Primary Care Commissioning Committee Part 1

Primary Care Commissioning Committee Part 1 Date: Wednesday 20 September 2017 Time: 10.00 12.00 Venue: The Gallery,The Woolwich Centre, 35 Wellington Street, Woolwich SE18 6HQ, Chair: Richard Rice Time Item Papers Presented by 1. 10.00 Welcome and Introductions & Apologies for Absence Chair 2. 10.03 Conflicts of interest a. To note declared interests b. To add new interests c. To identify potential conflicts of interest with the business on the agenda 3 10.05 Questions from members of the public previously submitted to the CCG 4 10.10 Minutes of Previous Meeting held on 26 July Matters Arising Not on the Agenda a) Update on Clinical Pharmacists in General Practice 5 10.30 Urgent Business To consider any items not already on the agenda a) Conway Partnership Proposal 6. 10.50 2017-18 Primary Care Budget Allocations and Presentation Note Declare Enc A for approval Enc B Enc C For approval To note Enc D Chair Chair Simon James Chair Jan Matthews David Maloney 7 11.00 Quality & Performance Dashboard Enc E Irene Grayson 8 11.20 Highlight Reports i. GP 5 Year Forward View Enc F Irene Grayson

ii. Primary Care Executive 9 11.30 Any Other Business: CCG Response to Healthwatch Report on Access 2017 10 Future Meetings 29 November 2017 10-12.00 at The Woolwich Centre 12.00 CLOSE Enc G Irene Grayson

PRIMARY CARE COMMISSIONING COMMITTEE DRAFT Enc. A 26 July 2017 The Gallery, The Woolwich Centre PRESENT: Richard Rice (RR) CHAIR, Governing Body lay member David Maloney (DM) Chief Finance Officer Ellen Wright (EW) GCCG Clinical Chair Irene Grayson (IG) AD Primary Care Jan Matthews (Jan M) Primary Care Delivery Manager Jill Webb (JW) Head of Primary Care, NHS England Joanne Murfitt (Jo M) Chief Officer Maggie Buckell (MB) Lay Member Rikki Garcia (RG) Healthwatch Dr Sabah Salman (SS) GP Executive Simon James (SJ) Primary Care Delivery Manager Steve Whiteman (SW) Director of Public Health, Royal Borough of Greenwich Tuan Tran (TT) Local Care Networks (LCN) Chair Vanessa Fowler (VF) Deputy Director of Commissioning IN ATTENDANCE: Toni Meyers Business Manager (Minutes) APOLOGIES: Jill Prescott (JP) Commissioning Manager Primary Care Liz James Director of Commissioning Item 2. Conflicts of interest No new conflicts were declared. Action 4. Minutes of previous meeting on 31 May 2017 The minutes were agreed as an accurate record. 4. Matters arising PCCC Terms of reference & Governance map Agreed subject to minor amendments. Primary Care Executive Group (PCEG) The PCCC received this paper and heard that pending the South East London (SEL) wide reorganisation this was still under development and the terms of reference were likely to change. IG confirmed that although Chair: Dr Ellen Wright Chief Officer: Joanne Murfitt

allocations come from NHS England (NHSE), the decision about how to deploy funds was still taken locally, with the PCEG acting as an advisory group for example in contractual matters such as the special allocation scheme. The decision on how to commission services remains with Greenwich PCCC. RR suggested that this be added to the Terms of reference as an addendum. Business Continuity Plans IG noted that this work was ongoing and that the Greenwich IT Group had asked the practices for updates. 5 Urgent business Clover subcontract with Grabadoc Jan M presented this item. She noted that from 1 September 2017 when the previous provider contract expires, Clover will enact a subcontract with Grabadoc to provide an innovative nurse-led service to patients in care homes. Jo M noted that prior to securing Grabadoc every practice in Greenwich had been offered the opportunity to take on this service to care homes. Jan M confirmed that stakeholder engagement activities had begun and were to continue, and that she expected the new service to deliver care which is as good if not better than that which would have been provided under the previous arrangements. The Primary Care Commissioning Committee APPROVED this proposal. 6. 2017-18 Primary Care Budget DM presented this item. He noted his intention to bring a report on month 3 onwards to the PCCC. He reported that the Primary Care budget had a break even position at the first quarter 17-18 with a slight overspend of 6k. The monthly run rate did not exceed the budget. DM mentioned that he submitted a return to NHSE on a monthly basis on risks not on the ledger and that the SEL Chief Finance Officers had asked NHSE for monthly reports from month 3 onwards. 7. Quality & Performance report JW presented this item. She noted that 4 out of the six SEL CCGs have developed their own quality reporting and Jo M queried which ones had involved patients in that process. JW noted the trend for using CQC indicators in CCG reporting. ACTION: To consult with Bexley who are considering collating their own local quality reporting to discover if any useful templates or learning can be gained. JP / Jan M JW noted NHSE intention of recommending an operating model to the September PCCC. JW pointed out that Greenwich scored well on the Friends & Family Test, was behind the London average on CQC inspection Requires Improvement and relatively high for contractual

breaches, though this may be affected by the percentage of singlehander GP practices in the borough which is higher than the national average. Overall average satisfaction levels within Greenwich are similar to the London average. SW suggested that QOF and clinical data would be useful. RR suggested that, local capacity permitting, that a similar report be produced using local data to be read alongside the Quality and Performance report. He also suggested to JW some improvement in presentation for the QP report. Clinical Pharmacists IG mentioned the successful bid for clinical pharmacists to be placed within General Practice. ACTION: To add an update on the clinical pharmacist bid to agenda for next meeting. IG 8. Review of CQC Action Plan Progress for Trinity PMS Jan M presented this update. She noted that Trinity have addressed the concerns raised with an action plan, and she was confident the CQC would be satisfied with this upon their expected return visit. No breach notice would be issued. 9. Strategy Review on Local Care Networks IG presented this item. She noted the national requirement for an Accountable Care System (ACS) but she and VF stressed Greenwich CCG s intention to work with providers, patients and stakeholders to craft a relevant way of working which supported practices at every stage. VF leads on this work and although noted that although it was in very early exploratory stages, described her aspiration to engage practices and patients as fully as possible. No timescales have yet been set. TT mentioned his concern about this process possibly adding to practices workloads Jo M assured him that the outcome was intended to support and assist practices and that Greenwich CCG would proceed thoughtfully. DM made the point that budgets had been fixed and as no further increases were expected CCGs must find different ways of working within finite resources. 10. Any other business None Questions from the public.

Members of the public raised the following concerns: 1. Would Greenwich CCG be engaging with patients in its work, particularly on ACS? Greenwich CCG response: Yes, an extensive programme of patient engagement was intended. 2. Concern over ACS in America, uncertain if it was appropriate for NHS? Greenwich CCG response: We have been mandated to design an ACS from scratch. We intend to proceed carefully and thoughtfully, consulting with as many stakeholders as possible. The ACS which GCCG designs is very likely to differ from similarly-named arrangements abroad. 3. What are your thoughts on the STP? Greenwich CCG response: We have been mandated to work within the STP and believe we are doing so successfully. Next meeting: Primary Care Commissioning Committee 20 September 2017

ACTIONS FROM PRIMARY CARE COMMISSIONING COMMITTEE Date 20 September 2017 No. Item/ref date 2 10b 31/5/17 Action Action owner To be Comments completed by ACTIONS BROUGHT FORWARD Cyber attacks Caroline 12 July 2017 TT to chase LCN to ask their members to check whether their business Hollingworth / continuity plans are fit for purpose. Tuan Tran 4 10d 31/5/17 Cyber attacks Add business continuity plans to risk register and via that means to consider at GCCG Finance Quality & Performance Committee for additional assurance. Yvonne Leese 12 July 2017 7 7 12/7/17 NHSE Quality & Performance report To consult with Bexley who are considering collating their own local quality reporting to discover if any useful templates or learning can be gained. Jill Prescott Jan Matthews 31 August 17 9 11 12/7/17 10 7 26/7/16 Primary Care Executive Highlight report Remove mention of Mark Easton new appointment as it is no longer new. ACTIONS FROM THIS MEETING Clinical Pharmacists in Primary Care To add an update on the clinical pharmacist bid to the agenda for the next PCCC meeting. Irene Grayson 26 July 2017 Irene Grayson 20 Sept 2017

CLOSED ACTIONS No. Item ref Date of mtg Action Owner Date closed Comments 1 6 31/5/17 Terms of reference To add governance map/diagram to ToR for information Irene Grayson 26 July 2017 3 10c 31/5/17 5 11 31/5/17 6 12 31/5/17 8 10 12/7/17 Cyber attacks Greenwich IT Group to consider the Greenwich CCG business continuity plan in conjunction with the plans from practices and Lewisham & Greenwich Trust and report on suitability to GEG. LCN Transformation Group Strategy review on Local Care Networks Transformation Group to be presented to next meeting of Primary Care Commissioning Committee. Primary Care Statistics To add primary care statistics as an agenda item for next Primary Care Commissioning Committee meeting. Progress for Trinity PMS To add evidence cited and verified to the action plan Ranil Perera 26 July 2017 RP has contacted LGT re lessons learnt Irene Grayson 26 July 2017 Irene Grayson 26 July 2017 Jo M suggests devising a timetable for expected data dissemination Jan Matthews 26 July 2017

: It Item 4 Enc B Primary Care Commissioning Committee DATE OF MEETING: 20 September 2017 AUTHOR: Irene Grayson Background Title: Update On Clinical Pharmacy Bid Associate Director Primary Care NHS England launched in 2015 a pilot scheme to support clinical pharmacists working in general practice in patient facing roles. Funding was made available to support more than 450 clinical pharmacists in 650 practices across 90 pilot sites. The General Practice Forward View (GPFV) includes a commitment to deliver an additional 5,000 clinical and non-clinical staff in general practice, of which the aim is to have a pharmacist per 30,000 of the population leading to a further 1,500 pharmacists in general practice by 2020. Through a national bidding process in summer 2017, Greenwich Health Ltd, on behalf of Greenwich general practice and GP its constituent GP Federations, successfully received funding to recruit clinical pharmacists to be trained and employed in Greenwich. This is a joint programme with Lewisham and Greenwich NHS Trust and is actively supported by the Trust s chief pharmacist. The funding contributes to the costs of recruitment, employment, training of twelve clinical pharmacists. These pharmacists will expected to work half-time within the Trust and half-time in the practices, so will in total bring six wholetime equivalent (WTE) staff into general practice. Twenty-eight Greenwich practices are signed up to receive clinical pharmacist capacity from the scheme, planned on the basis of one session (usually 3.5 hours) per 4,000 registered patients. Once employment arrangements and recruitment are completed, the pharmacists will begin training and deployment into general practice. This will augment a small number of clinical pharmacists who have previously been employed directly by Greenwich general practices and are working in a similar role. To note, the role of the clinical pharmacists is to work in general practice as part of a multi-disciplinary team to clinically assess and treat patients using their expert knowledge of medicines for specific disease areas. They are (or will train to be) prescribers who can take responsibility for patients with chronic diseases and undertake clinical medication reviews. This means they can proactively manage people with complex polypharmacy (e.g. older people, people in care homes and those with multiple co-morbidities), improving adherence and providing medication advice directly to the patient. They can also support practices with training and advice and help shift workload appropriately from GP and nurse to within their competencies and remit.

