Ellesmere Port and Neston GP Network

Ellesmere Port and Neston GP Network 8.30am on Thursday 6 th November 2014 at Ellesmere Port Civic Hall, Civic Way, Ellesmere Port, CH65 0AZ Attendants: Attendance.pdf In attendance Andy McAlavey Alison Lee Huw Charles-Jones Phil Morgan Colin McGuffie Medical Director, West Cheshire CCG Chief Executive, West Cheshire CCG Chair, West Cheshire CCG Locality Support Manager, Ellesmere Port and Neston Locality Support Manager, Rural Apologies Laura Marsh Sarah Murray Jeremy Perkins Head of Delivery, West Cheshire CCG Programme Lead, Primary Care and Membership Engagement GP, Neston Surgery and Locality Chair Practices not represented by a GP: Neston Surgery (apologies from Jeremy Perkins) Key Points to Communicate to your Practice DATIX all incidents, including reflective ones, should be recorded on DATIX Med 3 Forms the CCG is aware of the frustration felt by many practices that secondary care clinicians often refer patients back to GPs to get a Med 3 form. Andy McAlavey and Rob Nolan are looking at how to address this with NHS trusts and trusts in the private sector. Cross-Referral between hospital colleagues and follow up of hospital generated investigations The group asked for clarification with regard to consultants at COCH cross-referring patients. There is also concern regarding requests for GPs to follow up investigations instigated by the hospital. Vanguard Projects progress is being made on the Ellesmere Port Vanguard projects Improving Access to Physio, Community Connectors and Pharmacy First. More discussion of the detail of these services, along with decisions on start dates, will take place at the next Vanguard Steering Group on November 13 th. Over 75s the money for the over 75s projects is recurrent, but there will be consultation with Practices over the use of the money for future years. Child Protection the CCG is aware of the amount of time GPs spend at, and preparing for, Child Protection conferences. This issue will be discussed with Anne Eccles, the CCG s Designated Nurse, Safeguarding Children. Out of Hours Service the CCG is recommending to all practices that more consistent telephone answer-machine messages are provided to patients, with clear information about the Out of Hours Service. Andy McAlavey has drafted a script to be used. NHS 5 Year Forward Plan it was agreed that this is an essential read as it sets out some strategic challenges for the nature of Primary Care 1

Actions: Phil Morgan to correct last meeting s minutes relating to DATIX Andy McAlavey to talk to Rob Nolan to see if we can include the requirement for hospitals to provide a Med 3 when a patient is discharged in the contracts (via a contract variation). Ideally this should state that patients should be given a Med 3 for the full period of the anticipated illness. Huw Charles-Jones to communicate with Frank Joseph, Mark Brandreth and write to the Medical Directors of the Hospitals, informing them of concerns about requests to follow up investigations instigated by the hospital and clarify cross-referral procedures between consultants. The issue will also be raised at the December Clinical Senate. Huw will feedback on any outcomes from this at a future Network meeting. Phil Morgan (the LSM) will send the revised Innovation Application for voice recognition software to Dr. Dan Jones, asking him to comment on it and liaise with Great Sutton Practice. Phil Morgan to talk to Anne Eccles about how best to address the issue of improving the efficiency and effectiveness of GP input into the Child Protection conference process. Sarah Murray to take the issue of providing an initial message then an auto-divert to the OOH service to the Practice Managers meeting, using the agreed text. Practices would be responsible to set up the divert themselves, checking the costs first. Phil Morgan to contact Karen Warren and Catherine Roberts to get more information on requests to present at future Network meetings on Enhanced GP Referral templates and the Frailty Service respectively. Agenda 1 Introductions Colleagues were introduced to Phil Morgan, who is covering for Laura Jones while she is on maternity leave. Apologies for absence Sarah Murray Laura Marsh Jeremy Perkins Declarations of interest None Code of conduct Agreed to abide to this 2 Previous Minutes and Matters Arising 1. Accuracy DATIX issues (page 3) Simon Powell questioned the minutes of the last meeting (agenda item 2 DATIX issues) Simon queried whether DATIX should be used for reflective incidents as well as other incidents. Other colleagues requested clarity over the purpose of the DATIX reporting particularly the difference between SEAs and incident reports. Some colleagues said that the SEA feels like duplication on top of the DATIX. The meeting agreed that all issues should be recorded on DATIX and asked Phil Morgan to correct the minute from last time. Colleagues were reminded that DATIX recording is a key part of the CQUIN. 2

