A G E N D A - Shropshire CCG - Shropshire CCG€¦ · Keith Timmis 10.00 Verbal PCCC-2018-12.174...

of 1 Shropshire CCG Primary Care Commissioning Committee Meeting – Agenda 5 December 2018

William Farr House

Mytton Oak Road Shrewsbury Shropshire

SY3 8XL Tel: 01743 277580

E-mail: [email protected]

A G E N D A

Meeting Title

Primary Care Commissioning Committee

Date Wednesday 5 December 2018

Chair

Mr Keith Timmis Time 9.30 a.m.

Minute Taker

Mrs Chris Billingham Venue / Location

Room K2, William Farr House, Mytton Oak Road, Shrewsbury SY3 8XL

Reference

Agenda Item Presenter Time Paper

PCCC-2018-12.170 Apologies

Keith Timmis 9.30 Verbal

PCCC-2018-12.171 Members’ Declaration of Interests


PCCC-2018-12.172 Minutes/Actions of Previous Meeting and Action Log held on 3 October 2018

Keith Timmis 9.40 Enclosure 1 Enclosure 1A

PCCC-2018-12.173 Matters Arising


PCCC-2018-12.174

GPFV Progress Phil Morgan 10.15 Enclosure 2

PCCC-2018.12.175 Finance Update Claire Skidmore 10.35 Enclosure 3

PCCC-2018-12.176 Quality & Performance Jenny Stevenson 10.50 Enclosure 4

PCCC-2018-12.177 Review of Audit Claire Skidmore 11.05 Verbal

PCCC-2018-12.178 Primary Care Estates Update Steve Ellis 11.10 Enclosure 5

PCCC-2018-12.179

Whitehall Medical Practice Contract Nicky Wilde 11.20 Enclosure 6

PCCC-2018-12.180

NHS England Update

Rebecca Woods 11.30 Verbal

PCCC-2018-12.181

Items for information only:

PCCC Cycle of Work

Improvement Grants

11.40

Enclosure 7 Enclosure 8

PCCC-2018-12.182

Any Other Business Keith Timmis 11.50 Verbal

PCCC-2018-12.183

Date of Next Meeting Wednesday 2 January 2019, 9.00 a.m. Room K2, William Farr House, Mytton Oak Road, Shrewsbury SY3 8XL

mailto:[email protected]

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Agenda Item PCCC-2018-12.172

Enclosure Number 1 Shropshire Clinical Commissioning Group

MINUTES OF THE PRIMARY CARE COMMISSIONING COMMITTEE (PCCC) HELD IN ROOM K2, WILLIAM FARR HOUSE, SHREWSBURY AT 10.00 AM ON

WEDNESDAY 3 OCTOBER 2018

PART 1 SECTION

Present Mr Keith Timmis Lay Member - Performance (Chair) Mrs Nicky Wilde Director of Primary Care Dr Finola Lynch GP Member Dr Deborah Shepherd GP Member, Shrewsbury & Atcham Locality Chair Mrs Claire Skidmore Chief Finance Officer Mrs Sam Tilley Director of Corporate Affairs Dr Julian Povey GP Clinical Chair Mr William Hutton Lay Member – Governance & Audit Ms Dawn Clarke Director of Quality, Nursing & Patient Experience Mr Kevin Morris Practice Member Representative Mrs Sarah Porter Lay Member for Transformation In Attendance Mr Steve Ellis Head of Primary Care Mrs Chris Billingham Personal Assistant; Minute Taker Mrs Amanda Alamanos NHS England Primary Care Lead, Shropshire & Telford Mrs Rebecca Woods Head of Primary Care for Shropshire & Staffordshire, NHS England Andrea Harper Communications & Engagement Officer Mr Phil Morgan Primary Care Manager Apologies Mr Meredith Vivian Lay Member – Patient & Public Involvement Dr Colin Stanford GP Member PCCC-2018-10.151 - Apologies 1.1 Apologies were received as shown above.

PCCC-2018-10.152 - Members’ Declaration of Interests 2.1 There were no declarations of interests raised. Mr Timmis reminded Members that they

should declare any conflicts which may arise during discussions. PCCC-2018-10.153 - Minutes/Actions of Previous Meeting and Action Log held on 1 August 2018 3.1 The Minutes of the meeting held on 1 August 2018 were agreed to be a true and accurate

record, provided the following amendments are noted:-

Mrs Sarah Porter’s attendance at the previous meeting was not recorded.

Page 3 - Primary Care Priorities: This paragraph should refer to Dr Lynch, not Mrs Lynch.

Page 6 – Riverside Outline Business Case. Paragraph 11.3 should refer to Mr Smith, not Mr Willocks.

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3.2 An update on the actions from the previous meeting were noted as follows: PCCC-2018-1.005 - PCCC Terms of Reference ACTION: Mr Timmis to feedback outcome of the review of the effectiveness and operation of

the CCG’s Committees to the July PCCC meeting. 3.3 Mr Timmis advised that this meeting has been delayed yet again. This may be overtaken by

possible changes to the role of the Clinical Chairs. Mr Timmis will update the December Committee.

ACTION: Mr Timmis to update the December Committee regarding progress on reviewing the effectiveness and operation of the CCG’s Committees. PCCC-2018-8.126 – GP Forward View ACTION: Ms Clarke to provide a report from a quality perspective regarding Physician

Associates. 3.4 Ms Clarke had not yet written a report. It was agreed that this action will be taken forward to

the December meeting. ACTION: Ms Clarke to provide a report to the December Committee regarding Physician Associates. PCCC-2018-8.127 – GP Pay Rises ACTION: Mrs Skidmore to update the October Committee with the costs of the GP Pay rise. 3.5 Mrs Skidmore advised that the estimated cost is £320k, which has been built into the

forecasts. ACTION: Mrs Skidmore to update the October Public Meeting with a sense of scale of any

pressures facing the CCG in future years and actions to be taken to attempt to address those.

3.6 Mrs Skidmore advised that there are no specific costings currently available, although all

topics previously discussed will be included in the model. No further information is available regarding allocation commitments. Mrs Skidmore will incorporate what she can into the report brought to the December Committee.

ACTION: Mrs Skidmore to incorporate details of any pressures facing the CCG in future years into the Finance Report to the December Committee. PCCC-2018-8.128 – Estates Plan ACTION: Mr Ellis to provide an update regarding the Estates Plan to the October meeting. 3.7 Mr Ellis advised that the work on the Estates Plan has been delayed due to staff sick leave.

An update will be provided to the December Committee. ACTION: Mr Ellis to provide an update regarding the Estates Plan to the December meeting.

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PCCC-2018-6.128 – Estates Strategy ACTION: Mrs Wilde to update the next meeting regarding the Estates Strategy. 3.8 An update will be provided to the December Committee. ACTION: Mrs Wilde to provide an update on the Estates Strategy to the December meeting. PCCC-2018-10.154 – Matters Arising 4.1 There were no other matters arising. PCCC-2018-10.155 – Review of Progress – Primary Care Priorities 5.1 In June 2018 Primary Care Commissioning Committee (PCCC), as the corporate decision-

making body for the management of the Primary Care delegated functions, approved the Primary Care Commissioning Priorities for 2018/19.

5.2 The 7 agreed priorities to be delivered in 2018/19 contained within Mrs Wilde’s report are:-

GP Extended Access 8am – 8pm 7 days a week with a target of 100% coverage by 1st

October on 4 of the required criteria has been met. The remaining 3 criteria are to be

delivered to national timescales yet to be agreed.

A Primary Care Workforce plan addressing recruitment and retention issues in Primary

Care and introducing a wider clinical workforce to support GPs – all plans are on target

for delivery with final delivery date of 2020.

Development of Primary Care Hubs to support “at scale” working, resilience and

sustainable Primary Care.

Detailed review of Primary Care Estate finances.

An assurance level of “Significant” from internal audit. All 10 high impact actions as outlined in the GPFV delivered by all practices within the

CCG. A balanced financial plan.

5.3 Mrs Wilde reported that progress is being made as planned. PCCC-2018-10.156 – Terms of Reference Review 6.1 Mr Timmis advised that the review had been undertaken to ensure that the CCG are keeping

governance arrangements up to date and monitor the role of the Committee and its effectiveness.

6.2 The Terms of Reference have now been updated. The latest version was circulated with the

papers. 6.3 This topic had been discussed earlier in the Part 2 meeting, and a slight concern was

identified relating to changing the remit of the Locality Chairs which would change the membership of the Committee. When the two positions for new Locality Chairs have been filled, the Terms of Reference may need to be revised once again.

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6.4 The Committee agreed to accept the updated version of the Terms of Reference until the

position relating to replacements for the Locality Chairs is clarified. This will be taken forward as an issue once this is resolved.

6.5 Discussion took place regarding the formal appointment of a Vice Chair of the Committee.

Mr Timmis advised that Mr Meredith Vivian had expressed an interest in the position. Mr Timmis formally proposed Mr Vivian to be Vice Chair of Primary Care Commissioning Committee. This proposal was approved by the Committee.

PCCC-2018-10.157 – GPFV Workforce Update 7.1 The purpose of Mr Morgan’s report was to provide a formal report to Primary Care

Commissioning Committee on:

Delivery of the Workforce element of the GP Forward View (GPFV)

Plans to set up a Physician Associates Internship scheme across Shropshire

Details on the impact of the National Retention Scheme 7.2 Mr Morgan clarified the background to the GP Retention Scheme, how GPs can be involved

in the scheme, and how it fits with the CCG funding their involvement. He advised that the scheme had been running for some time and was formerly called the GP Retainer Scheme. It is a national scheme run collectively and jointly by Health Education England and NHS England which GPs can apply to in order to become a retained GP and work on a part time basis for up to four sessions a week in practice.

7.3 The scheme is open to doctors who are considering leaving or have left general practice but

are still on the National Medical Performance List. The cost of the scheme is £16k per year for a practice if the GP works all 4 sessions. The scheme can last for five years and the cost falls to the CCG to pay.

7.4 Mrs Wilde had spoken to Health Education England and NHS England about the process.

This is a national scheme which the CCG must support. The funding for the scheme is included in the CCG’s delegated baseline.

7.5 Mrs Wilde had also requested that as soon as an application is received, the CCG should be

made aware. The Deputy Medical Director is placing this on the Risk Register for the region as she is in agreement that this is an issue.

7.6 As the approval process is with NHS England and the finances are then approved by the

CCG, Mrs Wilde expressed her concern that it is not possible to know how many applications will be received at any time, which is a risk. She asked Mrs Woods NHS England’s perceptions of the CCG’s responsibilities.

7.7 Mrs Woods replied that the ambition of the scheme is to keep GPs within general practice,

which aligns to the CCG’s overarching strategy. She agreed that the CCG needs to be advised as applications are received as this will impact on finances. Mrs Woods intended to escalate this through the Umbrella Group meeting as part of the Workforce agenda item and try to obtain a recommendation to change the process as other CCGs were finding the financial pressures on budgets extremely challenging.

Ms Clarke left the meeting at 10.25 a.m. to take part in the daily ‘Safe Today’ call with

SaTH which is currently a priority for the CCG.

7.8 Mrs Woods stated that locally, NHS England recognises the current pressure around workforce and the limitations of the funding streams.

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Much of the funding is currently retained within the International GP Recruitment Programme and consideration is being given as to how funding identified for the national scheme could potentially be released downwards. She is also escalating with local NHS England colleagues the possibility of releasing additional funding into STP’s to support GP Retention Programmes which are over and above delegated budgets and may mitigate some of the risk when financial modelling is carried out.

7.9 Primary Care Commissioning Committee was asked to confirm that the required assurance

had been provided to confirm delivery of the Extended Access in Shropshire in line with NHSE expectations.

Primary Care Commissioning Committee was asked to:

Note progress being made towards sustaining the Primary Care Workforce and confirm any additional assurances required against the delivery of the trajectory

Agree that appropriate governance and assurance processes are in place

Approve the related funding for the application against the national GP Retention Scheme and note the ongoing risks to the CCG’s finances from possible future, successful applications to this scheme

The Committee approved the above requests. PCCC-2018-10.158 – GPFV Extended Access 8.1 The purpose of Mr Ellis’s report was to provide Primary Care Commissioning Committee with

assurance on the implementation of Extended Access Appointments in Shropshire. The requirement on CCGs is that by 1st October 2018 100% of the population should have

access to pre-bookable appointments between 6.30pm – 8.00pm Monday to Friday, and on Weekends and Bank Holidays, subject to local need.

8.2 Key issues and points to note are:-

The Extended Access target is being delivered by GP Practices and the GP Out of

Hours Service

GP Practices in Shropshire have come together in four groups to deliver extended

access for the whole population of the CCG

Shropdoc are supplementing delivery by providing appointments on Saturday, Sunday

and Bank Holidays

8.3 Mrs Wilde referred to her paper which set out the four criteria that the CCG has been asked

to commission for 100% coverage of the population and gave a brief outline of how the CCG

is meeting that requirement. Extended Access went live on Monday 1 October 2018. The

Shropdoc scheme ended on Sunday 30 September 2018.

8.4 Dr Shepherd referred to the commissioning of sessions on Saturdays both from practices

and from Shropdoc. There is a finite pool of GPs and both Shropdoc and practices were

calling on GPs to fill sessions which was proving to be problematic.

8.5 Mrs Wilde replied that the Shropdoc cover is across Shropshire and Telford & Wrekin.

It is a single service across both CCGs and was commissioned as part of the Out of Hours

process. It has only limited capacity.

Across both CCGs there are only 35 appointments available some of which are GP

appointments and some of which are nurse appointments.

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The Complaints and Enquiries line has been made aware of the process and all Practices

have details of who to contact in the event of patient queries. Patients will be asked to give

their permission to be booked into the appointments at other Practices and to agree to

patient notes being accessed by a Practice which is not their own. If permission is not given,

then the appointment will not be given out. The clinician who sees the patient will also have

to ask for permission to access their notes.

8.6 Mrs Wilde confirmed that this service had been commissioned on a full NHS standard

contract which includes KPIs and reporting mechanisms. There will be monitoring for all

four leading Practices who will have to sub-manage the partners they are working with. This

will now be added to the timetable of reports going forward although no reports will be

available until January 2019 at the earliest. However, it may be possible to provide the

Committee with a verbal report at the December meeting.

Mr Kevin Morris joined the meeting at 10.45 a.m.

8.7 Mr Timmis requested that a paper is brought to the December meeting.

ACTION: Mrs Wilde and Mr Ellis to bring a paper regarding GP Extended Access to the

December meeting.

Mr Ellis to send Mrs Alamanos details of Pharmacy cover and Hubs.

8.8 Mr Timmis confirmed on behalf of the Committee that the required assurance had been

provided regarding Extended Access in Shropshire in line with NHSE expectations.

PCCC-2018-10.159 – Finance Update

9.1 Mrs Skidmore referred to her report, key points of which were:-

The Co Commissioning spend for 2018/19 is currently within the budget allocation received.

The CCG is currently forecasting that spend will be contained within the allocation received for Primary Care delegated commissioning for 2018/19.

The CCG & NHSE Finance teams continue to scrutinise all areas of the delegated budgets.

9.2 Mrs Skidmore advised that in terms of the overall position, the CCG are still on target to meet

the break-even position aimed for. Contingency is being included in the figures to ensure

that break-even is achieved. Since the last report, an improvement in the position has been

seen as the Indemnity Charges have now been confirmed as being funded.

9.3 Mrs Skidmore noted that while this year looks relatively secure, the position for the next

financial year is a significant concern. She will bring a refresh of the long-term financial

model to the December meeting.

ACTION: Mrs Skidmore to bring a refresh of the long-term financial model to the December

meeting.

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9.4 Mrs Woods advised that other CCGs are in a similar position to Shropshire and suggested

that the Committee may wish to raise this with NHS England and the Finance team as a risk

on the budget for next year. The Committee agreed that this should be placed on the Risk

Register.

ACTION: Mrs Wilde to place the risks to the CCG’s budget for next year on the Risk

Register.

PCCC-2018-10.160 – Primary Care Audit Requirements 10.1 Mrs Skidmore advised the meeting that the Internal Audit team are drafting a paper to be

submitted to the next Audit Committee. An initial assessment shows that the full extent of requirements can easily be covered.

10.2 Mr Timmis confirmed that a GAP Analysis will be brought to the December Primary Care

Committee. ACTION: Mrs Skidmore to bring the GAP analysis of Primary Care Audit requirements to the

December Committee.

10.3 Mrs Skidmore confirmed that the Audit Committee will consider and prioritise the remainder

of the programme of work for the rest of the year. 10.4 Mrs Wilde asked if quarterly assurance would continue to be required, or merely a single

annual statement. Mrs Woods will obtain clarification of the ongoing requirements. ACTION: Mrs Woods to clarify assurance requirements going forward.

PCCC-2018-10.161 – Primary Care Committee Risk Register 11.1 The Committee reviewed the Risk Register at Appendix 1 of Mrs Wilde’s report, and in

particular Item PCCC 3/14 – “There is a risk that underspend against Primary Care budget will fail to deliver financial balance for delegated primary care”. Mrs Skidmore suggested that this should be re-worded to state “There is a risk that the CCG will not deliver financial balance”.

The Committee agreed that this should be replaced with suitable wording regarding the building threats for next year and the medium term financial plan.

It was agreed that items PCCC 6/14 and 10/14 should be removed from the Risk Register.

ACTION: Mrs Wilde to update the Risk Register as outlined above.

PCCC-2018-10.162 – Quarter 2 Assurance for NHS England 12.1 The Committee reviewed Mrs Wilde’s report, which identified the following key issues and

points to note:-

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Quality

Performance

GP Forward View

Communications and Engagement

Premises

Finance

12.2 Primary Care Committee was requested to:-

Agree the content of the Assurance Report

Recommend to Dr Simon Freeman, CCG Accountable Officer, and Mr William Hutton, Audit Committee Chair for signature prior to submission to NHS England.