Recommendation The committee is asked to Note the Update on the Clinical Pharmacy bid and scheme implementation. NHS Greenwich CCG CONTACT: Name: Irene Grayson AD Primary Care E-Mail: Irene.grayson1@nhs.net 2

Item: 5 Enc: C Primary Care Commissioning Committee Urgent Unplanned/Planned Decision Title of paper: Conway Medical Centre (G83633) Request for Contract Variation to Add Partner Date paper to be considered: 20 th September 2017 Presented by: Jan Matthews Title: Primary care Contracting and Performanace Manager & email contact: jan.matthews@nhs.net Corporate Objective addressed by this paper (please select one or more with an X): 1. To commission sustainable high quality services to meet the health needs of the population of Greenwich and reduce health inequalities. X 2. To ensure the CCG financial position recovers to meet all statutory financial duties. 3. To continue to ensure that the CCG is a clinically driven organisation. 4. To ensure diverse patient and public voices are fully considered. Purpose of the report: To inform the committee s decision regarding a request by the Conway Medical Centre for a new partner to be added to the practice PMS contract. Previous committee involvement: None Recommendations to the Committee: The Primary Care Commissioning Committee is asked to support the recommendation that: commissioner s 1. A contract variation should be implemented to add an additional partner to the Conway Medical Centre PMS contract

Background: The Care Quality Commission (CQC) undertook a comprehensive inspection of Conway Medical Centre on 2 nd February 2016. The inspection report was published on 27 th May 2016 and indicated an overall rating of inadequate. Within this overall rating the safety; the responsive and the well led domains were judged inadequate with the effective and the caring domains judged to be requiring improvement. The practice was put into special measures by the CQC. NHS England and Greenwich CCG then arranged a joint contractual compliance visit which took place on 13 th June 2016. At that visit, the practice advised that it had challenged a number of aspects of the CQC report which was subsequently withdrawn for review. An updated CQC report was published on 29 th September 2016 but this report did not differ significantly from the original version. The CQC carried out a follow up inspection on 13th December 2016. Subsequently, on 30 th December 2016 the CQC issued a warning notice that the PMS contract holder remained in breach of Regulation 17 (good governance) and that it was required to act to achieve compliance by 30 th March 2017. The report of the December inspection was published on 15 th April 2017 and showed the practice had been inadequate in all 5 domains i.e. the practice performance as against the CQC criteria had deteriorated since the original inspection. The report stated we 1 are taking action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed, could be escalated to urgent enforcement action. Such action could include the issue of a notice of deregistration. A key statement in the CQC report was we found the partners were largely absent from the practice and the leadership arrangements did not support the delivery of high quality care. Request for Contract Variation to Add Partner The current Conway Medical Centre PMS contract is currently held by a GP (Dr. J Bajwa) and a pharmacist (Mr S Gulsin). The practice employs a long term locum Dr R. Perera. In March 2017, the practice submitted a request for the addition of Dr Perera to the contract. It is normal practice not to implement contract variations where there are, as in this case, significant concerns about practice performance. In order to discuss the concerns and agree how they might best be resolved, a meeting between the practice partners; Dr Perera; CQC; Greenwich CCG and NHS England was 1 i.e. the Care Quality Commission 2

proposed. Unfortunately getting all parties to a meeting has proved to be difficult until now; a meeting took place mid-august 2017. As referred to above, the CQC report stated that the partners were largely absent from the practice and the leadership arrangements did not, in the CQC s view, support the delivery of high quality care. The practice application to add Dr Perera to the contract is its response to putting in place the provider level clinical leadership required. Dr Perera will lead on Clinical Governance areas at the practice and in particular: Business plans to demonstrate that the practice strategy was delivered, monitored and reviewed to address or improve areas where performance and patient outcomes were below average. Provide the presence required at the practice and the leadership arrangements to support the delivery of high quality care. Carry out reviews for at risk groups and ensure arrangements are in place for managing risks and ongoing monitoring. Admin/clinical staff training and engagement, sharing vision and values and responsibilities in relation to each individual. Review policies and procedures that govern activity, and bring up to date and amend to reflect current practice. Although as already discussed, a contract variation would not normally be approved where a practice is in CQC special measures, in these particular circumstances, the PCCC is asked to agree that the addition of Dr Perera should be agreed in order to improve governance arrangements within Conway Medical Centre. KEY ISSUES: Following a CQC comprehensive inspection in February 2016, Conway PMS was put under CQC Special Measures in May 2016 on publication of the inspection report. The original report findings were appealed by the practice but the appeal was not upheld. A second comprehensive inspection was carried out in December 2016 and, as a result, the CQC issued a formal warning notice to the practice that, unless it became compliant with CQC governance requirements by March 30 th 2017, the CQC might take enforcement action. A key finding of the CQC was that the existing partners (one GP and one pharmacist) were largely absent from the practice and the leadership arrangements did not support the delivery of high quality care. The practice wishes to add another GP Dr Perera to the contract. Contract variations are not normally agreed where commissioners have reason for significant concerns about a practice performance. The addition of a further GP partner to the contract may be considered to be a logical approach to improving governance arrangements and clinical leadership at the practice. In these exceptional circumstances, given that a significant element of the 3

performance concerns are linked to governance and leadership arrangements it is proposed that the request for this contract variation to be implemented be agreed. RECOMMENDATION: The Primary Care Commissioning Committee is asked to support the recommendation that: commissioner s A contract variation should be implemented asap to add an additional partner to the Conway Medical Centre PMS contract Author CONTACT: Name: E-Mail: Harry Goldingay england.primarycaresupport@nhs.net 4

: Item 6 Enc.D Primary Care Commissioning Committee DATE OF MEETING: 20 September 2017 Title: Financial Reports 4 Months to 31 st Medical Services July 2017. South East London Primary AUTHOR: NHSE Finance Team 1. Overview: The year to date reported financial position for South East London Primary Medical services is an overspend of 253k against total year to date (ytd) allocations of 82,781k. 2. 2017/18 Budgets: The total primary care medical services allocation for South East London STP for 17/18 is 248,232. After allowing for forecast population growth, anticipated increases in premises costs, 1% non-recurrent headroom and 0.5% contingency there is an underlying deficit of 2,707k for the STP, releasing the headroom and contingency reserves changes this to an STP surplus of 1,018k. The deficits and surpluses do not fall evenly across CCGs and are shown in the table below: 17/18 Allocations Surplus/(Gap) before release of Headroom and contingency Surplus/(Gap) after release of Headroom and contingency Bexley 28,652-532 -103 Bromley 40,558 974 1,607 Greenwich 37,127-482 76 Lambeth 54,671-1,396-584 Lewisham 41,908 567 1,213 Southwark 44,398-1,838-1,190 Sub-total SEL 247,315-2,707 1,018 3. Primary Medical Services Expenditure Summary

The expenditure summary for South East London for the current month is set out in Table 1 below with a break down at CCG level in Appendix A. Table 1 SEL Total Service Annual Budget YTD Budget YTD Actual Expenditure YTD Variance YTD Variance % 000's 000's 000's 000's % PMS 204,090 68,028 67,881 (146) -0.2% GMS 23,075 7,691 7,710 19 0.2% APMS 18,424 6,141 6,215 74 1.2% Other Medical Services 2,744 921 1,227 307 33.3% Total Primary Care Medical Services 248,332 82,781 83,034 253 0.3% Bexley CCG PMS 24,935 8,311 8,322 10 0.1% GMS 2,341 780 789 9 1.2% APMS 621 207 211 4 1.7% Other Medical Services 651 217 217 0 0.0% Total Primary Care Medical 28,548 9,515 9,538 23 0.2% Bromley CCG PMS 24,916 8,305 8,305 0 0.0% GMS 13,697 4,565 4,568 2 0.0% APMS 1,789 596 597 1 0.1% Other Medical Services 1,763 61 61 0 0.0% Total Primary Care Medical 42,165 13,527 13,530 3 0.0% Greenwich CCG PMS 34,175 11,391 11,355 (36) -0.3% GMS 267 89 88 (1) -0.6% APMS 2,548 849 905 56 6.6% Other Medical Services 214 71 51 (20) -27.9% Total Primary Care Medical 37,203 12,400 12,399 (0) 0.0% Lambeth CCG PMS 44,204 14,734 14,617 (117) -0.8% GMS 2,616 872 903 31 3.6% APMS 7,549 2,516 2,515 (1) 0.0% Other Medical Services (282) (94) 225 319-339.0% Total Primary Care Medical 54,087 18,028 18,260 232 1.3% 2

Lewisham CCG PMS 38,434 12,812 12,807 (5) 0.0% GMS 2,363 788 782 (6) -0.8% APMS 932 311 316 5 1.6% Other Medical Services 1,392 464 464 0 0.0% Total Primary Care Medical 43,121 14,374 14,367 (6) 0.0% Southwark CCG PMS 37,425 12,475 12,476 2 0.0% GMS 1,791 597 580 (17) -2.8% APMS 4,985 1,662 1,671 9 0.6% Other Medical Services (993) 203 210 7 3.5% Total Primary Care Medical 43,208 14,936 14,938 2 0.0% Brackets denote underspend Medical services are showing a ytd overspend of 253k. The only material variances from budget reported at Month 4 is for Lambeth CCG and reflects the gap between their allocation and budgets after releasing the headroom reserve and contingency into the position. 4 Capitation Report There was year on year growth of 2.1% in South East London s weighted population from April 2016 to April 2017. Demographic growth reserve budgets have been funded differentially at CCG level in London for 2017/18 based on the ONS predicted population growth figures. Figures by CCG, including growth between April 17 and July 17 are shown in Table 2 below. Table 2 CCG Normalised weighted list as at 01/04/2016 Normalised weighted list as at 01/04/2017 Year on Year % Movement Normalised weighted list as at 01/07/2017 April to July % Movement ONS % 16_17 ONS % 17_18 Bexley 219,428 223,645 1.92% 223,789 0.06% 1.00% 1.00% Bromley 320,947 323,703 0.86% 324,499 0.25% 1.10% 1.10% Greenwich 277,556 288,440 3.92% 288,660 0.08% 1.20% 1.10% Lambeth 376,673 385,999 2.48% 388,270 0.59% 1.20% 1.10% Lewisham 306,819 311,924 1.66% 312,859 0.30% 1.50% 1.40% Southwark 313,341 319,177 1.86% 320,526 0.42% 1.50% 1.30% Total SEL 1,814,765 1,852,888 2.10% 1,858,603 0.31% Overall, in absolute terms South East London saw an increase of 38,123 in the normalised weighted population between April 16 and April 17 and a further 5,715 (0.31%) to July 17. 5. Appendix A details each CCG s current financial performance. 5.1 Bexley The primary care medical budget calculated for this CCG leaves a net deficit position of 103k against the 17/18 allocation of 28,549k. It is expected that this deficit will be managed within the population growth reserve following low levels of list increase in Q2. 3

The reported ytd position is an overspend of 14k (0.2%), the majority relating to seniority, it is not certain that this overspend position will continue to year end. The CCG weighted practice list size has increased by 1.9% year on year from April 2016 to April 2017 and a further 0.06% to July 17. The primary care medical services allocation increased by 2.7%. 5.2 Bromley The primary care medical budget calculated for this CCG leaves a surplus position of 1,607k (inclusive of headroom reserve and contingency) against the 17/18 allocation of 42,165k. The reported ytd position is an overspend of 3k (0.02%), it is not certain that this overspend position will continue to year end. The CCG weighted practice list size has increased by 0.9% year on year from April 2016 to April 2017 and a further 0.25% to July 17. The primary care medical services allocation increased by 7.6%. 5.3 Greenwich The primary care medical budgets calculated for this CCG leaves a surplus position of 76k (the headroom and contingency reserves released into the position) against the 17/18 allocation of 37,203k. The reported ytd position is to break-even. The CCG weighted practice list size has increased by 3.9% year on year from April 2016 to April 2017 and a further 0.08% to July 17. The primary care medical services allocation increased by 4.4%. 5.4 Lambeth The primary care medical budget calculated for this CCG leaves a net deficit position of 584k against the 17/18 allocation of 54,087k. The reported ytd position is an over spend of 232k reflecting the release into the position of the net deficit. The CCG weighted practice list size has increased by 2.5% year on year from April 2016 to April 2017 and a further 0.59% to July 17. The primary care medical services allocation increased by 2.2%. 5.5 Lewisham The primary care medical budget calculated for this CCG leaves a surplus position of 1,213k (inclusive of headroom and contingency reserves) against the 17/18 allocation of 43,121k. The reported ytd position is an underspend of 6k (0.04%), the surplus has not been factored into the ytd position. The CCG weighted practice list size has increased by 1.7% year on year from April 2016 to April 2017 and a further 0.3% to July 17. The primary care medical services allocation increased by 6.3%. 5.6 Southwark The primary care medical budget calculated for this CCG leaves a net deficit position of 1,190k against the 17/18 allocation of 43,208k. 4

The reported ytd position is an overspend of 2k (0.01%), it is not certain that this overspend position will continue to year end. The CCG weighted practice list size has increased by 1.9% year on year from April 2016 to April 2017 and a further 0.42% to July 17. The primary care medical services allocation increased by 2.5%. 5