Action: Phil Morgan to correct last meeting s minute relating to DATIX There is a new reporting template, which means that any old data should be removed. Andy McAlavey and Julia Riley have been discussing developing a new method for capturing data. As part of the primary care CQUIN, members within primary care will be able to attend training, which Julia is organising. On a more general point, it was agreed that there is a need to make the approach to completing DATIX more consistent across Practices. City Walls (page 5) the minute relating to the City Walls Medical Centre in Chester (saying that the Centre is providing DVT sessions) is correct, but the service may not be happening yet. It was decided to leave the minute as it is. 2. Matters Arising Med 3 (page 3) Many GP colleagues said that the problem of patients being discharged from hospital without the issue of Med. 3 certificates has not been resolved. Colleagues said that the problem was happening at a number of hospitals, including the Countess of Chester, Spire Murrayfield and The Grosvenor Nuffield Andy McAlavey accepted that the problem was unresolved despite it being raised with the hospitals. Colleagues wondered whether the situation needed to be made more formal by including the requirement to provide a Med 3 in the contract. One of the actions agreed at the October Network meeting was for Laura Marsh to speak to Rob Nolan about this, with a view to a letter to be sent to the Murrayfield Hospital. Alison Lee said that she did not know if this had happened. Action: Andy McAlavey to talk to Rob Nolan to see if we can include the requirement for hospitals to provide a Med 3 when a patient is discharged in the contracts (via a contract variation). Ideally this should state that patients should be given a Med 3 for the full period of the anticipated illness. Colleagues then discussed what was seen as the wider problem of hospitals referring more work back to Practices. For example, the cases are referred back to Practices requesting that the patient should be referred to a different speciality, causing more work for GPs and patients, rather than being cross-referred between specialities. The meeting suggested that the CCG engage with hospital clinicians, including nurse specialists, with a view to identifying and agreeing the problems, and finding a better way to address the issues. 3

There were also concerns raised with regards to requests to follow up investigations instigated in hospital and also requests by radiology to arrange further tests Andy McAlavey said he and Chris Ritchieson attended a meeting with clinicians from Planned Care and raised this issue. Andy said that clinicians know that they can refer to each other and that this should be happening. It was noted, in connection to practices in the north of the locality, that there may be a different approach in Wirral CCG. Some colleagues said that some of these incidents have been DATIXed. Action: Huw Charles-Jones to communicate with Frank Joseph, Mark Brandreth and write to the Medical Directors of the Hospitals, informing them of concerns about requests to follow up investigations instigated by the hospital and clarify cross-referral procedures between consultants. The issue will also be raised at the December Clinical Senate. Huw will feedback on any outcomes from this at a future Network meeting. Action: Ask for an update from Philip Milner re: radiology referrals and requests for different diagnostic tests 3 Innovation Fund Application Chris Ritchieson introduced this item by saying that he had taken on board feedback from colleagues that the previous version of the application was not detailed enough to justify the money requested. He said that the revised application has been improved, with a stronger argument for the funding Chris Ritchieson The intention of the project is to improve the speed with which letters are generated and to improve the efficiency in many other areas of clinical practice. The system is very accurate, easy to use (with limited training) and allows GPs to dictate into EMIS, thereby speeding up the consultation and diagnostic process. Additionally, the system allows GPs to improve the quality of their notes by, for example, not using abbreviations. GPs can, if they wish, dictate notes into EMIS and/or dictate letters with the patient in the consulting room, thereby improving the engagement with the patient. The system also allows GPs to type into any other software programmes e.g. Outlook for emails, Word etc. Chris Ritchieson said that, in his view, the application has the potential to free up GP workload and, if successful, could be rolled out to other practices. After Chris s presentation, there was a discussion among colleagues. Chris was asked whether he was aware of any good practice sites Chris responded that he, and his practice colleagues, had seen a demonstration 4