12.3 The Committee approved both of the above requests. PCCC-2018-10.163 – GP Patient Survey

13.1 Mr Ellis reviewed his report, the purpose of which was to inform Primary Care

Commissioning Committee of the recently published General Practice Patient Survey

(GPPS) results for GP Practices within Shropshire CCG. Key points to note are:-

The report summarises the results of the latest survey carried out between 2nd January and 6th April 2018 and reported in August 2018.

Although the survey is annual, the results are not directly comparable to the 2017 survey in many areas as some of the questions asked are different between the 2 years.

Appendix 1 provides the responses to the 48 questions asked from 5,110 Shropshire patients and also provides a CCG comparison against national averages.

Appendix 2 provides the information in more detail at Practice level. However due to low numbers of responses at individual and smaller Practices this level of detail may not be statistically significant, therefore this Appendix should be read with care. The Primary Care Team will review the Practice level data in detail and report their findings through the Primary Care Commissioning Committee.

The overall results continue to show high levels of patient satisfaction when accessing General Practice in Shropshire evidenced by the overall CCG results performing above the national average on most of the outcome measures.

13.2 The GP Patient Survey measures patients’ experiences across a range of topics, including:

Making appointments

Perceptions of care

Practice opening hours

What happens when the Practice is closed

13.3 In Shropshire CCG, 10,582 questionnaires were sent out and 5,110 were returned

completed. This represents a response rate of 48% which compares very positively against

the national response rate of 34.1%.

13.4 Mr Timmis expressed the Committee’s appreciation for the efforts of GPs and Primary Care

staff. In general, patient feedback regarding Shropshire continues to be good and the

service has scored higher than Practices in other parts of the country.

13.5 Mrs Wilde asked the Committee to note that Mr Ellis’s paper had already been presented to

Governing Body due to the timing of the two meetings.

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13.6 As recommended in Mr Ellis’s report, the Committee:-

Noted the July 2018 General Practice Patient Survey results and the overall good

outcome for our patients and practices.

Agreed to receive assurance against recommendations in the February 2019 Primary

Care Commissioning Committee.

PCCC-2018-10.164 – Improvement Grants

14.1 The Committee noted the contents of Mr Ellis’s paper relating to Improvement Grants which

was circulated for information only.

PCCC-2018-10.165 – Shifnal Premises Development Business Case

15.1 Mrs Alamanos advised the Committee that the interim District Valuer’s assessment for the

build has now been received and the District Valuer and Assurer are in the process of

looking at the abated revenue to take into account the ETTF capital monies of c.£900k.

However, she was uncertain when the Business Case would be presented to the Committee.

15.2 Mrs Alamanos confirmed that there were no deadlines to the CCG securing ETTF funding,

which will be available into the next financial year and will be provided to the GPs upon

signing of the lease.

PCCC-2018-10.166 – NHS England Update 16.1 Mrs Woods will forward to Mrs Billingham her report, which should have been circulated prior

to the meeting. 16.2 Mrs Woods referred to a previous outstanding action regarding the updated Demand &

Capacity Tool and advised that she has now received an update that a Demand & Capacity Tool has been commissioned by NHS England which is able to access General Practice data.

16.3 As previously reported to Committee, it would appear that there are issues around

consistency in how Practices are using appointments templates. It is acknowledged by NHS England that there are challenges around the data being received.

16.4 Work to show best practice and greater standardisation is in the early stages of

development. 16.5 There is currently no further clarity around timescales.

PCCC-2018-10.167 – Items For Information Only

17.1 Papers regarding PCCC Cycle of Work; Primary Care Working Group Update; and Capita

Primary Care Support Services were circulated for information only.

17.2 Mr Timmis reflected upon the poor service provided by Capita, and certain risks which had

been discussed several times by the Committee.

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Earlier in the year the National Audit Office (NAO) reported on this contract and had

concluded that although NHS England had saved a considerable amount of money, the

process did not achieve many of the quality targets.

17.3 Mr Timmis referred to the recommendations contained within the National Audit Office (NAO)

report and asked how NHSE were going to seek improvement.

17.4 Mrs Woods had escalated this to the National Team to provide a view, but they have been

unable to provide a communication that she could bring back to this Committee. Mrs Woods

will continue to liaise with the Team to obtain a reply. Once received, she will forward the

response to Mr Timmis for circulation.

ACTION: Mrs Woods to liaise with the National Team to obtain a reply and, when received,

forward the response to Mr Timmis.

17.5 Mrs Woods referred to the issues around pensions which had been raised in July, and

advised that significant issues still exist around pension payments.

17.6 Dr Shepherd advised that a separate notice had been issued to GPs. It had not been

possible to access information on pension contributions since 2015 and this has been taken

in hand by NHS England who expect that by December, GPs should be able to access that

information.

17.7 Capita have been invited to the next Practice Provider Forum. Mr Ellis has asked Mrs

Woods to escalate this as the CCG have not received any response despite the date of the

Forum being set to suit the availability of Capita delegates.

17.8 Mrs Woods advised that Capita are restructuring their Engagement Team which she has

escalated as a risk nationally.

PCCC-2018-10.168 – Any Other Business

18.1 Mrs Wilde referred to the Practice at Whitehall which is run by Malling Health on an APMS

contract which expires next year. The CCG will be carrying out an engagement process with

patients and practices over the next few months and will report to the December Committee.

ACTION: Mrs Wilde to provide an update to the December Committee regarding the APMS

contract at Whitehall Practice.

18.2 Mr Timmis thanked members of the public who were in attendance, and asked for any

questions.

18.3 Cllr. Madge Shineton referred to the time taken to transfer from one GP practice to another,

commenting that she was aware of a patient who had been told that it would take three

months before medical records were transferred from their previous GP.

18.4 Cllr Shineton referred to the the location of Hubs in the South Locality and Mr Ellis confirmed

that hubs will be located at Albrighton, Bridgnorth, Highley, Ludlow and Bishop’s Castle.

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18.5 Cllr Shineton also referred to the lack of public transport. Mr Timmis acknowledged that an

issue existed as this was a topic that was repeatedly raised at the Future Fit events he had

attended and had resulted in the setting up of the Transport Working Group.

18.6 Ms Karen Calder referred to the four hubs in the North Locality and requested confirmation of

their location. Mr Ellis advised that they will be located at Ellesmere, Whitchurch, Hodnet

and Wem.

18.7 Mrs Wilde stated the importance of the public being advised that not all of the four hubs

would be providing a service every day. Patients should in the first instance contact their

own Practice to be directed which hub to attend.

PCCC-2018-10.169 – Date of Next Meeting 19.1 The next meeting will take place on Wednesday 5 December 2018 in Room K2, William Farr

House.

Agenda item: PCCC-2018.12.172 Enclosure Number 1A

Shropshire CCG Primary Care Committee meeting: 5

th December 2018

Primary Care Commissioning Committee – 03.10.18 Action Tracker – Part 1 Meeting

Agenda Item Action Required By Whom By When Date Completed

PCCC-2018-1.005 Mr Timmis to update the December Committee regarding progress on reviewing the effectiveness and operation of the CCG’s Committees.

Mr Timmis December meeting

PCCC-2018-8.126 Ms Clarke to provide a report from a quality perspective to the December Committee regarding Physician Associates

Ms Clarke December meeting

Pccc-2018-8.127 Mrs Skidmore to incorporate details of any pressures facing the CCG in future years into the Finance report to the December Committee.

Mrs Skidmore December meeting

PCCC-2018-8.128 Mr Ellis to provide an update regarding the Estates Plan to the December meeting

Mr Ellis December meeting

PCCC-2018-6.117 Mrs Wilde to provide an update on the Estates Strategy to the December meeting

Mrs Wilde December meeting

PCCC-2018-10.158 Mrs Wilde and Mr Ellis to bring a paper regarding GP Extended Access to the December meeting. Mr Ellis to send Mrs Alamanos details of Pharmacy cover and Hubs.

Mrs Wilde

Mr Ellis

December meeting ASAP

PCCC-2018-10.159 Mrs Skidmore to bring a refresh of the long term financial model to the December meeting. Mrs Wilde to place the risks to the CCG’s budget for next year on the Risk Register.

Mrs Skidmore

Mrs Wilde

December meeting December meeting

Agenda Item Action Required By Whom By When Date Completed

PCCC-2018-10.160 Mrs Skidmore to bring the GAP analysis of Primary Care Audit requirements to the December Committee. Mrs Woods to clarify assurance requirements going forward.

Mrs Skidmore

Mrs Woods

December meeting December meeting

PCCC-2018-10.161 Mrs Wilde to update the Primary Care Committee Risk Register


Pccc-2018-10.168 Mrs Wilde to provide an update to the December Committee regarding the APMS Contract at Whitehall Practice.


1

Agenda item: PCCC-2018.12.174 Enclosure Number 2

Shropshire CCG Primary Care Committee meeting: 5th December 2018

Title of the report:

General Practice Forward View – Progress Report

Responsible Director:

Nicky Wilde – Director of Primary Care

Authors of the report:

Steve Ellis – Head of Primary Care Phil Morgan – Primary Care Manager

Presenter:

Phil Morgan – Primary Care Manager

Purpose of the report: To provide a formal report to Primary Care Commissioning Committee on the key workstreams within the GP Forward View (GPFV):

Models of Care/the development of Primary Care Networks

Workforce

Extended Access

Workload/High-Impact Actions

IT The report also describes how the CCG is working with practices to assess the impact of the programme on health inequalities and outcomes for patients.

Key issues or points to note:

One of the key tools for the delivery of the GPFV in Shropshire is a series of GPFV Delivery Plans developed by groups of Practices. These plans contain actions and targets under each of the GPFV workstreams along with a series of success measures.

The CCG also works with other stakeholders across the STP to deliver a series of bespoke projects and initiatives to support delivery of the GPFV e.g. Telford and Wrekin CCG, NHS England and Health Education England

Actions from projects and initiatives are brought together via a series of milestones and targets designed to assess overall delivery at a CCG and, in some cases, at an STP footprint. Progress against these milestones and targets is reported to the CCG Primary Care Commissioning Committee (PCCC) and the NHS England North Midlands GPFV Umbrella Group on a monthly basis (Umbrella group report attached at appendix 1)

This report brings together the results of a mid-year review of the Delivery Plans, together with monitoring of the other projects, to provide PCCC with assurance of progress against the GPFV workstreams.

2

The report also sets out, where relevant, any risks to delivery against key targets that have been identified both through the mid-year review of the Delivery Plans and a review of the other projects and initiatives.

Key areas of progress, and next steps, against each workstream are as follows: Models of Care/the development of Primary Care Networks

The four practice groupings that have been commissioned to deliver Extended Access (Oswestry, Shrewsbury, North Shropshire and South Shropshire) are examining what further joint work can be delivered in these footprints. Examples of this may include increased exchanges of staff and shared learning initiatives.

The CCG is supporting practices in this process and is liaising with NHS England to understand in more detail how Primary Care Networks are expected to operate and link with wider improvements in integrating primary care with the rest of the local health and social care sector.

Workforce

All of the practice groupings have produced workforce plans with a series of individual targets/trajectories linked to the CCG’s overall Primary Care Workforce Plan.

These plans are currently being reviewed so that they provide more detail on projected vacancies, retirements and other workforce changes. This is also anticipated to support a more integrated approach to workforce planning across the emerging Networks.

The latest quarterly, raw workforce data (@ 30th September 2018) has been published by NHS Digital and indicates that there has been an increase in all staffing groups. The Primary Care Team is validating this data and waiting to be informed of how this data impacts on the trajectories set by NHS England.

Extended Access

The extended access service was successfully launched from October 1st and is being delivered by the four practice groups listed above and by Shropdoc.

Following some initial IT connectivity problems in the North, as result of Market Drayton being on the Vision system, the practices have been working hard to overcome these issues to ensure full access for all patients. In the Shrewsbury group all connectivity issues have been resolved and final arrangements are in hand to ensure that relevant staff in all practices are trained in using the new booking systems.

Further work is being done with the providers to ensure that the service is being clearly advertised and that practice staff are able to provide patients with clear information about the evening and weekend appointments.


Following successful bids against the NHS England Resilience Fund, a series of success measures have been agreed with practices.

16 practices are participating in the Learning in Action programme, led by the national NHS England Time for Care team.

The Primary Care Team will continue to work with practices to support delivery of the specific actions in the Delivery Plans around the 10 High Impact Actions.

IT

The roll-out of VoIP and WiFi is progressing and will be complete by December.

Future work in this area includes the procurement of e-consultation software and the identification of interest in telehealth

Health Inequalities

The focus of the GPFV programme, nationally and locally, was to provide resilience and stability to primary care however it is also important that the CCG makes clear links between the outcomes of the projects and tackling health inequalities for Shropshire residents.

3

The Primary Care Team will continue to work with practices to identify and quantify these links. Risks to GPFV delivery

The mid-year review of the GPFV has demonstrated progress in many areas, however one area where there is still concern is around the requirement for Practices to work in networks as this is not mandated via the GMS contract and therefore there is a risk that the CCG may not be able to deliver this to the requirements of NHS England. Further engagement and support from the Primary Care team with options of flexible delivery of projects, will help to mitigate this, however there may be individual practices who do not wish to work in this way and/or some who may wish to continue working in their established GPFV Delivery Groups.

The review has also highlighted the challenges faced by practices in terms of their capacity to deliver against the full range of GPFV projects. This will be mitigated by the Primary Care Team working with practices to both prioritise work and, where appropriate, to explore how individual projects can be linked.

National availability of international recruits will challenge delivery of the workforce model and other workforce plans are being developed to fill this potential shortfall.

Lack of longer term finances support to practices is also a risk post April 2019. This has been raised directly with NHS England.

The CCG is required, by NHS England, to ensure that there is effective connection between Extended Access and 111 by March 2019. Given the tight timescale, and the fact that the Extended Access scheme has only recently been operationalized, the CCG is working with colleagues at Telford and Wrekin CCG and delivery partners to mitigate this risk

Actions required by Governing Body Members: Primary Care Commissioning Committee is asked to:

Note the contents of the report

Agree that the paper provides the required assurance against delivery of the GPFV.

4

Monitoring form Agenda Item: Enclosure Number

Does this report and its recommendations have implications and impact with regard to the following:

1 Additional staffing or financial resource implications No

2 Health inequalities Yes All of the schemes and initiatives listed in this report, particularly

the larger ones, will need an Equality Impact Assessment to ensure that improvements to services reduce health inequalities or, at worst, do not worsen them.

3 Human Rights, equality and diversity requirements Yes All of the schemes and initiatives listed in this report, particularly

the larger ones, will need an Equality Impact Assessment to ensure that improvements to services are accessible to all.

4 Clinical engagement Yes Many of the schemes need clinical engagement, particularly the

plan to extend access to GP appointments and many of the workforce initiatives – such engagement is being developed.

5 Patient and public engagement Yes Many of the schemes need patient and public engagement,

particular the plan to extend access to GP appointments. 6 Risk to financial and clinical sustainability No

5

Shropshire CCG Primary Care Commissioning Committee

GP Forward View Progress Report – December 2018 Steve Ellis – Head of Primary Care

Phil Morgan – Primary Care Manager Introduction 1 The General Practice Forward View (GPFV) was published by NHSE in April

2016. The purpose of the document was to identify key actions which GP practices should take to secure delivery of Primary Care Services in the future.

2 Primary Care Commissioning Committee has previously been informed that the

main delivery vehicle for the CCG is a series of GPFV delivery plans produced by groups of practices across Shropshire. These plans were originally produced for the 2017/18 year and funded by a payment of £1.50 per head to practices. A further £1.50 per head was paid to practices in September 2018 following the sign-off of refreshed plans for 2018/19.

3 In addition to these plans, a number of other projects and initiatives have been developed by the CCG and, in some cases, with partners across the STP.

4 The GPFV has an overall series of milestones which are reported to PCCC to provide assurance against delivery and also to the NHSE “Umbrella” Group which monitors assurance across all the CCGs in Staffordshire, Shropshire, Derbyshire and Nottinghamshire.

5 The purpose of this paper is to provide a progress report to Primary Care Commissioning Committee on the key workstreams within the GP Forward View (GPFV):

Models of Care/the development of Primary Care Networks

Workforce

Extended Access


IT

6 Although the GPFV was introduced to support the resilience and sustainability of

Primary Care, the report also describes how the CCG is working with practices to assess the impact of the GPFV on health inequalities and outcomes for patients.

7 The information and data in this report comes from a mid-year review of the

practices’ GPFV Delivery Plans together with a review of the other projects and initiatives delivered with STP stakeholders. It is anticipated that an end-of-year review of the Delivery Plans will be undertaken in April 2019 with a subsequent report to committee.

8 This report also sets out, where relevant, any risks to delivery against key targets that have been identified both through the mid-year review of the Delivery Plans and a review of the other projects and initiatives. For each risk mitigation actions are identified which will be monitored and reported back to committee.

6

Key messages Primary Care Networks 9 There is a requirement for CCGs to encourage practices to work in networks;

however there is no formal definition set by NHS England to determine how this works in individual CCGs.

10 Following the commissioning of Extended Access through the four delivery groups (Oswestry, Shrewsbury, North Shropshire and South Shropshire) these groupings are examining what further, joint work can be delivered in these footprints. Examples of current initiatives being explored include increased sharing of staff, workforce planning and inter-practice learning initiatives.

11 The purchase and implementation of GP TeamNet by practices has further enabled the development of networking. Practices are working together to use GP TeamNet for joint projects and sharing policies and resources. GPFV funding is being used to enhance existing versions of GP TeamNet with training being provided for staff to use new modules.

12 Alongside the development of Primary Care Networks the CCG is continuing the development of the Shropshire Care Closer to Home programme. The GPFV delivery plans include a commitment from practices to work with the CCG on the SCCtH programme and to explore how delivery links to their Networks.

13 The CCG will be working with the four Extended Access groups to identify and agree the next steps required to move towards the NHS definition of Primary Care Networks. It is likely that this will include more integration around workforce planning, shared resources/IT systems and joint services/initiatives.