: It Item 7 Enc E Primary Care Commissioning Committee DATE OF MEETING: 20 September 2017 Title: Greenwich primary care quality dashboard AUTHOR: Simon James Primary Care Delivery Manager Current Position Greenwich CCG currently does not have a formally agreed quality dashboard which provides accessible and meaningful data on primary care in the borough. A quality report from the South East London primary care commissioning team has previously been provided for the Primary Care Commissioning Committee, but this is not perceived as being either comprehensive or current enough to afford an objective assessment of the quality of Greenwich primary care services. The London Operating Model is currently being finalised and will be presented to PCCCs in November/December 2017. To support the Operating Model, NHSE will be looking to develop a new Quality Report that will provide comparative data on agreed indicators. In the meantime, CCGs are developing their own bespoke Quality Reports until such time the NHSE reports will be available. The Dashboard The proposed Greenwich dashboard is based on a review of other local CCGs examples where available and exemplars from other parts of England. The core indicators are similar to those used by Bromley CCG and there is an indication that other South East London CCGs are interested in adopting a similar approach. This is likely to be an initial stage in development, as implementation of the new PMS/GMS contracts will eventually give the CCG a source of monitoring data that can be incorporated into a more comprehensive dashboard. Within the report, there is a summary of how this version has been developed and potential indicators which could be added to future iterations. The report to the September 2017 PCCC draws on available data sets that are as current and meaningful in terms of core primary care service delivery and patient feedback. This includes: - GP Patient Survey (published July 2017) - Friends and Family Test returns - Quality & Outcomes Framework (2016/17 outcome summary by practice); and - CQC ratings (from www.cqc.org.uk as of August 2017);

In addition, CCG level data for child immunisations for the period January-to-March 2017. This compares Greenwich to other South London CCGs, rather than practice-level rates. Workforce data focuses on GPs for this report, referring to baseline assessments of GP numbers, nationally-collected workforce data and a local survey of the primary care workforce carried out in June 2017. A summary of GP contractual variations in September 2017 are also included in this report, drawing on information collated by the Medical Directorate and Contract teams at NHS England. Data on practice list size growth and a map of Greenwich general practice are included for contextual information. Explanatory text about these indicators is included within the dashboard report and. Recommendation The committee is asked to consider and review the dashboard and comments are invited on how it may be developed and improved. NHS Greenwich CCG CONTACT: Name: Simon James, Primary Care Delivery Manager E-Mail: simon.james4@nhs.net 2

Greenwich Primary Care Quality Report Irene Grayson Associate Director, Primary Care NHS Greenwich CCG

Contents Item Page Number Introduction 3 Developing the Primary Care Dashboard 4 Greenwich Practices 5 Contract Indicators 6 Practice List Size Growth 7 Friends and Family Test 8 QOF Performance 11 CQC Ratings 13 Immunisations, Children 14 Primary Care Workforce: GPs 16 GP Patient Survey 2017: Access and Experience 19

Introduction The purpose of this report is to give the Primary Care Committee and the Greenwich public an overview of the quality of primary care services in Greenwich. The report is designed to present data that is current and meaningful to practices, professionals and patients and is based, as much as possible, on nationally-collected data. This is, however, a work-in-progress and further development and enhancement of the report is anticipated (for example, assessing progress in using digital services). The contents will also change through the year to ensure it reflects the activity and reporting cycle of primary care. Explanatory information about the data sources and the indicators is included in the pack and can be seen in red text boxes. Actions are shown in blue boxes.

Developing the Greenwich Primary Care Quality Dashboard Principles for Dashboard Constructive and developmental Fair and meaningful Accurate and objective Timely and reflecting Structure A core dashboard that reflects monitoring standards in rest of South East London Additional summary of contract indicators to mirror former SE London NHS England team Quality Report Future addition of new contract KPIs when it goes live in Greenwich Addition of local quality indicators to assess clinical, access, workforce and digital performance Gaps Estates Public engagement & complaints Outpatient referrals / Electronic Referral System use GP Forward View impact and progress assessment Proactive Care indicators Coordinated Care indicators (e.g. progress in developing at-scale integrated care at network/borough level) Greenwich Dashboard Friends and Family Test GP-Patient Survey (selected indicators) CQC ratings QOF performance List Growth Workforce Contract indicators Retirements Partnership changes Mergers List Closures Breaches Performer Issues New PMS contract Key Performance Indicators (2018-) Add. Quality indicators Patient Online Digital inclusion Access hub appointments A&E attendances Vacccination and Immunisations Dementia Cervical Screening Learning Disability health checks Diabetes 4

Greenwich practices Serial No Surgery Name Syndicate Serial No Surgery Name 1 7 Day Healthcare (Bramch) Network 30 Manor Brook Medical Centre Blackheath_Charlton 2 Abbeywood Surgery Excel 31 New Eltham Medical Practice 3 All Saints Medical Centre Excel 32 Nightingale Surgery (Branch) 4 Avery Hill Surgery (Branch) Eltham 33 Plumbridge Medical Centre 5 Bannockburn Surgery Excel 34 Plumstead Health Centre 6 Basildon Road Surgery Excel 35 Rochester Way Surgery (Branch) 7 Blackfen Road (Branch) Eltham 36 Royal Arsenal PMS 8 Blackheath Standard Surgery Blackheath_Charlton 37 Samuel Street Surgery (Branch) 9 Briset Corner Surgery Eltham 38 Sherard Road Medical Centre 10 Burney Street Practice Blackheath_Charlton 39 Shooters Hill Medical Centre 11 Charlton Road Surgery (Branch) Blackheath_Charlton 40 (Branch) South St Medical Centre 12 Clover Health Centre Excel 41 St Marks Medical Centre 13 Conway PMS Network 42 Thamesmead NHS Health Centre 14 Dr M Baksh The Coldharbour Eltham 43 The Fairfield Centre 15 Surgery Dr Mostafa PMS Excel 44 The Hill Surgery-Dr Baksh (Branch) 16 Dr S Ratneswaren Surgery Eltham 45 The Hill Surgery-Dr S Ratsnewaren 17 Eltham Medical Practice Eltham 46 (Branch) The Mound Medical Centre 18 Eltham Medical Practice Branch Eltham 47 The Slade Surgery 19 Eltham Palace Surgery Eltham 48 The Trinity Medical Centre 20 Eltham Park Surgery Eltham 49 The Waverley Practice 21 Ferryview Health Centre Network 50 Triveni PMS 22 Frances Street Surgery (Branch) Network 51 Triveni PMS Branch (Branch) 23 Gallions Reach Health Centre Network 52 Tudway Road (Branch) 24 Garland Road Health Centre Excel 53 Vanbrugh Health Centre 25 (Branch) Glyndon Medical Centre Excel 54 Wallace Centre (Branch) 26 Greenwich Peninsula Practice Blackheath_Charlton 55 Westmount Surgery 27 Henley Cross Medical Practice Eltham 56 Wickam Lane Surgery (Branch) 28 Henley Cross Medical Practice Eltham 57 Wickham Street (Branch) 29 Branch Heronsgate Medical Centre (Branch) Network 58 Woodland Walk Surgery Syndicate Eltham Network Blackheath_Charlton Excel Eltham Network Excel Eltham Network Blackheath_Charlton Network Network Blackheath_Charlton Eltham Eltham Eltham Excel Network Excel Excel Excel Eltham Blackheath_Charlton Blackheath_Charlton Eltham Excel Excel Blackheath_Charlton This map shows practices (main and branch surgeries) by syndicate area as at the start of 2017 5

Contract indicators: September 2017 Indicator Number this quarter Retirements 0 Partnership changes 1 Mergers 0 List Closures 0 Breaches 0 Performance Issues 0 The partnership change is to Abbeyslade PMS who have a new partner, Dr Jyoti Chand. She joined the Contract from 26/5/17 and this is now finalised through a contractual variation.

Practice List Size Growth PRACTICE CODE PRACTICE NAME Raw list size 1.4.2016 Raw list size 1.4.2017 Increase % Increase G83628 DR J LAL'S PRACTICE 6892 8445 1553 22.5 Y03296 CLOVER HEALTH CENTRE 5089 5747 658 12.9 G83021 VANBRUGH GROUP PRACTICE 11891 13419 1528 12.9 Y02974 AT MEDICS 6526 7322 796 12.2 G83016 ROYAL ARSENAL MEDICAL CENTRE 8225 9100 875 10.6 Y03755 GREENWICH PNINSULA 7740 8561 821 10.6 G83015 ELTHAM PALACE PMS 4808 5308 500 10.4 G83673 PRIMECARE PMS (COLDHARBOUR) 4379 4771 392 9.0 G83680 ELTHAM MEDICAL PRACTICE 13887 15019 1132 8.2 G83019 PLUMSTEAD HEALTH CENTRE PMS 10550 11290 740 7.0 G83027 SHERARD ROAD MEDICAL CENTRE 10103 10801 698 6.9 G83003 DR M BAKSH'S PRACTICE 4223 4500 277 6.6 G83663 BRISET CORNER SURGERY 2172 2302 130 6.0 G83651 WOODLANDS SURGERY 5587 5921 334 6.0 G83641 Plumbridge MC 2264 2395 131 5.8 Y02222 THE TRINITY MEDICAL CENTRE 3230 3411 181 5.6 G83039 ST MARKS PMS 7774 8188 414 5.3 G83065 BURNEY STREET PMS 15332 16035 703 4.6 G83044 FAIRFIELD PMS 10447 10865 418 4.0 G83647 MOSTAFA PMS 6212 6449 237 3.8 G83026 TRIVENI PMS 7338 7613 275 3.7 G83013 BLACKHEATH STANDARD PMS 6474 6700 226 3.5 G83001 MANOR BROOK PMS 12450 12881 431 3.5 G83034 ELTHAM PARK SURGERY 4775 4930 155 3.2 G83030 ALL SAINTS MEDICAL CENTRE PMS 5094 5231 137 2.7 G83022 DR V SANDRASAGRAS PRACTICE 2339 2401 62 2.7 G83058 PRIMECARE PMS (SOUTH STREET) 8281 8472 191 2.3 G83654 BANNOCKBURN SURGERY 5408 5504 96 1.8 G83631 ABBEYSLADE PMS (DR CHAND) 4568 4616 48 1.1 G83031 ABBEY WOOD SURGERY 7691 7763 72 0.9 G83060 GLYNDON PMS 6836 6894 58 0.8 G83633 CONWAY PMS 4226 4439 13 0.3 G83067 VALENTINE HEALTH PARTNERSHIP 25444 25502 58 0.2 G83635 WAVERLEY PMS 4753 4643 110-2.3 G83012 GALLIONS REACH HEALTH CENTRE 16859 15490 1369-8.1 G83017 HENLEY CROSS MEDICAL PRACTICE 4529 3727 G83063 DR B P C PEIRIS' PRACTICE 2801 673 G83655 DR V AGARWAL'S PRACTICE 1616 1037 G83668 THE SLADE SURGERY 3673 2129 Year-on-year to April 2017, seven practices had 10% plus list size growth. Individual list size growth has resulted from: Practices taking on additional patients due to practice closures Population growth generated through new housing developments Greenwich is monitoring list size by practice and is using this as a key indicator for its use of GP Forward View resilience funding in 2017/18. 7

Friends and Family Test The Friends and Family Test (FFT) is an important feedback tool that supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. It asks people if they would recommend the services they have used and offers a range of responses. When combined with supplementary follow-up questions, the FFT provides a mechanism to highlight both good and poor patient experience. The feedback is vital in transforming NHS services and supporting patient choice. Whilst a useful tool to measure patient satisfaction/experience the response numbers are very low so this can skew the results at individual practice level. The chart that follows details FFT data for June 2017. It should be noted that these practices did not submit data: Royal Arsenal Medical Centre Burney Street PMS Clover Health Centre Plumbridge Medical Centre

Friends and Family Test The highest number of responses for an individual practice was 164 (Abbey Wood Surgery) and the lowest was 8 (Dr V Sandrasagra practice). The SMS/Text message returns account for 91% of the response collection type. Practices are supported by the CCG and Greenwich Healthcare GP Federation by funding the i-plato friends and family test function, so patients can quickly and electronically register their opinions. 9

Friends and Family test: data table 10

Quality and Outcomes Framework The Quality and Outcomes Framework (QOF) is the annual reward and incentive programme detailing GP practice achievement results. It rewards practices for the provision of quality care and helps standardise improvement in the delivery of primary medical services. It is a voluntary process for all surgeries in England and was introduced as part of the GP contract in 2004. The indicators for the QOF change annually, with the introduction of new measures and some indicators are retired. The QOF contains three domains (Clinical, Public Health and Public Health - Additional services) with each domain consists of a set of achievement measures, known as indicators, against which practices score points according to their level of achievement. The QOF measures achievement against these indicators with practices scored points on the basis of achievement against these indicators, up to a maximum of 559 points. The QOF gives an indication of the overall achievement of a surgery through a points based system. Practices aim to deliver high quality care across a range of areas for which they score points. The next slide sets out the overall achievement for all Greenwich practices. The latest published data is 2015/16, so the 2016-17 & 2017/18 scores is yet to be published. 2016/17 QOF data is due to be published in October 2017.