of the system and that they were impressed with it. One specific benefit of the system is that it has medical terminology built into it. Two GPs at the meeting, Andy McAlavey and Nigel Wood, have had the opportunity to use the system and were both positive about it. Nigel commented that it is an intelligent system and that it gets quicker as it is used. The proposal is for all doctors in the Great Sutton practice to use it the relevant number of licences would be purchased. There is no proposal to reduce administrative staff hours, the staff will be used differently, and smarter working arrangements will be identified. There was some concern over whether the Network has had adequate specialist commentary from ICT lead, Dr Dan Jones. ME read out Dan s comments in which he expressed some support for the system, but made the point that he had not actually used it. A concern was raised over how VFM/improvements in productivity will be measured and demonstrated. Chris said that there were proposals for monitoring the project in the application. One of the ways in which the pilot would be monitored is to look at the quality of the dictated notes and compare them with the normal written notes. There would be a focus on errors and quality of notes. The GPs from Great Sutton then left the room while a discussion took place, followed by a vote. The discussion focused on the need for the project to be treated as a pilot and colleagues thought that a thorough evaluation would need to be carried out. Decision: There was a vote, resulting in the proposal being recommended for approval. This will be taken to the CDC for consideration of formal approval. 4 Vanguard update Improving Access to Physio: Figures from the practices showing the numbers of MSK consultations have been sent in and analysed. Practices were asked to indicate whether they preferred the service to be run from surgeries or from a central point (Ellesmere Port Hospital). An equal number of Practices expressed a preference for both options; therefore pilots of both approaches will be run. There is a final meeting with CWP (Alison Swanton) on the 14 th November to discuss the details of the service. The Ellesmere Port Vanguard Steering Group will have an opportunity to discuss these issues at the meeting on 13 th November Phil Morgan will bring a draft business case to this meeting. 5

Community Connectors Phil Morgan will be providing some more information for the Vanguard Steering Group on the offers from the CAB and AgeUK. Some of the Vanguard Steering Group members will be meeting with the AgeUK Cheshire Chief Executive, Ken Clemens, on November 25 th. Pharmacy First The list of conditions for which Pharmacists are able to prescribe is going to the Area Prescribing Committee this afternoon. Over 75s The Network was informed that the money for the over 75s projects is recurrent, but there will be consultation with Practices over the use of the money for future years. ESA Chris Ritchieson informed the meeting that there is a simple, secure website, the details of which will be sent to Practices. This will enable GPs to input patient details into the form and the information goes securely to the Council Child Protection Conferences Marc England introduced a discussion about the demands on GPs from the Child Protection case conference process and asked colleagues to consider whether the Vanguard fund could be used to assist in anyway. GPs are often asked to attend a number of conferences both initial and review, but only get reimbursed for the initial conference. Meetings are often in the middle of surgery times and the work required takes a long time. The input from GPs into CP meetings is often only very short, but within long meetings. There are problems over the short-notice given of meetings, and the problems of getting locums to cover. The Network wondered whether there are improvements that can be made by, and with, the Council to make the GP input more efficient and effective. Colleagues also discussed whether this is a Vanguard issue, or whether it should be looked at separately. Huw Charles-Jones said that there has been some discussion at a previous Membership Council meeting with Gerald Meehan, the Council s Director of Children s Services. The meeting agreed that it would be good to discover more about the issue and whether there is best practice elsewhere. It was agreed that there is a need for more discussion with the Council and for GPs to consider the impact the current arrangements have on their other patients which due to their attendance at CP meetings Action: Phil Morgan to talk to Anne Eccles about how best to address the issue of improving the efficiency and effectiveness of GP input into the Child Protection conference process. 6

5 Out of Hours Phone Messages Andy McAlavey introduced this item by saying that there is a massive variance in the quality of the messages that Practices put on their answer machines. This is true both in general and specifically of the messages concerning the Out of Hours (OOH) service. There are some Practices that automatically divert to OOH. Andy McAlavey The CCG is suggesting that a more consistent message is put out across the localities to ensure that patients get a better service. There is a recommended text which has been developed in conjunction with 111 and Caroline Young from OOH. Before a patient is diverted, the suggested message is that people are advised to phone 111 if they need advice only. Some colleagues raised the issue of the cost of changing existing messages, but it was agreed that this was fairly minor for Practices. Huw stated that it is very important that diverts to OOH is put in place, particularly to reduce the amount of attendances at A&E. There is evidence that shows that patients do not know about the OOH service. The objective is to use a message on the Practice phone system that diverts the caller to OOH once they have been given a message about alternatives. The proposed text is: Thank you for ringing XXX Medical Centre but we are now closed. Our opening hours are 8am to 6.30pm Monday to Friday. If you would like non-urgent medical help or advice, you can dial 111 free of charge. If you need urgent medical attention that cannot wait until the surgery reopens, please hold the line and you will be diverted to the GP Out-of-Hours service Action: Sarah Murray to take the issue of providing an initial message then an auto-divert to the OOH service to the Practice Managers meeting, using the agreed text. Practices would be responsible to set up the divert themselves, checking the costs first. If the costs of moving to a new messaging situation are high, the CCG may need to consider how to fund this. It was suggested that more work could be done with the local press to get the message out about the OOH service both in terms of the service availability and the quality of the service. Greater publicity could be done nationally, but as the OOH service in West Cheshire CCG is unique, this might be difficult. Practices could use their in-practice screens to put out messages about the OOH. 7