14 There is a risk that not all Practices will actively involve themselves with the development of Networks either because this is not mandated by their GMS/PMS contract or because they prefer to work as a completely independent practice. The CCG is continuing to support and encourage conversations to address any concerns.

Workforce Workforce data and trajectories 15 Committee has previously been informed of the workforce recruitment and

retention targets, submitted by the two CCGs for the Shropshire and Telford & Wrekin STP footprint, and agreed by NHS England. The current targets for the STP footprint are to recruit and/or retain, by September 2020, 82 GPs and 38 other clinicians. A detailed breakdown of these figures is set out in appendix 1.

16 Due to some inaccuracies in previous quarters’ data the CCG has been working with all practices to validate the data submitted by practices via the Primary Care Web Tool. As a result of this work it is anticipated that ongoing data will more accurately reflect the workforce across Shropshire practices. These improvements will be further supported by the Primary Care Team by the provision of more detailed guidance and training on the data submission process and, where relevant, analysis of individual practices’ data.

17 The latest quarterly, raw workforce data (@ 30th September 2018) has been published by NHS Digital and indicates that there has been an increase in all staffing groups. The Primary Care Team is validating this data and waiting to be

7

informed of how this data impacts on the trajectories set by NHS England. This information will be provided to a future PCCC committee.

18 The following sections set out the main ways in which the above recruitment and retention targets are being tackled and addressed by both STP-wide projects and by the development of practice group workforce plans. There is a full list of the projects, with commentary, at appendix 1.

STP-wide projects and initiatives 19 The STP Primary Care Workforce Plan contains a series of projects designed to

both recruit and retain staff in practices. The key projects where notable progress has been made are as follows:

Physician Associates

Clinical Pharmacists

International GP Recruitment

GP Fellowships

GPN 10 Point Action Plan

GP Retention Fund

20 The Shropshire Physician Associates Internship scheme has been set up and recruitment has begun. Funding for up to four PA interns has been secured from Health Education England with the latest indication being that two practices across the STP, including one from Shropshire CCG, are interested in joining the scheme.

21 Following the Darwin group’s successful bid to the national NHS England Clinical Pharmacists scheme three Clinical Pharmacists have started work across the group. NHS England has now amended the criteria for the scheme (the population size has been reduced to 15,000 with bids possibly accepted from smaller, rural footprints) and we are hopeful that there will be more applications from Shropshire practices due to this change.

22 As previously reported to committee the STP has been successful in securing

funding for up to 18 international GP recruits across the STP. Nationally however there have been problems with securing suitable applications. The CCG is mindful of this and is developing additional schemes to address this recruitment issue.

23 PCCC has previously been informed of the allocation of £40k to the STP from HEE for fellowships for GP trainees and newly qualified GPs. Following the publicising of this scheme to local practices, and the receipt of applications from this cohort of doctors, five awards have so far been made with a further application being considered. The initiatives that will be funded include training courses for doctors to gain further qualifications and local schemes to develop new service models across practices. Part of the criteria for the funding (which will be paid to the relevant practices for distribution to the doctors) is for the doctors to provide written feedback on the impact the funding is having both on their individual development and on wider improvements to patient care.

24 The CCG, in conjunction with Telford & Wrekin CCG, have recently refreshed the GP Nursing (GPN) 10 Point Action Plan and identified priorities around the provision of training and upskilling for Nurses and HCAs. A GPN Development Group has been established which includes the two GPN Facilitators who work for both Shropshire and Telford and Wrekin. Current, funded training includes 3 GPNs undertaking an MSc in Advanced Clinical Practice, 2 Nurses new to General Practice undertaking the Fundamentals of General Practice Nursing

8

Programme and 11 GPNs undertaking a V300 Independent Prescribing Course. Future initiatives include Spirometry training and further Prescribing, Physical Assessment and HCSW LTC management training.

25 Following the award by NHS England to the CCG of £42k to support retaining GPs in practice, the CCG is developing a survey which will be distributed to GPs in early December. The survey is designed to identify the key issues that lead GPs to consider leaving general practice – these issues will then form the basis for the commissioning of a series of workshops, led by a national GP training organisation, which will aim to clarify the issues and develop solutions. The CCG anticipates that further funding will be available this year which will strengthen the ability of this programme to fund a series of initiatives identified from the workshops.

Practice Group Workforce Plans

26 The key Workforce activity set out in the GPFV Delivery Plans is the development

and implementation of workforce plans. All of the practice groupings have produced workforce plans with a series of individual targets/trajectories set which link to the projects above (and the other projects in the STP Primary Care Workforce Plan). The practice groupings workforce plans also contain data showing the collective number of clinical staff across the practice grouping, broken down into GPs and other clinicians.

27 The key areas of success from the Workforce Delivery Plans are:

The appointment, by the Darwin Group, of three Clinical Pharmacists who work across the group of practices

The formation by Bridgnorth Practice of a new Urgent Care Team, consisting of a doctor, minor illness nurse and two UCPs to increase the number of same day appointments

The recruitment of an ANP at Knockin Practice

The recruitment of a Clinical Psychologist by Station Drive Practice

The expansion of the role of HCAs in a number of practices to ease the pressure on other clinicians

The upskilling of a number of GPNs enabling them to take on more complex cases and procedures including coil implants

The introduction of a “Triage First” scheme at Shifnal practice

28 The Primary Care Team will continue to support the groups of practices to develop and refine their workforce plans to improve the likelihood of the targets in the STP Workforce Plan being met. The Team will also work with practices to ensure that any wider workforce initiatives, including the publication of the STP People Strategy, are reflected in practice workforce plans.

Extended Access 29 As reported to the October Primary Care Commissioning Committee the CCG

successfully commissioned the Extended Access service across Shropshire, starting on October 1st 2018. The service is provided on weekday evenings and Saturday mornings by four practice groupings (South Shropshire, North Shropshire, Oswestry and Shrewsbury) and by Shropdoc (via the IUC contract) on Saturday mornings, Sunday mornings and on Bank Holidays.

30 Following some initial IT connectivity problems in the North, as result of Market Drayton being on the Vision system; the practices have been working hard to overcome these issues to ensure full access for all patients. In the Shrewsbury group all connectivity issues have been resolved and final arrangements are in

9

hand to ensure that relevant staff in all practices are trained in using the new booking systems.

31 The data for October shows that the commissioned activity has been made available and that, on average, there is a good level of take-up of the appointments from patients. The data also shows that the number of DNAs is relatively low.

Number of appointments available 2,630

Number of appointments utilised 1,950

Percentage Utilisation 74%

Number of DNAs 202

Percentage of DNAs 10%

32 The detailed data shows that the utilisation rate varied both from day to day and between the delivery groups. The highest, daily utilisation rate was 95% and the lowest was 25%. The Primary Care Team will be analyzing the data in more detail following the receipt of the November data to identify trends and liaise with the delivery groups to explore any outliers in terms of both utilisation and DNAs. We will work with the lead practices to analyse the data to assist best utilisation of their resources.

33 A key part of the national NHS England criteria for Extended Access is around publicity and marketing. A review by the Primary Care Team of all 41 practice websites, at 21st November, found that 38 had a good level of information about the Extended Access appointments on their websites but 3 practices either had no information at all or the information was incomplete and/or unclear. The Primary Care Team is working with the relevant lead practice to ensure that this situation is addressed, resulting in full information on all practice websites.

34 NHS England expect all relevant practice staff to provide information to patients on extended access appointments in the same way as core hours appointments. The Primary Care Team is working with the delivery groups to ensure that full guidance and training is provided to receptionists so that patients are able to access evening and weekend appointments in the same way as core hours’ appointments.

35 The Primary Care Team will continue to work with the delivery groups, and Shropdoc, to identify and address any operational issues with the delivery of Extended Access and to ensure that the service is fully and clearly advertised. The team will also continue to work with NHS England to understand and implement the timescale for the remaining criterion around integration with 111. Although the CCG currently sees this as a risk.

Workload/High Impact Actions 36 The key areas of activity in the Workload workstream are the implementation of

the 10 High Impact Actions and the improvement to practice resilience (funded via the NHS England Resilience Fund).

10

37 All practices, via the group GPFV Delivery Plans, have agreed a set of targets and actions across the 10 High Impact Actions. The mid-year review of the Plans indicated that, in general, good progress has been made in this area. Notable activities and initiatives are listed below, beneath each of the High Impact Actions (in some cases information on the Action is covered elsewhere in this report).

Active Signposting

38 All Delivery Plans contain targets for increasing the number of staff trained in Active Signposting. The latest data, collected from the practices, show that 254 staff, from all except two practices, have received at least the minimum level of training. To supplement this most of the practice plans contain targets to train additional staff at a higher level (level 3), using the ongoing GPFV funding. Progress against these plans will be monitored as part of the end-of-year review of the Delivery Plans.

39 In some practices work has been undertaken with the Community and Care Coordinators to update directories of local services that patients can be directed to.

40 Future work in this area includes measuring the levels of staff and patient satisfaction with the additional signposting information that practices are able to provide patients with.

New Consultation Types

41 The CCG has received funding for on-line consultation software and is currently

in the process of developing a procurement exercise to identify a supplier. Practices have been asked to identify whether they were interested in installing new technology which would enable patients to communicate with clinicians on-line and for clinicians to respond with either information or the recommendation for a consultation. Interested practices have identified, within the GPFV Delivery Plans, whether they are interested in this scheme with the latest indication being that 11 practices will work with the CCG and the appointed supplier to install the necessary applications.

42 Future work in this area, once the procurement exercise is complete, will include the CCG working with interested practices to measure and monitor the impact of new technology, including the impact on freeing-up GP time.

DNAs (did not attend)

43 All of the GPFV Delivery Plans contain actions to identify and address the issue of DNAs. Many of the practices are using GPFV funding to install software (MJOG) which, among other things, contains the functionality to send reminder messages to patients. The Delivery Plans contain actions to implement this software, develop policies and processes within practices and to monitor the impact of this work.

44 Future work in this area includes carrying out patient and staff surveys to assess the extent to which the DNA rate has improved and how this has improved patient care within practices.

Develop the Team

11

45 The key delivery mechanism, within the GPFV programme, for the High Impact action, “developing the team” is the production and delivery of the practice group Workforce Plans and support from the national programme.

Productive Workflows

46 Along with Active Signposting one of the key areas of work included in the GPFV

plans is the delivery of training on improving workflows (also referred to as Document Management). Latest data shows that 111 staff have received training in this area from over half of the practices. Where this training has been successful (e.g. Portcullis Surgery) local feedback indicates that there has been a significant reduction in the amount of time GPs spend reviewing and managing letters and other documents.

47 Future work in this area includes the identification of further training for staff in practices where training has already taken place and the provision of training for those practices yet to receive it. The Primary Care Team is currently working with groups of practices to agree how practices should utilize the funding for this and the Active Signposting training referred to above.

Personal Productivity

48 The main area of work included in the GPFV Delivery Plans for Personal

Productivity is the involvement of practices in activities run by the national Time for Care team. The main programme, which has been coordinated by the Primary Care Team, is “Learning in Action” which is running from September 2018 to February 2019. Two workshops have so far taken place with positive comment and full participation from 16 Shropshire practices.

49 The programme focuses on supporting practices with a project of their choice relating to the 10 High Impact Actions. Quality Improvement tools and theories (e.g. process mapping, models of change, PDSA cycles) are used to help make the changes successful and sustainable. Between each session, tests and changes are made and the findings brought back to the next workshop, maximising the benefits of sharing and group learning.

Partnership Working

50 The key delivery mechanism, within the GPFV programme, for the High Impact

action, “Partnership Working” is the development of Primary Care Networks referred to above and the involvement of practices in the CCG’s Care Closer to Home programme.

Social Prescribing

51 The main area of work included in the GPFV Delivery Plans under “Social

Prescribing” is the development of the way in which practices work with the Community and Care Coordinators and, where relevant, Shropshire Council’s social prescribing staff, to ensure that patients are provided with relevant support and signposting to local support services. The mid-year review of Delivery Plans indicates that a number of specific initiatives are being developed in practices including the production of a cancer self-help book and a scheme to increase bike usage.

52 Further work in this area will be the use of impact measures to collate data on both the numbers of patients assisted with such initiatives and the impact that this is having on their health. The Primary Care Team will continue to work closely

12

with the Community and Care Coordinator project to improve the way in which data on C&CC activity can be used to assess the impact on patients of wider work under this High-Impact Action.

Supporting Self-Care

53 The GPFV Delivery Plans include commitments from practices to engage with the

CCG’s overall approach to Self-Care, led by the Medicines Management team. The mid-year review of the Delivery Plans indicates that practices have engaged with this team to ensure a successful roll-out of the Self-Care week programme across the county. Practices have supported this initiative by the provision of information on their websites and by providing patient leaflets in waiting rooms.

Developing QI expertise (see “Personal Productivity”)

54 The key delivery mechanism, within the GPFV programme, for the High Impact

action, “Developing QI expertise” are the Time for Care programmes described above under “Personal Productivity”.

IT 55 The main 2018/19 IT initiatives, coordinated by the CCG and referred to in all of

the GPFV Delivery Plans are the installation of VoIP and WiFi in practices. This project has been progressing well and is due to be completed with all sites live by December. The mid-year review of the GPFV Delivery Plans shows that, due to the delays in this project, the review of impact has not yet been undertaken.

56 The other key area of IT development this year has been the Telecare/Telehealth & Video consultations. Feedback from the workshop which took place in November will be used to inform the procurement of solutions.

57 Finally, in terms of current activity, a number of practices have been installing and using EMIS mobile, for example in Shifnal and Bridgnorth practices. Early indications suggest that this is helping to reduce pressure on GPs.

58 Future developments in IT for practices are focused on the various bids that the CCG has submitted for next year:

GP Network Infrastructure, to install a domain for the GP practices

Comms Cabinet Refresh, updating the comms cabinets to be able to install further technology

Office 365, a more agile Microsoft technology to support the delivery of primary care services

Lloyd George Digitisation, this will remove the paper notes from practices by scanning the notes and making them available in EMIS Web

Health Inequalities 59 Although the main focus of the GPFV programme, nationally and locally, was to

provide resilience and stability to primary care, there are clear links between the above projects and tackling health inequalities for Shropshire residents.

60 Examples of these include:

a greater diversity in the workforce should enable patients with specific needs to access the right care at the right time

13

the use of software to remind patients of appointments and other clinical services should help patients who struggle with self-management

improved networking and joined-up practice processes should lead to quicker more integrated responses to patient issues

the provision of evening and weekend appointments should help patients who, for various reasons (childcare, transportation problems etc.) struggle to access core hours appointments

improved provision of social prescribing should enable patients with wider, social and emotional needs to access support

the implementation of new technology should enable access to services for people who often struggle with traditional service models

61 The Primary Care Team will be working with the GPFV Delivery Groups to identify how these links can be further strengthened and, crucially, monitored so that more quantitative data can be obtained.

Risks and Mitigations 62 The mid-year review of the Delivery Plans and the other projects and initiatives

have identified some risks to delivery:

The mid-year review of the GPFV has demonstrated progress in many areas, however one area where there is still concern is around the requirement for Practices to work in networks as this is not mandated via the GMS contract and therefore there is a risk that the CCG may not be able to deliver this to the requirements of NHS England. Further engagement and support from the Primary Care team with options of flexibility delivery of projects, will help to mitigate this, however there may be individual practices who do work wish to work in this way.

The review has also highlighted the challenges faced by practices in terms of their capacity to deliver against the full range of GPFV projects. This will be mitigated by the Primary Care Team working with practices to both prioritise work and, where appropriate, to explore how individual projects can be linked.

National availability of international recruits will challenge delivery of the workforce model and other workforce plans are being developed to fill this potential shortfall.

Lack of longer term finances support to practices is also a risk post April 2019. This has been raised directly with NHS England.

The CCG is required, by NHS England, to ensure that there is effective connection between Extended Access and 111 by March 2019. Given the tight timescale, and the fact that the Extended Access scheme has only recently been operationalized, the CCG is working with colleagues at Telford and Wrekin CCG and delivery partners to mitigate this risk

Next Steps 63 The key milestones for the next two months in the work areas described above

are:

Continuation of the overarching delivery plans.

Closer working between the Primary Care Team and the GPFV Delivery Plan groups to obtain more robust data on the impact that the actions in the plans are having both on practice resilience and on improvements to patient outcomes and tackling health inequalities.

Recommendations

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64 Primary Care Commissioning Committee is asked to:

Note the contents of the report

Agree that the paper provides the required assurance against delivery of the GPFV.

15

Appendix 1 Workforce Data, Targets and Progress NB – the figures below are across the STP Footprint and are based on the 2018/19 Q1 data. The CCG is working with Telford and Wrekin CCG and NHS England to analyse and validate the Q2 data which was released at the end of November, prior to a formal submission of the targets and trajectories in mid-December 2018. These updated figures will be reported to a subsequent PCCC meeting.

Overall GP data Q1 FTE data (rounded)

Comments/Progress to date

Number of GPs @ 30th June 2018 265

This data is reported by NHS Digital and based on data inputted into the Primary Care Web Tool by practices.

NHS England Target for GPs @ Sept 2020

306 This is the target that was set for the STP around 18 months ago and has remained consistent since.

Gap 41

The difference between the target and the actual number of GPs.

GPs projected to leave before Sept 2020

41 This figure is based on assessments of the likely number of GPs to retire or leave for other reasons before September 2020.

Total needed to recruit and/or retain by Sept 2020

82 The total of the current Gap and the numbers projected to leave

GP recruitment schemes

New fully qualified doctors

31

The CCG’s main focus is on working with current ST3 trainees (and the subsequent cohort of ST3s) to maximize the number staying in general practice in Shropshire.

IGPR 16

This is the figure that the STP has received funding for. (see para 21 for more on this).

Tier 2 visa

4

The CCG is encouraging practices to become Tier 2 sponsoring employers so that they are able to recruit current trainees who are on Tier 2 Visas.