Quality and Outcomes Framework 12

CQC Ratings Practice code Location Name Location Street Address Postcode Latest Rating Publication Date G83001 Manor Brook PMS Manor Brook Medical Centre SE3 0EN Good 22/09/2016 G83003 DR M BAKSH'S PRACTICE Coldharbour Surgery SE9 3JD Good 10/12/2015 G83012 Thamesmead Medical Associates - PMS Gallions Reach Health Centre SE28 8BE Good 25/04/2017 G83013 Blackheath Standard PMS Blackheath Surgery, SE3 7HB Good 29/09/2016 G83015 Eltham Palace PMS 30 Passey Place SE9 5DQ Not visited on new site G83016 Royal Arsenal Medical Centre 21 Arsenal Way SE18 6TE Good 26/04/2017 G83019 Plumstead Health Centre PMS Tewson Road SE18 1BH Good 11/01/2017 G83021 Vanbrugh Group Practice Lambarde Square SE10 9GB Not visited on new site G83022 Dr Vasanti Sandrasagra 191 Westmount Road SE9 1XY Good 26/07/2016 G83026 Triveni PMS Escreet Grove Surgery SE18 5TE Good 27/03/2017 G83027 Sherards Road Medical Centre 71 Sherard Road SE9 6ER Requires improvement 06/07/2017 G83030 All Saints Medical Centre PMS 13a Ripon Road SE18 3PS Good 11/08/2016 G83031 Abbey Wood Surgery 9 Godstow Road SE2 9AT Good 19/02/2015 G83034 Eltham Park Surgery 46 Westmount Road SE9 1JE Good 17/03/2016 G83039 St Marks PMS St Marks Medical Centre SE18 3EP Good 04/11/2016 G83044 Fairfield PMS The Fairfield Centre SE7 8TX Good 23/08/2016 G83058 Primecare PMS (South Street) 71A Greenwich South Street SE10 8NT Good 22/12/2016 G83060 Glyndon PMS Glyndon Medical Centre SE18 7LU Requires improvement 22/02/2017 G83065 Burney Street PMS Burney Street Practice, SE10 8EX Good 23/03/2016 G83067 Ferryview Health Centre GP Surgery 25 John Wilson Street SE18 6PZ Good 16/11/2016 G83628 New Eltham Medical Centre 52 Thaxted Road SE9 3PT Requires improvement 28/01/2016 G83631 Abbeyslade PMS - Dr Chand 111 Basildon Road SE2 0ER Good 22/03/2016 G83633 Conway PMS Conway Medical Centre SE18 1AH Inadequate 05/04/2017 G83635 Waverley PMS The Waverley Practice SE18 7QU Good 17/12/2015 G83641 Plumbridge MC 32-33 Plumbridge Street SE10 8PA New provider, to be visited G83647 Mostafa PMS 141 Plumstead High Street SE18 1SE Good 16/02/2017 G83651 Woodlands Surgery Woodland Surgery, Woodland Walk SE10 9UB Good 29/09/2016 G83654 Bannockburn PMS 20-22 Bannockburn Road SE18 1ES Good 18/08/2016 G83663 Briset Corner Surgery Briset Corner, SE9 6JX Good 24/02/2017 G83673 Primecare PMS (Coldharbour) 79 William Barefoot Drive SE9 3JD Good 09/04/2015 G83680 Eltham Medical Practice 30 Passey Place SE9 5DQ Good 20/07/2017 Y02222 Trinity Medical Centre 2 Garland Road SE18 2AE Requires improvement 14/12/2016 Y02974 AT MEDICS Thamesmead Health Centre SE28 0NY New provider, to be visited Y03296 Clover Health Centre Equitable House, 10 Woolwich New RSE18 6AB Good 09/04/2015 Y03755 Greenwich Peninsula Practice Millenium Village Health Centre SE10 0QN Good 09/05/2016 13 Several practices require re-visits to new premises or providers of their service. Their reports are archived by CQC and are not available to report here. Our single lowest rated practice has received RCGP support to improve and proposal to improve clinical leadership is before the PCCC. Their CQC revisit took place on 13 September 2017.

Immunisation Programmes: Children Immunisations data covers a widerange of services provided, primarily, in general practice (e.g. flu, cancer, shingles). Data for January-March 2017 is available for child immunisations by CCG is available, and the following shows Greenwich as a whole in comparison to the rest of South London. However, there are campaigns like flu which are seasonal and for which data will now be a year out-of-date. This performance is best reported at a spring PCCC. Dtap / IPV / Hib coverage (2 years old) MMR for one dose coverage (2 years old) Hib/Men C booster coverage (2 years old) Latest period 16-17 Q4 Latest period 16-17 Q4 Latest period 16-17 Q4 Lower threshold 90.0% Lower threshold 90.0% Lower threshold 90.0% Standard 95.0% Standard 95.0% Standard 95.0% Richmond upon Thames 82.9% 1 Richmond upon Thames 73.3% 1 Richmond upon Thames 72.4% Croydon 90.1% 2 Croydon 80.3% 2 Croydon 80.2% Bromley 90.3% 3 Bromley 81.7% 3 Lewisham 81.0% Wandsworth 90.7% 4 Greenwich 82.8% 4 Bromley 81.3% Greenwich 91.0% 5 Lambeth 83.4% 5 Greenwich 82.4% Lambeth 91.5% 6 Wandsworth 83.5% 6 Lambeth 83.3% Lewisham 92.8% 7 Lewisham 85.0% 7 Wandsworth 83.5% Southwark 93.7% 8 Bexley 87.5% 8 Bexley 88.4% Merton 94.1% 9 Southwark 88.3% 9 Merton 88.6% Sutton 94.3% 10 Merton 88.8% 10 Sutton 88.7% Bexley 94.5% 11 Sutton 88.8% 11 Southwark 89.3% Kingston upon Thames 95.4% 12 Kingston upon Thames 90.5% 12 Kingston upon Thames 89.9% Rotavirus coverage (two dose, 12 mths) Men B coverage (12 mths) Dtap / IPV / Hib coverage (12 mths) PCV coverage (12 mths) Latest period 16-17 Q4 Latest period 16-17 Q4 Latest period 16-17 Q4 Latest period 16-17 Q4 Lower threshold 90.0% Lower threshold 90.0% Lower threshold 90.0% Lower threshold 90.0% Standard 95.0% Standard 95.0% Standard 95.0% Standard 95.0% Richmond upon Thames 77.0% 1 Lewisham 83.8% 1 Richmond upon Thames 75.0% 1 Richmond upon Thames 75.3% Croydon 85.3% 2 Croydon 84.8% 2 Croydon 86.3% 2 Croydon 86.4% Lambeth 85.7% 3 Richmond upon Thames 85.2% 3 Lambeth 88.4% 3 Bromley 88.7% Bromley 87.5% 4 Lambeth 85.6% 4 Bromley 88.7% 4 Lambeth 88.7% Southwark 88.2% 5 Bexley 87.9% 5 Greenwich 89.6% 5 Greenwich 89.3% Wandsworth 89.1% 6 Bromley 88.4% 6 Wandsworth 90.3% 6 Wandsworth 90.8% Merton 92.3% 7 Southwark 88.5% 7 Lewisham 91.1% 7 Lewisham 91.4% Sutton 92.4% 8 Greenwich 92.2% 8 Southwark 91.9% 8 Southwark 91.9% Greenwich 92.8% 9 Kingston upon Thames 93.3% 9 Bexley 92.7% 9 Bexley 92.3% Kingston upon Thames 93.3% 10 Merton 98.0% 10 Merton 93.2% 10 Merton 93.6% Lewisham 93.4% 11 Sutton 98.0% 11 Sutton 93.4% 11 Sutton 93.6% Bexley 96.0% 12 Wandsworth No data 12 Kingston upon Thames 95.3% 12 Kingston upon Thames 95.2% 14

Immunisation Programmes: Children PCV booster coverage (2 years old) Hib / Men C booster coverage (5 years old) MMR for one dose coverage (5 years old) Latest period 16-17 Q4 Latest period 16-17 Q4 Latest period 16-17 Q4 Lower threshold 90.0% Lower threshold 90.0% Lower threshold 90.0% Standard 95.0% Standard 95.0% Standard 95.0% Richmond upon Thames 73.5% 1 Richmond upon Thames 84.5% 1 Richmond upon Thames 86.7% Croydon 80.8% 2 Croydon 84.7% 2 Croydon 88.2% Bromley 80.8% 3 Lewisham 86.0% 3 Greenwich 89.0% Greenwich 82.5% 4 Greenwich 86.2% 4 Merton 89.7% Lambeth 83.2% 5 Wandsworth 87.8% 5 Southwark 89.7% Wandsworth 83.5% 6 Merton 88.1% 6 Wandsworth 89.7% Lewisham 84.0% 7 Sutton 88.2% 7 Sutton 89.7% Bexley 88.2% 8 Southwark 88.3% 8 Lewisham 90.8% Merton 88.5% 9 Kingston upon Thames 90.2% 9 Lambeth 91.0% Sutton 88.7% 10 Lambeth 90.2% 10 Kingston upon Thames 93.4% Southwark 89.2% 11 Bexley 92.7% 11 Bexley 94.1% Kingston upon Thames 89.9% 12 Bromley 93.4% 12 Bromley 95.2% MMR for two doses coverage (5 years old) DTaP/IPV/Hib coverage (5 years old) DTaP/IPV booster coverage (5 years old) Latest period 16-17 Q4 Latest period 16-17 Q4 Latest period 16-17 Q4 Lower threshold 90.0% Lower threshold 90.0% Lower threshold 90.0% Standard 95.0% Standard 95.0% Standard 95.0% Richmond upon Thames 65.8% 1 Croydon 90.4% 1 Richmond upon Thames 31.8% Croydon 71.3% 2 Richmond upon Thames 91.8% 2 Wandsworth 68.2% Bromley 77.4% 3 Greenwich 91.9% 3 Croydon 70.7% Merton 79.7% 4 Southwark 92.2% 4 Greenwich 73.9% Sutton 79.7% 5 Merton 92.7% 5 Bexley 74.7% Bexley 82.2% 6 Sutton 92.8% 6 Bromley 76.8% Kingston upon Thames 82.5% 7 Wandsworth 93.4% 7 Merton 76.9% Wandsworth 83.2% 8 Lewisham 93.9% 8 Lambeth 76.9% Greenwich 84.1% 9 Lambeth 94.2% 9 Sutton 77.1% Lambeth 85.3% 10 Kingston upon Thames 95.6% 10 Lewisham 77.4% Lewisham 86.2% 11 Bexley 95.6% 11 Southwark 77.5% Southwark 86.4% 12 Bromley 96.3% 12 Kingston upon Thames 82.8% 15

Primary Care Workforce: GPs To assist primary care workforce planning for CCGs as part of the GP Forward View implementation, Healthy London Partnership projected GP supply and demand by CCG in 2016. GP numbers in Greenwich were running behind demand in 2016 and projected to show a similar gap by 2021 if no action taken to improve recruitment and retention. Much of the gap will be based on retirement 1/3 rd of Greenwich GPs are over 55 years of age and 22% over 60 (the 5 th highest in London). 200 150 100 50 0 157 132 GP Supply vs demand WTE 2016 2017 2018 2019 2020 2021 GP Supply GP Demand 186 157 Reference: www.healthylondon.org/workforce/workforcemodelling/primary-care The CCG carried out a survey of Greenwich practices in June 2017. this was designed to augment nationally-collected workforce data (reported as of March 2017) and assess local recruitment need across all primary care professionals and staff. The data also contributed towards a SE London bid against the new NHS International Recruitment programme. This was successful and, with three other CCGs, 45 overseas GPs are expected to be recruited into the area from 2018.