6 CCG Updates AgeUK AgeUK Cheshire has successfully won 5.2m from the lottery to make Growing Old in Cheshire a Positive Experience their project is called Bright Life. This is a huge opportunity for us to work with the charity. The type of work they will be carrying out is around social media, social prescribing, addressing loneliness, isolation, Men in Sheds etc. Alison South Cheshire and Vale Royal CCGs are considering merging. One potential problem with this is the lack of co-terminosity with the Cheshire Councils. To date, there has been no formal consultation with us from the two CCGs. Pressure to deliver targets Alison Lee stressed the importance that NHS England is placing on meeting key targets including A&E, 18 weeks, Cancer and dementia diagnosis. Continuing Healthcare NHS West Cheshire Clinical Commissioning Group has made a decision to bring the commissioning of Continuing Health Care within the CCG. This will be a joint service to be provided across Cheshire CCG's with a host CCG that will lead on the service. Integrated Teams There is some inconsistency in how these are working. Some teams are more mature than others and work continues to ensure that all nine teams are fully staffed and working cohesively. Sexual Health specification The contract has been awarded to East Cheshire Hospital Trust. This is a local Council (Public Health) decision. NHS 5 Year Forward Report Huw indicated to the Network that it is very important to read this document. It is well written and has some serious consequence for General Practice. There are some consistencies with the West Cheshire Way and with Huw s General Practice paper produced last year. Huw Charles- Jones The paper acknowledges the role of Primary Care and stresses the importance of coming up with a new deal, including finding ways of getting more young doctors into General Practice. The paper suggests two models the Multi-Speciality Community Provider and the Primary and Acute Care System. The paper also refers to an interesting model in Birmingham The Vitality Partnership, which is a single GP organisation that operates across 13 different locations in Sandwell and Birmingham. The consequence for Primary Care is that there are some choices to make. Huw expressed a preference for a move towards the multi-speciality community provider. It is clear that there is a need to be proactive about this to make sure that the right approach for West Cheshire is developed. 8

The CIC may need to be developed to improve the way in which Practices work together. The danger of not seeking to proactively innovate and develop a distinct, local model, is that Primary Care in West Cheshire may be led by the local acute provider. The CIC may need to look at partnerships with other providers. At the moment, the CIC doesn t have the infrastructure to develop radical models. The only money the CIC has is money put in from Practices. We need to be aware that, due to the lack of an obvious reason/impetus for change, the danger is that we may not develop proactive alternatives. Action: We should all read the NHS 5 year Forward Report and consider how we might develop ideas for our future. Palliative Care re-design a service redesign proposal has been approved by the Commissioning Delivery Committee. The redesigned service will have a greater skill mix and will include a community consultant. The service will be expanded to incorporate seven day working and will support patients to be cared for and to die in their preferred place. The redesign is being supported by Macmillan who initially will be investing a significant amount into the new service. 7 Items for Future Meetings Cancer 2 Week Referral Yes for December Enhanced GP referral templates need some information for December meeting, maybe they could come to the January. Phil Morgan to contact Karen Warren Diagnostics Review yes for December Category Care Frameworks yes for December Frailty Service need some information for December meeting, maybe they could come to the January. Phil Morgan to contact Catherine Roberts. 8 Any Other Business Prime Ministers Challenge Fund mk 2. Practices are now able to bid for a share of 100m in the second wave of the Prime Minister s Challenge Fund. Practices are encouraged to work with peers to develop proposals for improving and extending patient access to services with priority given to localities where practices are opening for longer such as 8am to 8pm on weekdays and at weekends. Bids have to be in by mid-january and the CCG is working on how we are going to bid for this. Blacon There is a meeting arranged by NHS England to discuss the Blacon Development and the nature of the Primary Care presence within it. Close @ 11.35am Date and Time of Next Meeting: Thursday 4 th December 8.30am 9