GP retention schemes

GP Fellowships

8

There are two schemes – the regional Health Education England scheme which is available to all GPs and the local, Shropshire scheme which is targeted at ST3s and newly qualified doctors (see para 22 for more on this)

Targeted Enhanced Recruitment Scheme

4 The TERS is administered by HEE and provides a “golden handshake” of £20k to GP trainees.

Strategic OD programme 15

This relates to the programme funded by the NHS England GP Retention Fund (see para 24 for more on this)

Workflow Optimisation 4

The rationale with this target is that successful workflow optimisation/document management training will improve GPs’ work/life balance.

16

Overall Other Clinicians data

Q1 FTE data (rounded)

Progress to date

Number of Other Clinicians @ June 2018

255 This data is reported by NHS Digital and based on data inputted into the Primary Care Web Tool by practices.

Target for Other Clinicians @ Sept 2020

261 This is the target that was set for the STP around 18 months ago and has remained consistent since.

Gap 6

The difference between the target and the actual number of Other Clinicians.

Other Clinicians projected to leave before Sept 2020

32

This figure is based on assessments of the likely number of Other Clinicians to retire or leave for other reasons before September 2020.

Total Other Clinicians needed to recruit and/or retain

38 The total of the current Gap and the numbers projected to leave

Other Clinicians recruitment schemes

Direct patient care (excl. CP and PA) 5

As stated above (para 26) there is a steady growth in the number of other clinicians being recruited by practices.

Clinical Pharmacists 8

This relates to both the national, NHS England scheme and direct recruitment by practices (see para 20 for more on this)

Physicians Associates

5 See para 19 for more on this.

Nurses 12 See para 23 for more on this

Other Clinicians retention schemes

Upskilling HCAs 4 See para 23 for more on this Upskilling Nurses 4 See para 23 for more on this

17

Appendix 2 – Shropshire STP report to the NHS England NM GPFV Umbrella Group

1

Purpose of this Report Bundle This report bundle provides a concise update on the overall position of each work stream and specific progress made in the last period. It sets out priorities for action in the next period and any new risks or issues identified and requiring the attention of the STP governance group(s) The bundle includes individual papers as follows:

1. Access Steve Ellis and Darren Francis

2. Workload including Resilience Funding Phil Morgan and Berni Williams

3. Workforce Phil Morgan and Jane Sullivan

4. Nursing Workforce Jane Sullivan and Jenny Bate

5. Infrastructure: Estates and Technology Transformation Fund (ETTF) and Digital

Steve Ellis, Sara Spencer, Antony Armstrong, and Darren Francis

6. Models of Care Steve Ellis and Rebecca Thornley

Update Bundle: December 11th

2018

North Midlands DCO GPFV: Shropshire STP Report

2

Progress Status Key On schedule Behind schedule with

mitigating actions in place

Behind schedule

Abbreviation Key

GPFV General Practice Forward View

STP Sustainability and Transformation Plan

PM Practice Manager

ETTF Estates and Technology Transformation Fund

DCO Director of Commissioning Organisation

CEPN Community Education Provider Network

SRO Senior Responsible Officer

Risk Scoring Key

Probability

1. Rare The event may only occur in exceptional circumstances (<1%)

2. Unlikely The event could occur at some time (1-5%)

3. Possible Reasonable chance of occurring at some time (6-20%)

4. Likely The event will occur in most circumstances (21-50%)

5. Almost certain More likely to occur than not (>50%)

Impact

1. Insignificant No impact on GPFV outcomes, insignificant cost or financial loss, no media interest

2. Minor Limited impact on GPFV, moderate financial loss, potential local short-term media interest

3. Moderate Moderate impact on GPFV outcomes, moderate loss of reputation, moderate business interruption, high financial loss, potential local long-term media interest

4. Major Significant impact on GPFV, major loss of reputation, major business interruption, major financial loss, potential national media interest

5. Severe Severe impact on patient outcomes, far reaching environmental implications, permanent loss of service or facility, catastrophic loss of reputation, multiple claims, parliamentary questions, prosecutions, highly significant financial loss

IMP

AC

T

5 5 10 15 20 25

4 4 8 12 16 20

3 3 6 9 12 15

2 2 4 6 8 10

1 1 2 3 4 5

1 2 3 4 5

Probability

3

Work Stream Access Month covered

November 2018

Author Steve Ellis and Darren Francis Status

Summary Status:

The two CCGs (Shropshire and Telford & Wrekin) are now delivering Extended Access appointments in line with the national target. In both CCGs 100% of the population has access to pre-bookable and on-the-day GP appointments Mon-Fri evening, weekends and Bank Holidays.

Both CCGs are working with their practices, who are delivering the scheme, to ensure that the services are fully advertised and accessible.

Activities and Updates from the Last Period

Shropshire CCG 1. The CCG has commissioned a total of 30 minutes evening and weekend appointments per 1,000 population

across Shropshire, starting on October 1st 2018. The service is provided on weekday evenings and Saturday mornings by four practice groupings (South Shropshire, North Shropshire, Oswestry and Shrewsbury) and by Shropdoc (via the IUC contract) on Saturday mornings, Sunday mornings and on Bank Holidays.

2. Data received from the five delivery groups for October show that 2,630 appointments were made available with 1,950 of these taken up – a utilisation rate of 74%. There were 202 DNAs, a rate (rounded) of 10%

3. The detailed data shows that the utilisation rate varied both from day to day and between the delivery groups. The highest, daily utilisation rate was 95% and the lowest was 25%.

4. A key part of the national NHS England criteria for Extended Access is around publicity and marketing. A review by the Primary Care Team of all 41 practice websites, at 21st November, found that 38 had a good level of information about the Extended Access appointments on their websites but 3 practices either had no information at all or the information was incomplete and/or unclear. Telford & Wrekin CCG

1. The CCG has commissioned the 30mins/1000 patients required as a mixture of direct practice delivery and 2 hubs (for additional weekday, weekend and Bank Holiday provision). The service went live to 100% of the population from 1st October 2018.

2. For October, 3,132 appointments were made available, of which around 2,700 were booked – uptake of 86%. After taking DNAs into account, the overall utilisation was around 81%

3. Highest uptake was on Tuesday, Friday and Saturday – highest being around 98%. Lowest uptake by some margin was on Monday (around 68%)

4. The CCG is 100% compliant for publicising information about the extended hours services on both practice websites (x14) and the CCG website

Actions Planned for Next Period

Shropshire CCG 1. The CCG will be analysing the data received from the five delivery groups in more detail following the receipt

of the November data to identify trends and liaise with the delivery groups to explore any outliers in terms of both utilisation and DNAs. We will work with the lead practices to analyse the data to assist best utilisation of their resources.

2. The CCG is continuing to work with the relevant lead practice to ensure that the Extended Access service is fully advertised on all practice websites – it is anticipate that there will be 100% compliance by the end of November 2018.

3. The CCG will be working with the delivery groups to ensure that full guidance and training is provided to receptionists, enabling patients to be able to access evening and weekend appointments in the same way as core hours’ appointments.

4. The CCG will develop an action plan to ensure the remaining core criteria are met by the end of March 2019. Telford & Wrekin CCG

1. The CCG will continue to monitor uptake and utilisation throughout November – especially on Mondays – and will implement any changes as necessary to ensure the additional capacity is being used to best effect

Recommendations for the Umbrella Group

1. None

4

New risks and issues that need input from the Umbrella Group – what do we need the Umbrella Group to do to help mitigate risks?

No. New Risk / Issue Risk Rating

Mitigation Support Requested

1.

There is a need for further clarity around funding from April 2020 onwards – specifically as regards the level of funding, recurrence, method of award and requirements for delivery i.e. 45mins / 1000 population

12

NHS England to continue to seek confirmation on behalf of the CCGs as uncertainty about recurrent funding is delaying CCGs’ ability to move from a pilot to a fully procured service.

3.

The remaining 3 of the original 7 Core Requirements for GPFV Access will not be met by March 2019 if the required technology has not been implemented regionally/nationally by this time. This includes:

- resolution of the already highlighted issues regarding the inaccuracies in reporting from the GP Workload Tool

- any issues due to late delivery in enabling the technology to allow other services (for example NHS111 or other urgent care services) to directly book appointments into GP practice systems, and

- any regional/national delays around implementation of the new HSCN network (replacing the current N3 network) which could impact on delivery of some of the digital requirements, including eConsultations and other online services

12

Continued communication between the NHS England Access leads and the relevant leads for the technology issues listed in the risk. CCGs to work closely with CSU and regional colleagues to ensure implementation in line with the national timetable

5

Work Stream Workload including Resilience Funding

Month covered

November 2018

Author Phil Morgan and Berni Williams Status

Summary Status:

Shropshire CCG

Following payment from the 2018/19 Resilience Fund practices, working in groups, are developing their implementation plans which include a series of success measures agreed with the CCG.

A recent of review of the practice groupings’ GPFV Delivery Plans indicates a good level of progress against all of the 10 High Impact Actions.

“Learning in Action” workshops are being run, facilitated by the national NHS England Time for Care team. Telford and Wrekin CCG:

OD programme being led by the Supporting General Practice team due to commence January 2019.

Working with Thornfields to support practice management resilience with a focus on clinical correspondence and active signposting.


1. Both CCGs have started to work with their practices to plan the delivery of the projects set out in the 2018/19

Resilience Fund bids. 2. Following the 10 High Impact Actions event, run by the NHS England Time for Care team in February 2018,

the CCGs are working with the National and Team and other stakeholders to identify specific, ongoing training and development needs within the practices.

3. The “Learning in Action” programme events have started for practices, run by the national team. 17 practices from both CCGs are involved in this initiative.

4. Across both CCGs 386 staff have been trained on Active Signposting with many having received level 2 training. In addition, 160 staff at around half of the CCGs’ practices have received Productive Workflow training. Early indications from practices suggest that the Productive Workflow training has resulted in a significant reduction in the amount of time GPs spend reviewing and managing letters and other documents.

5. Work is progressing against the remaining 10 High Impact actions with highlights including: the identification of interest from practices in New Consultation Types, the installation of software (MJOG) and the introduction of booking on-line designed to manage and reduce DNAs, the development of workforce plans aimed at Developing the Team, addressing issues around Personal Productivity and Developing QI Expertise via the Time for Care engagement activities, improvements in Partnership Working as part of the work around Primary Care Networks, increased focus within practices, via Community Care Coordinators, on Social Prescribing and involvement by both CCGs and practices in increasing the focus on Self-Care, including participation in national Self-Care week.


1. Both CCGs will continue to work with their practices to plan the delivery of the projects set out in the 2018/19

Resilience Fund bids 2. The “Learning in Action” programme for practices across both CCGs will continue in December. 3. Detailed actions will be developed to enable measurement of the 10 High Impact Actions including assessing

the time saved by GPs as a result of Workflow Optimisation training and the impact on practices of work around managing DNAs. In addition, further data will be sought to measure the impact of work around social prescribing and self-care.

4. The CCGs will liaise with colleagues in Staffordshire over the use of dashboards to assess the impact of Active Signposting training.

Recommendations for Umbrella Group

1. None




1. None

6

Work Stream Workforce Month covered

November 2018

Author Phil Morgan and Jane Sullivan Status

Summary Status:

The CCGs are working closely together to implement a number of projects set out in the STP Primary Care workforce plan. In particular final planning is taking place to ensure that the Physician Associates Internship scheme is delivered, and the local GP Retention fund programmes are in development

SCCG’s clinical workforce lead continues to work with the CCG on ensuring that all current projects have a robust level of clinical input and Telford & Wrekin CCG is soon to appoint its own clinical lead.

See Workforce Tracker, separately provided (NB this has not yet been updated following the release of the Q2 data)


GP recruitment schemes New fully qualified doctors

The CCGs’ main focus is on working with current ST3 trainees (and the subsequent cohort of ST3s) to maximize the number staying in general practice in Shropshire. Current data indicates that there are around 15 ST3s across both CCGs.

IGPR

The STP has received funding for 16 (fte) international recruits and has interest from practices for around 10. However, the CCGs are aware that, nationally, there are problems with securing suitable applications. The CCG has worked with the regional IGPR team to develop this level of interest and provide information to practices.

Tier 2 visa

The CCGs are encouraging practices to become Tier 2 sponsoring employers so that they are able to recruit current trainees who are on Tier 2 Visas.

GP retention schemes GP Fellowships

There are two schemes – the regional Health Education England scheme which is available to all GPs and the local, Shropshire scheme which is targeted at ST3s and newly qualified doctors. Five awards have so far been made from the Shropshire scheme for initiatives that include training courses for doctors to gain further qualifications and local schemes to develop new service models across practices.


The CCGs has liaised with HEE to obtain more information on the next round of TERS funding. Strategic OD programme

Following the award by NHS England to the STP of £70k to support retaining GPs in practice, the two CCGs are developing different schemes, but both involve working enabling GPs to identify the key issues that lead them to consider leaving general practice and working with external facilitators to develop solutions to these issues. The CCGs anticipate that further funding will be available this year which will strengthen the ability of this programme to fund a series of initiatives identified from the workshops

Workflow Optimisation

The rationale with this target is that successful workflow optimisation/document management training will improve GPs’ work/life balance. The CCGs are collating case studies to share across practices.

Other Clinicians recruitment schemes Direct patient care (excl. CP and PA)

There is a steady growth in the number of other clinicians being recruited by practices including Urgent Care Practitioners and a Clinical Psychologist.


Following the Darwin group’s successful bid to the national NHS England Clinical Pharmacists scheme three Clinical Pharmacists have started work across the group. A number of other practices in both CCGs have employed their own Clinical Pharmacists.


The Shropshire Physician Associates Internship scheme has been set up and recruitment has begun. Funding for up to four PA interns has been secured from Health Education England with the latest indication being that two practices across the STP are currently interested in joining the scheme

7


GP recruitment schemes New fully qualified doctors

The CCGs will make contact with the ST3s with a view to developing ongoing dialogue and support for this cohort, designed to maximise the number that stay in general practice across Shropshire.

IGPR

The CCGs will continue to work with the regional IGPR team to develop this level of interest and provide information to practices.

Tier 2 visa

The CCGs will continue to encourage practices to become Tier 2 sponsoring employers so that they are able to recruit current trainees who are on Tier 2 Visas. The CCGs will also make contact with the 5 Tier 2 Visa Trainees identified by NHS England to provide them with information and support.

GP retention schemes GP Fellowships

The CCGs will liaise with the successful doctors to develop suitable, bespoke timescales for obtaining feedback on the impact the funded activities are having on both the doctors and on patient care.


The CCGs will continue to liaise with HEE to understand where the next round of TERS funding will be allocated and to agree a communications approach for the trainees who obtain the TERS posts.

Strategic OD programme

The two CCGs will continue to develop their respective initiatives; Shropshire CCG will be sending out a survey to all GPs to identify retention issues which will be used to design a series of events/workshops; Telford & Wrekin CCG will focus on the first fives and clinical leadership as directed by the GP workforce lead. This CCG will also be working with its communications team to identify how it can best promote Telford and Wrekin as a place to live and work.

. Other Clinicians recruitment schemes Direct patient care (excl. CP and PA)

The two CCGs will be liaising with Julie Downie from NHS England to assess the impact of recent recruitment within practices and to provide information to practices on emerging new workforce models.


Following the amendments to the criteria for the national scheme the CCGs will be encouraging practices to develop applications to the scheme – early indications suggest that there are three practices interested.


Adverts for the Shropshire Physician Associates Internship scheme will be issued via NHS jobs with interviews following shortly afterwards

Data

Following release of the Q2 2018/19 workforce data the CCGs will be reviewing all of the targets and trajectories in the light of revised “gaps” for both GPs and other clinicians.


None




1.

National availability of international recruits will challenge delivery of the workforce model and

Other workforce plans are being developed by the CCGs to fill this potential shortfall.

8

Work Stream Workforce – Nursing Month covered

November 2018

Author Jane Sullivan and Jenny Bate Status

Summary Status:

The CCG, in conjunction with Telford & Wrekin CCG, have recently refreshed the GP Nursing (GPN) 10 Point Action Plan and identified priorities around the provision of training and upskilling for Nurses and HCAs.

A GPN Development Group has been established which includes the two GPN Facilitators who work for both Shropshire and Telford and Wrekin.

Telford and Wrekin held a practice nursing event focussed on the 10 point nursing plan with more focussed work planned as a result of the session.


A successful practice nursing event was held which focussed on resilience and worked through actions to realise improvement – the result is the establishment of a practice nursing resilience working group which is linked to the wider GPFV workforce training and development programmes.

The main activity in the last period has been the development of training and upskilling. The GP Nursing (GPN) 10 Point Action Plan has been updated to identify key cohorts requiring training and ensure that training plans are put in place.

Current, funded training includes: o 7 GPNs undertaking an MSc in Advanced Clinical Practice o 8 Nurses new to General Practice undertaking the Fundamentals of General Practice Nursing

Programme o 1 Nurse undertaking the Specialist Nurse Qualification, and o 16 GPNs undertaking a V300 Independent Prescribing Course.

Other work undertaken by the STP’s GPN Development Group includes o Developing an STP GPN strategy o Identified funding streams to support bidding opportunities o Attendance at the digital nurse champion workshop o Delivery of the Reshaping Primary Care Nurse Services Event by TW


Future training plans include Spirometry training and further Prescribing, Physical Assessment and HCSW LTC management training

Other actions plans include: o Scoping exercise within practices to identify training needs for the upskilling of HCSW’s, in possibly

immunisation and wound care o Review of the nursing associate scheme and its role in primary care


None


New Risk / Issue Risk Rating


9

Work Stream ETTF Month covered

November 2018

Author Steve Ellis, Sara Spencer, Antony Armstrong and Darren Francis

Status

Summary Status:

All of the IT projects, funded through the ETTF, are now progressing following the resolution of a number or issues around funding, procurement and delivery of some of the schemes.

Progress is also being made on the estates projects


1. The procurement documents for e-Consultation are being written with the support of the Procurement Hub 2. Telehealth conference event held on the 16th November with over 40 attendees ranging from GP’s, Practice

Managers, Exec leads and Patient representatives. 6 Providers demonstrated their telehealth solutions to the group and feedback captured from questionnaires completed by attendees. Next step in T&W is to offer and expression of interest to our practices to then view iPlato and Emis E-consultation solution.

