Buckinghamshire Primary Care Commissioning Committee · Dr Stephen Burr (SB), Clinical Locality...

of 2

Buckinghamshire Primary Care Commissioning Committee

AGENDA – Part 1 Thursday 6th June 2019, 3pm – 4.40pm

Diamond Room, The Gateway, Gatehouse Road, Aylesbury, Bucks HP19 8FF

Agenda Item

Desired Outcome(s)

Contributor Papers/Times

1

Welcome and Introductions:

Apologies: Dawn Bing-Lowe

Confirmation of Quoracy:

Graham Smith - CHAIR 3.00pm

2 Declarations of Interest Graham Smith - CHAIR 3.02pm

3 Questions from Members of the Public

Graham Smith - CHAIR 3.03pm

4 Minutes and Action Log from the meeting held on 7

th March 2019

For Approval Graham Smith - CHAIR Paper A

3.05pm – 3.10pm

Assurance Reports

5 Head of Primary Care Report For Assurance Helen Delaitre Paper B

3.10pm – 3.20pm

6 Primary Care Risk Register For Assurance Helen Delaitre /

Wendy Newton Paper C

3.20pm – 3.25pm

7 2019/20 GP Primary Medical Services Delegated Budget Plans

For Assurance Colin Hobbs Paper D

3.25pm – 3.30pm

8 Quality Report For Assurance David Williams Paper E

3.30pm – 3.40pm

9 Outcome of PCCC Effectiveness Review For Assurance Russell Carpenter Paper F

3.40pm – 3.50pm

Primary Care Commissioning

10 Primary Care Annual Report For Approval Helen Delaitre Paper G

3.50pm – 4.00pm

11 Primary Care Network Update For Assurance Helen Delaitre Paper H

4.00pm – 4.10pm

Primary Care Transformation

12 Digital Transformation and GP IT

Update For Information Anna Lewis

Paper I 4.10pm – 4.20pm

13

Performance Review of the Primary

Care Development Scheme 2017/2018

and 2018/19

For Information Simon Kearey Paper J

4.20pm – 4.35pm

Any Other Business

14 Any Other Business Graham Smith - CHAIR 4.35pm – 4.40pm

15

Date of Next Meetings: 5

th September 2019: 3pm – 5pm,

Olympic Room, Aylesbury 5

th December 2019: 3pm – 5pm,

Olympic Room, Aylesbury

For Information

of 2

16 Report from the Primary Care Operational Group meetings held on 4

th

April 2019 and 16th

May 2019 For Information Paper K

17 Notes of Premises Sub-Group Meeting held on 26

th April 2019

For Information Paper L

18 Contract Variations For Information Paper M

Paper A – Notes of the Last Meeting (Part 1)

Primary Care Commissioning Committee – Part 1 7 March 2019, 3pm – 4.45pm

Olympic Room, The Gateway, Gatehouse Road, Aylesbury, Bucks HP19 8FF

Voting Members:

Graham Smith (GS), Lay Member, CCG – Chair of PCCC

Tony Dixon (TD), Lay Member, CCG

Robert Majilton (RM), Deputy Chief Officer, CCG

David Williams (DW), Associate Director of Quality and Safeguarding, CCG

Nicola Lester (NL), Director of Transformation, CCG

Alan Cadman (AC), Deputy Chief Finance Officer, CCG

In Attendance:

Dr Raj Bajwa (RB), Clinical Chair, CCG

Helen Delaitre (HD), Associate Director of Primary Care, CCG

Thalia Jervis (TJ), CEO, Healthwatch Bucks

Russell Carpenter (RC), Corporate Governance Lead, CCG

Alan Overton (AO), Finance Analyst, NHS England

Dr Stephen Burr (SB), Clinical Locality Director, CCG

Jessica Newman (JN), Senior Primary Care Manager, CCG

Peter Redman (PR) Estates and Development Manager, CCG

Wendy Newton (WN), Primary Care Manager, CCG

Simon Kearey (SK), Head of Locality Delivery, CCG – joined the meeting for item 12 only

Jack Workman (JW) Mental Health & PSD Commissioning Manager, Bucks County Council – joined the meeting for item 12 only

Apologies:

Louise Patten (LP), Chief Officer, CCG

Gary Heneage (GH), Chief Finance Officer, CCG

Dr Rebecca Mallard-Smith (RMS), Clinical Commissioning Director, CCG

Colin Hobbs (CB), Assistant Head of Finance – Primary Care, NHS England

Nick Spence (NS), Assistant Head of Primary Care – Medical, NHS England

Anna Lewis (AL), Associate Director of Digitalisation and IM&T, CCG

Welcome & Introductions Primary Care Commissioning Committee (PCCC) members were welcomed to the meeting. The meeting was declared quorate. It was noted that no members of the public were in attendance.

Apologies: Apologies were received from LP, GH, RMS, CB, NS and AL.

Declaration of Interests The Chair reminded members of their obligation to declare any interest they may have, on any issues arising at the PCCC meeting, which might conflict with the business of NHS Buckinghamshire Clinical Commissioning Group. Declarations declared by members are listed in the CCG’s Register of Interests. The Register is available on the CCG website through the following link:

https://www.buckinghamshireccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/

Questions From Members Of The Public There were no questions raised from members of the public.

Minutes And Action Log From The Meeting Held On 6 December 2018. Minutes were agreed as a true and accurate record of the previous meeting The action log was updated accordingly

PCCC Terms of Reference – Annual Review Terms of Reference for the PCCC were previously reviewed and approved by the PCCC on 01/03/2018 and ratified by the Governing Body on 14/06/2018. The Committee should consider if its terms of reference remain fit for purpose at least once a year. If Committee members agree that any changes to the Terms of Reference should be made, in line with the CCG’s Constitution these changes should be recommended to Governing Body for formal ratification. Following the annual review in February 2019, PCCC were asked to note and approve the following amendments to the PCCC Terms of Reference for 2019/20 prior to ratification by the Governing Body on 14 March 2019:

Associate Director of Digital and IM&T included as a standing invitee.

Clear instruction that quoracy relates to delegated decision making only.

Where quorum may be affected by availability of voting members a pre-decision in advance is preferable in order to minimise potential delay in decision making.

Removal of “if GP members need to withdraw from decision making for conflicts of interest reasons; the Committee would still need to be quorate with a lay and executive member”. This is on the basis that those members are standing invitees and have no voting rights for delegated decisions

NHS England’s annual review of the CCG’s constitution resulted in a recommendation that the CCG includes extra lines to strengthen clinical engagement and to ensure that clinical engagement takes place prior to decisions being made by PCCC. Therefore the PCCC terms of reference include the option to co-opt additional clinical representation (either as a voting member or standing invitee) and acknowledge the valued role of clinicians, whilst recognising they may be conflicted. Clinical representatives’ ability to engage should be decided by the PCCC Chair on a case by case basis. PCCC requested that the terms of reference state the co-opted additional clinical representatives should have “suitable skills and experience”. Scheme of Reservation and Delegation The scheme previously cited a number of financial values, e.g. up to 100k, but it was not clear whether this relates to annual value, composite value over the length of the contract, or change in value on an annual or other timescale basis. PCCC noted that Oxfordshire CCG has delegated authority based on change in contractual value. Updating the Scheme of Reservation and Delegation in line with Oxfordshire CCG will allow greater scope for the PCCC to transact decisions. It is acknowledged that some decisions will still require escalation to Governing Body due to non-financial considerations.



Actions:

PCCC terms of reference to be updated to reflect comments on reasons for escalation of contract award decisions to Governing Body.

PCCC terms of reference to state that The Primary Care Commissioning Committee retains a right to co-opt additional clinical representation, with suitable skills and experience to ensure that any co-opted individual for purpose of discussion and decision on matters is appropriately qualified.

Approved subject to the recommendations recorded above.

RC

RC

Primary Care Commissioning Committee Effectiveness Review The Committee noted that it is best practice that Committees and Sub-Committees in any organisation review their effectiveness at least annually. The CCG internal audit plan for 2019/20 also includes an audit on key committees’ effectiveness and how Governing Body receives its assurances from its committees. As a result Governing Body and all sub-committees of the Governing Body will be asked to undertake a self-assessment. RC provided a short briefing on plans for an effectiveness review as part of governance best practice. A self-assessment will be circulated to PCCC voting members and standing invitees and the outcomes will be presented at PCCC in June 2019. The committee will also receive a link to a paper provided to the Governing Body in public which summarises the findings of its own self-assessment evaluation.