Ellesmere Port and Neston GP Network 8.30am on Thursday 4 th December 2014 at Ellesmere Port Civic Hall, Civic Way, Ellesmere Port, CH65 0AZ Attendants: Attendance December EP&N Netw In attendance Andy McAlavey Sarah Murray Tanya Jefcoate-Malham Phil Morgan Medical Director, West Cheshire CCG Primary Care Programme Lead CCG Primary Care Quality Manager Locality Support Manager, Ellesmere Port and Neston Apologies Jeremy Perkins Jon Stringer Mark Adams GP, Neston Surgery and Locality Chair GP, Willaston Surgery GP, Westminster Surgery Practices not represented by a GP: Neston Surgery, Westminster Surgery and Willaston Surgery Key Points to Communicate to your Practice Child Protection conferences a series of specific issues and questions concerning GPs involvement in this process were identified by the meeting. These will form the basis of a conversation between the CCG and Cheshire West and Chester Council about how the process can be improved. Provision of Med 3 Notes by secondary clinicians new contracts, from April onwards, will contain a requirement, probably in the quality schedule, for Med 3 notes to be provided by secondary clinicians for appropriate timescales. Cancer referral forms a number of changes are being made to the two-week cancer referral forms, with the aim of increasing the likelihood of patients attending their secondary care appointment The Prime Minister s Challenge Fund - the CCG is planning is to apply for funding across the whole CCG area. Part of this will be aimed at improving the extended hours service. Other Challenge Fund bids should be about what clusters can do in areas other than extended hours. Co-commissioning the CCG s preferred option is joint-commissioning. This was endorsed by the Network. Primary Care CQUIN a new CQUIN is being developed for implementation from April 2015. 1

Actions: Phil Morgan to liaise with Anne Eccles to take the issues concerning GP s involvement in the Child Protection Conference process forward. Huw Charles-Jones to postpone the 15 th December meeting at the CoCH to discuss referrals from secondary care clinicians and rearrange for early January. Practices to provide examples, to Huw Charles-Jones, of problems they have been having with referrals to specialists for patients by secondary care clinicians. Huw Charles-Jones to talk to Dave Rowlands and Rob Nolan to agree how to raise with hospitals in the Wirral CCG area the issue of referrals to specialists for patients by secondary care clinicians. Sarah Murray to report back to the January Network meeting on what evidence exists to demonstrate the effectiveness for patients of auto-divert mechanisms to an out-of-hours service. Paula Taylor to carry out the following actions in relation to the two-week cancer forms: 1. to investigate and inform the Network about any evidence around patients not attending two week cancer referral appointments and also about what more, if anything, GPs could do to improve the likelihood of patients attending. 2. to investigate whether there is a need for a telephone number on the cancer public leaflet. 3. to discuss with Rachel Warner whether there is unnecessary duplication on the upper GI cancer referral form in terms of asking for information from GPs. 4. to discuss with Rachel Warner what form GPs should complete when they weren t sure whether the suspected cancer was upper or lower GI for instance, in cases where patients have iron deficiency anaemia and it is unclear as to the reason. 5. to obtain figures on how many colorectal cancer referrals could be prevented by checking CA125, i.e. how many colorectal cancer referrals turn out to be ovarian cancer instead. Practices to contact Sarah Murray with ideas for submissions to the Prime Minister s Challenge fund. Colin McGuffie to arrange a meeting between the M56 and Neston clusters to reflect on the different models and to ensure that evaluation includes the impact of the service back at the practice, where partners are delivering the early visiting service. Phil Morgan to contact the colleagues who will be presenting on the Frailty Service and the Community Pain Clinic at the January Network meeting. Tanya Jefcoate-Malham and Julia Riley to send out ideas about the potential content of the Primary Care CQUIN directly to Practices. 2