3. The implementation plan for VoIP and Wi-Fi, provided by the supplier of the WiFi and VoIP system (Redcentric), is being rolled-out across practices with most practices now completed

4. Shawbirch new premises: Outline Business Case approved at PCCC in June for progression to Full Business Case. Project added to STP Estates Workbook and prioritised.

5. Whitchurch new premises: a project board and project steering group have been appointed and an outline business case has been approved by PCCC – final layout plans have been agreed by practices.

6. Shifnal new premises: ongoing work on a business case continuing


1. The draft procurement documents for e-Consultation will be discussed at the Primary Working

Group/Practice Manager Forum for sign off before approval to advertise on the framework. 2. The roll-out of VoIP/WiFi, in line with the implementation plan, will continue during December 2018 3. Whitchurch new premises: further work will continue on the business case with a view to an FBC going to

PCCC by May 2019 and a planning application is expected to be submitted in December 2018 4. Shifnal new premises: further work will continue on a business case with a view to an OBC going to PCCC

in early 2019, final negotiations are underway with the District Valuer 5. Shawbirch: further work will continue on the full business case – expected to be completed by Q4 2018/19.

The project has been added to the STP Estates Workbook with any capital funding expected to be confirmed around December 2018.


1. None




10

Work Stream Models of Care Month covered

November 2018

Author Steve Ellis and Rebecca Thornley Status

Summary Status:

The CCGs are working with NHS England to develop actions that will assist both CCGs in identifying next steps around developing new models of primary care, based on the national Primary Care Networks guidance.

Both CCGs have begun the process of encouraging and enabling practices to work at-scale but it has been recognised that more work is needed to identify key issues around cultural change and organisational development.


Telford and Wrekin: 1. The CCG’s four primary care network areas are working to identify primary care delivery priorities which

include achieving the CCG diabetic targets (SET practices met on 2 October to share best practice and develop new approaches to delivering diabetic care); Telford Healthy Hearts programme to address CVD and other LTC priorities, extended access; support of winter pressures; shaping the universal patient offer and reducing admissions.

2. The CCG’s OD programme will see it working with regional experts (Duncan Gooch); Steve Bradder's team and NHS England to understand the cultural changes and governance structures required to progress primary care networks which will support the neighbourhood vision..

3. The Teldoc partnership has seen the merger of five practices and has now moved to a single neighbourhood footprint. Other mergers from other neighbourhood areas are also planned to further support resilience

Shropshire: 1. All practices are currently working with the CCG to define Primary Care Networks of 30,000 – 50,000

patients; however we are still working up formal plans for delivery in line with the NHS E requirements taking into consideration parts of our rural geography.

2. Already 11 of the practices in the Shrewsbury area are part of the Darwin group of practices, with a total of around 90,000 registered patients. In addition 6 Shropshire practices are part of Our Health Partnership.

3. The CCG is working with all of the remaining practices to encourage closer, integrated, at-scale working with some early examples of joined-up work around workforce plans and extended access pilots.


Telford and Wrekin: 1. Meeting to be held with our OD provider, and discussions to be held with Duncan Gooch and GP

representatives to inform how primary care network development is communicated with practice groups.

Shropshire: 1. The CCG will continue to work with key stakeholders to identify the benefits of at-scale, integrated working

within primary care and to agree key OD issues that will need to be addressed, going forward, to ensure that primary care networks are in place by the end of 2018/19.


1. None




1

Agenda item: PCCC-2018.12.175 Enclosure Number 3



Primary Care Committee Finance Report


Claire Skidmore

Author of the report:

Roger Eades

Presenter:

Claire Skidmore

Purpose of the report: To inform the Primary Care Committee of the financial position of the

Delegated Co-Commissioning Primary Care services to month 7 October 2018.


The Co Commissioning spend for 18/19 is currently within the budget allocation received.

The CCG is currently forecasting that spend will be contained within the allocation received for primary care delegated commissioning for 2018/19 recording a small forecast surplus of £120k.(less than 0.3% of budget)

The CCG & NHSE finance teams continue to scrutinise all areas of the delegated budgets.

Actions required by Committee Body Members:

Note the position reported as at month 7

2



1 Additional staffing or financial resource implications No If yes, please provide details of additional resources required

2 Health inequalities No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements No If yes, please provide details of the effect upon these requirements

4 Clinical engagement No If yes, please provide details of the clinical engagement

5 Patient and public engagement No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability No If yes how will this be mitigated

3

Introduction: This report outlines the month 7 (October 2018) financial position for Shropshire CCG’s delegated primary care budgets. The reported position as at month 7 shows a £66k underspend against £24,564k plan. Current Position: The month 7 position shows a variance of £66k underspend. This position consists of the following areas of (under)/ overspend:

Below is additional information for the subjectives noted above. Dispensing & Prescribing

The YTD variance is reflective of the release of prior year accruals and current year savings. This pattern of savings has slowed slightly in the last two months and this is reflected in the adjustment of the forecast position. Enhanced Services

The under spend for the year is a reflection of the release of prior year accruals relating to Minor Surgery £25k and Learning Disability £70k, and the current year to date savings relating to those categories, plus Extended hours. The forecast position reflects these savings to continue, particularly Extended hours as several practices have indicated that they will be withdrawing from the scheme in the coming months.

Month 7 October 18

Subjective Description

YTD Budget YTD Actual

YTD VarianceAnnual

Budget

Forecast

spend M7

Forecast

var M7Forecast M5

Forecast

Movement

M5 V M7 **

(£) (£) (£) (£) (£) (£) (£) (£)

Dispensing & Prescribing 1,272,947 1,240,477 (32,470) 2,324,509 2,148,846 (175,663) 2,132,044 16,802

Enhanced Services 533,443 381,698 (151,745) 946,224 714,176 (232,048) 742,697 (28,521)

General Practice APMS 698,510 698,515 5 1,197,455 1,197,465 10 1,197,465 0

General Practice GMS 16,032,255 16,526,357 494,102 27,484,198 28,173,785 689,587 28,100,198 73,587

General Practice PMS 213,165 213,165 0 365,431 365,431 0 365,431 0

Other GP Services 702,047 653,659 (48,388) 1,132,317 1,005,929 (126,388) 1,096,826 (90,897)

Premises Costs Reimbursements 3,267,802 3,045,112 (222,690) 5,155,317 4,896,955 (258,362) 4,987,927 (90,972)

QOF 1,843,618 1,738,827 (104,791) 4,515,204 4,410,413 (104,791) 4,410,413 0

0.50 Contingency 0 0 0 216,740 0 216,740- 0 0

Local Reserves 0 0 0 (304,395) 0 304,395 0 0

TOTAL 24,563,787 24,497,810 (65,977) 43,033,000 42,913,000 (120,000) 43,033,000 (120,000)

* For further information on the contents of the subjective descriptions above,see Appendix 1

**Variance to the month 5 position is reported as ths was the last position reported to this committee

YTD Budget YTD Actual YTD VarianceAnnual

BudgetForecast M7

Forecast var

M7Forecast M5

Movement

Forecast M7 v

Forecast M5

1,272,947 1,240,477 (32,470) 2,324,509 2,148,846 (175,663) 2,132,044 16,802


BudgetForecast M7

Forecast var

M7Forecast M5

Movement

Forecast M7 v

Forecast M5

533,443 381,698 (151,745) 946,224 714,176 (232,048) 742,697 (28,521)

4

General Practice APMS

Charges are in line with budget as at M7 and the forecast movement reflects the transfer of the Indemnity budget to the reserves line, as this expense is now to be covered by NHSE.

General Practice GMS

This position reflects the current overspend year to date on the Global sum, which increased by £244k in M7 as a result of the backdated 2% pay award, plus the Quarter 3 list size growth. A balance of (£70k) relates to additional charges linked to the Churchmere Practice, agreed as part of the practice consolidation. The forecast movement reflects both these costs pressure to remain for the remainder of the year, plus note the budget has been adjusted to reflect the removal of the Indemnity Liability as noted above.

General Practice PMS

Charges are in line with budget as at M7, with the forecast movement reflective of the Indemnity budget transfer, noted above.

Other GP Services

The Current year to date position is reflective of the release of prior year accruals relating to Locum charges as well as current year Seniority savings. The forecast movement reflects the release of the remaining prior year Locum charges savings, as we become satisfied that no further liability will be due, plus the Seniority saving noted above.


BudgetForecast M7

Forecast var

M7Forecast M5

Movement

Forecast M7 v

Forecast M5

698,510 698,515 5 1,197,455 1,197,465 10 1,197,465 0


BudgetForecast M7

Forecast var

M7Forecast M5

Movement

Forecast M7 v

Forecast M5

16,032,255 16,526,357 494,102 27,484,198 28,173,785 689,587 28,100,198 73,587


BudgetForecast M7

Forecast var

M7Forecast M5

Movement

Forecast M7 v

Forecast M5

213,165 213,165 0 365,431 365,431 0 365,431 0


BudgetForecast M7

Forecast var

M7Forecast M5

Movement

Forecast M7 v

Forecast M5

702,047 653,659 (48,388) 1,132,317 1,005,929 (126,388) 1,096,826 (90,897)

5

Premises Costs Reimbursements

This favorable variance is a reflection of two issues.

A number of one off savings linked to rent reviews (£87k), with the majority of

the savings being achieved against prior year accruals.

The release of current year savings of £135k linked to Rates payments for

18/19 being lower than planned.

The forecast position reflects the current balance and modest further savings with regards the trend of rent reviews for the current year. It also assumes the QIPP of £239k relating to Rates savings re GL Hearn will be achieved in full.

QOF

The savings of £104k relates to the full release of prior year charges, that have come through now and were lower that we had expected, so can be released into the current year position. It is prudent at this time to forecast at budget level as practices may still claim for the reporting period. 0.50% Contingency

The CCG continues to uphold the guidelines on national business rules for primary care budgets and so a 0.50% Contingency is budgeted for. At month 7, the CCG is reporting utilising this contingency in full to offset the cost pressures that have emerged in year.


BudgetForecast M7

Forecast var

M7Forecast M5

Movement

Forecast M7 v

Forecast M5

3,267,802 3,045,112 (222,690) 5,155,317 4,896,955 (258,362) 4,987,927 (90,972)


BudgetForecast M7

Forecast var

M7Forecast M5

Movement

Forecast M7 v

Forecast M5

1,843,618 1,738,827 (104,791) 4,515,204 4,410,413 (104,791) 4,410,413 0


BudgetForecast M7

Forecast var

M7Forecast M5

Movement

Forecast M7 v

Forecast M5

0 0 0 216,740 0 (216,740) 0 0

6

Local Reserves

Reserves - Start Point The original budget had a £147k over commitment against allocation, which it is believed can be offset by in year saving. Reserves – M3 Adjustment As a result of an NHSE direction, a transfer from the delegated budget to the core CCG budget of £315k was completed. This is to fund the GPFV allocation for 18/19 in respect of Reception and Clerical Training/Online Consultation/Improving Access. It is unclear at this stage if this transfer will be recurrent; however in the current year it creates an additional cost burden. Whilst we have at M7 assumed this can be managed in year, it does pose a financial risk to the overall finance position. Reserves – M5 Adjustment NHSE informed the CCG that the Indemnity charges that were due to be paid in 18/19, will now be covered, and so the budget of £158k can be released from the main position to the reserves. This manifests in the APMS, GMS, PMS, lines. The impact of this benefit is to reduce the cost pressure generated by the GPFV budget transfer noted above. Cost Pressures 18/19 G.P. Retention Scheme This is a national scheme, providing benefits to the CCG in respect of improved patient care. The cost burden for this must be carried by the CCG and therefore is an additional pressure to the Co Commissioning budget if practices sign up to the scheme. So far we have become aware of one proposed appointment. The proposed charge of £20k per year for a five year period has been incorporated into the forecast position for M7 and also the medium term financial plan. It should be noted that other proposed appointments may follow, all of which would place additional pressure on this budget area.

Conclusion

It continues be a very challenging financial year, but with appropriate controls and monitoring we now feel a small saving of £120k is likely based on the fact that we have sufficient information concerning most of our known liabilities for the remainder of the year. This is less than 0.3% of the delegated budget. We will continue to monitor this situation closely and update the committee of any changes to this forecast accordingly.


BudgetForecast M7

Forecast var

M7Forecast M5

Movement

Forecast M7 v

Forecast M5

0 0 0 (304,395) 0 304,395 0 0

1

Agenda item: PCCC-2018.12.175 Enclosure Number 3A



Five Year Forecast - Finance Report


Claire Skidmore


Roger Eades

Presenter:

Claire Skidmore

Purpose of the report: To update the Primary Care Committee of the Five Year Forecast for Delegated Co-Commissioning Primary Care budgets.


This Report contains the projected spend and notes the growing financial risk over the period if

no corrective action is taken.

Actions required by Committee Members:

To note the current projections regarding five year spend and agree to continue to receive periodic updates through the existing Finance report.

2



1 Additional staffing or financial resource implications No If yes, please provide details of additional resources required

2 Health inequalities No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements No If yes, please provide details of the effect upon these requirements

4 Clinical engagement No If yes, please provide details of the clinical engagement

5 Patient and public engagement No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability Yes If yes how will this be mitigated – Review expenditure forecasts on regular basis

and maintain oversight of the position and management actions through this committee.

3

Introduction: This report includes an update to the original the five year forecast position presented to the committee in June 18, which the CCG has collated to provide members with an outlook of the financial position over the medium to long term. It is intended that this plan will continue to be updated periodically and presented to Committee on a regular basis with the latest Indicators/Movements highlighted in the Finance report. Current Position: The plan below is based on current information available, and is summarised below with a more detail explanation then provided.

Deficit / Surplus Summary

This category reflects the budgetary pressures on the yearly allocation, if no corrective action is taken. The current forecast would suggest, as first reported in June 18,that the CCG faces a significant cost pressure with its delegated budget. Below is additional information for the subjectives noted above. Budget Allocation The allocation figures used in the summary above, are from the latest LTFM (Long Term Financial Model) analysis provided to the CCG by NHSE. Updated allocation information is due in December 2018 alongside new NHS planning guidance.

£,000 £,000 £,000 £,000 £,000

Budget Allocation 43,033,000- 43,951,000- 45,205,000- 45,657,000- 46,113,520-

Allocation % Increase 2.13% 2.85% 1.00% 1.00%

Forecast Spend

18/19

Budget Amount

19/20

Budget Amount

20/21

Budget Amount

21/22

Budget Amount

22/23

Dispensing & Prescribing 2,148,846 2,170,334 2,192,038 2,213,958 2,236,098

Enhanced Services 714,176 600,314 606,317 612,380 618,504

General Practice APMS 1,197,465 1,233,389 1,270,391 1,308,502 1,347,757

General Practice GMS 28,173,785 28,619,387 29,726,058 30,295,565 30,892,489

General Practice PMS 365,431 376,394 387,686 - -

Other GP Services 1,005,929 1,205,584 825,496 879,304 933,388

Premises Costs Reimbursements 4,896,955 5,405,859 5,996,809 6,342,406 6,587,820

QOF 4,410,413 4,605,508 4,697,618 4,791,571 4,887,402

Reserves - - - - -

0.50% Contingency 219,755 226,025 228,285 230,568

Deficit /Surplus - Before Corrective

Actions 120,000 (485,524) (723,437) (1,014,972) (1,620,506)

Total - - - - -

Forecast 18/19

Budget

Amount 19/20

Budget

Amount 20/21

Budget

Amount 21/22

Budget

Amount 22/23

22/23

Variance

Forecast - Jun 18 462,020- 403,356- 595,658- 961,847- 1,523,829-

Forecast - Oct 18 120,000 485,524- 723,437- 1,014,972- 1,620,506- 96,677-

Variance 582,020 82,167- 127,779- 53,125- 96,677-

4

Dispensing & Prescribing

The forecast is based on a 1% growth in expenditure year on year, and has been amended to reflect the current year profile, with the same growth figure factored in for future years. Enhanced Services

The forecast made the assumptions that Minor surgery will increase by 1% year on year, and Extended Access and Learning Difficulties remain constant. Extended Access is to be withdrawn at the end of 18/19 and this is the reason for the savings in the forecast. We are aware of the risk that this budget allocation may be withdrawn, but have not been notified of any decision to date. This saving is therefore currently used to partly offset other pressures identified in this report.

General Practice APMS

The charges for APMS have been increased by 3% to reflect the pattern in 16/17 v 17/18. It is noted also that this expense type may be removed in future years, but the

costs will be incurred in the GMS category. General Practice GMS

The main expense type movements are as follows:

The GMS global sum, has been increase by 3% per annum to reflect recent

trends, and also adjusted by £650k in 20/21 and subsequent years to

shadow the increase in the overall resource allocation which has increased

above the average amount, currently without any explanation. It is

considered prudent to assume spend to correspond to the marginal increase

in allocation.

The removal of the PMS category costs has also been reflected in 21/22 and

22/23, as these costs will then transfer to GMS status.

Forecast

Spend 18/19

Budget

Amount 19/20

Budget

Amount 20/21

Budget

Amount 21/22

Budget

Amount 22/23

22/23

Variance

Forecast - Jun 18 2,324,509 2,347,754 2,371,231 2,394,943 2,418,893

Forecast - Oct 18 2,148,846 2,170,334 2,192,038 2,213,958 2,236,098 182,795-

Forecast

Spend 18/19

Budget

Amount 19/20

Budget

Amount 20/21

Budget

Amount 21/22

Budget

Amount 22/23

22/23

Variance

Forecast - Jun 18 946,224 955,686 965,243 974,895 984,644

Forecast - Oct 18 714,176 600,314 606,317 612,380 618,504 366,140-

Forecast

Spend 18/19

Budget

Amount 19/20

Budget

Amount 20/21

Budget

Amount 21/22

Budget

Amount 22/23

22/23

Variance

Forecast - Jun 18 1,199,120 1,235,093 1,272,146 1,310,310 1,349,620

Forecast - Oct 18 1,197,465 1,233,389 1,270,391 1,308,502 1,347,757 1,862-

Forecast

Spend 18/19

Budget

Amount 19/20

Budget

Amount 20/21

Budget

Amount 21/22

Budget

Amount 22/23

22/23

Variance

Forecast - Jun 18 27,638,399 28,073,293 29,169,042 29,849,809 30,437,818

Forecast - Oct 18 28,173,785 28,619,387 29,726,058 30,295,565 30,892,489 454,671

5

MPIG Payment costs have been removed after 19/20 as they will stop after

that date

FDR Payment costs have been removed after 20/21 as they will stop after

that date.