RC / WN

Head of Primary Care Report CHMC Procurement At its meeting on 6 December 2018, the PCCC agreed that a procurement exercise should be undertaken to find a new contractor for the patients registered at Chiltern House Medical Centre (CHMC). In order to ensure the contract offered is attractive to bidders, the CCG sought approval from NHS England’s Commercial Executive Group to procure an APMS contract for up to 7 years (5 years with an option to extend for a further 2 years). This aligns the contract term to that of the lease for the current building at Temple End, High Wycombe giving a provider the option to continue to provide services from there. A service specification for the contract has been prepared along with a comprehensive tender pack. A steering group has been convened which includes a clinical and a Healthwatch representative. It is anticipated that PCCC will be asked to approve the award of the contract when it next meets on 6 June 2019. If the award of contract is made within the expected timescales, a 3 month mobilisation period will commence with the new contract starting on 1 September 2019. An extension to the interim contract has been agreed with Primary Care Management Solutions (PCMS) to ensure continuity of services until the new provider starts on 1 September 2019. Primary Care Networks (PCN) The new Network Contract Directed Enhanced Service (DES) will see general practice taking a lead role in every PCN. The timescale for establishing PCNs is challenging and much work needs to be done to ensure that PCNs are in place by 1 July 2019. The CCGs role is to confirm to NHS England that all registration requirements have been met by no later than 31 May 2019. The CCG is waiting for guidance from NHS England, however in the meantime, a mobilisation group has been established to ensure we meet the stated deadline. Due to timeframes PCCC is requested to delegate responsibility for approving the formation of PCNs to the Primary Care Operational Group (PCOG). PCNs have until 15 May 2019 to submit their registration documentation to the CCG and in order to meet the tight timeframes it is recommended that the May PCOG meeting is postponed until 16 May 2019. Approved.

PCCC noted that Mike Etkind has written to GS recommending that practices involve patients in decisions regarding the formation of PCNs. PCCC recognised the short timescales and agreed that although the CCG will stress to practices the desirability of including patients at every stage of the process, the CCG does not have the contractual levers to stipulate this requirement. Healthwatch Bucks endorsed patient involvement and agreed to support all mechanisms to enable patient representatives to be part of the decision making process. East Berks OOH Provision Patients registered at three practices in the south of Bucks (Southmead, Threeways and Burnham Health Centre) currently have their GP Out of Hours service provided by East Berkshire GP Out of Hours service (EBOOH), rather than Buckinghamshire 24/7. Work to review how services could be brought in-county started in September 2018 when both practice staff and Patient Participation Groups were asked for their views on how and where services should be delivered in the future. The proposal went out to consultation for 9 weeks starting 26th November 2018. The preferred option from the public consultation was for the Out of Hours Service to be provided from Threeways Practice, Stoke Poges.

Now that a preferred base and service model has been proposed, more detailed evaluation will need to be undertaken before a final decision about adopting the proposal can be made. Subject to the results of a travel options appraisal, equality impact assessment and mobilisation plan, PCOG will be asked to approve the proposal to provide a new service base for the GP OOH service from Threeways Practice, Stoke Poges in April 2019. Wye Valley Surgery Premises Move Wye Valley Surgery will be moving to the Wycombe Hospital site at the end of April 2019. The negotiation of some details has caused delay to the signing of the lease but these have been resolved and the lease has now been signed by all parties. A comprehensive engagement process has commenced. The practice has been awarded ETTF funding to undertake necessary modifications. PCOG will be asked to approve a contract variation, reflecting the new location in April 2019. Other Estates

The Outline Business Case for the Beaconsfield Primary Care Centre was approved by NHS

England on 21st January 2019. Work is now underway to complete the Full Business Case which PCCC will be asked to approve prior to submission to NHS England. The CCG has also submitted an Outline Business Case for the Aylesbury Primary Care Centre which will be reviewed by NHS England on 18th March 2019. Funding under Wave 7 One Public Estate has also been secured by ICS system partners to progress an outline business case to develop a Health and Wellbeing facility for the people of North Buckinghamshire. The Outline Business Case will be prepared in readiness for the next STP bidding round. Move to Aylesbury North Locality for Waddesdon Surgery In January 2019, the CCG was notified by the practice of their intention to move locality from Aylesbury South to Aylesbury North. The CCG’s Executive Committee considered this matter and was minded to support it, subject to the localities themselves approving it. Approval by the localities took place at their meetings during February 2019, and so the move has been approved and will take effect as of 1 April 2019.

Patients will not be affected by this internal move from one CCG locality to another since localities in their current form are a commissioning construct. Annual Report The CCG has been delegated specific primary care commissioning functions under Section 13 of the NHS Act. The Delegation Agreement requires delegated CCGs to provide a report within 2 months of the end of each year setting out how they have carried out their delegated functions. Buckinghamshire CCG is in the process of preparing this Annual Report, which will be presented to PCCC on 6 June 2019.

Primary Care Risk Register In normal circumstances only risks that score 12 or above are escalated to PCCC, however on this occasion no risks have reached the threshold for escalation, therefore PCCC are asked to take the opportunity to review all risks and determine if score and actions are appropriate. The Corporate Risk Register is currently being reviewed and it is anticipated that following this review that any discrepancies with the Primary Care Risk Register will be aligned. PCCC considered whether the Improved Access to Primary Care risk is still required given that the Improved Access service is now running across Buckinghamshire. It was agreed that due to the infancy of the new service provision that the risk should remain on the Primary Care Risk Register. PCCC noted that a contract review with FedBucks is scheduled for April 2019. The risk will need to be reviewed to include the Extended Access DES, in line with the Primary Care Networks (PCN) DES; there is a potential risk that a PCN will be formed where no participating practices offer Extended Access.

Finance Report (M10) The position at month 10 is £66k overspend. Overall the YTD position at month 10 is £355k overspend. The forecast outturn at M10 is £570k overspend. This is due to the additional 1% GP Pay Award that was not budgeted for and no funding has been identified to cover the additional costs.

Quality Report DW presented the quarterly Quality Report which provides PCCC members with a progress update of the work being completed by the Quality Team within Primary Care in NHS Buckinghamshire CCG. The focus of the March report was:

Patient Safety – Incidents and Clinical Concerns

Infection Prevention Control

Patient Safety – Incidents and Clinical Concerns The Quality Team are now aware of any significant incidents or clinical concerns and reported that early interventions have helped to resolve any potential issues relatively quickly. The Quality Team are starting to make considerable progress by facilitating a joined up approach to ensure swifter responses to any concerns highlighted. Most issues raised relate to prescribing issues or referral / discharge letter information. Of the 51 Clinical Concerns that have been logged since January 2018, 33 have been closed to the satisfaction of the original reporter, 18 remain open; all 18 of these are outside of the 30 working day timeframe – these are being followed up by the Quality Team.

As of the 1 April 2017 Buckinghamshire CCG became fully delegated. This means that the CCG is responsible for tracking and supporting practices as and when they log Significant Events. Due to this new responsibility the CCG developed a database similar to the Serious Incident Management System (SIMS) which it uses to monitor secondary care providers’ Serious Incidents (Significant Events). Following a review it is clear that using the NRLS as a standalone system is not viable as the e-reports generated when an incident is reported, only last for 30 days before they are removed. The new SIMS has been developed as a means to support GP Practices to investigate and learn from serious incidents.

Infection Prevention and Control Winter flu has not been as challenging this year compared to last year and the Quality Team has worked with NHS England Public Health Team to raise public awareness (particularly with pregnant women) of the flu vaccine. There was one reported outbreak of flu within a local care home which was responded to by FedBucks. At the end of the flu season the Quality Team will evaluate to assist preparations for next year’s plan. TJ reported that flu vaccination communications (e.g. letters sent to parents of school age children) have been highly complicated letters which are difficult to understand. Healthwatch encourages all communications to the general public to use simpler language. PCCC noted that flu vaccination letters were sent out by the NHS England Public Health Team; DW will pass this feedback onto the relevant contact within Public Health.

DW

New Quality and Outcomes Framework, the Buckinghamshire Primary Care Development Scheme and Locally Commissioned Services QOF and PCDS The Five-year Framework for GP Contract Reform to Implement the NHS Long Term plan signals important changes to the national Quality and Outcomes Framework (QOF) with effect from 1st April 2019. The CCG made the decision to develop the Primary Care Development Scheme (PCDS) which supplemented QOF over the last 2 years and added weight to some local clinical targets and priorities. However the changes to QOF for 2019/20 are based upon the principles incorporated into our local PCDS. Therefore the CCG has established a clinical task and finish group to consider the best scheme for our practices and local population in 2019/20. Following discussion, and with consideration of the future opportunities for PCNs to deliver some of these services, the group recommends that member practices sign up to 2019/20 QOF scheme with some of the PCDS elements not covered by QOF being commissioned from practices separately by the CCG. It is anticipated that over the next few years the new QOF scheme will supersede PCDS however there will need to be a transitional period. Practices will be informed of the recommendations from the task and finish group by the end of March 2019. The new QOF scheme starts from the end of June 2019. It is acknowledged that members of the CCG Executive Committee will be directly conflicted and therefore unable to approve future plans for QOF and PCDS therefore PCOG will be given delegated approval for making this decision. The administration of QOF is via the CQRS reporting system. The CCG will need to increase internal expertise on CQRS and provide required additional reporting. It is anticipated that some of the dedicated workforce who have been facilitating the PCDS can support practices

in this task. Locally Commissioned Services (LCS) Governing Body has approved the rollover of all LCS’s for 2019/20 and practices have been informed. With the formation of PCNs, the CCG will need to ensure that it will be commissioning the right services from the right providers going forward. This is in line with NHS Oxfordshire CCG who also plan to roll over LCSs for 2019/20.