Greenwich primary care workforce survey For General Practitioners, the results were for the 29 practices that responded: A total of 115.6 whole-time equivalent (WTE) GPs were in post, with a declared vacancy total of 22.7 WTE GPs this approximately 16% of the total complement. Practices reported a high level of GP partnership vacancies in practices 8 WTEs in total. From the reported baseline of GP partners in post plus vacancies, this gave a reported vacancy rate of 12.5%. Practices also reported high levels of vacancies for salaried GPs in Greenwich, equivalent to 18.4 WTE. GPs identified as locums covering the combined gap of partners and salaried were reported as 40.9 WTE. There were 10 practices reporting they had 11 GPs who were expecting to retire in the next two years. Ten training practices reported a total of 19.25 WTEs Year 3 GP Registrars (i.e. GPs in training). Of the practices, 24 had an interest in help to recruit GPs and expressed this against the international recruitment programme. Of those, 17 of these had GP vacancies now equivalent to 20.8 WTEs in total. Of these, 14 practices were for at least 1 full-time GP. 17

Comparative data: GPs Geography Total GP WTE (excluding registrars) Total GP Partner and Salaried Ratio of Total GP / Patient Ratio of GP Partner and Salaried / Patient List Size National* 29,937 29,336 1:1912 1:1952 57,254,188 London* 4,701 4,521 1:1995 1:2074 9,377,393 Greenwich 120.9 111.5 1:2270 1:2461 274,443** * National data taken from the General and Personal Medical Services, England September to March 2016, Provisional Experimental statistics (NHS Digital) ** Total practice list size, March 2017 This table shows a top-down summary of GP numbers and a comparison against London and England data. Combining this nationally-reported primary care workforce data with reported GP numbers from the local survey (excluding GP Registrars) would give Greenwich an estimated total of 120.9 WTE GPs. Other reported data seems to back up the overall message that Greenwich is under-doctored compared to the rest of London. Health Education England analysis for London from 2016 also showed

GP Patient Survey 2017 The GP Patient Survey (GPPS) is an England-wide survey, providing practice-level data about patients experiences of their GP practices. Ipsos MORI administers the survey on behalf of NHS England. The survey measures patients experiences across a range of topics, including: Making appointments Waiting times Perceptions of care at appointments Practice opening hours Out-of-hours services The data in this slide pack are based on the July 2017 GPPS publication from a single wave of fieldwork carried out annually, from January 2017 to March 2017. In NHS Greenwich CCG, 13,826 questionnaires were sent out, and 4,055 were returned completed. This represents a response rate of 29%. A selection of graphs from the Greenwich CCG published pack are included in this report, focusing on Access and Patient Experience. Note that several of the practices in these slides have since merged or closed. 19

Success in getting an appointment: how the CCG s practices compare AT MEDICS SHERARD ROAD MEDICAL CENTRE THE SLADE SURGERY CLOVER HEALTH CENTRE HENLEY CROSS MEDICAL PRACTICE CONWAY PMS WAVERLEY PMS GLYNDON PMS THE TRINITY MEDICAL CENTRE DR BPC PEIRIS' PRACTICE TEWSON ROAD PMS TRIVENI PMS ROYAL ARSENAL MEDICAL CENTRE DR J LAL'S PRACTICE GALLIONS REACH HEALTH CENTRE ALL SAINTS MEDICAL CENTRE PMS VALENTINE HEALTH PARTNERSHIP BLACKHEATH STANDARD PMS GREENWICH PENINSULA CCG PRIMECARE PMS (SOUTH STREET) ABBEYSLADE PMS (DR CHAND) COLDHARBOUR HILL PMS ELTHAM PALACE PMS WOODLANDS SURGERY DR V AGARWAL'S PRACTICE BANNOCKBURN SURGERY ELTHAM MEDICAL PRACTICE ELTHAM PARK SURGERY ST MARKS PMS FAIRFIELD PMS BURNEY STREET PMS PLUMBRIDGE MEDICAL CENTRE BRISET CORNER SURGERY PLUMSTEAD H/C PMS VANBRUGH GROUP PRACTICE MOSTAFA PMS PRIMECARE PMS (COLDHARBOUR) ABBEY WOOD SURGERY MANOR BROOK PMS DR V SANDRASAGRA'S PRACTICE Q12. Last time you wanted to see or speak to a GP or nurse from your GP surgery, were you able to get an appointment to see or speak to someone? Practices CCG National average Percentage of patients who said they were able to get an appointment last time they tried to see or speak to a GP or nurse 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Comparisons are indicative only: differences may not be statistically significant, particularly at practice level due to low numbers of responses Base: All those completing a questionnaire: National (772,293); CCG (3,854); Practice bases range from 21 to 128 20 %Yes = %Yes + %Yes, but I had to call back closer to or on the day Ipsos MORI 15-080216-01 Version 1 Public

Ease of getting through to GP surgery on the phone: how the CCG s practices compare CLOVER HEALTH CENTRE GALLIONS REACH HEALTH CENTRE BLACKHEATH STANDARD PMS SHERARD ROAD MEDICAL CENTRE VANBRUGH GROUP PRACTICE DR J LAL'S PRACTICE ELTHAM PALACE PMS GLYNDON PMS TEWSON ROAD PMS HENLEY CROSS MEDICAL PRACTICE FAIRFIELD PMS DR BPC PEIRIS' PRACTICE ROYAL ARSENAL MEDICAL CENTRE PRIMECARE PMS (SOUTH STREET) THE SLADE SURGERY CONWAY PMS MANOR BROOK PMS ELTHAM MEDICAL PRACTICE CCG GREENWICH PENINSULA ST MARKS PMS PRIMECARE PMS (COLDHARBOUR) THE TRINITY MEDICAL CENTRE PLUMSTEAD H/C PMS ABBEY WOOD SURGERY VALENTINE HEALTH PARTNERSHIP AT MEDICS TRIVENI PMS WAVERLEY PMS MOSTAFA PMS COLDHARBOUR HILL PMS BURNEY STREET PMS ABBEYSLADE PMS (DR CHAND) BANNOCKBURN SURGERY ELTHAM PARK SURGERY WOODLANDS SURGERY DR V AGARWAL'S PRACTICE ALL SAINTS MEDICAL CENTRE PMS PLUMBRIDGE MEDICAL CENTRE BRISET CORNER SURGERY DR V SANDRASAGRA'S PRACTICE Q3. Generally, how easy is it to get through to someone at your GP surgery on the phone? Practices Percentage of patients saying it is easy to get through to someone on the phone 100% 90% CCG National average 80% 70% 60% 50% 40% 30% 20% 10% 0% Comparisons are indicative only: differences may not be statistically significant, particularly at practice level due to low numbers of responses Base: All those completing a questionnaire: National (804,177); CCG (4,029); Practice bases range from 25 to 131 %Easy = %Very easy + %Fairly easy 21 Ipsos MORI 15-080216-01 Version 1 Public

Overall experience of making an appointment: how the CCG s practices compare CLOVER HEALTH CENTRE CONWAY PMS GALLIONS REACH HEALTH CENTRE ROYAL ARSENAL MEDICAL CENTRE BLACKHEATH STANDARD PMS HENLEY CROSS MEDICAL PRACTICE THE SLADE SURGERY DR BPC PEIRIS' PRACTICE WAVERLEY PMS TEWSON ROAD PMS SHERARD ROAD MEDICAL CENTRE ELTHAM PALACE PMS DR J LAL'S PRACTICE THE TRINITY MEDICAL CENTRE GLYNDON PMS AT MEDICS FAIRFIELD PMS GREENWICH PENINSULA VALENTINE HEALTH PARTNERSHIP CCG VANBRUGH GROUP PRACTICE BANNOCKBURN SURGERY ABBEYSLADE PMS (DR CHAND) ELTHAM MEDICAL PRACTICE ELTHAM PARK SURGERY DR V AGARWAL'S PRACTICE PRIMECARE PMS (SOUTH STREET) BURNEY STREET PMS ABBEY WOOD SURGERY MANOR BROOK PMS WOODLANDS SURGERY COLDHARBOUR HILL PMS ALL SAINTS MEDICAL CENTRE PMS TRIVENI PMS PLUMSTEAD H/C PMS ST MARKS PMS PRIMECARE PMS (COLDHARBOUR) MOSTAFA PMS PLUMBRIDGE MEDICAL CENTRE BRISET CORNER SURGERY DR V SANDRASAGRA'S PRACTICE Q18. Overall, how would you describe your experience of making an appointment? Practices Percentage of patients saying they had a good experience of making an appointment 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CCG National average Comparisons are indicative only: differences may not be statistically significant, particularly at practice level due to low numbers of responses Base: All those completing a questionnaire: National (768,706); CCG (3,860); Practice bases range from 21 to 127 %Good = %Very good + %Fairly good 22 Ipsos MORI 15-080216-01 Version 1 Public

Waiting times at the GP surgery: how the CCG s practices compare ABBEYSLADE PMS (DR CHAND) VALENTINE HEALTH PARTNERSHIP CLOVER HEALTH CENTRE THE SLADE SURGERY ABBEY WOOD SURGERY PRIMECARE PMS (SOUTH STREET) HENLEY CROSS MEDICAL PRACTICE BLACKHEATH STANDARD PMS FAIRFIELD PMS SHERARD ROAD MEDICAL CENTRE WAVERLEY PMS ROYAL ARSENAL MEDICAL CENTRE ELTHAM PALACE PMS BANNOCKBURN SURGERY CCG TRIVENI PMS ALL SAINTS MEDICAL CENTRE PMS CONWAY PMS MANOR BROOK PMS TEWSON ROAD PMS BURNEY STREET PMS ELTHAM MEDICAL PRACTICE AT MEDICS VANBRUGH GROUP PRACTICE GLYNDON PMS DR J LAL'S PRACTICE PLUMBRIDGE MEDICAL CENTRE DR V AGARWAL'S PRACTICE GALLIONS REACH HEALTH CENTRE THE TRINITY MEDICAL CENTRE DR BPC PEIRIS' PRACTICE PRIMECARE PMS (COLDHARBOUR) ELTHAM PARK SURGERY DR V SANDRASAGRA'S PRACTICE ST MARKS PMS BRISET CORNER SURGERY WOODLANDS SURGERY COLDHARBOUR HILL PMS PLUMSTEAD H/C PMS GREENWICH PENINSULA MOSTAFA PMS Q20. How do you feel about how long you normally have to wait to be seen? Practices Percentage of patients saying they don t normally have to wait too long 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CCG National average Comparisons are indicative only: differences may not be statistically significant, particularly at practice level due to low numbers of responses Base: All those completing a questionnaire: National (772,842); CCG (3,851); Practice bases range from 21 to 127 23 Ipsos MORI 15-080216-01 Version 1 Public

Satisfaction with opening hours: how the CCG s practices compare THE SLADE SURGERY HENLEY CROSS MEDICAL PRACTICE SHERARD ROAD MEDICAL CENTRE CONWAY PMS GALLIONS REACH HEALTH CENTRE THE TRINITY MEDICAL CENTRE ROYAL ARSENAL MEDICAL CENTRE ELTHAM PALACE PMS WAVERLEY PMS DR BPC PEIRIS' PRACTICE CLOVER HEALTH CENTRE PRIMECARE PMS (SOUTH STREET) DR J LAL'S PRACTICE WOODLANDS SURGERY ABBEY WOOD SURGERY GREENWICH PENINSULA BLACKHEATH STANDARD PMS GLYNDON PMS ABBEYSLADE PMS (DR CHAND) DR V AGARWAL'S PRACTICE CCG MANOR BROOK PMS PRIMECARE PMS (COLDHARBOUR) AT MEDICS TEWSON ROAD PMS FAIRFIELD PMS BANNOCKBURN SURGERY VANBRUGH GROUP PRACTICE BURNEY STREET PMS COLDHARBOUR HILL PMS MOSTAFA PMS ELTHAM MEDICAL PRACTICE TRIVENI PMS VALENTINE HEALTH PARTNERSHIP BRISET CORNER SURGERY PLUMSTEAD H/C PMS ALL SAINTS MEDICAL CENTRE PMS ELTHAM PARK SURGERY PLUMBRIDGE MEDICAL CENTRE ST MARKS PMS DR V SANDRASAGRA'S PRACTICE Q25. How satisfied are you with the hours that your GP surgery is open? Practices CCG Percentage of patients saying they are satisfied with the hours their GP surgery is open 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% National average Comparisons are indicative only: differences may not be statistically significant, particularly at practice level due to low numbers of responses Base: All those completing a questionnaire: National (795,461); CCG (3,994); Practice bases range from 24 to 131 24 %Satisfied = %Very satisfied + %Fairly satisfied Ipsos MORI 15-080216-01 Version 1 Public