The increased cost pressure in the October 18 forecast compared to the original draft relates to the pay award in 18/19 as well as increased list size growth within the year. It is currently assumed any similar pressures will be covered by the annual percentage increase reflected in the budget profile noted above. General Practice PMS

The charges for PMS have been increased by 3% to reflect the pattern in 16/17 v 17/18. As noted above this status is being removed in 21/22 onwards, so the costs have been transferred accordingly for those years. Other GP Services

The main change year on year is related to Locum charges which have been increased by 2% per annum to reflect the policy change in 17/18 which enables a greater scope of circumstances for claims to be made. Otherwise Other Prof fees (Rent review charges) have remained constant, as has Translation and Retention payment. The drop in budget in the latter three years represents the Seniority payments cessation from 19/20. After discussions with Primary Care colleagues we have made the assumption that two additional GP‘s would be recruited per year, to the GP retention scheme (£20k per GP per annum). Premises Costs Reimbursements

Premises charges, specifically rent are currently one of the more volatile of our costs and hence difficult to provide future costs accurately, and we are continuing to work closely with NHSE colleagues to review the current costs by practice and have a better understanding of future costs. As part of the forecast we have included currently known future development, these include Whitchurch, Riverside and Shifnal Practices.

Forecast

Spend 18/19

Budget

Amount 19/20

Budget

Amount 20/21

Budget

Amount 21/22

Budget

Amount 22/23

22/23

Variance

Forecast - Jun 18 367,235 378,252 389,599 - -

Forecast - Oct 18 365,431 376,394 387,686 - - -

Forecast

Spend 18/19

Budget

Amount 19/20

Budget

Amount 20/21

Budget

Amount 21/22

Budget

Amount 22/23

22/23

Variance

Forecast - Jun 18 1,132,312 1,145,584 725,496 739,304 753,388

Forecast - Oct 18 1,005,929 1,205,584 825,496 879,304 933,388 180,000

Forecast

Spend 18/19

Budget

Amount 19/20

Budget

Amount 20/21

Budget

Amount 21/22

Budget

Amount 22/23

22/23

Variance

Forecast - Jun 18 5,155,279 5,393,432 5,984,257 6,329,729 6,575,016

Forecast - Oct 18 4,896,955 5,405,859 5,996,809 6,342,406 6,587,820 12,804

6

The forecast is broken down into four cost categories as noted below:

Rent – The overall assumption reflects a 5% growth in charges for the five

years, and also any Abatement’s currently known. As more reliable

information becomes known, we aim to profile this expense type at a practice

level, as each is specific. The profile will also change to reflect any Practice

amalgamations as they become known.

Rates – The current rate review concludes in 18/19 and a 2% inflation

increase has been applied thereafter.

Water Rates – The 18/19 budgetary figure has been used to project future

years with a 1% inflation increase applied each year.

Clinical Waste - The 18/19 budgetary figure has been used to project future

years with a 1% inflation increase applied each year.

We will have a more informed view of this area of spend when information with regards to 19/20 becomes available. We have also reviewed our future development liabilities,and no new information as to additional future costs is known at this stage. It should also be noted that work is on-going with regards to an Estates plan that is likely to include additional cost pressures, that are not currently recorded in this plan. QOF

The forecast is reflective of a 2% growth per annum as seen in the last couple of years, this currently is the best formula as QOF is difficult to predict due to the constantly changing framework, from which it is paid. The current year savings relate to 17/18 year payments, and we have no new information that would indicate a change was required to our original forecast profile set in June 18. 0.50% Contingency

The CCG continues to uphold the guidelines on national business rules for primary care budgets and so a 0.50 % Contingency is included in the forecast plan.

Conclusion We have modelled the medium term outlook with current information available to us, and this indicates a future cost pressure if no action is taken. The CCG Management team working with NHS colleagues will work together to identify avenues to mitigate this position.

Forecast

Spend 18/19

Budget

Amount 19/20

Budget

Amount 20/21

Budget

Amount 21/22

Budget

Amount 22/23

22/23

Variance

Forecast - Jun 18 4,515,204 4,605,508 4,697,618 4,791,571 4,887,402

Forecast - Oct 18 4,410,413 4,605,508 4,697,618 4,791,571 4,887,402 -

0.50% Contingency

Forecast

Spend 18/19

Budget

Amount 19/20

Budget

Amount 20/21

Budget

Amount 21/22

Budget

Amount 22/23

22/23

Variance

Forecast - Jun 18 216,740 219,755 226,025 228,285 230,568

Forecast - Oct 18 219,755 226,025 228,285 230,568 -

Agenda item: PCCC-2018.12.176

Enclosure Number 4



Primary Care Performance and Quality Report


Nicky Wilde, Director of Primary Care


Janet Gittins, Locality Commissioning Group Manager Jenny Stevenson, Locality Commissioning Group Manager

Presenter:

Jenny Stevenson, Locality Commissioning Group Manager

Purpose of the report: To provide Primary Care Commissioning Committee with an update on available performance and

quality information relating to General Practice.


1. The CCG’s GP practices continue to perform very highly.

2. CQC ratings and patient experience scores are generally good.

3. A low number of PALS issues and formal complaints have been reported to the CCG and

NHS England regarding general practice between July and September 2018.

4. The Primary Care team has received, and followed up on two recent Healthwatch reports

around ear wax removal services in Primary Care and the NHS Accessible Information

Standard.

5. The Primary Care Web Tool shows that we have a number of high achieving practices but

also five practices approaching review (showing standard deviations from the national

average in a number of triggers).

6. Shropshire appears toward the upper end of the national spectrum for the majority of the

Quality and Outcomes Framework domains and has prevalence rates above the national

average rate for many of these. Further analysis is needed of those areas where there is

wider variation across practices, and of those practice with high clinical exception reporting.

7. Two incidents have been reported via Datix in the 2018/19 Q2 period by other providers

about primary care. These have been escalated to the practices concerned; one practice

has provided a response and the other has not yet responded.

8. The data within this report will be used to inform ongoing practice visits by the Locality

Managers to ensure all issues are addressed; clinical and quality team input may be

required.

Actions required by Primary Care Commissioning Committee Members: Primary Care Commissioning Committee are asked to:

note the content of the report.

agree to receiving a quality and performance report on a quarterly basis.

advise on additional areas to be covered in future reporting




2 Health inequalities Yes Potentially in so far as it identifies variation in performance

which may be indicative of inequality of access

3 Human Rights, equality and diversity requirements No

4 Clinical engagement Yes Discussions with and visits to practices will require clinical

engagement where relating to clinical aspects of quality and performance

5 Patient and public engagement No Not specifically for the compiling of this report

6 Risk to financial and clinical sustainability No

Primary Care Commissioning Committee – December 2018

Primary Care Performance and Quality Report

Authors – Janet Gittins and Jenny Stevenson, Locality Managers

Introduction

1 Primary Care Committee has previously received reports on primary care performance

and quality and this report builds on previous information submitted.

2 The aim of this report is to present an update on performance and quality to provide the

Primary Care Commissioning Committee (PCCC) with some assurance around the

monitoring of the provision of primary care in Shropshire CCG.

Background

3 The report covers published information and seeks to present this in a manner so that

key messages and issues may be identified and to provide a guide for further in depth

analysis.

4 The report is divided into a number of sections covering the following:

o Summary of CQC Inspection status

o Summary of Patient Experience, including the GP Patient Survey, Patient Advice

and Liaison Service (PALS) issues and complaints

o Summary of recent Healthwatch reports

o Summary of the Primary Care Web Tool data

o Summary of 2017/18 Quality and Outcomes Framework (QOF) achievement

o Incidents (N2N reporting via Datix)

5 Information is presented at CCG or locality level. Some data may be suppressed in the

original data sources for confidentiality reasons around small number identification rules.

Within the report, individual practices are not specifically identified, but the CCG Primary

care team has access to the underlying data and illustrations which will allow

identification of these to inform scheduled practice visits. Any individual practice issues

highlighted will initially be discussed with the practice to ensure that the data source is

correct and to enable the practice to address the situation. Any significant individual

practice level issues will be presented initially in part 2 PCCC.

Care Quality Commission (CQC) Inspections

6 The summary position across the CCG is as follows. This reflects the current published

inspections from 2015 to 2018:

‘Outstanding’ rating: 6 practices

‘Good’ rating: 29 practices

‘Requires improvement’: 0 practices

Not inspected: 7 Practices N.B: Marysville Medical Practice are listed twice as both outstanding in 2015 but also as

not inspected due to re-registration when the practice became a single handed practice

in October 2018

7 Six Shropshire practices are a member of Our Health Partnership (OHP) whereby their

policies and records are now centralised. CQC will be undertaking pilot inspections with

OHP which will include a Head Office inspection in Birmingham in December and some

practice inspections in January. Due to the fact that this is a new type of inspection, the

practices involved have been notified in advance of the timescales normally expected.

8 The Primary Care Team will work with both CQC and OHP to understand the new

inspection process and rating as this unfolds.

9 The latest inspection reports can be found online at https://www.cqc.org.uk/

10 An update on this CQC inspection data will be presented at PCCC in the next quarterly

report.

Patient Experience

GP Patient Survey

11 The most recent GP Patient Survey (GPPS) data was published in July 2018 and the

CCG results were reported to PCCC in August 2018. This data is summarised below,

along with additional national comparisons (a more detailed overview of which is

included at Appendix 1).

12 Overall and when comparing against the national average, GP Practices in Shropshire

compare favourably, showing the CCG as one of the highest rated in the country. For

the questions reported in the Shropshire CCG slide pack (nationally issued) the average

CCG score was above the national averages in all areas apart from one.

13 The area which had a lower satisfaction rate than 2017 was the overall experience of

making an appointment which reduced by 5%. The national average also reduced by

4%. Patient satisfaction with making an appointment will be kept under review now that

the extended access programme has been implemented. Where individual practice

results have reduced significantly, this will be discussed as part of practice visits.

14 Use of online methods to contact practice services is low both locally and nationally.

The South Locality appears slightly more engaged in the on line dimension.

To support practices to improve online access, the CCG:

has managed a short tender process to appoint an e-Consultation software supplier.

The project is in line to have the chosen supplier in place by January 2019.

is working with the CSU to find a Telehealth & Video Consultation solution, based

upon the findings of the telehealth workshop held on 16 November 2018.

15 The overall experience of patients in Shropshire is 89% satisfaction which was the same

result as in 2017. Given the additional pressures seen nationally in General Practice

this is an excellent outcome. The national average was 84% which was a reduction of

1% when compared to 2017.

https://www.cqc.org.uk/

16 Trust and confidence in the health professionals remains almost universally high and

patients feel listened to and that they have their needs met.

17 Whilst the overall results of the GPPS are good, the survey does identify some individual

practices that may require some additional support to improve on their results with the

variation between the few less well performing practices and their peers being quite

marked. The Primary Care Team have drawn practices’ attention to the survey results

and are raising patient satisfaction as part of ongoing practice visits.

18 It should be noted that although the survey is annual, the results are not directly

comparable to the 2017 survey in many areas as some of the questions asked are

different between the 2 years.

PALS and Complaints

19 An Insight report is produced for the CCG’s Quality Committee on a quarterly basis,

which summarises the patient issues, concerns and complaints received during that

timeframe. This includes complaints, MP letters, Parliamentary and Health Service

Ombudsman (PHSO) cases and contacts with the CCG’s Patient Advice and Liaison

Service (PALS).

20 Complaints and issues raised with the CCG’s PALS about general practice are

forwarded on to NHS England.

21 The 2018/19 Quarter 2 Insight report includes numbers and themes of the issues raised

and re-directed to NHS England as follows:

CCG Q2 2018/19 feedback recorded by Speciality/Pathway

Themes Number Ombudsman Complaints MPs PALS

NHSE Issues

GP Registration (6) Appointments

(5) Staff Attitude (Pharmacy)

12 0 2 1 9

Primary Care

Problems contacting Practices (2)

Ear Irrigation, GP cover for weekly

commuter

4 0 0 0 4

22 A summary of complaints received by NHS England about general practice is shared

with the CCG each month. Two formal complaints were reported to the CCG by NHS

England during Quarter 2; these related to different practices. One related to clinical

care and treatment, which was subsequently closed due to patient consent not being

received to explore the case further. The other related to delay in treatment (this has

recently been closed and not upheld).

23 A summary of issues received by NHS England’s Customer Care Team (PALS) will be

requested for inclusion in future reports to PCCC.

24 In addition, the 2017/18 NHS data collection on written complaints was published in

September 2018. This information is submitted by GP practices on an annual basis and

relates to written complaints received from or on behalf of a patient between 1st April

2017 and 31st March 2018. For Shropshire CCG, 401 new complaints were received by

our practices during the reporting period (compared to 443 in 2016/17, a reduction of

4%). In contrast, the total number of all reported Primary Care written complaints in

2017/18 nationally had increased by 4.5% compared to the previous year. Of the 401

complaints received across our practices, 362 were resolved, 124 were upheld, 46 were

partially upheld and 192 were not upheld.

Healthwatch Reports

Removal of Ear wax

25 A Healthwatch report on the removal of ear wax was published in November 2018

following research carried out into audiology and hearing loss services as the

Healthwatch Hot Topic for May and June 2018. This was following comments that

people were finding it increasingly difficult to access ear wax removal services, even

though they had previously received treatment for this.

26 In terms of Primary Care services, the report showed inequity in service in that:

Only 39/41 practices were providing the service

The criteria for eligibility seemed to be applied to different standards by different

practices with some implementing time limits for repeat treatments

Coordination between primary and secondary care seems to be inconsistent and at

times difficult for patients to understand

Manual syringing is still taking place in some practices

27 In response to this report the CCG have assured Healthwatch that:

All 41 practices are delivering the ear wax removal locally commissioned service

(LCS)

All 41 practices are following NICE guidelines and performing ear irrigation and/or

microsuction

The LCS aims to cover non GMS contracted work where ear wax removal is being

requested by secondary care audiology services

A clinical pathway for primary care ear wax removal has been developed, which

once finalised and ratified should help to guide practices in a standardised way

The inequality suggested from this report will be explored as part of a wider review

of audiology services (across both primary and secondary care)

28 It should be noted that the Healthwatch survey was carried out around the time that the

CCG’s locally commissioned service for ear wax removal was being introduced, which

should have addressed some of the issues of lack of service that were highlighted.

29 The primary care team have followed up with those practices that were highlighted

within the report as not providing ear wax removal services, and those highlighted as

carrying out manual syringing. Confirmation has been received that no manual

syringing is taking place (‘syringing’ continues to be used as a general term for ear wax

removal, but the majority of practices use irrigation machines with a couple of practices

also offering microsuction). Confirmation has also been received that ear wax removal

is being carried out in all 41 practices, although the criteria for offering this service does

vary across practices. The CCG would expect practices to provide this service outside

of the LCS specification criteria, as deemed clinically appropriate, and support practices

to promote self care.

Accessible Information Standard in GP Practices

30 The NHS Accessible Information Standard (AIS) became law from 1st August 2016 and

applies to all NHS services and publicly funded adult social care organisations. The

Care Quality Commission is now including the AIS in their inspections of services

(including hospitals, GP practices and dentists). The Standard sets out a specific,

consistent approach to identifying, recording, flagging, sharing and meeting the

information and communication support needs of patients, service users, carers and

parents with a disability, impairment or sensory loss.

31 Between November 2017 and June 2018 Healthwatch Shropshire decided to visit a

number of GP practices in the county to find out what progress had been made locally in

implementing the Accessible Information Standard and any challenges the practices

faced. They visited nine GP practices and spoke to a total of 82 services users

(patients, carers and Patient Participation Group members) and 23 staff, including

Practice Managers and reception staff.

32 The main findings show that:

A large number of patients, carers and Patient Participation Group members had not heard of the Accessible Information Standard at the time of the visit, but could describe what their practice was doing to identify patients with a communication need and how this information was used.

There is a need for staff training about the term ‘accessible information’ and the five steps to meeting the standard as well as the practice responsibilities.

33 The CCG has shared the report with practices highlighting the assumed need for staff training in this area.

34 The CCG aims to raise this through the Locality Managers at the next Practice Manager meetings to assess any further support needs and how these can be addressed.

Primary Care Web Tool Data

35 PCCC received a report in August 2018 on the performance data compiled by NHS

England via its Primary Care Web Tool. The data used to compile the reports result in

practices being put into four categories, with the lowest being “approaching review”. A

practice’s individual categorisation is based on the number of “triggers” identified across

a range of performance areas.

36 The scoring methodology used by NHS England flags outlier practices on each of the

indicators based on Z-scores. These scores are a measure of how far a value is from

the national average (measured in terms of a number of standard deviations). This leads

to three categories of outliers:

“Positive Variation” – where a practice is more than 2 standard deviations from the national average in the desired direction

“Level 1 Trigger” – where a practice is more than 2 standard deviations from the national average against the desired direction

“Level 2 Trigger” – where a practice is more than 3 standard deviations from the national average against the desired direction

The NHS guidance states that where an indicator has been identified as an outlier the variation may be warranted or unwarranted. Information needs to be put in correct context for the practice and used alongside other data to form part of a triangulation of intelligence.