Locally Commissioned Service: Physical Health Checks For People With Serious Mental Illness (SMI) In 2018/19 the CCG commissioned a new LCS on a trial basis for practices to undertake physical health checks for patients with SMI. Approximately 4260 patients in Buckinghamshire were registered with an SMI in 2018. The target of the LCS was for 50% of that population to receive a physical health check. At the end of Q3 we had achieved 19.7% (approx. 900 patients received a health check). Practices have highlighted some challenges e.g. when a patient declines the check. The recommendation is to continue the scheme for 2019/20 on a similar basis as in 2018/19. For 2019/20 the LMC has recommended a flat rate of £45 per health check. Approximately 40 Buckinghamshire practices signed up for the 2018/19 scheme and the CCG is confident that if we continue the scheme in 2019/20 we can meet the 50% target. Healthwatch queried whether there had been any evaluation of the patient experience to understand what may be discouraging this cohort of patients to take up the health check offer. Feedback from the Mental Health Partnership Board has been encouraging although it is recognised that this Board may not be representative of all patients with SMI. It is recognised that some of these individuals may struggle to engage with services and therefore the CCG plan to review the structure in 2019/20. The Mental Health Trusts have their own workstream for health checks. Approved PCCC approved the continuation of the LCS for Physical Health Checks for People with Serious SMI for 2019/20.

Strategy For Health Provision In South Aylesbury The CCG and Aylesbury Vale District Council Planning Department are currently discussing the need for new health infrastructure in response to housing and employment growth in Aylesbury, south of the A41. The developments include Hampden Fields, Woodlands, Aylesbury Garden Town1 and RAF Halton. The anticipated population increase is circa 18,461. The proposed growth for the developments south of the A41 will require a significant investment in general practice infrastructure. The CCG strategy for this area is to encourage the Westongrove Partnership, which already supports approximately 30,000 patients, to take on the new patients. The practice is keen to register the new patients but is currently unable to do so within their existing premises where physical expansion is not possible. Therefore new investment will need to be found to support service transformation with particular emphasis on delivering healthcare ‘at scale’ and integrating general practice with acute, community, mental health and social care services to serve the population. This will enable the Westongrove Partnership to operate as its own cluster and provide suitably resourced integrated teams. The CCGs long term plan is to consolidate services into practices that are larger and more resilient. It is no longer deemed sustainable for the increasing population to be served by

small GP practices as planned for in the S106’s some years ago. The ambition for this area is to deliver healthcare at scale within the Westongrove Partnership, that has a boundary which takes into account all development and to use all available S106 funding for a purpose-built facility. The CCG has liaised with the other Aylesbury practices and are confident they do not want to register significant numbers of patients from the new developments. Given the proximity of the local developments to the Westongrove Partnership, patients would be highly likely to choose to register with Westongrove Partnership even if alternative provisions were made.

Potential Ownership Models For GP Premises Using S106 Monies The CCG is proactively working with Local Authorities to negotiate S106 contributions for primary care services which support residents of new housing developments and aligns with the recent changes in models of care delivery in general practice. Previously, Buckinghamshire PCT negotiated Section 106 provision for much smaller GP surgeries; ones that could be as small as 750sqm and catering for a list size of as little as 7,500 patients. This has resulted in historic Section 106 Agreements that are not fit for purpose in light of new models of care. There are a number of tests to pass to qualify for S106 or the Community Infrastructure Levy (CIL) and one of the challenges faced by the CCG is re-negotiating historic S106 agreements so they align to modern strategies. This can leave the CCG in a vulnerable position, increasing risk by allowing Planning Consent and s106 Agreements to be implemented when the CCG disagrees with the provision being offered which provides little or no value to the NHS. When the CCG initially made an application to have the S9106 funding pooled for the four developments the view from the District Council was that this money could not fund commercial businesses and that general practice is classified as such. The CCG has exhausted internal NHS England advice to resolve this issue. Looking at examples of this issue nationally it would appear that there is already a precedent to challenge this view. PCCC was asked to approve funding to employ a legal team to provide a legal opinion which would stand up to scrutiny. Significant funding is at stake, the offer from one development alone is £1.5m and if the CCG is unable to utilise this funding in an acceptable way to the planners it risks losing the money. Approved PCCC approved funding of up to £10k for legal advice.

Any Other Business No other business raised.

Dates of Next Meetings 6 June 2019, 3pm – 5pm, Diamond Room, The Gateway, Aylesbury 5 September 2019, 3pm – 5pm, Olympic Room, The Gateway, Aylesbury 5 December 2019, 3pm – 5pm, Olympic Room, The Gateway, Aylesbury

Action Log

Date Action Raised Action Description Responsibility / Owner Status Progress Details / Comments

05/04/2018 Extended Access DES - Primary Care Team to conduct an analysis of sign-up and hours provided under the Extended Hours DES

Wendy Newton Closed Extended Hours DES will now be

reviewed in line with the PCN DES and

the CCG will work with PCNs to ensure

any outstanding issues are incorporated

and that 100% of the population is

covered by Extended Hours services.

05/07/2018 Practice Opening Hours - Following concerns raised by CQC re access to primary medical services in the Central Aylesbury Locality.

Jessica Newman On going 04/04/19 – JN to draft communications ready for practices and will be meeting with LMC to discuss. Following an audit of opening hours on practice websites JN to discuss discrepancies to contractual hours with individual practices. JN to meet with Urgent Care Team to formulate communications for practices to ensure they are compliant with core access requirements. Update 16.05.2019 Primary Care Team working with Quality and Assurance undertaking a specific piece of work within Central Aylesbury

07/03/2019 PCCC Review of Effectiveness – Primary Care Team to liaise with Russell Carpenter to prepare the self-assessment template prior to distribution to PCCC membership.

Primary Care Team Closed 04/04/2019 - Currently working through this and will send out to PCCC as this needs to be completed by June. Self- assessment template finalised by the Primary Care Team and sent out. Presentation on the findings of the Effectiveness Review at PCCC in June 2019.

07/03/2019 PCCC Terms of Reference - PCCC terms of reference to be updated to reflect comments on reasons for escalation of contract award decisions to Governing Body.

PCCC terms of reference to state that The Primary Care Commissioning Committee retains a right to co-opt additional clinical representation, with suitable skills and experience to ensure that any co-opted individual for purpose of discussion and decision on matters is appropriately qualified.

Russell Carpenter Closed Terms of Reference amended accordingly and approved by Governing Body.

07/03/2019 DW to pass on PCCC’s comments to Public

Health that going forward flu vaccination

communications should be written in simpler

language to encourage and assist uptake of

the vaccination.

David Williams Closed DW has shared PCCC’s comments with Public Health England and BHT.

MEETING: Primary Care Commissioning Committee PAPER: B

DATE: 7th March 2019

TITLE: Head of Primary Care Report

AUTHOR: Helen Delaitre, Associate Director of Primary Care

LEAD DIRECTOR: Nicola Lester, Director of Transformation

Reason for presenting this paper:

For Action

For Approval

For Decision

For Assurance

For Information

Summary of Purpose and Scope of Report:

To inform the Primary Care Commissioning Committee of local and national developments within primary care between March and May 2019 in the context of NHS Buckinghamshire CCG.

Conflicts of Interest:

None to note.

Strategic aims supported by this paper (please tick)

Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all

Better Care for Bucks – to commission personalised, high value integrated care in the right place at the right time

Better Care for Bucks – to ensure local people and stakeholders have a greater influence on the services we commission

Sustainability within Bucks – to contribute to the delivery of a financially sustainable health and care economy that achieves value for money and encourages innovation

Leadership across Bucks – to promote equity as an employer and as clinical commissioners

Governance requirements: (Please tick each box as is relevant to the paper)

Governance Element Y N N/A Comments/Summary

Patient & Public Involvement

Equality

Quality

Financial

Risks

Statutory/Legal

Prior consideration Committees /Forums/Groups

Membership Involvement

Supporting Papers:

Head of Primary Care Report.

Head of Primary Care Report Primary Care Commissioning Committee

6th June 2019 NHS England Primary Care Policy and Guidance Manual (PGM) Update NHS England has updated its PGM to reflect the changing landscape in primary care commissioning. The suite of policies should be followed by all commissioners of NHS Primary Medical Care. This approach ensures that all commissioners, providers and most importantly patients are treated equitably and that NHS England and CCGs meet their statutory duties.