Overall experience: how the CCG s practices compare THE SLADE SURGERY CLOVER HEALTH CENTRE HENLEY CROSS MEDICAL PRACTICE SHERARD ROAD MEDICAL CENTRE WAVERLEY PMS DR BPC PEIRIS' PRACTICE TEWSON ROAD PMS ROYAL ARSENAL MEDICAL CENTRE CONWAY PMS GALLIONS REACH HEALTH CENTRE BLACKHEATH STANDARD PMS BRISET CORNER SURGERY AT MEDICS ELTHAM PARK SURGERY ABBEYSLADE PMS (DR CHAND) ELTHAM PALACE PMS ABBEY WOOD SURGERY FAIRFIELD PMS THE TRINITY MEDICAL CENTRE CCG VALENTINE HEALTH PARTNERSHIP WOODLANDS SURGERY GREENWICH PENINSULA PRIMECARE PMS (SOUTH STREET) GLYNDON PMS DR J LAL'S PRACTICE BURNEY STREET PMS DR V AGARWAL'S PRACTICE COLDHARBOUR HILL PMS PLUMSTEAD H/C PMS VANBRUGH GROUP PRACTICE ELTHAM MEDICAL PRACTICE BANNOCKBURN SURGERY MANOR BROOK PMS ALL SAINTS MEDICAL CENTRE PMS MOSTAFA PMS TRIVENI PMS ST MARKS PMS DR V SANDRASAGRA'S PRACTICE PRIMECARE PMS (COLDHARBOUR) PLUMBRIDGE MEDICAL CENTRE Q28. Overall, how would you describe your experience of your GP surgery? Percentage of patients saying good Practices CCG National average 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Comparisons are indicative only: differences may not be statistically significant, particularly at practice level due to low numbers of responses Base: All those completing a questionnaire: National (794,704); CCG (3,987); Practice bases range from 24 to 131 %Good = %Very good + %Fairly good 25 Ipsos MORI 15-080216-01 Version 1 Public

Overall experience of GP surgery Q28. Overall, how would you describe your experience of your GP surgery? 100 90 80 70 60 50 40 30 20 10 0 CCG s results over time 84 83 81 82 81 5 5 7 6 7 June 2013 % Good % Poor July 2014 July 2015 July 2016 July 2017 12% 46% 5% CCG s results Very good Fairly good 35% Neither good nor poor Fairly poor Very poor Comparison of results CCG 81% Good 7% Poor National 85% Good 5% Poor Practice range in CCG % Good Local CCG range % Good Lowest Performing Highest Performing 54% 94% Lowest Performing Highest Performing 73% 87% Base: All those completing a questionnaire: National (794,704); CCG 2017 (3,987); CCG 2016 (4,108); CCG 2015 (4,426); CCG 2014 (4,590); CCG 2013 (5,201); Practice bases range from 24 to 131; CCG bases range from 2,464 to 7,689 %Good = %Very good + %Fairly good %Poor = %Very poor + %Fairly poor 26 Ipsos MORI 15-080216-01 Version 1 Public

: It Item 8 Enc F Primary Care Commissioning Committee DATE OF MEETING: 20 September 2017 Title: Primary Care Highlight Reports AUTHOR: Irene Grayson Associate Director Primary Care Background Currently there are 3 main meetings that take place which report on primary care activity. SE London Primary Care Executive Board Greenwich GP Forward View Programme Board Greenwich Primary Care Commissioning Committee Each of these meetings have a different function; SE London Primary Care Executive Board meets monthly with senior representatives from the 6 CCGs and is chaired by the Programme Director for SE London for Community Based Care. The remit of this Board is to ensure a fair and equitable approach to decisions made regarding primary care funding initiatives, sharing best practice and collectively working together to develop the primary care delivery plan for South East London STP. Greenwich GP Forward View Programme Board meets bi-monthly and is responsible for approving decisions at a local level associated with financial allocations that are discussed at the SE London Executive Board. The Board will also escalate issues of concern up to the SEL Executive Board Greenwich Primary Care Commissioning Committee (PCCC) is corporate decision-making body for the management of primary care delegated functions and meets quarterly in public The Highlight Reports It is important that the PCCC receives highlight reports from these groups and that these reports are shared across the Greenwich Boards and Committees to enable collaborative working and avoid duplication. The work of these Boards should complement the overall primary care strategy for Greenwich Recommendation The committee is asked to Note the Highlight Reports attached.

NHS Greenwich CCG CONTACT: Name: Irene Grayson AD Primary Care E-Mail: Irene.grayson1@nhs.net 2

GP FORWARD VIEW - Highlight Report September 2017 No 7 Board Frequency Reporting Frequency Author Executive Lead Clinical Lead GP Forward View Programme Board Bi-monthly Quarterly Irene Grayson Vanessa Fowler Dr Ellen Wright & Dr Ranil Perera Item 10 Encl F General Healthy London Partnerships is setting up a new GPFV assurance regime on behalf of SEL STP. CCGs will be required to submit regular update reports as part of this assurance process. Progress 1. Access Hubs Our GP Access Hubs based at Eltham and Thamesmead are now operating from 9am 5pm Saturdays, 9am 1pm Sundays and 4pm 8pm Monday to Friday. The extension of opening hours on Saturdays and Sundays from 8am 8pm will be completed during Quarter 2 2017/18. Patients will then have access to primary care services in Greenwich 7 days a week from 8am to 8pm. July Data Hub utilisation per day Day # appts available # appts booked # DNAs Monday 184 184 0 Tuesday 184 162 19 Wednesday 184 119 23 Thursday 184 162 35 Friday 184 184 35 Saturday 738 334 54 Sunday 190 117 54 Total this month 1848 1262 220 There has been a drop in utilisation, particularly at weekends, which could be due to the holiday period and will continue to be monitored closely. The hubs have sufficient capacity to take 111 bookings but the interoperability between the Hubs and 111 is still not available, therefore the bookings are completed by phone. The hubs are also working on setting up SMS messaging in order to reduce the DNA rate which remains high. Greenwich Health Ltd have developed their communication plan to GP Practices and patient facing leaflets have been produced which were distributed at the Great Get Together on 24 June 2017. Sign posting posters and leaflets have been developed for the Urgent Care Centre (UCC) and the Patient Champion in the UCC will also be signposting patients to primary care services. 2. Resilience Plans Heat Maps Healthy London Partnerships are managing the resilience funding process for 2017 and have produced a heat map identifying practices across SEL which would automatically meet the criteria for support based on performance against a set of indicators. However all practices have been written to with the option to self-nominate for practice support using a template developed by HLP. CCGs were required to add local intelligence to the heat maps and to encourage practices to nominate themselves as appropriate. A SEL panel is being set up to review and agree those nominations that meet a set scoring criteria. SEL have allocated its funding to individual CCGs based on a weighted allocation of which Greenwich has been allocated circa 36k. HLP have sent out information on the number of self-nominations by CCG. No Greenwich practice nominations

GP FORWARD VIEW - Highlight Report September 2017 No 7 have been received. The CCG will now be seeking clarification on whether it can allocate the 36k to locally agreed resilience schemes. The 2016/17 resilience plan which provides access to education and training for practice managers and practice nurses is in implementation stage. The workflow management programme is due to start late November 2017. 3. General Practice Workforce As part of a combined South East London proposal, Greenwich has been successful in its bid to the new NHS International Recruitment Programme. This is a major GP Forward View initiative to recruit qualified GPs from overseas and our bid with colleagues from Bromley, Bexley and Lewisham CCGs. It will see 45 GPs coming into our four CCGs local primary care system over the next twelve months and, via direct negotiation with general practices, they will commit to contracts to work as general practitioners in Greenwich for a minimum of three years. Our bid included a wide range of local partners, both educational and provider organisations, and we feel confident that this will support successful delivery. The CCG Commissioning Project Lead for Workforce, Dr Eugenia Lee, is writing to the 24 general practices that both completed our recent primary care workforce survey and indicated an interest in participating in the scheme. This will hopefully begin the process of establishing the current and emerging level of their GP vacancies and firmer interest in potentially sourcing new clinicians via this scheme. NHS England are coordinating an initial meeting with all the successful bidders for the scheme, together with phase 1 pilot sites, on 14 September and the four South East London CCGs will be represented by OHSEL workforce project manager, Rebekah Middleton, and Simon James from Greenwich CCG. A meeting is taking place on 5 September with key stakeholders regarding the successful bid for clinical pharmacists in General Practice. The meeting will be planning next steps in implementing the project plan that was submitted. 4. Patient On-Line and e-consultations Patient On-Line: The latest figures which include Iplato show a significant increase over that short space of time for Greenwich. EMIS data should be ready by the end of this month which should confirm the continual progress that has been made in Greenwich since March 2017. However the CCG recognises that when benchmarked against other SEL CCGs our percentages which range between just under 10% - 30% are low and more work needs to be done to increase uptake. E-Consultations: The necessity of making progress towards commissioning an e-consultation package to meet the requirements of the GP Forward View and release 2017/18 funding is clear and work has taken place in the summer to review other South East London CCGs progress and a desktop review of the market. Further consultative work with end users (i.e. patients) in collaboration with Healthwatch, and primary care staff who would need to integrate an e-consultation package into their day-to-day work and organisational processes of their practices, is planned for September. This should enable Greenwich to finalise its preference in terms of functionality and initiate commissioning of an e-consultation package for 2017/18. 5. Estates A Gallions Reach reconfiguration group is meeting monthly to oversee progress on site and Essentia are continuing to work on the Outline Business Case. The expectation is that this is received in November and finalised during December 2017. Subject to approval by all parties, Essentia will then move to develop the Full Business Case in early 2018. Kidbrooke Village: an agreed design for the health centre facility within Berkeley Homes Kidbrook Village development was submitted to RBG Planning Committee in August as part of the overall next implementation stage. This was agreed and development of a section 106 agreement will start the next phase of the project, working through the expectations of both parties, the general practice and other service providers prior to the build phase.

SEL PRIMARY CARE EXECUTIVE BOARD - Highlight Report No 2 Board SEL PRIMARY CARE EXECUTIVE BOARD Date of Last Meeting 15 August 2017 Reporting Frequency Monthly Author Jessica Arnold (Bromley) Tom Bunting (Southwark) Executive Lead Andrew Bland Item 8 Encl Fii 1. London Operating Model SEL CCG leads are advised to keep their Primary Care Working Groups (or equivalent local name) sighted on the development of the London Operating Model between now and the 13 October meeting of the Primary Care Management Board, after which time the final Operating Model will go to PCCCs (across London) for approval during November and December. This board will aim to reach a commonality of approach and recommendations via SEL CCG leads to their working groups/pcccs on the development and finalising of the Operating Model. 2. FYFV Primary Care STP Delivery Plan feedback from NHSE and next steps The SE London Delivery Plan has been broadly well-received by NHSE. There were a number of development areas across the sections on Workforce and ETTF, with minor feedback on Access also. However, the general response was positive. Healthy London Partnership has not asked for a resubmission of the primary care delivery plan, but that SE London will need to have actions progressed and be in a position to demonstrate how these are being tracked before the end of August. Circulated amongst the meeting papers were (i) the FYFV Primary Care plan submitted on 30 June, (ii) the feedback received from TPMO/NHSE on 28 July, (iii) the SE London internal draft response to the main points in the feedback (put together by JA and Paul White). To further develop the response, SEL CCG leads were asked to consider the following questions: 1. What workforce planning and modeling have you/partners undertaken within your borough; how has this informed your actions; and how frequently has/will this be updated? 2. What nurse training are you offering/commissioning; how will this increase the numbers of nurses working in your practices; and how will you monitor this? 3. What work are you doing on productivity; and how will this be assessed/monitored to articulate the benefits? 4. How are your recruitment and retention programmes being monitored and assessed? (any information in addition to the above) 5. Are you doing any work locally to link in with HEE and the Local Workforce Advisory Board? CCG leads were asked to send further responses to JA, TB and Paul White by 23 August to inform the response to the feedback. (this has been progressed further since the meeting and Mark Edginton is now taking a lead on this since he commenced in his role as CBC Programme Director). 3. PMS Review A summary of feedback from Londonwide LMCs (LWLMCs) was tabled, who had identified some contractual issues within SE London PMS Contract Offer Pack that had been received very recently. It was noted that the comments included in it were provided by LWLMC Officers who had not been present at the meetings with each CCG. The PMS Support Team would shortly be reviewing this feedback to identify the items within it that might potentially be resolved relatively quickly and simply (as well as the correction of any factual errors included in it), and to identify the more fundamental issues. A discussion took place on the potential implications of this feedback across SE London. It was agreed that a follow-up call with CCG leads would be scheduled for next week to update and gather further local views in response and to agree next steps.