1 Introductions Apologies for absence Jeremy Perkins Jon Stringer Mark Adams Declarations of interest None Code of conduct All of those at the meeting agreed to abide to this. 2 Previous Minutes and Matters Arising 1. Accuracy No points raised 2. Matters Arising a) Action for Philip Milner (p4 November minutes) Philip Milner will be attending the January Network meeting to give the update. b) Innovation Fund Application Phil Morgan contacted Dan Jones and Chris Ritchieson concerning the Innovation Fund application. The application has gone to Commissioning Delivery Committee without any further changes. c) Child Protection Phil Morgan reported that he had discussed the issues raised at the November Network meeting with Anne Eccles, the designated children s safeguarding nurse. In order to take the issue forward, Anne asked that some specific issues or questions were identified by the Network so she could liaise with Cheshire West and Chester Council, as necessary. After a discussion about the concerns GPs had about the impact of the Child Protection processes on their time, the following specific questions and issues were identified: Could meetings be scheduled in the afternoon, and, ideally, not on Monday? Could the meetings be arranged so that GPs could provide their input without having to stay for the whole meeting? Is there a possibility of using IT more effectively to reduce the need for GPs to physically attend the meetings i.e. using Skype from the GP s office? Could there be an improvement in the way in which medical information is collated and reported to the meetings more specifically, could the Health Visitors provide the initial report 3

which could then be added to and amended by the relevant GP? Where GPs are required to attend multiple review meetings (sometimes up to five) would it be possible for the Council to provide funding for locum cover? Action: Phil Morgan to liaise with Anne Eccles to take the above issues forward. d) Med 3s Andy McAlavey reported to the meeting that the issue of changing contracts to improve the provision of appropriate Med 3 certificates by secondary clinicians had been discussed by the CCG. The decision was not to change the existing contracts (due to the cost implications of this) but to ensure that new contracts, from April onwards, contained a requirement, probably in the quality schedule, for Med 3 notes to be provided for appropriate timescales. The contract would also allow for fines if this requirement was not met. Andy McAlavey said that, although senior clinicians at the CoCH hospital understood the issue, it may take time for other clinicians, for example junior doctors and nursing staff, to be fully aware of what is required from them. Finally, Andy McAlavey said that there were ongoing discussions with Hospitals in neighbouring CCG areas and with some private hospitals about this issue. e) Referrals from secondary care At the November Network meeting there was a discussion of the problem of patients being told by secondary clinicians to ask their GP to refer them to other specialists. Following this discussion Huw Charles-Jones had arranged a meeting on 15 th December at the Hospital to discuss how this situation could be improved. The Network agreed that, as this was such an important issue, it is important that GPs were fully represented at the meeting so that all relevant issues could be discussed. Following a discussion it was agreed that, given the importance of the issue, the fact that the issue is due to be discussed at the Clinical Senate and the fact that some key colleagues were not able to attend the 15 th December meeting, Huw should be asked to rearrange the meeting to early in January. Two other linked issues were raised firstly the need to have as many specific examples as possible from GPs to take to the meeting and, secondly, the need to raise the same issue with hospitals within the Wirral CCG area. Action: Huw to postpone the 15 th December meeting and rearrange for early January. Action: GPs to provide examples, to Huw Charles-Jones, of problems they have been having with referrals to specialists. Action: Huw to talk to Dave Rowlands and Rob Nolan to agree how to raise this issue with hospitals in the Wirral CCG area. f) Out of Hours Service Sarah Murray reported to the meeting that she has spoken to Practice 4