Changes in the PGM which may require action to ensure the CCG is in line with the guidance are:

General discussion on Commissioning Arrangements updated to include PCNs.

Special Allocation Service – strengthening of the appeals process for patient placed on

the scheme.

Incorporation/disincorporation section within Contract Variations expanded to include

scenarios under which incorporation/disincorporation might occur and how to deal with

them.

Additional chapter on the National Procurement Support Contract.

Additional chapter on Premises Running Costs and Service Charges which requires

Commissioners to consider applications for the same, where they are not reimbursable

under other Premises Cost Directions.

Chapter on the GP IT Operating Model; Data and Cyber Security Arrangements updated

to include guidance in the 2018/19 Addendum to the GP IT Operating Model.

Discretionary payments for locum reimbursement for parental and sickness leave

updated to reflect latest SFEs.

Other more minor amendments are included and will be used when circumstances require the CCG to reference the PGM.

2019/20 Contract Variations Guidance and Audit Requirements

NHS England and the BMA have issued guidance providing information about the new and amended contractual requirements for 2019/20 and the enhanced services (ES) commissioned by NHS England. This includes the changes as a result of Investment and Evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan, published in January 2019 and most significantly references the PCN Contract DES. Expectation is that CCGs and Contractors will work to all the contract variations from April 2019 although the contract variation documentation will not be published until October.

Primary Care Commissioning Activity Report (PCAR) The Primary Care Commissioning Activity Report was introduced in 2016/17 to support greater assurance and oversight of NHS England’s primary care commissioning responsibilities, and as part of the delegated co-commissioning process responsibility for completion passed to Buckinghamshire CCG under the Delegation Agreement. The report was completed and submitted by the deadline of 17 May 2019. A copy of the submission is attached in Annex 1 of this report. STP Primary Care Programme Board

A Primary Care Programme Board has been established by the 3 CCGs in the Strategic Transformation Partnership (STP) (Buckinghamshire, Oxfordshire and Berkshire West (BOB)) to provide a forum for co-operation and collaboration across the footprint. Its core purpose is to provide a structure through which CCGs can support one another to successfully deliver their local primary care strategy.

As the purpose of the Programme Board is principally to co-ordinate activities, it does not have the authority to take decisions about resources that will bind an individual CCG. The Programme Board will be chaired by Cathy Winfield, Chief Officer Berkshire West CCG and BOB STP Chief Executive Sponsor for Primary Care. A Deputy Chair, who is also a CCG Clinical Chair will be appointed. The Programme Board is accountable to CCG Boards and the STP Chief Executives Group. STP Primary Care Strategy One of the first tasks of the Primary Care Programme Board has been to oversee the preparation of a draft STP Primary Care Strategy which needs to be submitted to NHS England by the end of June and aligns with Primary Care Network plans. The strategy will cover primary care development to 2023/24 in alignment to the five-year allocations to CCGs and GP contract. The expectation is a system plan in response to the Long Term Plan will be finalised by the autumn. The Primary Care Team is also working with STP partners to draft a Primary Care Estates Strategy that focuses on identifying priority schemes and sources of funding for future estates developments across BOB. The CCG will work with BHT and ICS system partners to ensure plans are aligned to local stakeholders before publishing plans. The Role of CCG Localities following the establishment of Primary Care Networks

Primary Care Networks (PCNs) have become the building blocks of Integrated Care Systems and all GP practices are expected to be part of a PCN by 1st July 2019. Although Buckinghamshire practices have, since 2013, a history of working in 7 localities, it could be argued that many of the functions of the commissioning locality meetings will be taken on by PCNs. Although there is a residual need for PCNs to be connected to the CCG, for the PCN contract to be managed and for vital member engagement to be maintained, it is equally important that PCNs have the time they need to work at pace so that they are fully prepared by 2020 to take on additional services. The Executive Committee was therefore invited to discuss stopping locality meetings from 30th June 2019 and this proposal was supported.

Further work will now be undertaken to ensure that membership engagement is maintained while at the same time, providing PCNs with support they need to develop into provider entities. Protected Learning Time for Practices

All practices have one afternoon per month dedicated to protected learning time. The CCG hosted the May Protected Learning Time (PLT) afternoon at Adam’s Park in Wycombe on 22nd May and invited ICS member organisations to join the event dedicated to Primary Care Networks.

The event, opened by Dr Raj Bajwa, Clinical Chair of the CCG and Dr Rebecca Mallard-Smith, Clinical Commissioning Director for Unplanned Community Care, had record attendance with over 170 members of staff and patients from organisations across Buckinghamshire. Attendees received presentations on how Patient Participation Groups (PPGs) can get involved with PCNs, integrated working, the role of clinical pharmacists and the development of social prescribing roles within primary care. General Practice Forward View (GPFV) Oversight Group The GPFV Oversight Group has been formed to bring together all parties involved in the implementation of the Buckinghamshire GPFV Delivery Plan and provide oversight and assurance for the delivery of the GPFV workstreams. The group will report into PCCC. The first meeting was held on 30 May and it was agreed that the current workstream plans should be revised to reflect PCN formation and joint working across BOB STP and the ICS. An update will be provided to PCCC in September 2019. GP Out of Hours in South Bucks Patients registered at three practices in the south of Bucks (Southmead, Threeways and Burnham Health Centre) currently have their GP Out of Hours service provided by East Berkshire GP Out of Hours service (EBOOH). Work to review how services could be brought in-county started in September 2018 when both practice staff and practice Patient Participation Groups were asked for their views on how and where services should be delivered in the future. The proposal went out to consultation for 9 weeks starting 26th November 2018. The consultation concluded that the majority of patients preferred Threeways Practice as the location of the service going forward. Following this, work looking at the location, travel times and distances from each practice within the South Bucks Locality to where the service is currently being delivered compared to the proposed new location (Threeways Surgery) has been undertaken noting that as the new service will be extended to provide GP OOHs to other practices in the South Bucks Locality, the proposed location appears to be more convenient to the majority of patients. The service provider is currently in discussions with Threeways Surgery to agree a launch date which will be communicated to all patients and other stakeholders as soon as the date is confirmed. The current service operated under East Berkshire Out of Hours will continue until the relocation of the service takes place. Wye Valley Surgery, High Wycombe Following completion of the building works on the Wycombe Hospital site, Wye Valley surgery is on track to relocate to the Hospital with effect from Monday 17th June 2019. Patient communications will be reissued one week before the relocation date to remind patients of the proposed move.

New Build for Berryfields and Meadowcroft Surgeries, Aylesbury

We are pleased to update that the outline business case (OBC) submitted to NHS England in April for a new surgery to accommodate both Berryfields and Meadowcroft surgeries has been approved, subject to further work to complete the full business case. The OBC supports the colocation of the two practice teams and brings primary and community care together into a local facility that is aligned to the ICS model of care. This will deliver improved access to care for patients and transform the way care is delivered, through the implementation of digital technology and working in collaboration with other services to meet the health and social care needs of patients. The scheme will also improve local resilience and create capacity to manage future population growth.

The proposed health facility is designed to accommodate a patient list size of 31,000 patients. It is set out over three storeys in a 1.5 acre site with approximately 120 car parking spaces (in accordance with local planning requirements), and will be situated on Paradise Orchard, on the Berryfields development. S106 Developer Contributions

The CCG is seeking legal advice to vary legacy (PCT) Section 106 Agreements where developer commitments to either allocate or gift land (sometimes with additional contributions in the form of money or shell and core structures) for GP buildings in areas of housing growth where the proposed provision does not fit with the CCG’s current strategic objectives. The advice we are seeking will enable more effective negotiations in securing Deeds of Variation to these agreements to enable financial contributions from the developers concerned to be put towards other more appropriate health infrastructure developments, such as extensions to other viable GP practice buildings or in respect of large, new and viable practice buildings via the “pooling” old legacy S106 Agreement commitments and proposed S106 Agreements. Regarding developer contributions generally, the legal advice we are seeking will also assist us in being as effective as possible in maximising developer contributions for both Community Infrastructure Levy (CIL) and S106 developer contributions for health infrastructure going forward.

Appendix 1 Primary Care Commissioning Activity Report (PCAR)

MEETING: Primary Care Commissioning Committee PAPER: C

DATE: Thursday 6 June 2019

TITLE: Primary Care Risk Register

AUTHOR: Wendy Newton, Primary Care Manager



For Action ☐

For Approval For Decision ☐

For Assurance For Information ☐


The CCG has reviewed the way in which it manages risks and how these are reported to the Governing Body. A risk management software tool called Verto has been introduced and each sub-group of the Governing Body reviews the way it monitors and manages risks. This includes the Primary Care Commissioning Committee (PCCC). Primary Care Risk Register The Primary Care Operational Group (PCOG) reviews the Primary Care Risk Register on a monthly basis and escalates any items scoring 12 or above to the PCCC. The PCCC is asked to:

- Review items on the Primary Care Risk Register scoring 12 or above. - Be assured that the risks are mitigated with appropriate actions in place.