SEL PRIMARY CARE EXECUTIVE BOARD - Highlight Report No 2 4. SE London potential APMS re procurements There are 15 APMS contracts due to expire within SE London between now and end of March 2018. The immediate priority is to procure those contracts that expire in the early part of this timeframe. To determine what needs to be procured, strategic commissioning intentions must be finalised by the end of September. The SE London Primary Care team will support CCGs in taking the commissioning intentions to Primary Care Commissioning Committee (PCCC) part 2 meetings for timely approval. It was noted that, in instances where PCCC meetings fell outside of this timeframe, that urgent planned decisions would be enacted as appropriate and in line with PCCC ToRs. A London APMS work stream has been established. Jill Webb is currently overseeing a review of the process that will establish whether the Once for London arrangements for procuring/reprocuring APMS contracts, based on a single price, performance framework and KPI/performance management arrangements were sustainable in light of the PMS equalisation agenda and the increasing focus on STP working. An extraordinary PCMB meeting has been scheduled for early September to enable NHSE London and STP PC leads to focus specifically on the recommendations of the review. 5. Quality & Performance report consider data requirements and frequency for SE London The Primary Care SE London CCG leads agreed that there is a need to collectively identify what data would be helpful to PCCCs within this report, and to work with the SE London STP primary care team to prioritise the ongoing offer of performance information to CCGs. A view will also be taken on any potential additional borough-level information (e.g. held by CCGs) to be added to each local report. The CCG leads made it clear that they wanted to see the current provision of reporting maintained in the meantime whilst these potential changes were being developed. 6. Escalation of issue of concern re Primary Care Support England At a recent meeting of this Board, several CCGs had highlighted serious concerns, including the loss of up to 700 patient records by the provider and multiple failures to make patient records available to practices in a timely manner for patient care, as well as the extent to which this issue has been taken seriously by the provider and the commissioner. CCGs have generally been told to escalate their problems directly with the provider, rather than the commissioner of the services, agreeing to take up serious concerns through contract management mechanisms. However, generic email addresses and telephones numbers are the only contact details available and there have been no or delayed responses to serious problems. It was noted that this this matter should be escalated to NHSE as the contract holder (lead contact Karen Wheeler). It was also escalated by SE London at the PCMB meeting on 4 August. A separate related matter regarding the annual Service Audit Review (SAR; a national document) was raised. Jill Webb said that a number of the SE London PCCCs had requested sight of the SAR and that this request would be passed to NHSE s national team in order to obtain and issue it in SE London. It was agreed that this Board should review the SAR in order to consider consistent recommendations being made about it to each CCG, with particular regard to potential direct and indirect consequences of its findings, for CCGs. The SE London CCG leads on this Board will also need to determine whether the SAR should be reviewed by their respective PCCC or Audit Committee. Once the identified committee in each borough has considered the Board s recommendations relating to the SAR, each will need to consider whether further assurance is required (ie whether its recommendations go far enough) and feedback to NHSE accordingly. An update on this will come to the next meeting on 19 September. 7. Next Meeting The next meeting of this board is scheduled to take place on 19 September. Mark Edginton (new CBC Programme Director) will attend for the first time since his appointment.

: Item: 9 Enc: G Primary Care Commissioning Committee DATE OF MEETING: 20 September 2017 Title: Greenwich Clinical Commissioning Group - Response to Healthwatch Report on GP Access 2017 AUTHOR: Irene Grayson Associate Director Primary Care BACKGROUND The impetus for this project was generated from the outreach work Healthwatch Greenwich undertakes with Greenwich Migrant Hub. The Migrant Hub provides advice and legal support to people who have Nil Recourse to Public Funds (NRPF). Healthwatch provides advice on health services, as well as engaging with local people to obtain their views and experiences on the health and social care services. Healthwatch had obtained initial data which indicated a rise in the number of families that were experiencing difficulties registering with a GP, especially those who were homeless or in emergency accommodation. The main message was that to register, GP practices were requesting, in some cases, passports/photo ID as well as 2 proofs of address. If the patient was unable to provide these documents then they were not able to register. These registration requirements do not comply with NHS England guidance as highlighted here: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/11/pat-reg-soppmc-gp.pdf. The attached report highlights the outcomes of an audit carried out between January and March 2017 by Greenwich Healthwatch. Please note that the number of practices sited in the report as 48 is inaccurate during the stated period, there were 37 GP practices and 18 branch surgeries. The CCG is assuming that some of the practices contacted were the branch surgeries. The CCG was invited to comment on the recommendations made on page 19 of the report and this paper outlines the CCG s formal response to this report. Initial Response

Identifying barriers to registration and promoting registration is a key priority for the CCG and we welcome the report produced by Healthwatch. Those patients registered with a GP will ensure that they get timely access to health services and that they access the right service at the right time. Patients will also benefit from the various preventative initiatives within primary care that will help to keep them healthy and well. Our primary care budgets are based on financial allocations in accordance with how many patients are registered with a Greenwich GP, therefore it is in the CCG s interest to ensure that as many of local Greenwich residents are registered in order for the CCG budget allocations to adequately meet the growing health needs of our population. In Greenwich our population is changing, attracting a younger and more transient population. It is predicted that by 2026 the population of Greenwich will increase by around 67,000 to 322,000. Greenwich is also an ethnically diverse borough with around 38% of the population coming from a non-white ethnic group (Greenwich Joint Strategic Needs Assessment Greenwich Profile). The recommendations set out in the Healthwatch report provides a good platform for discussion and action planning, recognising the issues raised in the report go beyond the barriers highlighted in the report, for example language and cultural barriers. Healthwatch Recommendations Formal Response Recommendation 1: All Greenwich GP practices should undertake an urgent review of their own patient registration requirements and ensure they are compliant. The CCG will support Practices in this by providing further training at the Practice Managers meeting in October 2017. This will be supplemented through discussion with practice staff during primary care Protected Learning Time Events. The CCG will review practices arrangements for registering patients as part of our contract management process and use the data in Appendix 2 to help inform where to target our resources. Practices will be reminded of the Once for London registration guidance through key messages being delivered from the CCG to primary care. Recommendation 2: In collaboration with the CCG, Greenwich GPs should arrange training for front line practice staff to update them on the NHS England Patient Registration guidance (2016). The CCG will include training for front line staff as part of the Protected Learning Time training events. See above Recommendation 3: The CCG should provide further written guidance for GPs on their patient registration practice and procedures. The Once for London guidance and the new Homelessness resource pack issued by NHSE will be distributed to Practices and discussed at the Practice Managers meeting. The information 2

will also be made available at the Greenwich Wide Forum a quarterly meeting of GP practices. Guidance will also be uploaded onto the Greenwich Intranet an internal website which all GP practice staff can access. Recommendation 4: The CCG should work with statutory and voluntary community groups, in particular BME groups, to provide and distribute the Healthy London Partnership health care cards to Greenwich residents and patients. The CCG is in the process of updating its leaflet Is everyone in your household registered with a Greenwich GP and will include signposting to My Right to Access Healthcare. The CCG will also include references to this initiative when training practices on registration guidelines. The CCG has commissioned Goundswell, a homeless health peer advocacy service, to support homeless people by improving their access to services through volunteers engaging and accompanying people to health care appointments. Patient education via this service will help to increase knowledge, confidence and motivation of homeless people to better manage their own healthcare as well as supporting patients to access the right services in the right place. Recommendation 5: The CCG should provide and require appropriate posters to be displayed in prominent places in practices, setting out clearly the registration requirements for vulnerable people, focusing on those who are unlikely to have documentation, as set out in the Patient Registration guidance. As a result of this recommendation, the CCG is sourcing this material to put into practices. We will ask members of our Patient Reference Group to check when they visit local surgeries that the posters are being appropriately displayed. Recommendation 6: The CCG should, where possible, ensure that adherence to NHS England patient registration guidance is monitored as part of the GP contract, with robust performance monitoring indicators. In addition, in consultation with patient representatives, the CCG should develop a policy on what to do with non-compliance with the registration guidance by practices. See Recommendation 1. The issue of non-compliance is very much reliant on patients contacting NHSE through the complaints procedure complaints is a function that still sits with NHS England and not the CCG. The CCG will aim to empower patients through education and ensuring that appropriate information is made available via its Communication and Patient Engagement Team. Recommendation 7: In conjunction with NHS England, the CCG should consider incorporation on the GSM1 information (patient registration form); information on what is required to register. This would involve a national change in process as GMS1 is a national form. The CCG will feed this back to NHS England and ask for a written response. Recommendation 8: GP practices should ensure that accurate and up to date patient information is readily available to potential new registrants, including information on practice 3

website and a link to a patient reference document or fact sheet on registration. The CCG will work with Practices and the GP Federation to produce some generic guidance that will be consistent across all Practice web sites. The leaflet highlighted in Recommendation 4 can also be added as a link on practice websites. Recommendation 9: The CCG should consider the possibility of providing a local appeals process for patients who have been de-registered by the GPs against their will (either via the ghost patient process or any other reason). Patients can already appeal via the NHS England complaints process. Complaints of this nature have not been delegated to the CCG as highlighted under Recommendations 6. However, we are mindful that some de-registration issues are often a result of a break down in relationships between the patient and the practice. The CCG has a role to play in supporting patients to register elsewhere. Recommendation The CCG will formally respond to the recommendations in the Healthwatch Report and will wait to receive feedback before drawing up a final action plan with timelines which will be monitored as part of the quality improvement work of the primary care team within the CCG. NHS Greenwich CCG CONTACT: Name: Irene Grayson Associated Director Primary Care E-mail: Irene.grayson1@nhs.net 4

Greenwich GP Access Report 2017

We know that you want local services that work for you, your friends and family. That s why we want you to share your experiences of using health and care services with us both good and bad. We use your voice to encourage those who run services to act on what matters to you. We are uniquely placed as a national network, with a local Healthwatch in every local authority area in England. We confirm that we are using the Healthwatch Trademark (which covers the logo and Healthwatch brand) when undertaking work on our statutory activities as covered by the licence agreement. Copyright Healthwatch Greenwich 2017 Healthwatch Greenwich 2

Contents Contents... 3 1 Introduction... 4 1.1. Acknowledgements... 4 1.2. Disclaimer... 4 1.3. Context... 4 1.4. Strategic drivers... 6 2 GP Access Audit... 9 2.1. Methodology... 9 2.2. Summary of findings... 9 2.3. Charts... 10 3 NHS Regulations and Guidance... 12 3.1. NHS regulations... 12 3.2. GP Contracts... 12 3.3. Care Quality Commission Standards of care... 12 3.4. Greenwich CCG Commissioned Report Staff Attitudes... 13 3.5. My Right to Access Healthcare cards... 14 4 Conclusions... 16 4.1. Access to GP services GP registration... 16 4.2. De-registration... 17 4.3. GSM 1 Form Patient Registration Form... 18 5 Recommendations... 19 6 Service provider responses... 20 7 References... 21 Appendix 1: HWG phone audit form... 22 GP access phone audit... 22 Introduction:... 22 Questions:... 22 Appendix 2: Phone audit raw data... 24 Contact us... 30 Healthwatch Greenwich 3