Managers at the November Practice Manager meetings about the need for a more consistent approach to telephone messages concerning the out of hours service. Sarah said that Practice Managers will now be taking the action to ensure that patients get appropriate messages and are able to be transferred, via an auto-divert, to the out of hours service when relevant. There was a discussion about whether there is evidence to demonstrate that an auto-divert improves the process for patients and it was agreed that Sarah Murray would investigate this further. Action: Sarah Murray to report back to the January Network meeting on what evidence exists to demonstrate the effectiveness for patients of autodivert mechanisms to an out-of-hours service. 3 Cancer two week referral Paula Taylor the Cancer commissioning lead for the CCG, delivered a presentation on changes to the two week cancer referral forms (see forms distributed with December meeting agenda). Paula said that one of the key reasons for the changes is that, according to secondary care clinicians, patients often do not understand the urgency of the appointment and often cancel or don t attend, also patients are not always informed about the details of the pathway they are on. The new forms will also improve the quality of information sent into secondary care to speed up diagnosis. Paula Taylor GPs at the meeting asked whether there was evidence both that patients did not attend referral appointments, and that GPs did not give patients enough information about the pathway. GPs said that they would be interested to hear whether there was anything that they are not doing as well as they might to increase the likelihood of patients attending. Paula agreed to look into this. Action: Paula to investigate and inform the Network about any evidence around patients not attending two week cancer referral appointments and also about what more, if anything, GPs could do to improve the likelihood of patients attending. Paula then informed the meeting that a leaflet for patients had been produced, giving them information about the 2 week wait pathway they were on. The meeting queried whether there was a need for a bespoke telephone number on the leaflet Paula agreed to look into this. Action: Paula to investigate whether there is a need for a telephone number on the cancer public leaflet. The meeting then had a discussion about the detail of the new referral forms. GPs identified a potential duplication in the information requested on the upper GI form the box asking GPs about the suspected cancer and a more detailed question later on asking for medical history. Paula explained this was due to the number of upper GI cancers and if GPs could suspected a specific site they could indicate it on the form. Action: Paula to discuss query with Rachael and whether there was unnecessary duplication on the upper GI cancer referral. GPs also queried which form they should complete when they weren t sure whether the suspected cancer was upper or lower GI. 5

Action: Paula to discuss with Rachel Warner what form GPs should complete when they weren t sure whether the suspected cancer was upper or lower GI for instance, in cases where patients have iron deficiency anaemia and it is unclear as to the reason. The meeting queried one aspect of the colorectal cancer referral form regarding the question as to whether CA125 levels had been checked prior to referral. The GPs then went onto ask if the form was requesting that all female patients had ovarian cancer ruled out before being referred via the colorectal form. Paula said that this was only to ensure GPs had considered ovarian and that it they weren t required to do this for all female patients. Action: Paula to obtain figures on how many colorectal cancer referrals could be prevented by checking CA125, i.e. how many colorectal cancer referrals turn out to be ovarian cancer instead. This might require GPs to check CA125 in all patients prior to referral. Paula asked whether GPs would be happy to participate in a twice yearly exercise to identify patients diagnosed with cancer with a 12 month period from their patient lists, in order to invite them to a Cancer Health & Wellbeing event organised by CCG, COCH and Macmillan cancer support centre. The GPs agreed that they were happy to continue to do this. Practices will be informed when this takes place. Finally Paula said that the new forms would be going live very soon probably early January. Practices will be informed when this takes place. 4 Prime Minister s Challenge Fund Sarah Murray introduced this topic, as a follow-on the Membership Council workshops. Sarah Murray Sarah informed the meeting that the second wave of the Fund has recently been announced and explained that the CCG s plan is to apply for funding across the whole CCG area. Part of this will be aimed at improving the extended hours service. After Sarah s presentation there was a discussion regarding the possibilities of service provision for an enhanced extended hours service across West Cheshire. Given that there will be a CCG-wide bid on extended hours, other Challenge Fund bids should be about what clusters can do in areas other than extended hours. Practices need to be willing to move at pace dedication and time is needed. A key point for practices is to ensure that local solutions are developed, so that they are owned locally. A template has been produced and sent out to practices, asking for indications of interest in making a bid to the fund. Practices are advised that, if they are interested, they need to be prepared to work quickly as the deadline for submissions is the end of January. Action: Practices to contact Sarah Murray with ideas for submissions to the fund. 6