GP practices have been grouped by NHS England into one of five categories based on an overall assessment of performance across the full range of indicators. Where a practice does not have data for the most recent time period for over half of the indicators it will not be categorised, and will instead be shown as “insufficient data”. The following criteria determine the categorisation of each practice:

Criteria – number of triggers

Category Positive OR Level 1 OR Level 2

Higher achieving practice

>6 <4 <2

Achieving practice <7 >3 >1

Approaching review

>7 >3

Review identified >10 >5

Insufficient data >50% missing

37 The current position for Shropshire practices is:

Number of Higher Achieving Practices: 12 Number of Achieving Practices: 25 Number of Practices Approaching Review: 5 Number of Practices with Review Identified: 0 NB: Ellesmere and Bridgewater practices are shown separately.

38 For the five practices that are categorised as “Approaching Review” there is no

consistent pattern of either Level 1 or Level 2 Triggers, with the Triggers covering 24

different indicators. Two indicators to note are “Cervical Screening” which relates to all

five practices and “the percentage of diabetes patients where last BP is 140/80 or less”

which relates to four of the practices.

39 For the group of 12 practices that are categorised as “Higher Achieving” there is no

consistent pattern of Positive Triggers, with the Triggers covering 33 different indicators.

The indicators which are most common with this group of practices include:

The percentage of patients with atrial fibrillation who are currently treated with anti-coagulation therapy in whom there is a record of a CHA2DS2-VASc score of 2 or more

GP recorded patient smoking status (selected long term conditions)

Percentage of diabetes patients with cholesterol of 5 or less

Dementia Face to Face review

40 The data has been provided to Locality Managers to inform their upcoming practice visits which will be focused on providing support around ongoing improvements in

services provided to their patients.

2017/18 Quality and Outcomes Framework achievement (QOF)

41 The Quality and Outcomes Framework (QOF) is a voluntary annual reward and incentive programme for all GP surgeries in England, detailing practice achievement results. It is not about performance management but resourcing and then rewarding good practice.

42 The QOF contains three main components, known as domains. The three domains are: Clinical; Public Health and Public Health – Additional Services. Each domain consists of a set of achievement measures, known as indicators, against which practices score points according to their level of achievement. The 2017/18 QOF measured achievement against 77 indicators; practices scored points on the basis of achievement against each indicator, up to a maximum of 559 points. QOF results and more information can be found at https://qof.digital.nhs.uk/search/index.asp

43 A more detailed overview of clinical QOF prevalence and achievement data for 2017/2018 can be found at Appendix 2.

44 There is very little variation nationally amongst CCGs in the average QOF points achieved by practices, with most domains showing little difference between the top and bottom of the national range. Shropshire appears toward the upper end of this range for the majority of the QOF domains which is very positive.

45 Shropshire CCG has prevalence rates above the national average rate for many of the QOF domains. This likely reflects our more elderly population profile.

46 For the CCG, QOF points achievement was as follows:

Practice range CCG average National average

Clinical domain 88.2% - 100% 97.89% 95.95%

Public Health domain 92.86% - 100% 99.17% 96.86%

Public Health – additional services

92.96% - 100% 99.31% 97.02%

Overall achievement 90.59% – 100% 98.18% 96%

7 practices achieved the full 100% of QOF points available

47 For individual practices, there are:

5 Practices whose overall achievement is below the England average

14 Practice whose overall achievement is below the Shropshire CCG average

48 Although the CCG average clinical QOF achievement is very high, there is variation within indicators across individual practices. The clinical indicators with a wider range of achievement include:

Max. points available

CCG average Lowest practice achievement

Asthma 45 44.70 37.05

CHD 35 34.15 26.05

COPD 35 34.50 28.92

Diabetes 86 80.62 60.25

https://qof.digital.nhs.uk/search/index.asp

Hypertension 26 25.43 18.28

Mental Health 26 25.07 18.57

49 Exception reporting rates show the percentage of patients who are not included when

determining Quality and Outcomes Framework (QOF) achievement. Patients can be

exception-reported from individual indicators for various reasons, for example if they are

newly diagnosed or newly registered with a practice, if they do not attend appointments

or where the treatment is judged to be inappropriate by the GP (such as medication

cannot be prescribed due to side-effects). The overall effective exception rate across all

clinical domain indicators for England was 5.41 per cent, though there is variation

between indicators. Shropshire has 13 practices showing a higher QOF clinical

exception rate than the England national average.

50 This data needs more analysis to examine any trends, to identify which indicator groups

have the higher exception rates, and to review those practices with a lower achievement

rate. This data will then be shared and discussed with practices.

Incidents reported via Datix (N2N)

51 Three issues were reported about primary care via Datix between July and September 2018. Two of these related to General Practice (the third relating to a Community Hospital):

1 related to medication / prescribing

1 related to patient care

52 These issues were raised separately about two different GP practices by teams within Shropshire Community Health NHS Trust.

53 The issue relating to medication / prescribing was a patient who suffered anaphylaxis after being prescribed medication that contained penicillin. The incident was escalated to the GP practice and fully investigated. On investigation, it was clear that no clinical errors were made, and measures have been put in place to prevent a recurrence.

54 The issue relating to patient care (relating to a GP refusing to visit a patient at home) has been escalated to the GP practice but no response received as yet.

55 N2N summary reports are produced on a quarterly basis by the Quality Team, summarising the types of incidents reported in the time period and which providers they relate to, how many are open and how many have been resolved. These reports will inform this quality and performance report going forward.

Conclusion

56 The CCG’s GP practices continue to perform very highly overall, with high patient satisfaction and CQC ratings, high QOF achievement and low numbers of complaints and reported incidents via Datix.

57 The GP Patient Survey results remain very positive. The survey does identify some individual practices that require some additional support to improve on their results, with the variation between the few less well performing practices and their peers being quite marked. The Primary Care Team is following up with these practices as part of ongoing practice visits and the next quarterly performance report will demonstrate the actions

and progress made.

58 Use of online methods to contact practice services is low both locally and nationally.

The South Locality appears slightly more engaged in the on line dimension. The

promotion of online access to patients is an area the CCG will continue to encourage,

and the e-consultation and telehealth projects will support increased uptake of patients

accessing services online.

59 QOF achievements show little deviation from the maximum achievable. Shropshire appears toward the upper end of the national spectrum for the majority of the QOF domains and has prevalence rates above the national average rate for many of these. Further analysis is required to look at individual practice prevalence rates and exception reporting, and to review the areas where practice rates vary significantly from the local average.

60 The CCG exhibits relatively high prevalence rates across many of the disease conditions covered in the QOF assessment, which likely reflects our more elderly population profile. Both the NHS and locality authority use disease prevalence data to inform strategy, decision making and resource allocation.

61 The Primary Care team will continue to follow up any areas of improvement identified

with practices. Further analysis of the more clinical data is required, which may need

support from the Business Intelligence team, and input from clinicians and/or members

of the CCG’s Quality Team may be required to aid discussions with practices. A further

update will be provided to PCCC in April 2019.

Recommendation

62 The Primary Care Commissioning Committee are asked to:

note the content of the report.

agree to receiving a quality and performance report on a quarterly basis.

advise on additional areas to be covered in future reporting

1

Appendix 1

2017/18 GP Patient Survey Results Data

1. Overall Survey Response Rates

2. Making Contact with The Practice

2

3. Reception Staff

3

4. Methods of Making Appointments

7

5. Practice websites

8

6. Appointments

Making the Appointment

9

Seeing preferred GP

Choice of appointment

10

Satisfaction with making appointment

11

During the Appointment

16

When the Practice is Closed

Overall Experience of the Practice

17

Appendix 2

QOF 2017/18 Summary – Clinical Domain Data

1. Atrial Fibrillation

18

2. Asthma

19

3. Cancer

20

4. CHD

21

5. CKD

22

6. COPD

23

7. CVD Primary Prevention

24

8. Depression

25

9. Dementia

26

10. Diabetes

27

11. Epilepsy

28

12. Hypertension

29

13. Heart Failure

30

14. Learning Disability

31

15. Mental Health

32

16. Obesity

33

17. Osteoporosis

34

18. Peripheral Arterial Disease

35

19. Palliative Care

36

20. Rheumatoid Arthritis

37

21. Stroke & TIA

38

Public Health Domain – Additional Indicators

22. Blood Pressure

39

23. Smoking

40

24. Contraception

41

25. Cervical Screening

1


Enclosure Number 5



Primary Care Estates Update




Steve Ellis, Head of Primary Care

Presenter:


Purpose of the report: To provide Primary Care Committee with latest updates on Estates Progress


1. There are a number of major estates projects underway at the moment which PCCC are being kept updated about

2. The Primary Care Team are also being notified of practices where space issues are becoming apparent

3. Primary Care have gained Executive Team support to recruit interim resource for further development of the Primary Care Estates Plan

Actions required by Primary Care Commissioning Committee Members:

Primary Care Commissioning Committee are asked to:

Note the contents of this report.

2



1 Additional staffing or financial resource implications Yes

New premises will have an impact on revenue expenditure – full details are presented as part of individual Business Cases

2 Health inequalities Yes

New premises should seek to reduce Health Inequalities and details are presented within individual Business Cases

3 Human Rights, equality and diversity requirements

4 Clinical engagement Yes

Clinical engagement will be through the GP partners of the practices involved and the governance structures of the CCG.

5 Patient and public engagement Yes

Details of patient and public engagement for all three projects have been presented at previous committees and will continue to be monitored.

6 Risk to financial and clinical sustainability Yes

Possibility that current revenue funding is not sufficient to support medium to long term planning. Work is progressing with the finance team to determine the level of financial risk.

3

Primary Care Commissioning Committee December 2018

Primary Care Estates Update


Introduction

1. Primary Care Commissioning Committee have received regular updates on the

progress of the development of Primary Care Estate across the CCG.

2. There are three key projects at different stages of development:-

Whitchurch – amalgamation of 3 existing practice buildings into single

premises. OBC approved by PCCC awaiting FBC – ETTF funding secured

Shifnal & Priorslee Medical Practice – ETTF funding secured, however we are

still awaiting a business case to present to PCCC

Riverside – OBC has been approved by PCCC and progress is ongoing

3. Whilst the CCG had developed a Primary Care Estates plan, there has been little

progress on this recently, mainly due to a lack of resource.

4. The CCG is aware that due to overcrowding in practices, there is a need to continue

to develop Primary Care Estate to enable sustainable Primary Care Services in the

future.

Existing Projects

Whitchurch

5. Regular Project Boards and Steering Group meetings are being held to move the

development forward.

6. Final plans have now been agreed by the practices and are ready to be reviewed by

the District Valuer

7. There are ongoing discussions around the way that the GPs will hold the lease.

8. The plans are going forward for planning permission approval in December

9. A Full Business Case is expected to be presented to PCCC in May/June 2019

Shifnal

10. The DV and Assura the developer for the Shifnal project are in the final stages of

negotiations regarding the revenue.

11. The District Valuer has put forward an abated rental to Assura and is currently

waiting to hear whether this is acceptable.

4

12. The treatment of ETTF grants within the overall rental required for a scheme to be

viable is still the subject of some debate nationally. At present, the Distric Valuer

Services (DVS) method is to discount the grant over the term of the lease, 25 years

in the case of Haughton Road, so the NHS receive the benefit over the lease term

whereas developers would like a longer period and this has the effect of the rental

not being so heavily discounted.

13. The Final Business Case will be presented to PCCC in the coming months once the

revenue and ETTF discussions have been concluded and agreed.

Riverside

14. The OBC for Riverside has been approved by both PCCC and Shropshire Council

15. Fortnightly planning and business meetings are taking place with practice, local

authority, architects, builders, NHSE and CCG representation

16. Plans have now been sent to the District Valuer for approval and a Final Business

Case will follow as soon as is practicable.

Future Developments

17. The CCG is aware of other Practices who require significant premises developments

and who are frustrated that progress is not being made.

18. We are also being contacted by practices who require relatively minor increases in

space but that fall outside of the Improvement Grant process.

19. The reasons behind these needs are linked to both a changing workforce model,

where there is an increase in the use of non-medical clinicians (Physicians

Associates, Advanced Clinical Practitioners etc.) and also to increasing populations

across the CCG area.

20. To ensure that the CCG has estate to fulfil the future needs of Primary Care, we must

resurrect the Primary Care Estate plan, last updated in 2015, and raise the profile of

Primary Care estates planning.

21. It is recognised that the Primary Care Team does not currently have the capacity to

support this estates planning project.

22. Given that lack of resource, a paper was presented to the Executive Team in early

November to request their support to recruit interim resource to further develop the

Primary Care Estates Plan. This request was supported.

23. The post is interim and is expected to last around 4 – 6 months, the costs being met

from current vacancies within the Primary Care Directorate.

24. The Primary Care Team is now working on a specification for the required work so

that they can commence the recruitment process.

5

Recommendations

10 Primary Care Commissioning Committee are asked to:

Note the contents of this report.

1


Enclosure Number 6



IMH Shropshire GP and Walk in Centre


Mrs. Nicky Wilde, Director of Primary Care


Steve Ellis, Head of Primary Care Mrs. Amanda Alamanos, Primary Care Lead, NHSE

Presenter:

Steve Ellis, Head of Primary Care Mrs. Amanda Alamanos, Primary Care Lead, NHSE

Purpose of the report:

To make Primary Care Commissioning Committee (PCCC) aware of the current position of the APMS contract for Whitehall Medical Practice and GP Walk in Centre provided by Malling (IMH) Shropshire

To advise of the current engagement processes for the registered patient list.

To confirm that a paper will be presented to the January PCCC meeting advising of the outcome of the engagement and to seek agreement on next steps in relation to the future service provision.


The contract which secures services commissioned from Malling (IMH) Shropshire is coming to an end in June 2019. There is no mechanism in the contract to extend it again with the same provider.

There are two elements to the contract. The GMS registered list is based at Whitehall, Monkmoor and the walk in element is based at the Royal Shrewsbury Hospital.

PCCC are responsible for decision making around the registered patient list therefore this paper concentrates on this element.

The GP walk in service is part of the wider urgent care provision and therefore the decision making on the future of this will be through separate Governance arrangements.

Engagement has commenced with the registered patient list and neighbouring GP Practices. Health Overview and Scrutiny Committee have also been advised of the position.

2


To note the content of the report

To agree to hold a January PCCC meeting specifically to consider the future commissioning of services

3

Primary Care Commissioning Committee

IMH Shropshire GP and Walk in Centre

Background

1 In March 2009 Malling Health (IMH) were awarded a contract from Shropshire PCT

under the Equitable Access in Primary Care (EAPC) programme. This contract was

to provide GP services to both a registered patient list and also a walk-in service for

patients across the CCG.

2 The contract was awarded via an Alternative Provider Medical Services (APMS)

contract for an initial period of 5 years. Both elements of the contract initially operated

from Whitehall in Monkmoor, Shrewsbury, however subsequently the walk-in service

moved to RSH.

3 Within the initial contract there was a mechanism to extend the contract with the

same provider for a maximum term of a further 5 years. This option was enacted in

2014 and therefore cannot be further extended. The CCG has issued a formal letter

of notice to the provider with an end date of 30th June 2019.

4 PCCC is responsible for the commissioning of the registered patient list and the

Primary Care Team together with NHS England have commenced an engagement

process to gauge opinion which will be used to inform future commissioning

arrangements.

5 The walk-in element of the contract is part of the wider urgent care services

commissioned by the CCG and will be discussed at Clinical Commissioning

Committee.

Process

6 NHS England’s Primary Medical Care Policy and Guidance Manual outlines the

process to be followed in relation to contracts that are coming to an end.

7 Stage 1 (Appendix 1) should be undertaken ideally a minimum of 9 months prior to

the end of the contract. Fundamentally this is a requirement for the undertaking of

robust needs and impact assessment and the development of a detailed engagement

proposal.

8 The engagement with the registered patients commenced on Thursday, 1 November,

and runs to Friday, 30 November, 2018. This engagement seeks to understand the

views on the potential range of possibilities for the contract and to help inform future

service provision and commissioning of services post June 2019. A copy of the

engagement letter can be found at appendix 2, with a copy of the FAQs that were

also sent to patients at appendix 3. The CCG will use the intelligence gained from the

engagement process to inform a decision on future commissioning arrangements.

4

9 The CCG is also engaging with other GP Practices in Shropshire (appendix 4) and

has informed the Health Overview and Scrutiny Committee of the position.

Options

10 Post engagement there are 2 options for the registered list which will need to be

considered by PCCC:

Option 1 - Termination of contract and dispersal of registered list to other

practices in Shropshire

Option 2 - Termination of contract and re-procurement of registered list

element at standard GMS.

11 There will be challenges with both options and these will be presented to PCCC in

January when a decision on future service provision will need to be taken.

Recommendations

To note the content of the report

To agree to hold a January PCCC meeting specifically to consider the future commissioning of services

5

Appendix 1 Extract from NHS England Primary Medical Care Policy and Guidance Manual (PGM)

1.1 Stage 1 – 9 – 15 Months before Contract End

1.1.1 The considerations that should be given when completing each action are provided below. This list is not exhaustive but does provide a platform for commissioners to fully assess the existing and future service needs of its population. Commissioners should ensure that all appropriate stakeholders are given the opportunity to input into the needs assessment for their population, including but not limited to public health.

1.1.2 Needs assessment

1.1.3 Is there still a demand for this service in this locality and a requirement for it to continue? For example to reduce inequalities in access or health outcomes

1.1.4 Does the contract specification still address current local priorities?

1.1.5 Has the contract delivered on the expected outcomes?

1.1.6 Has it provided added value to the local population and service provision?

1.1.7 Have you assessed the potential service needs for any forthcoming new developments?

1.1.8 What is the capacity of other local providers and the market for other providers to deliver services?

1.1.9 Have you given consideration to any specialist services needs in the locality?

1.1.10 Are there any needs which are not met by the contract, which could be delivered?

1.1.11 Impact

1.1.12 Have you considered available outcome and delivery data held nationally and locally, regarding the current service and impact on other providers?

1.1.13 Have you compared the cost of the current service against other providers i.e. cost per head of population whilst taking into account any differences in the scope of the services provided?