None.

Strategic aims supported by this paper: (please tick)









☐ ☐

Equality ☐ ☐

Quality ☐ ☐

Financial ☐ ☐

Risks ☐ ☐ CCGs have a responsibility to ensure proper governance which will in turn enable the CCGs to be compliant with statutory obligations and ensure aims/goals and objectives are met. Every activity that the CCGs undertake, or commissions others to undertake on its behalf, brings with it some element of risk that has the potential to undermine or prevent the organisation achieving its strategic aims/goals. Therefore it is vital that appropriate governance is applied to manage and mitigate this.

Statutory/Legal

☐ ☐


☐ ☐ The management of the risk register has been considered and agreed by the PCCC and the PCOG.

Membership Involvement ☐ ☐

Supporting Papers:

Primary Care Risk Register Guidance for Evaluating Risks

Primary Care Risk Register

Risk Title Raised

On

Risk Causes

Risk Description (IF & THEN)

Consequence (LEADING TO)

Project Risk Owner

Delegated Risk Owner

Risk

Baseline Score

Risk Score After

Mitigation

Corporate Risk Score

Reasoning for Current

Score

Risk Proximity

Controls & Assurances in

Place

Actions Required Last Review

Date

Next Review

Date

STPProg01 : Primary Care

Primary Care Transformation

27/02/19 Primary Care Networks (PCN) need to submit a completed registration form to its CCG by no later than 15th May 2019, and have all member practices signed-up to the DES ready to go live on 01/07/19 Implement GPFV working on an STP and ICS level.

Member practices have not agreed PCN membership in time

100% sign up is not achieved

CCG does not have the resource to support the sign up process

Member practices are not full engaged in GPFV workstreams

CCG does not have the resource to support GPFV implementation at CCG level

CCG will be unable to meet the requirements and expectations of the 2019 GP Contract, Long Term Plan, the GPFV and the ICS transformation agenda

Unable to instigate innovation and redesign services to improve outcomes and drive transformation

Member practices do not embrace change or see the advantages of doing so

Member practices do not engage with transformation agenda, hindering achievement of CCGs objectives

Local unsustainability

Loss of reputation

Poor patient outcomes

Nicola Lester

Helen Delaitre, Louise Smith

16 12 9 Risk score after mitigation suggests that the consequence of not having an agreed PCN structure by 1st July 2019 is major (4) and that it is possible. (3) This risk has been changed to reflect development of Primary Care Networks.

Immediate Controls: Clear engagement with the membership and work on PCN development underway.

Good member practice engagement on a range of GPFV initiatives.

Development of workforce programme at an STP level agreed March 2019 to be implemented forthwith.

Assurances:

PCN Mobilisation Group meets fortnightly to monitor implementation of PCNs and therefore this risk.

Continuing operationalisation of GPFV plan work streams.

Locality Team is providing support to localities around PCN formation. Owner - PCN Mobilisation Group, timescale 1 July 2019

16/05/19 30/06/19

EVALUATE THE RISK – grading / scoring Documented risk and assessment (evaluation) are essential to enable the CCG to:

Identify risk priorities, in particular the most significant risk issues

In parallel with the risk registers, capture decisions about what is and what isn’t acceptable risk

Provide a consistent record of the way in which risk is addressed

Facilitate the review and monitoring of risks Risk falls into three components:

The baseline risk – before any controls are put in place

Risk mitigation – management controls, assurances and actions

Current risk – after controls, assurances and actions have been implemented An evaluation matrix provides a method of quantifying risk by defining measures of likelihood (frequency or probability) and consequence (severity) using a 1 to 5 rating system. The higher the risk level, the greater the likelihood an opportunity or threat will occur and the greater its consequence. The resulting score (from 1 to 25) result in the grading of risks from Low (Green) to Extreme (Red). It is therefore important to use a process that measures impact and likelihood consistently and enables the development of a hierarchy of risk for the registers.

Risk Ratings Rating Score Comments

Red 12-25 Extreme and unacceptable. The consequences of these risks could seriously impact on the organisation’s objectives and the responsible Director should ensure that there are suitable and sufficient action plans in place to reduce the risk and that strategic risks are escalated to the Governing Body Assurance Framework (GBAF).

Orange 8-10 High risk and unacceptable; reported on the Corporate Risk Register (CRR). Managers or staff who identify risks to be ‘high’, should bring them to the attention of the Risk Owner immediately, who will be responsible for adding the risk to Verto, taking advice where necessary from a Director and the Corporate Governance Lead.

Yellow 4-6 Moderate and tolerable provided the appropriate responses are in place to minimise the likelihood of undesirable occurrences. It is the responsibility of relevant managers to ensure that the risk register is kept up-to-date, reviewed at Programme Board meetings, with relevant actions taken in order to monitor and mitigate all moderate risks.

Green 0-3 These are low risk and would probably be unlikely to occur. These risks are regarded as acceptable and should be managed locally or within the relevant directorate areas.

Risk Evaluation - likelihood

Co

nseq

uen

ce

Catastrophic 5 10 15 20 25

Major 4 8 12 16 20

Moderate 3 6 9 12 15

Minor 2 4 6 8 10

Insignificant 1 2 3 4 5

Likelihood Measure of the probability that the predicted harm, loss or damage will occur.

Rare Unlikely Possible Likely Almost Certain

Extremely unlikely. May only occur in exceptional circumstances. Has never occurred before.

Unlikely to occur /recur, but possible. Occurred less than once per annum.

May occur/recur, but not definite. Has previously occurred once or twice per annum.

Will probably occur/recur. Has happened several times per annum before.

Continuous exposure to risk. Has happened before regularly and frequently.

Frequency How often night it happen?

Not expected to occur for years

Expected to occur at least annually

Expected to occur at least monthly

Expected to occur at least weekly

Expected to occur at least daily

Probability <1% 1-5% 6-20% 21-50% >50%

Will occur only in exceptional

Unlikely to occur

Reasonable chance of

Likely to More likely to occur than

circumstances occurring occur not

Consequence score (severity levels) and examples of descriptors

1 2 3 4 5

Domains Insignificant Minor Moderate Major Catastrophic

Impact on the safety of patients, staff or public (physical / psychological harm)

Minimal injury requiring no/minimal intervention or treatment. No time off work

Minor injury or illness, requiring minor intervention Requiring time off work for >3 days Increase in length of hospital stay by 1-3 days

Moderate injury requiring professional intervention Requiring time off work for 4-14 days Increase in length of hospital stay by 4-15 days RIDDOR / agency reportable incident An event which impacts on a small number of patients

Major injury leading to long-term incapacity / disability Requiring time off work for >14 days Increase in length of hospital stay by >15 days Mismanagement of patient care with long-term effects

Incident leading to death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients

Quality /complaints / audit

Peripheral element of treatment or service suboptimal Informal complaint / inquiry

Overall treatment or service suboptimal Formal complaint (stage 1) Local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved

Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) complaint Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Major patient safety implications if findings are not acted on

Non-compliance with national standards with significant risk to patients if unresolved Multiple complaints / independent review Low performance rating Critical report

Totally unacceptable level or quality of treatment/service Gross failure of patient safety if findings not acted on Inquest/ombudsman inquiry Gross failure to meet national standards

Consequence score (severity levels) and examples of descriptors

Human resources / organisational development / staffing / competence

Short-term low staffing level that temporarily reduces service quality (< 1 day)

Low staffing level that reduces the service quality

Late delivery of key objective / service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Poor staff attendance for mandatory / key training

Uncertain delivery of key objective / service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Very low staff morale No staff attending mandatory / key training

Non-delivery of key objective / service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training / key training on an ongoing basis

Statutory duty / inspections

No or minimal impact or breech of guidance / statutory duty

Breech of statutory legislation Reduced performance rating if unresolved

Single breech in statutory duty Challenging external recommendations / improvement notice

Enforcement action Multiple breeches in statutory duty Improvement notices Low performance rating Critical report

Multiple breeches in statutory duty Prosecution Complete systems change required Zero performance rating Severely critical report

Adverse publicity / reputation

Rumours

Potential for public concern

Local media coverage – short-term reduction in public confidence Elements of public expectation not being met

Local media coverage – long-term reduction in public confidence

National media coverage with <3 days service well below reasonable public expectation

National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House) Total loss of public confidence

Business objectives / projects

Insignificant cost increase / schedule slippage

<5 per cent over project budget Schedule slippage

5–10 per cent over project budget Schedule slippage

Non-compliance with national 10–25 per cent over project budget Schedule slippage Key objectives not met