5 Vanguard update Ellesmere Port Progress has been made on both the Direct Access to Physiotherapy and Community Connector Projects. The Physio project is going live in early January and it is hoped that the Community Connector project will also start then, although this is subject to AgeUK being able to recruit within the short timescale. The Pharmacy First project is also underway with information (leaflets and posters) sent out to practices. Some GPs have had experience of problems with level 2 services from some pharmacies. If this is the case, practices are encouraged to DATIX the issue. The Primary Care team will be delivering fridge magnets and leaflets to primary schools in the next week. M56 The early visiting service is proving to be successful. 212 patients have been seen to date, with an admission-avoidance rate of 37% being achieved. Partners from across the practices have been delivering the service which has led to good communication and cooperation between the practices. Formal evaluation of the project will be carried within six weeks. Neston A similar project to that in the M56 cluster is being rolled out in Neston. Practices have had a good experience of this so far, with a specific doctor with administrative support delivering the service. City The CHIMP project is due to be delivered. A meeting was held recently to discuss the project and City GPs have been invited to take up this initiative by 14 th January. Mid-Rural The process-mapping project is being delivered. Outputs from this were discussed at a recent rolling half-day event. Also, a self-care event was held in the cluster in self-care week, with the overall aim of encouraging patients to increase their level of self-care and to contact each other more. In addition, three commissioned services, Puffle, NHS self-management UK and a coaching service have been launched. Self-management UK is providing 10 courses across the CCG four available in mid-rural, four in EP and two in Neston. It is hoped that these will be starting in January. Broxton Malpas practice is looking to work with a community geriatrician to help patients leave hospital more quickly by creating a virtual community hospital. Action: Colin McGuffie to arrange a meeting between the M56 and Neston clusters to reflect on the different models and to ensure that evaluation includes the impact of the service back at the practice, where partners are delivering the early visiting service. 6 Co-commissioning of Primary Care Laura Marsh delivered a presentation (see below) on the changes to the way in which Primary Care is commissioned. The three options set out by NHS England are: Vanguard Leads Laura Marsh 7

1. Greater involvement in primary care decision making, best described as co commissioning of primary care 2. Joint commissioning of primary care, and 3. Delegated commissioning of primary care Laura said that the CCG s preferred option was the second one jointcommissioning. There was a vote on this which resulted in this approach being endorsed by the Network (with Nigel Wood abstaining). Co-commissioning Presentation for Netw 6 CCG Updates Senate At the recent Senate meeting there was a discussion about demand management, with Philip Milner leading the discussion about what is the best approach. Various options will be developed and included in contracts, depending on specific specialisations. Andy McAlavey There was also a presentation from Fiona Reynolds, Cheshire West and Chester Council s Director of Public Health, on draft Obesity recommendations from the Obesity Forum. This included specific actions that the Council could do in this area. Governing Body One of the key issues discussed was the high number of complaints about the Continuing Healthcare process. This has been a difficult process for the CCG to manage, but the service has now been brought in-house. Although the situation is improving, Continuing Healthcare remains a high-risk issue and, as such, an assurance report is being provided, on a monthly basis, to the Commissioning Delivery Committee. Another issue raised was the increase in the number of clostridium difficile cases in the community. Although there are no specific trends, Andy McAlavey said that it is likely that the target will be breached. There was a discussion, at the Governing Body, of the recent process for the re-commissioning of the Sexual Health service. Some colleagues were concerned that the commissioning process, now led by public health within the local authority, did not work as well as it should have done. West Cheshire CCG has indicated that, in future commissioning, it needs to work more closely with public health colleagues at Cheshire West and Chester Council. Huw Charles-Jones has written to the Chief Executive of the Council raising the CCG s concerns about the process. The new Sexual Health service will be going live in February. Staff are likely to be based in Chester, but there are concerns about the risks for patients with the new service as it might be less accessible. If GPs become aware of any weaknesses in the sexual health service they should feed these back to the CCG. 8

Commissioning Delivery Committee A summary of the minutes from the last CDC will be sent out with these minutes. 7 Items for Future Meetings Enhanced GP referral templates the meeting agreed that the information provided on this topic in the video that can be accessed here should be enough for colleagues. Diagnostics Review this will be presented in January. Frailty Service the meeting decided to have this presentation at the January meeting. Community Pain Clinic the meeting decided to have this presentation at the January meeting. Action: Phil Morgan to contact the colleagues who will be presenting on the Frailty Service and the Community Pain Clinic at the January meeting. 8 Any Other Business CQUIN. Currently there are a number of different funds available to practices requiring different admin approaches. The CCG is keen to develop these pots into one scheme to reduce the administrative burden and to change the approach from box ticking to focusing on outcomes. Considerable work will need to be done to agree which outcomes will be measured and how and this will be done in a formative way with practices. Tanya Jefcoate- Malham. Deadline the new CQUIN should be in place by April 1 st 2015. Julia Riley is the clinical lead. She and Tanya want to consult and engage with Practices from now until April. Action: Tanya and Julia Riley to send out ideas about the potential content of the CQUIN directly to Practices following their meeting in late December. Close @ 11.35am Date and Time of Next Meeting: Thursday 8 th January 8.30am 9