1.1.14 Is the current service still affordable within projected future budgets?

1.1.15 Has the contract delivered on the expected financial outcomes?

1.1.16 What other objectives might be set within the existing budget?

1.1.17 Have you considered the potential impact on service users/patients?

1.1.18 Have you considered the potential impact on other service providers, e.g. GPs, pharmacy, local trust, out of hours, community services?

1.1.19 Have you considered the potential impact on the current provider, i.e. continued viability within the locality?

1.1.20 Have you considered patient choice and equality?

1.1.21 Have you considered the potential risks i.e. reputational (adverse publicity, Commissioner/provider relationship), market testing, timescales and financial?

1.1.22 Have you considered how the expiry of the contract affects compliance with the general duties? For further information, please refer to the chapter covering General duties of NHS England.

1.1.23 Engagement proposal

1.1.24 Each situation will need to be managed regarding each individual circumstance and the nature of the procurement process to be followed, if at all. However, where it has been deemed appropriate to complete a form of engagement before taking action, the Commissioner should consider:

1.1.25 have arrangements been made for involvement of patients and the public (please refer to the chapter covering General duties of NHS England) for more information on this requirement)?

6

1.1.26 have other local providers and other interested parties i.e. LMC, local members of parliament, review and scrutiny committee, etc been engaged?

1.1.27 have the local CCGs been engaged?

1.1.28 If the answer is ‘no’ regarding any of the above, the Commissioner should be able to identify the grounds under which they felt engagement was unnecessary and these should be included in the report defined below.

1.1.29 Completion of Stage 1

1.1.30 Completion of stage 1 will provide all the information required to enable the Commissioner to make an informed commissioning decision on whether to re commission, procure or allow the service to end. At this stage, the Commissioner should develop a detailed report (a template is provided in Annex 3) about the investigations undertaken, engagement and outcomes. This report shall demonstrate that the Commissioner has considered all possible options and the rationale behind the decision taken.

7

Appendix 2

Somerby Suite Mytton Oak Road

Shrewsbury SY3 8XL

Tel: 01743 277500

Email:[email protected] 1 November 2018 Dear Patient,

Your Views are Needed

For Patients Registered at Whitehall Medical Practice (Malling Health)

NHS Shropshire Clinical Commissioning Group (CCG) wishes to inform you of possible changes to your GP Practice in the future and to seek your opinions to help us in making a decision about this.

The contract with Malling Health comes to an end in June 2019. More information can be found in the attached Q&A sheet.

The CCG would now like to gather the views of individuals who are registered patients at Malling Health, Whitehall Medical Practice. We would like to know about the factors that influence your choice of GP Practice before we decide whether to retender the contract (the process by which we select who provides care) or consider reallocating patients to other nearby GP practices. To inform the CCG further, we are also discussing this with other GP Practices in Shropshire as the changes could have an impact on them.

As a patient registered at the surgery, we would like to invite you to share your views by completing an online survey available via the NHS Shropshire CCG website www.shropshireccg.nhs.uk

If you prefer to complete a paper survey, or to share your views via telephone, please contact the Primary Care Team on team on 01743 277517 or email [email protected]. (All surveys and responses must be received before midnight on Friday, 30 November, 2018).

If you would prefer to share your opinions with an independent organisation, you can also contact Healthwatch Shropshire (the independent consumer champion for health and social care in this area)

on 01743 237 884 or email [email protected].

This engagement process will take place between Thursday, 1 November, and Friday, 30 November, 2018. We will then consider the information gathered to inform the decision on the future provision of services and a decision is expected to be made by the end of January 2019.

Yours faithfully

Nicky Wilde

Director of Primary Care

NHS Shropshire Clinical Commissioning Group



8

Malling Health, Whitehall Medical Practice – Additional Information NHS Shropshire Commissioning Group (CCG) is the name for the local organisation that purchases Healthcare on behalf of the population of Shropshire.

The reason why there may be changes is due to the type of contract used to set up Malling Health in 2014. This is known as an Alternative Provider Medical Services (APMS) Contract and comes to an end in June 2019. This is different to all other GP Practices in Shropshire who have a General Medical Services (GMS) Contract which is not time limited. The other difference is that the Malling Health contract delivers GP services to a registered patient list for the whole population of Shropshire.

9

Appendix 3

WHITEHALL MEDICAL PRACTICE (MALLING HEALTH)

SURVEY DETAILS AND HOW TO GIVE FEEDBACK

FREQUENTLY ASKED QUESTIONS

What is this engagement all about?

The current contract for the Malling Health, Whitehall Medical Practice is due to end in June 2019 and as a result the CCG wishes to take the opportunity to engage with registered patients in order to understand how to best provide this service in the future. Registered patients are being invited to take part by completing a simple survey to help the CCG gather views and feedback.

Why do you need to make changes?

The contract for the current service naturally comes to an end on 30 June 2019. Before we decide what service is required, we would like to hear your views on how the service should look.

How long do I have to give my feedback and views?

The survey will run from Thursday, 1 November, 2018, until Friday, 30 November,

2018.

What happens after the survey has finished?

The CCG will collect and review all the feedback and findings and will consider these

further along with other sources of information to look at a way forward and identify

options of how this service may be delivered after the contract finishes.

Do my views really count?

Yes, your experiences and ideas for what the service needs to deliver are really

important and we want to hear them to inform the future design and delivery of the

service. No decision has been made which is why the CCG wants to hear the views

and opinions of patients.

How can I tell you what I think about any changes to the contract and how I would like to access my local GP services?

Listed below are the details of different ways to let us know your views about Whitehall Medical Practice (Malling Health);

You can complete the survey on-line at our website: www.shropshireccg.nhs.uk

Call into the practice to collect and post a hard copy of the survey

http://www.shropshireccg.nhs.uk/

10

Contact the Primary Care Team on 01743 277517 if you would like help completing a survey or have any questions and queries.

Who will evaluate the responses and what will the process be?

CCG staff will analyse the engagement feedback. This will be compiled into a report. We will ensure this report is also added to our website and hard copies will be available upon request.

As an independent voice, will Healthwatch have a part to play in the engagement?

The CCG is working in partnership with Healthwatch and they are fully aware of the engagement process. If you would prefer to share your opinions with an independent organisation, you can contact Healthwatch Shropshire (the independent consumer champion for health and social care in this area) on 01743 237 884 or email [email protected].

Alternatively, contact NHS England (for PALS enquiries relating to primary care services) on 0300 311 22 33 or email: [email protected].


11

Appendix 4

Somerby Suite Mytton Oak Road

Shrewsbury SY3 8XL

Tel: 01743 277500

Email:[email protected]

1 November 2018 Dear Practice Manager RE: Future Contracting Arrangements Malling Health, Whitehall Medical Practice NHS Shropshire Clinical Commissioning Group (CCG) would like to inform you of changes to the provision of GP services provided by Malling Health at the Whitehall Medical Practice, Monkmoor. Malling Health provides GP services to a registered population of circa 3,500 patients from Whitehall Medical Practice. This contract is provided under an Alternative Provider Medical Services (APMS) contract which is different to all other GP Practices in Shropshire. One of the differences is that APMS contracts have a natural end date, which in the case of Malling Health is June 2019.

The contract includes the provision for a GP registered list at Whitehall Medical Practice. To determine the future commissioning requirements for the registered patient list at Whitehall Medical Practice, the CCG has commenced an engagement process to ensure that the views of the registered patients are taken into account when considering future service provision. The engagement with the registered patients takes place between Thursday, 1 November, 2018 and Friday, 30 November, 2018. The CCG will be gathering the views of patients who are registered with Malling Health, about factors that influence their choice of GP Practice, before a decision is taken on future provision of services. Registered patients are being provided with various ways in which to provide their views and opinions on future service provision. The various ways on how they can provide feedback, is provided in a letter which has been sent to all registered patients. As a Shropshire practice that may be affected by these changes, the CCG wanted to make you aware of the current position and should you have any comments please contact the Primary Care Team on 01743 277517 or email [email protected]. (All surveys and responses must be received before midnight on Friday, 30 November, 2018). The CCG will consider all feedback when making a decision on the future service provision. A decision is expected to be made by the end of January 2019. Yours sincerely Nicky Wilde Director of Primary Care


1


Enclosure Number 7



Primary Care Commissioning Committee Cycle of Business


Mrs Nicky Wilde – Director of Primary Care

Authors of the report:


Presenter:


Purpose of the report: To ensure that Primary Care Commissioning Committee receive regular updates on the key areas of assurance for delegated commissioning

Key issues or points to note: The schedule has been amended to take into consideration the move to bi-monthly Primary Care Commissioning Committee meetings.

Actions required by Governing Body Members: Primary Care Commissioning Committee are asked to:

Note the schedule of reporting

2


Does this report and its recommendations have implications and impact with regard to the following:*


2 Health inequalities No

3 Human Rights, equality and diversity requirements No

4 Clinical engagement No

5 Patient and public engagement No

6 Risk to financial and clinical sustainability No If yes how will this be mitigated

*This is a scheduling paper, individual papers will cover the points of the monitoring form.

3

NHS Shropshire CCG

Primary Care Commissioning Committee – December 2018 Cycle of Business Nicky Wilde, Director of Primary Care Executive Summary

1 The CCG Primary Care Commissioning Committee (PCCC) is the corporate decision-making body for the management of the Primary Care delegated functions.

2 To ensure that the functions are monitored and delivered, a cycle of routine business reporting

has been developed. Actions Required 3 PCCC is asked to note the cycle of reporting which is designed to provide assurance around

the delegated commissioning of Primary Care. Introduction

4 The CCG Primary Care Commissioning Committee (PCCC) is the corporate decision-making body for the management of the delegated functions. The Committee has been established to enable the members to make collective decisions on the review, planning and procurement of primary care services in the Shropshire CCG area under delegated authority from NHS England.

5 PCCC has a duty for the following:

To promote the NHS Constitution (section 14P);

To exercise its functions effectively, efficiently and economically (section 14Q);

To improve in quality of services (section 14R);

In relation to quality of primary medical services (section 14S);

To reduce inequalities (section 14T);

To promote the involvement of each patient (section 14U);

To patient choice (section 14V);

To promote integration (section 14Z1);

For public involvement and consultation (section 14Z2)

6 The functions of the Committee should be undertaken in the context of a desire to promote commissioning of primary care services to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

Purpose of Report

7 The purpose of this report is to provide PCCC with a cycle of business which will enable Committee to provide assurance that it is delivering its primary function of Delegated Commissioning.

8 Appendix 1 provides the detail of the reporting for the main cycle of business.

9 Committee will note that the communications and engagement update is now recommended to be 6 monthly and the schedule has been updated to reflect this.

10 There is also the insertion of a January PCCC with a single agenda item to discuss the future commissioning arrangements of the IMH Malling Health Contract.

4

11 There will be additional papers where PCCC requests further information from the main papers or when “ad hoc” issues are to be reported e.g. a practice merger or details of new programmes of work from NHS England.

Recommendations

PCCC are asked to note the schedule of reporting.

5

PRIMARY CARE COMMISSIONING COMMITTEE CYCLE OF BUSINESS Appendix 1

Month December 2018 January 2019 February 2019 April 2019 June 2019 August 2019 October 2019 Standing Items

Apologies Apologies Apologies Apologies Apologies Apologies Apologies Members declaration of interest

Members declaration of interest






Minutes of the previous meeting







Matters arising from previous meeting







Strategy

NHS England Update Future Commissioning arrangements for IMH Malling health contract

NHS England Update NHS England Update NHS England Update NHS England Update NHS England Update

Agreement of Primary Care priorities 2019/20

Review of progress -Primary Care Priorities

Terms of Reference review

Assurance

GPFV progress reports GPFV progress reports GPFV progress reports GPFV progress reports GPFV progress reports GPFV progress reports

Finance Report Finance Report Finance Report Finance Report Finance Report Finance Report

Quality / Performance reports Quality / Performance reports

Quality / Performance reports




Primary Care Committee Risk Register



Quarterly Assurance for NHSE (qtr 3)




Review of audit recommendations

Review of audit recommendations

Primary Care Estates Primary Care Estates Primary Care Estates

Communications and Engagement report

Communications and Engagement report

Addressing inequalities and patient outcomes

Addressing inequalities and patient outcomes

For information

Cycle of Business Cycle of Business Cycle of Business Cycle of Business Cycle of Business

Cycle of Business

Primary Care Working Group report






1


Enclosure Number 8



NHSE Improvement Grant 2018





Presenter:

For Information Only

Purpose of the report: To provide Primary Care Committee with information around funding made available by NHS England to support GP Practice Improvement Grants.


1. Funding for Practice Improvement Grants has been made available by NHS England

2. This process sits outside the CCG process for improvement grants, however all criteria apply to the prioritisation and use of funding


Primary Care Commissioning Committee are asked to:

Note the outcomes of the bids received.

2




2 Health inequalities Yes Some of improvements will reduce health inequalities by

improving access for the disabled

3 Human Rights, equality and diversity requirements Yes Some of the improvements will significantly improve equality

of access to the practices.

4 Clinical engagement No

5 Patient and public engagement Yes Practices will be requested to engage with their patient

groups as part of the process of carrying out these improvements.

6 Risk to financial and clinical sustainability No

3

Primary Care Commissioning Committee December 2018

NHSE Improvement Grants 2018


Introduction

1 NHS England – North Midlands has made capital funding available to support GP

Practice Improvement Grants across Shropshire and Staffordshire.

2 As this money is from NHSE, their process is being used rather than the CCG

Improvement Grant Process agreed at PCCC in August 2017.

Approach

3 As soon as the CCG had been notified of the existence of this funding, all Practice

Managers were emailed to inform them of its availability, what the funding could be used

for, the process and the timescales involved.

4 The closing date for applications to the CCG is set as Friday 19 October to allow the

CCG time to review and prioritise the bids prior to NHSE’s closing date of Friday 26

October.

Prioritisation Process

5 The bids were prioritised by a panel including Amanda Alamanos, Primary Care Lead

NHS England and Steve Ellis, Head of Primary Care. The bids were initially checked for

their adherence to NHS Premises Costs Directions to ensure that they met the relevant

guidance and then the relevant parts of the 6-facet surveys carried out in 2016 were

also utilised to ensure that practices with most need were at the top of the prioritised list.

6 Following this process, it was agreed that there was sufficient funding to meet the

requests of all practices where their bids fell wholly within the NHS England Premises

Cost Directions.

7 Some Practice bids fell partially within the directions and, provided the cost of those

relevant parts were above the £5,000 floor, those sections were approved.

8 The outcome of the bids is summarised in Appendix 1

Recommendations

10 Primary Care Commissioning Committee are asked to:

Note the outcome of the bids

4

Appendix 1 – Fully Approved Bids

Practice Name

Description of Works Cost Estimate

Approved Cost Estimate

66% of Approved Cost

NHSE comments

NHSE decision

Alveley New vinyl flooring in clinical rooms to be capped and coved to replace existing carpet

£6,700.00 £6,700.00 £4,422.00 approved

Caxton Clinical flooring to replace carpets in 4 GP rooms Clinical sink units in 4 GP rooms

£5,660.00 £5,660.00 £3,735.60 complete approved

Marysville Vinyl flooring in ground floor corridor and GP rooms 3-6


Radbrook Green

Revamp toilet to make it more accessible to disabled patients, convert unused kitchen into quiet administration room


Shawbury Refurbish 2 previously used offices into consulting rooms £2,397

£2,397.00 £5,737.50 £3,786.75 unsigned approved

Fit automatic door to patient entrance £4,488

£4,488.00 need more info

South hermitage

Replacement of 7 clinical sinks, replacement of 7 unregulated water heaters, removal of partition wall, making good the walls, tiles, floors around improvements

£35,143.00 £35,143.00 £23,194.38 unsigned approved

Station Drive

Replacement of portacabin currently used for consulting rooms, currently not fit for purpose, condemned in the next 6 months. £172,433


5

Worthen improved access reception hatch, relocation of utility into unused space creating additional medical records area, DDA access to patient toilet and re-fit, relocation of sink in reception to enable hot water for infection control, infection control flooring, auto door at entrance and motored doors at reception DDA front entrance door

£18,593.00 £18,593.33 £12,271.60 visit arranged 15/11/18

approved

6

Appendix 2 – Part Approved Bids

Practice

Name

Description of Works Cost

Estimate

Approved

Cost

Estimate

66% of

Approved

Cost

NHSE

comments

NHSE

decision

Broseley New sinks and taps, new cupboards, new flooring, new lights and improvement to front door for disabled access £9,068.66

£9,068.66 £6,488.66 £4,282.52 complete part approved

Knockin

Installation of capped and coved vinyl flooring,


Replacement of rear fire door

Installation of heating management system £22,500

£22,500.00 £0.00 not in PCD refused

7

Appendix 3 – Refused Bids

Practice

Name

Description of Works Cost

Estimate

Approved

Cost

Estimate

66% of

Approved

Cost

NHSE

comments

NHSE

decision

Belvidere Air conditioning to 1st floor and ground floor £7,089.60

£7,089.60 £0.00 not in PCD refused

Bishops castle

Create new clinical room, create new counselling room, increase security inside and improve access and safety outside of building quotes also include car charging point and replacement windows on first floor at £16,000

£20,000.00 £4,000.00 most schemes not in PCD remaining scheme below £5,000

pending - likely to have to refuse

Church Stretton

Create new clinical room converting large loft space £102,000

£102,000.00 £0.00 refused

The Meadows

enlarge consulting room by removing existing kitchen - remains below £5,000 refurb dispensary and admin areas £9156

£9,156.00 £0.00 admin/dispensary refurb

Refused

Wem and Prees

Modernise waiting room and reception area £30,492

£30,492.00 £0.00 no DDA or infection control?

Refused

A G E N D A - Shropshire CCG - Shropshire CCG€¦ · Keith Timmis 10.00 Verbal PCCC-2018-12.174...

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Transcript of A G E N D A - Shropshire CCG - Shropshire CCG€¦ · Keith Timmis 10.00 Verbal PCCC-2018-12.174...