Incident leading >25 per cent over project budget Schedule slippage Key objectives not met

Finance including claims

Small loss Risk of claim remote

Loss of 0.1–0.25 per cent of budget Claim less than £10,000

Loss of 0.25–0.5 per cent of budget Claim(s) between £10,000 and £100,000

Uncertain delivery of key objective / Loss of 0.5–1.0 per cent of budget Claim(s) between £100,000 and £1 million Purchasers failing to pay on time

Non-delivery of key objective / Loss of >1 per cent of budget Failure to meet specification/ slippage Loss of contract / payment by results Claim(s) >£1 million

Service / business interruption Environmental impact

Loss / interruption of >1 hour Minimal or no impact on the environment

Loss / interruption of >8 hours Minor impact on environment

Loss / interruption of >1 day Moderate impact on environment

Loss / interruption of >1 week Major impact on environment

Permanent loss of service or facility Catastrophic impact on environment

MEETING: Primary Care Commissioning Committee AGENDA ITEM: D

DATE: Thursday 6th June 2019

TITLE: 2019/20 GP Primary Medical Services Delegated Budget Plans

AUTHOR: Colin Hobbs, Assistant Head of Finance Primary Care, NHS England



For Action

For Approval For Decision For Assurance For Information For Ratification Summary of Purpose and Scope of Report:

To note the Buckinghamshire delegated budget plans for GP Primary Medical Services for 2019/20.

Authority to make a decision – process and/or commissioning (if relevant)

Not applicable.

Conflicts of Interest: (please tick accordingly)

No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below)

Conflicted party is excluded from discussion (see below) Governance assurance (see below)







of 9




Equality

Quality

Privacy

Financial As stated in paper.

Risks

Statutory/Legal


Standing item on the agenda for PCOG and PCCC.


Supporting Papers:

2019/20 GP Primary Medical Services Delegated Budget Plans.

of 9

Commissioning Primary Medical Services – Buckinghamshire CCG

of 9

Prepared by: Colin Hobbs NHS England, Hampshire, Isle of Wight & Thames Valley,

Assistant Head of Finance

Classification: OFFICIAL

The National Health Service Commissioning Board was established on 1 October

2012 as an executive non-departmental public body. Since 1 April 2013, the National

Health Service Commissioning Board has used the name NHS England for

operational purposes.

of 9

2019/20 GP Primary Medical Services Delegated Budget Plans

Overview

The purpose of this paper is to provide the CCG with an overview, prior to submission, of the

final version of their 1 year Operational Plan for 2019/20 for the delegated GP Primary

Medical Services budget.

The budget has been included within the NHS Buckinghamshire CCG Plans submitted on

the 4th April in accordance with the national guidance.

Changes to the draft plan submitted on the 12th February 2019 are detailed in Table 2 below.

The NHS England local office will work with the CCG to refine the budget detail at practice

level for the 2019/20 budget upload to the financial ledger.

Allocation

The initial overall BoB STP Allocation for Primary Medical Services includes 6.38% growth

for 2019/20; however, this varies at individual CCG level with NHS Buckinghamshire CCG

receiving 6.31%.

The final allocations include an adjustment to remove funding for the introduction of the new

centrally-funded Clinical Negligence Scheme for General Practice (CNSGP) which started in

April 2019.

The Final overall BoB STP Allocation for Primary Medical Services includes 3.32% growth

for 2019/20; however, this varies at individual CCG level with NHS Buckinghamshire CCG

receiving 3.25%.

5 year allocations have been published including growth funds for estimated population

growth as shown in Table 1 below:

of 9

Surplus Position

The CCG Financial Planning Template does not require a 1% surplus against Delegated

Primary Medical Services Co-Commissioning Allocations for the plan submission.

The Delegated Primary Medical Services Plan presents a breakeven position against the

baseline allocation.

of 9

Assumptions

GP contract changes in 2019/20 are to be implemented through a 1.09% change in

the global sum rate per weighted patient. A multiyear pay settlement framework has

been agreed as a basis to negotiate pay settlements for the next 5 years.

PC Network costs are as below:

Network Participation Des £1.761 per weighted patient

Network Clinical Directors £0.51 per registered patient

Network Additional Roles £1.85 per registered patient

Demographic growth of 0.72% overall for 2019/20 based upon 2018/19 in year

growth.

MPIG and Seniority phased reduction as per national guidance.

Premises included at FOT level with 1.6% growth for triannual rent reviews.

(equivalent to 5% inflation on a review of 1/3rd of premises).

Impact from changes in rateable values factored into position.

QOF Assumption (based on 100% achievement).

Detailed practice level budgets with updated FOTs based upon M9 FOT.

CQC fee increase estimated at the same level as the previous year.

Changes

Changes to the draft plan submitted on the 12th February 2019 are detailed below:

of 9

2019/20 Plan

Note:

Other GP services include the following:

0.5% Contingency £354k.

PCDS QOF plus scheme £213k.

2018/19 FOT to 2019/20 Budget Bridge Analysis

The tables below provide a bridge analysis of the movement from 2018/19 forecast outturn

(based upon M9 YTD expenditure) to the 2019/20 delegated budget.

The explanatory narrative below covers the main changes.

Non Recurrent

Removal of non-recurrent expenditure in the QOF 2018/19 outturn.

Full Year Effect (FYE) of recurrent changes in 2018/19

Change in contract type e.g. GMS to APMS and full year effect of the impact of population

changes during 2018/19.

Inflation

As per assumptions above.

Demographic Growth

As per assumptions above.

Other Adjustments

Reserves required as per national guidance and Other Reserves available to mitigate in year

risks.

NHS Buckinghamshire 2018/19 Plan 2018/19 Outturn 2019/20 Plan

Category £'000's £'000's £'000's

Enhanced services 1,827 1,827 1,613

General Practice - GMS 42,388 42,958 42,996

General Practice - PMS 2,427 2,427 2,515

Other - GP Services 893 893 1,813

Other List-Based Services (APMS incl.) 6,100 6,100 7,025

Other premises costs 238 238 154

Premises cost reimbursements 6,922 6,922 7,302

QOF 7,198 7,198 6,414

Enhanced Services - PCN DES 0 0 961

Totals 67,993 68,563 70,792

of 9

Investment

Estimated investment required to fund contract commitments and risks arising during

2019/20.

2018/19 FOT to 2019/20 Budget Bridge Analysis

Reserves

Reserves include 0.5% contingency as per national planning guidance and Other

Reserves.to balance planned expenditure to the CCG delegated budget.

Key risks

Pressure to be quantified on potential rent increases following outstanding rent

reviews.

Impact of GP Contract Reform and confirmation of the funding source for the “Investment and Impact Funds”. The current assumption is that this will be centrally funded rather than from the delegated Primary Care budget but this is yet to be confirmed.

Key Mitigations

Reserves.

1

MEETING: Primary Care Commissioning Committee PAPER: E


TITLE: Primary Care Quality Report

AUTHOR: Asela Ali, Quality & Patient Safety Manager

LEAD DIRECTOR: David Williams, Acting Associate Director of Nursing and Quality


For Action For Approval For Decision For Assurance

For Information



Strategic aims supported by this paper:(please tick)








Patient & Public Involvement Equality Quality Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups

None


Supporting Papers:

Primary Care Quality Report.

This report provides a progress update of the work being completed by the Quality Team within Primary Care in the Buckinghamshire CCG.

N/A

2

Primary Care Quality Report

1. Introduction

This report provides a progress update of the work being completed by the Quality Team within Primary Care in the NHS Buckinghamshire CCG.

Patient Safety – Incidents and Clinical Concerns Safeguarding Infection Prevention Control Quality oversight

2. Patient Safety

2.1 Incidents

As of the 1st

April 2017 Buckinghamshire CCG became fully delegated. This means that the CCG is responsible for tracking and supporting practices as and when they log Significant Events. Due to this new responsibility the CCG developed a database similar to the Serious Incident Management System (SIMS) which it uses to monitor secondary care providers’ Serious Incidents (Significant Events). Following a review we have found using the NRLS as a standalone system is not viable as the e-reports that are generated when an incident is reported, only last for 30 days before they are removed. The new system has been developed as a means to support GP Practices to investigate and learn from Significant Incidents.

Since the previous report in February 2019, the CCG has been made aware of an incident involving an Information Governance Breach at a GP Practice. The practice in question had inadvertently sent data outside of scope to a third party. The third party are routinely sent information from all practices, however the information supplied fell outside of governance arrangements. The breach involved 7 patients and the practice involved has completed a self-assessment form from the Information Commissioners Office (ICO) and the completed self-assessment has indicated that this is a non-reportable incident to the ICO.

