in work or young. General Practice Forward View Represents a turning point in investment. Sets out support package. Sets out the ambition to strengthen and redesign general practice, including delivering extended access in primary care. Vision builds on the potential for transformation in general practice and GP Access Fund: Enabling self care and direct access to other services. Better use of the talents of the wider workforce. Greater use of digital technology. Working at scale across practices to shape capacity. www.england.nhs.uk 9 of 23
What are we trying to do? Ensure everyone has easier and more convenient access to GP services, including appointments at evening and weekends Make the most of access offer a joined up service to patients effectively connect extended access to the wider system, especially urgent care use money across general practice to truly transform make the best connections for patients and staff and get the best outcomes we possibly can This is within the context of considerable pressure in and on general practice. In delivering improved access we will want to secure transformation in general practice, including a step change in our use of digital technologies, support for urgent care and changes in general practice services that lay the foundations for general practice providers to move to a model of more integrated services through delivery of new models of care as we describe in the General Practice Forward View and Five Year Forward View. 10 of 23
What will this look like for patients? Steven drops into his GP practice on a Friday morning to make an appointment for a routine check up. The receptionist offers him a choice to see his own GP the following week or attend the local GP hub on Saturday. Steven is able to get an 8.30am appointment meaning he still enjoys the rest of his weekend - and he doesn t have to take time off work the following week to see his GP. Angela has an on going condition which has flared up and needs attention, however it is not urgent. Angela calls her GP practice and is able to book a same day appointment to see a GP in a local hub after work. The GP is able to access her patient record and provide some additional medication to help Angela manage her condition. Tom has been ill during the night and has been managing his symptoms with medication he bought from his local pharmacy. Whilst he knows his condition doesn t need urgent attention, he decides to phone NHS 111 to seek advice when his symptoms persist. The call handler triages Tom to the appropriate service and he is offered an appointment at the local GP access hub later that day. The GP reassures Tom that his condition isn t serious and advises him on managing the symptoms. Seema has a long term condition which her GP practice has been helping her to manage Her practice has provided her with a phone app which holds a raft of information about managing her condition, meaning she needs less appointments with her GP. She also attends a fortnightly group consultation where a number of patients with the same condition as Seema meet with the practice nurse. Seema feels she has her condition under control and is pleased with the support she is receiving from the practice. She enjoys meeting the other patients in her group. 11 of 23
Delivering improved access to general practice our ambition Trajectory and requirements for Improving Access to General Practice are outlined in in the NHS Operational Planning and Contracting Guidance 2017-19 National coverage will reach: 50% of the population by March 2018 and 100% of the population by March 2019 London will offer 8am-8pm to over 9 million people across the capital by March 2018 www.england.nhs.uk CCGs will: receive funding per head of population (weighted) need to commission services that meet national requirements spend 3 per head non recurrent on practice transformational support (commencing 17-18 and can take place over two years, 3 in 17-18 or 18-19 or split over the two years) be required to secure services following appropriate procurement processes In addition: In 2017-18 we will invest more than 138m and in 2018-19 this investment will rise to 258m as new recurrent funding We are working to assure CCG plans for improving access and ensure we have tracking in place to support delivery We are learning and sharing best practice to support providers and commissioners We are supplementing this throughout 2017-18 with further practical products and advice 12 of 23 5
Rollout of improved access www.england.nhs.uk 13 of 23
What have we got to deliver: seven core requirements Timing of appointments Capacity Measurement Advertising and ease of access Commission weekday provision of access to pre-bookable and same day appointments to general practice services in evenings (after 6.30pm) to provide an additional 1.5 hours every evening Commission weekend provision of access to pre-bookable and same day appointments on both Saturdays and Sundays to meet local population needs Provide robust evidence, based on utilisation rates, for the proposed disposition of services throughout the week Commission a minimum additional 30 minutes consultation capacity per 1000 population per week, rising to 45 minutes per 1000 population Ensure usage of a nationally commissioned new tool to be introduced during 2017-18 to automatically measure appointment activity by all participating practices, both in-hours and in extended hours. This will enable improvements in matching capacity to times of great demand Ensure services are advertised to patients, including notification on practice websites, notices in local urgent care services and publicity into the community, so that it is clear to patients how they can access these appointments and associated service Ensure ease of access for patients including: All practice receptionists able to direct patients to the service and offer appointments to extended hours service on the same basis as appointments to non-extended hours services Patients should be offered a choice of evening or weekend appointments on an equal footing to core hours appointments Digital Use of digital approaches to support new models of care in general practice Inequalities Issues of inequalities in patients experience of accessing general practice identified by local evidence and actions to resolve in place Effective Effective connection to other system services enabling patients to receive the right care the right access to wider whole system professional including access from and to other primary care and general practice services such as 14 of 23 services www.england.nhs.uk urgent care 7
What have we got to deliver: an example of capacity: Based on population 100,000 = 50 hrs (30 mins per 1,000 pop) Or: There are multiple ways of delivering to meet local needs including for example some in hours and through Urgent Treatment Centres 15 of 23