1 Introduction 1.1. Acknowledgements Healthwatch Greenwich would like to thank the GP practices, service users, and staff for their contribution to the work programme of Healthwatch Greenwich. 1.2. Disclaimer Please note that this report relates to findings observed on the specific date(s) stated. Our report is not a representative portrayal of the experiences of all service users and staff, only an account of what was observed and contributed at the time. 1.3. Context The impetus for this project was generated from the outreach work Healthwatch Greenwich undertakes with Greenwich Migrant Hub. The Migrant Hub provides advice and legal support to people that have Nil Recourse to Public Funds (NRPF). Healthwatch provides advice on health services, as well as engaging with the clients to obtain their views and experiences on the health and social care services. Initial data indicated a rise in the number of families that were experiencing difficulties registering with a GP, especially those who were homeless or in emergency accommodation. The main message was that to register, the GP practices were requesting, in some cases, passports/photo ID as well as 2 proofs of address. If the patient was unable to provide these documents then they were not able to register. These registration requirements do not comply with NHS England guidance 1. In 2015, Greenwich Clinical Commissioning Group (GCCG) ran a GP registration campaign which produced a leaflet Is everyone in your household registered with a GP. This leaflet provided advice on how to register. Included on the leaflet, in bold, was the statement that your immigration status does not affect your right to register with a GP, in fact you shouldn t even be asked. This information was incorporated into the leaflet following concerns by GCCG that some black and minority ethnic (BME) residents were reluctant to register because of their immigration status. Healthwatch Greenwich 4

In October 2016, Greenwich s GP walk-in centres were closed and replaced by a GP Access Hub. The Access Hub provides weekend appointments (9am to 5pm on Saturdays and 9am to 1pm on Sundays), accessed via a Greenwich GP or by calling the NHS111 service. However, to be able to use the Access Hub service, a patient needs to be already registered with a Greenwich GP, in part so that their medical details could be accessed. Some of the key strategic drivers for the action by NHS England, and the campaign by GCCG, was to improve access to GP services, reduce the number of unregistered patients attending Accident and Emergency, and to ensure that the most vulnerable people would be able to access health care services. In addition, there was concern that patients could be at risk of being de-registered from a GP list if they were identified as ghosts. Ghost patients are people that have not used their GP practice for 5 years. The aim being to cleanse the GP patient list of any patients that could have died, moved away, or left the country. The accuracy of the patient list is vital as it is directly related to the funding the practice receives. The GP practice has a duty to provide this list to NHS England, who have commissioned a private contractor (Capita) to contact the patient. A key component of confirming registration details is providing an address. For people who have become homeless, don t have ID or are in emergency housing this can be very difficult. In addition to this, once a GP has asked for the removal of a patient from their list, there is no way for the patient to stop, suspend or appeal against removal. We are concerned about the lack of checks and balances in this process and will make comments to this effect in our recommendations Healthwatch Greenwich decided to carry out an audit of the registration process of all GP practices. Undertaking the audit, combined with various bits of feedback from local patients, has given us valuable insight into the GP patient registration and de-registration processes. With GCCG now taking on responsibility for commissioning primary care services, including the management of the GP contract, this report s recommendations are intended to help both them and local GPs to improve the patient registration process (and potentially reduce the pressure on the Accident and Emergency and Urgent Care Centre). Healthwatch Greenwich 5

1.4. Strategic drivers GP patient registration is fundamental in ensuring that patients can exercise their right to access to primary care services. The role of primary care is pivotal in achieving this, acting as gatekeeper to the health system and the main point of contact for the patient. Registration is the first step in the journey. NHSE Patient Registration Standard Operating Principles for Primary Medical Care (General Practice) 1 In December 2016, the NHS England updated its registration guidance. It stated: The reason for issuing this guidance now is evidence of an increasing number of patients finding it difficult to register with some GP practices. This is because they cannot provide documentation to the practice in support of who they are or where they live and the subsequent problems they have in accessing health care. The guidance is designed to clarify the position for all patients, in particular though this issue is affecting migrants and asylum seekers who do not have ready access to documents. The Guidance goes on to say that: If a patient cannot produce any supportive documentation but states that they reside within the practice boundary then practices should accept the registration. Where necessary, (e.g. homeless patients), the practice may use the practice address to register them if they wish. If possible, practices should try to ensure they have a way of contacting the patient if they need to (for example provide test results). (NHS England Sec 1 -Policy Statement) The Guidance also provides examples of people who are legitimately unable to produce any of the listed documentation. These include; People fleeing domestic violence staying with friends or family, People living on a boat, in unstable accommodation or street homeless, People staying long term with friends but who aren t receiving bills, People working in exploitative situations whose employer has taken their documents, Healthwatch Greenwich 6

People who have submitted their documents to the Home Office as part of an application, People trafficked into the country who had their documents taken on arrival, Children born in the UK to parents without documentation. NHS England are expecting GP Practices to act reasonably and that the individual be registered with sensitivity to their situation. Greenwich Clinical Commissioning Group Recent research conducted by the Royal Borough of Greenwich (RBG) estimated that those not registered with a GP was between 1.2% and 5.4% of the Greenwich population 2. The research suggested that specific groups were more likely to be unregistered than others. The Picker Institute was commissioned to undertake research with some of these groups, to better understand the unregistered population and identify barriers they may face in registering with a GP 3. Building on research by RBG and GCCG 2, the Picker Institute focused on exploring these issues with specific communities identified as being more likely to be unregistered with a GP practice. These communities included the: Somali Nepali Vietnamese Although there were no specific recommendations the research identified three key barriers 3 : Language Lack of information Lack of confidence In response to the report suggestions, GCCG printed the leaflet Is everyone in your household registered with a GP to encourage and increase the numbers of patients registering. The leaflet focused on an individual s rights to register, and aimed to give confidence to people from BME communities to register, by stating that proof of immigration status is not required to register and that GP practices should not be asking. Healthwatch Greenwich 7

This was followed in December 2015, by a workshop on advice and guidance concerning patient registration at a GCCG protected learning time event. This workshop was aimed primarily at GP practice staff. NHS England and Public Health gave presentations. The participatory workshop was led by the Picker Institute who also presented their findings from research into the unregistered population in Greenwich, looking at the barriers patients face, and some of the difficulties encountered by practices in registering patients 3. The aim was to ensure that practice staff understood the registration guidance better, how best to implement it, and how to ensure that GP registration is easy, equitable and safe to both patients and practices. The report from this workshop with the staff (GP Registration Staff Attitudes) 4 is discussed further in section 3.4 Healthwatch Greenwich 8

2 GP Access Audit 2.1. Methodology We conducted this audit between January and March 2017. We developed a call audit form (Appendix 1) that was used to illicit the information required. We phoned each GP practice and asking the receptionist what information is needed for registration. The calls were carried out by our Staff and Authorised Representatives (volunteers of Healthwatch Greenwich). We also carried out an audit of the web-site of each practice, to identify what, if any, advice and guidance was provided on registration. 2.2. Summary of findings All 48 GP practices in Greenwich were contacted, including branch practices. Key findings included: All the GP practices requested some form of registration documentation, ranging from passport identification to two forms of proof of address. 32 practices requested proof of identity (e.g. drivers licence or passport). 18 practices requested two proofs of address. 17 practices requested one proof of address. Three practices requested the patients NHS number. Six practices stated that they would not register a patient who did not have any documents. One practice requested the NHS number, two proofs of address and proof of ID (i.e. passport) with at least six months remaining until the expiration date. Although most practices had a link on their website to download the registration form, none of the practices had any information about patient s rights to registering without documents, or immigration status not being required. Although no practices requested immigration status documents to register, 32 of the practices did request passports or photo ID. Although there was no evidence that administrative staff were making decisions to register on their status in their passport, this requirement could act as a significant deterrent to many people. Healthwatch Greenwich 9

2.3. Charts Figure 1 sets out the percentage responses to the survey question What documentation do you ask for from a registering patient. 2 proof of address 26% GP REQUESTING DOCUMENTS TO REGISTER NHS number 4% Unsure 0% Proof of Uk residency 0% Proof of identity 46% 1 proof of address 24% Figure 1: GP Practices requesting documents to register. Figure 2 sets out the responses to the question: If a person registering does not have a proof of address, is homeless or in temporary accommodation can you still register them? REGISTERING WITH NO DOCUMENTATION N/A 4% No 13% Unsure 27% Yes, if practice manager agrees 31% Yes 25% Fig 2 Can a person register without documentation Healthwatch Greenwich 10

Of the 48 practices/branches: 58% of the respondents were either unsure or would refer to the practice manager. The responses varied from I would get a letter from Healthwatch to I don t know, never had to deal with this situation before. The overwhelming impression is that staff are unsure what to do as this situation does not frequently occur. Many were of the view that the practice manager had a separate process for these applications. 31% of the practices stated they could register patients without any proof of address or form of identification, only after referring to the practice manager, with the majority unsure of what to do in such circumstances. One practice stated that an address is not required for registration but prefaced the response by firstly asking for proof of address. One practice positively stated to this question that they can and must register...and would never turn anyone away. Four practices correctly stated that a homeless person or a person without documentation would be able to register at the practice address. The GSM1 (patient registration form) which is used by all GP practices does not provide any guidance on registering without proof of documents or if homeless. Healthwatch Greenwich 11

3 NHS regulations and guidance 3.1. NHS regulations Registering without proof of identity and address There is no contractual duty to seek evidence of identity or immigration status or proof of address. Therefore, practices should not refuse registration on the grounds that a patient is unable to produce such evidence 1. Anyone in England is entitled to receive NHS primary medical services at a GP practice and applications for registration for any patient in England must be considered in exactly the same way, regardless of country of residence. Registering homeless patients People who are homeless have particular health needs and often suffer some of the worst outcomes. Both the British Medical Association (BMA) and NHS England are committed to ensuring homeless patients receive the same level of care as those with permanent addresses. The same obligation on practices regarding identity and proof of address applies to homeless patients as a population group. Homeless patients are entitled to register with a GP using a temporary address which may be a friend's address or a day centre. The practice may also use the practice address to register them. 3.2. GP Contracts The General Medical Services Contracts Regulations (2004) 5 state that practices may only refuse an application to go on their list if they have reasonable grounds for doing so which do not relate to the applicant s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition. 3.3. Care Quality Commission Standards of care Expected standards of care The Care Quality Commission (CQC) expects practices to: Healthwatch Greenwich 12

register people who are homeless, people with no fixed abode, or those legitimately unable to provide documentation living within their catchment area who wish to register with them. Homeless patients are entitled to register with a GP using a temporary address which may be a friend's address or a day centre. The practice may also use the practice address to register them. Practices should try to ensure they have a way of contacting the patient if they need to (for example with test results). Some areas will have special services for homeless patients and practices may refer homeless patients into those services in line with local arrangements where it is in the best interests and with the agreement of the patient. 3.4. Greenwich CCG Commissioned Report Staff Attitudes The report, GP Registration Practice Staff (Picker, 2015) 4 is key in gathering insight into the views and attitudes of practice staff for patient registration administration, and provides evidence of what is happening in the practices. The report identified many issues influencing practice staff attitudes and behaviours towards patient registration. Although intertwined, the researchers were able to group them at different levels of influence: national, local, and personal influences. A key finding by Picker: was the strength of personal views about patient registration that emerged; specifically, about who should be entitled to receive NHS primary care. These were primarily associated with concerns about protecting NHS resources from those who attempt to abuse the system, either through fraud or simply because they are considered undeserving. Several receptionists saw themselves as conscientiously defending the NHS from people who try to defraud it and similarly, receptionists expressed concerns about people coming from overseas specifically to take advantage of free NHS healthcare. This was seen as a waste of NHS resources and something they had a responsibility to prevent. The report went on to state that: "a combination of these influences on registration behaviour means that simply clarifying the national guidance to frontline staff may not be sufficient. Healthwatch Greenwich 13

The report suggested that due to the strength of practice level influences, the focus should be on: supporting practices as a whole to understand the guidance and helping them to translate this into practice-level processes. That means engaging with primary care staff at all levels receptionists, practice managers, GPs to clarify the guidance and what this means for day-to-day practice, and also outline any implications of noncompliance. 3.5. My Right to Access Healthcare cards Front (left) and back (right) design of the My right to access healthcare cards available to download or can be ordered via the website 6. Healthy London Partnership and Groundswell have produced My Right to Access Healthcare cards to help people who are homeless to register and receive treatment at GP practices in London. If those who are homeless, or have concerns about their immigration status, are more able to access primary care this could lead to fewer people presenting at A&E with health concerns. The plastic cards are designed to be carried by people who are homeless across London, including people who sleep rough, live in hostels, sleep on family and friend's sofas, or who are chronically insecurely housed. They can be used to remind GP receptionists and other practice staff of the national patient registration guidance from NHS England 5. This states that: people do not need a fixed address or identification to register or access treatment at GP practices Healthwatch Greenwich 14