. 2.2 – Clinical Concerns

Of the 95 Clinical Concerns that have been reported to the CCG since 1st October 2017, 51 have been closed to the satisfaction of the original reporter, 44 remain open. Of these 44, 32 are overdue with the remainder still within the 30 working day timeframe. Of these 32, 26 are concerns related to our main Acute and Community provider Buckinghamshire Healthcare NHS Trust (BHT), the CCG quality team are following up on these outstanding concerns with the provider.

3

As illustrated in the charts to above and below, the majority of concerns raised have been directed to BHT (65%). This is a slight shift from the previous report (where 75% of concerns related to BHT). BHT had a good response rate for dealing with all concerns raised, with most being resolved within 5 working days of being raised although a number of outstanding concerns are being followed up by the CCG Quality Team.

The most frequent type of Clinical Concern raised related to medication or prescription issues (23); an example would be a patient may be started on Dalteparin whilst an inpatient and then told to see their GP for follow up doses (incidents of this nature have been escalated via the Trust’s pharmacy team). The “Other” category includes delays in mortality notifications, discharge letters, rejected referrals, for example.

Over all, the most common “theme” when all concerns are looked at as a whole continues to be a lack of or delayed communication/understanding between secondary and primary care. This may be in the form of awareness of the formulary (prescibing issues) or in receiving results from Secondary Care, for delays in diagnostics results, this is being monitored at the Trusts internal meetings and is being raised as a quality concern at the next Clinical Quality Review meeting, (CQRM).

3. Infection Prevention & Control (IPC)

Since March 2019, two audits were undertaken with practices with a new IPC lead to prepare them for the IPC role and both practices scored as compliant. In addition two general support visits were carried out with new IPC leads to help equip them for the role. The IPC Forums were held in May with education on wound infections and updates on rabies, Sepsis & NEWS2 followed by the standard discussion of any IPC issues the members were struggling with. The ultraviolet light hand inspection cabinet was loaned to two practices for them to conduct local hand hygiene training sessions.

4

4. Safeguarding

Each GP practice has a safeguarding lead. A Practice Safeguarding Leads Network session with the CCG Safeguarding team was held on 13.3.19 giving the practice safeguarding leads training while offering peer support at the same time

A guide to the legal framework when sharing information with Children’s Social Care was also circulated to all practices during this quarter to support understanding and awareness of the requirements based on feedback from practices.

5. Quality Oversight

Following the CQC inspections that took place in the quarter, as at May 2019, 49 of our practices are rated as good (47) or outstanding (2), with 1 practice rated as requires improvement, an action plan and regular supportive visits are in place for the practice requiring improvement. This is a positive sign of the general quality of primary care in Buckinghamshire.

We are reviewing the Primary Care Quality Assurance Framework accounting for changes to the approaches to regulation by the Care Quality Commission (CQC).

6. Friends and Family Test

Aylesbury Vale M Mar-19 89%

Chiltern M Mar-19 90%

Combined M Mar-19 90%

National Average M Mar-19 89%




National Average M Mar-19 6%

Aylesbury Vale M Mar-19 8

Chiltern M Mar-19 12

Combined M Mar-19 20

Aylesbury Vale M Mar-19 1

Chiltern M Mar-19 1

Combined M Mar-19 2




Friends and Family Test

GP Practices

% Recommended

Percentage of Practices with

unpublished FFT

No. Practices Returning Zero

Results

No. Practices Returning <5 Results

Friends and Family Test

GP Practices

% NOT Recommended

Aylesbury Chiltern

Combined National Average

4 5 5 3 3 3 6 2 5 5 4 5 7 7

12 14 15 14 17 12 15 13 17 17 19 13 19 22

16 19 20 17 20 15 21 15 22 22 23 18 26 29

2 2 1 2 1 1 2 1 1 1 2 1 1 0

0 1 1 1 0 1 2 2 0 2 0 0 0 0

2 3 2 3 1 2 4 3 1 3 2 1 1 0

33% 39% 33% 28% 22% 22% 44% 17% 33% 33% 33% 33% 44% 39%

35% 44% 47% 44% 50% 38% 50% 44% 50% 56% 56% 38% 56% 65%

35% 42% 42% 38% 40% 33% 48% 35% 44% 48% 48% 37% 52% 56%

Aylesbury Chiltern

Combined National Average

MEETING: Primary Care Commissioning Committee PAPER: F

DATE: 6 June 2019

TITLE: Sub- Committee Effectiveness Review – findings and actions

AUTHOR: Russell Carpenter, Head of Governance/Board Secretary

LEAD DIRECTOR: Robert Majilton, Deputy Chief Officer

LINK TO RISKS: Governing Body Assurance Framework

No direct link to risks

Corporate Risk Register

No direct link to risks


For Action

For Approval

For Decision

For Assurance

For Information

For Ratification


The PCCC is asked to:

1. NOTE AND DISCUSS findings of the self-assessment 2. AGREE follow-up actions to address findings 3. NOTE next steps.

It is best practice that Committees and Sub-Committees in any organisation review at least annually their effectiveness. The CCG internal audit plan for 2019/20 also includes an audit to review the effectiveness of the CCG’s key committees with the particular focus to be agreed as part of the detailed scoping, including:

Are committee roles and responsibilities appropriately defined;

Has the Governing Body defined its expectations for the committee;

Is the Governing Body receiving the right assurances at the right time to enable it to discharge its responsibilities?

This paper documents the results of the PCCC self-assessment with opportunity to consider, discuss and agree follow up actions/improvements.


Not applicable to this paper


No conflict identified

Conflict noted, conflicted party can participate in discussion and decision (see below)

Conflict noted, conflicted party can participate in discussion but not decision (see below)

Conflict noted, conflicted party can remain but not participate in discussion (see below)

Conflicted party is excluded from discussion (see below)

Governance assurance (see below)

Not applicable to this paper










Equality

Quality

Privacy

Financial

Risks

Statutory/Legal No implications per se, but an annual effectiveness review is best governance practice



Member GPs as standing invitees to the Sub-Committee

Supporting Papers:

Supporting slide set

MEETING: Primary Care Commissioning

Committee PAPER: G


TITLE: Primary Care Annual Report 2018/19

AUTHOR: Helen Delaitre, Associate Director for Primary Care



For Action

For Approval

For Decision

For Assurance

For Information


NHS England has delegated specific primary care commissioning functions to the CCG under Section 13 of the NHS Act. The Delegation Agreement requires delegated CCGs to provide a report within 2 months of the end of each year setting out how they have carried out their delegated functions. The attached report sets out the activity undertaken or approach developed in relation to these delegated functions and summarises the contractual changes agreed in year and any procurements undertaken. For completeness the report also includes the wider Primary Care commissioning activities. Primary Care Commissioning Committee is requested to approve the Primary Care Annual Report for wider circulation.


None arising from this paper.

Strategic aims supported by this paper:(please tick)






☐



.

Equality

Quality

Financial

Risks

Statutory/Legal

Prior consideration Committees / Forums / Groups


Supporting Papers:

Primary Care Annual Report 2018/19.

Delegated Primary Care Commissioning

Annual Report 2018/19

1. Introduction NHS England delegated specific primary care commissioning functions to the CCG under Section 13 of the NHS Act with effect from April 2016 to Aylesbury Vale CCG and April 2017 to Chiltern CCGs. In April 2018, these two CCGs merged and became NHS Buckinghamshire CCG and the delegation agreement with NHS England was amended to reflect this. The specific delegated functions are set out in Schedule 2 of the legal delegation agreement and are:

1. Decisions in relation to the commissioning, procurement and management of Primary Medical

Services Contracts, including but not limited to the following activities: a. decisions in relation to Enhanced Services; b. decisions in relation to Local Incentive Schemes (including the design of such

schemes); c. decisions in relation to the establishment of new GP practices (including

branch surgeries) and closure of GP practices; d. decisions about ‘discretionary’ payments; e. decisions about commissioning urgent care (including home visits as required) for out

of area registered patients; f. the approval of practice mergers.

2. Planning primary medical care services in the Area, including carrying out needs assessments.

3. Undertaking reviews of primary medical care services in the Area. 4. Decisions in relation to the management of poorly performing GP practices and including,

without limitation, decisions and liaison with the CQC where the CQC has reported non-compliance with standards (but excluding any decisions in relation to the performers list).

5. Management of the Delegated Funds in the Area. 6. Premises Costs Directions Functions. 7. Co-ordinating a common approach to the commissioning of primary care services with other

commissioners in the Area where appropriate.

The Delegation Agreement requires delegated CCGs to provide a report within 2 months of the end of each year setting out how they have carried out their delegated functions. The following report sets out the activity undertaken or approach developed in relation to these delegated functions and summarises the contractual changes agreed in year and any procurements undertaken. For completeness the report also includes the wider Primary Care commissioning activities. A financial report describing the management of the delegated funds as well as the wider Primary Care commissioning investment is also included. 1.1 Buckinghamshire Primary Care Landscape

Buckinghamshire is part of the Buckinghamshire Integrated Care System as well as the Buckinghamshire, Oxfordshire and Berkshire West Sustainability and Transformation Partnership (STP).