Mythbusters This is not about every practice being open seven days a week: needs to be provided at scale. This is about delivering additional capacity to and choice of appointments beyond what is provided at general practice level. 30 minutes per 1,000 population is per week: this is new capacity and doesn t include existing provision e.g. the extended hours DES does not count or existing walk in centres. This DES is linked to the GP contract any future changes would have to be negotiated with the profession. Appointments with clinical staff who would be routinely available within general practice count towards the 30 minutes per 1,000, e.g. nurses/anps, pharmacists, physiotherapists etc. Appointments with non-clinical staff e.g. care navigators, VCS etc. would not count. Service provision will be dependent upon local needs: and should be commissioned to reflect this. We would expect capacity to grow to meet demand over time especially with increased advertising of the service. There is no requirement to deliver 45 minutes per 1,000 per week by 2019 but CCGs will need to demonstrate they are meeting local need and monitoring utilisation. Extended hours services must be available to the whole population: not targeted solely to one demographic in isolation e.g. under 5s. This cannot be the only offer. Patients must be able to see a GP face to face: if that is what they wish across the designated population for that service, but not necessarily in every access hub. www.england.nhs.uk. 16 of 23 9
Mythbusters Must provide additional appointments on weekday evenings after 6.30pm and on a Saturday and Sunday: actual disposition to be determined locally and be supported by good communications so patients know about the service and how to access it 365 days a year. Not all capacity needs to be provided outside core hours: some can be provided in core hours if supported by robust evidence of need. 50% target for coverage by March 2018 is a national not regional target. Implementation is phased with CCGs going live in 2017-18 and 2018-19. Because funding in 2018-19 is back loaded, implementation will be back loaded too. Patients should be able to access pre-bookable and same day appointments on weekday evenings and at the weekend, which means: patients can book an appointment, in advance, via their own practice or other provider, or patients can access a routine appointment on the same day e.g. on a Saturday or Sunday if they choose to in premises available within the local area. www.england.nhs.uk 17 of 23 10
Mythbusters CCGs will need to secure services through appropriate procurement process which means they must adhere to the public contract regulations 2015: these set out that contracts for clinical services that are above the threshold ( 589,148) may need to be advertised in the Official Journal of the European Union (OJEU) dependent on whether one of the exemptions applies. CCGs delivering a new improved access service in 2017-18 will receive 6 per head, in 2018-19, 3.34 per head and 6 per head in 2019-20: CCGs are also investing 3 per head non recurrent on practice transformation support. This is not simply about delivering more of the same: but about making the most of our opportunity for transformation as part of the GPFV. That includes better integration between services such as NHS111 and urgent care services such as GP OOH. www.england.nhs.uk 18 of 23 11
Support to deliver core requirements We are putting in place a number of specific actions to support CCGs in delivering access and the seven core requirements. Regional teams will support CCGs directly, with additional national support and products which include: Communications Guide and Resource Pack designed to support commissioners and providers to meet the core requirement to ensure services are advertised to patients, including featuring information on practice websites and ensuring practice receptionists can signpost patients. Inequalities Resource designed to support the core requirement to address issues of inequalities in patients experience of accessing general practice and put actions to resolve in place. Top Tips for General Practice Providers guidance on key areas for establishing improved access to general practice services. Case studies and innovation showcases: sharing learning from the GP Access Fund pilot schemes. Bespoke resources e.g. procurement rules. Keep checking the NHS England website for further details: www.england.nhs.uk/gpaccess 19 of 23 12
General Practice Workload Tool As set out in the GP Forward View, rollout of a national GP Workload Tool to all general practices will begin in 2017. This will provide each practice with a workload report using their own data. This can be used to better understand appointment activity and how it varies over time and better match supply of appointments more closely to demand. Practice reporting functionality will be provided within existing GP clinical systems. Rollout to a small number of practices for user testing recently commenced with further rollout from the autumn for most practices. In addition, NHS Digital commenced a monthly national collection of general practice workload data in September 2017 which will provide GP appointment capacity and utilisation data aggregated at a CCG level. www.england.nhs.uk 20 of 23 13
Key messages to take away We want to improve access in and out of hours and ensure we make the most of our opportunity for transformation as part of the General Practice Forward View and give the public confidence in general practice. Additional access funding is intended to develop general practice at scale as part of a wider set of integrated services, not just deliver additional appointments. It will be crucial to ensure integration of extended access with out of hours and urgent care services, including reformed 111, Urgent Treatment Centres and local clinical hubs. It is acceptable for urgent and emergency care and extended access services to be integrated e.g. UTC and extended access operating from the same place and working together. NHS 111 should be able to book into extended access as part of our NHS urgent care offer and we would expect commissioners to include these kind of initiatives in their requirements and specifications. The most important part of implementation is for us to take the opportunity to invest in general practice to enable sustainability today and transformation tomorrow and make the service better for patients and health practitioners (clinicians and staff) alike. www.england.nhs.uk 21 of 23
Please send any queries or comments to: england.gpaccess@nhs.net Or visit our website: www.england.nhs.uk/gpaccess www.england.nhs.uk 22 of 23
Extract from National Planning Guidance 2017-19 Overall Goals for 2017-2019 Stabilise general practice today and support the transformation of primary care and for tomorrow, by delivering General Practice Forward View and Next Steps on the NHS Five Year Forward View. Progress in 2017/18 52% of the country now benefitting from extended access including appointments on evenings and weekends, beating the target of 40% for 2017/18. Primary care workforce: o Over 770 additional GP trainees started specialist training since 2015 baseline (3,157 in total in 2017/18); o Begun GP international recruitment, with the first 100 GPs being recruited; Deliverables for 2018/19 Progress against all Next Steps on the NHS Five Year Forward View and General Practice Forward View commitments. This includes all CCGs: Providing extended access to GP services, including at evenings and weekends, for 100% of their population by 1 October 2018. This must include ensuring access is available during peak times of demand, including bank holidays and across the Easter, Christmas and New Year periods. Delivering their contribution to the workforce commitment 23 of 23