The CCG has 50 practices of which:

Two are APMS;

One is an interim APMS;

One PMS; and,

46 are GMS.

The registered population is some 559,191 patients and in 2018, the CCG was divided into 7 localities as follows:

Locality Name Practice Name (01.01.2018) Registered Population (01.01.2018)

Aylesbury North The Swan Practice Whitchurch Surgery Norden House Surgery Ashcroft Surgery Edlesborough Surgery Wing Surgery

60,172

Aylesbury Central Oakfield Surgery Meadowcroft Surgery Mandeville Surgery Poplar Grove Practice Whitehill Surgery Westongrove Partnership Berryfields Medical Centre

106,656

Aylesbury South The Cross Keys Practice Haddenham Medical Centre Unity Health Waddesdon Surgery

48,748

Amersham & Chesham Amersham Health Centre Gladstone Surgery Hughenden Valley Surgery John Hampden Surgery Little Chalfont Surgery Prospect House Surgery

76,569

Rectory Meadow Surgery The New Surgery Water Meadow Surgery

Wycombe Carrington House Surgery Chiltern House Medical Centre Cressex Health Centre Desborough Surgery Kingswood Surgery Priory Surgery Riverside Surgery Tower House Surgery Wye Valley Surgery

91,817

Wooburn Green Cherrymead Surgery Highfield Surgery Millbarn Medical Centre Hawthornden Surgery Pound House Surgery Stokenchurch Medical Centre The Marlow Medical Group The Simpson Centre

90,701

Southern Burnham Health Centre Denham Medical Centre Southmead Surgery The Allan Practice The Hall Practice The Ivers Practice The Misbourne Practice Threeways Surgery

84,528

2. Primary Care Commissioning Governance In 2016, the Primary Care Commissioning Committee (PCCC) was established and since then, has been meeting in public on a quarterly basis. In April 2018, the Committees that were meeting in common for Aylesbury Vale and Chiltern CCGs merged to become the Buckinghamshire Primary Care Commissioning Committee. The Committee is a statutory sub group of the Governing Body – see diagram at Appendix 1.

The Primary Care Operational Group (PCOG) meets monthly to oversee and manage the day to day business associated with commissioning and contracting of all primary care activity and reports to the Primary Care Commissioning Committee. The Premises Sub Group also meets monthly with the purpose of ensuring primary care premises are developed in Buckinghamshire to support the implementation of CCG and the Sustainability and Transformation Partnership (STP) commissioning plans which are aligned with the One Public Estate initiative. The Premises Sub Group is not a decision making group but is a sub group of the PCCC and makes recommendations into that committee. In July 2018, RSM who provide internal audit functions for the CCG, carried out an Assurance Review of the CCG’s delegated Primary Care Commissioning processes and functions. The scope of their review included:

Review of the governance arrangements between the CCG and NHSE, responsibility and powers retained by NHSE are clear.

The level and quality of information received from NHSE to support the CCG in carrying out its duties

Role of the Primary Care Commissioning Committee in supporting the primary care commissioning agenda.

Work plans have been established for the management of primary medical services including performance against contracts and additional services. These also include clear objectives and outcomes.

Arrangements for receiving and where required acting upon performance reports.

Focus on how quality and outcome issues from providers are highlighted, monitored, reported and actioned in order to improve the service provided

RSM’s report did not raise any “major” concerns; however two “moderate” risks were noted. First, that there should be a regular, formal reporting process in place on practice performance against the Primary Care Development Scheme (this has already been added as a standing agenda item for the Primary Care Operational Group and second, that a performance management framework is formalised for monitoring primary care contracts. To meet this requirement a Quality Improvement and Assurance Framework is being developed jointly between the Quality and Primary Care Teams and will be launched in Autumn 2019. This framework includes NHS England’s guidance on performance management of primary care contracts as set out in their Primary Medical Care Policy and Guidance Manual (PGM).

3. Managing Delegated Functions

3.1 Contract Review The primary care team regular meets with the quality team to review information relating to non- compliance of general medical practice within the terms of the contract. This includes the review of concerns which are thought to pose a risk to the efficiency, effectiveness, reputation or patient safety of NHS services and those likely to be non-compliant with the contract. Quarterly meetings are held with local CQC representatives and CQC reports are reviewed and the Primary Care Team considers whether any contractual action needs to be taken as a consequence of any CQC Requirement Notices, for example breach or remedial notice. No such notices were issued in 2018/19.

3.2 CQC Inspections

CQC inspected 13 practices during 2018/2019 and all achieved a rating of ‘Good’, including 1 practice that had previously been rated as ‘Inadequate’. Currently all 50 member practices have been rated overall by CQC as Good or Outstanding and all also report the same for each of the individual domains, i.e. Safety, Effectiveness, Caring, Responsive and Well-led.

3.3 Mergers and Closures The CCG is responsible for the contractual management of a range of contract variations including practice mergers, boundary changes, branch closures and full practice closures. In 2018/19 the Primary Care Commissioning Committee (PCCC) approved the following contractual changes:

Practice Change Date Approved

With Effect From

Pound House Surgery and Hawthornden Surgery

Practice Merger to become the Bourne End and Wooburn Green Medical Centre

01/03/2018 09/07/2018

Dragon Cottage (Chiltern House Medical Centre)

Branch Closure 06/09/2018 07/09/2018

Oakfield Surgery Boundary Change 07/06/2018 02/07/2018

Poplar Grove Practice Boundary Change 07/06/2018 11/07/2018

Mandeville Practice Boundary Change 03/01/2019 04/12/2019

Water Meadow Surgery Boundary Change 07/02/2019 01/04/2019

3.3.1 Chiltern House Medical Centre

The CCG was notified on 9 July 2018 that one of the partners at Chiltern House Medical Centre (CHMC) was immediately dissolving the partnership which held the contract for provision of primary medical services. NHS Regulations governing GMS contracts require that the contract ceases at the same time as the dissolution. Buckinghamshire CCG awarded an interim APMS contract to Primary Care Management Solutions, for up to 12 months to maintain patient services from the practice while a robust options appraisal and engagement exercise was undertaken.

On 6th December 2018, the PCCC received the options appraisal and noted the extensive patient involvement undertaken where over 1000 responses to a survey were received. The engagement process asked patients and practice staff to indicate their preference out of the following three options: 1. A managed list dispersal over many practices 2. A managed list dispersal to one particular practice 3. Procurement

Both patients and practice staff showed clear support for the CCG to procure a new provider for patients registered at CHMC. This was duly approved by PCCC and the CCG launched a procurement exercise on 12 March 2019 to identify a new contract provider. The CCG is anticipating a new APMS contract will commence on 1st September 2019.

3.4 Applications for Minor Premises Improvement Grants From time to time, NHS England announces the availability of minor improvement grant funding (MIG) to support certain premises improvements. The level of funding available in 2018/19 was such that it was suitable for small scale work that would allow practice premises to be functionally suitable and/or have improved capacity for the near future. The primary care team requested practices to submit bids, which were reviewed to ensure they did not conflict with the wider estates strategy and to determine whether they met the requirements of the Premises Cost Directions (2013). Bids were then submitted to NHS England for approval.

Under the Premises Costs Directions (2013) practices have to contribute 34% of the costs of any work undertaken. The following bids were approved:

Practice Details of bid Total cost of works (£)

Amount reimbursed at 66% (£)

Status

Hughenden Valley Surgery (Prestwood branch surgery)

DDA improvement Lift installation

35,802 23,629 Complete

Meadowcroft Practice

Installation of modular units to provide additional capacity

45,454 30,000 Complete

Berryfields Practice

Installation of modular units to provide additional capacity

45,454 30,000 Complete

The Hall Practice

Converting office space to consultation rooms to provide additional capacity and installation of Air Conditioning Units

22,788 15,253 Complete

The Swan Practice

Converting office space to consulting rooms at Verney Close to provide additional capacity

20,000 12,324 Complete

Bourne End & Wooburn Green

Upgrading rooms for use as clinical space

3,322 2,193 Underway

Westongrove Converting meeting room space into a group room for leg ulcer clinics


Mandeville Practice

Refurbishing rooms for clinical use, automatic doors fitted and improvements to security

15,050 9,933 Underway

Ashcroft Surgery

Move administration function to first floor in loft space so that practice can become a training practice

209,400 138,204 Underway

Priory Consulting room on ground floor to provide additional capacity


Cressex Health Centre

Internal reconfiguration to create additional capacity

250,000 125,000 Project not started as no lease in place

Highfield Infection Control improvements Vinyl flooring

8,000 5,280 Practice withdrew bid

Iver Medical Centre

DDA improvements Lift Installation

50,000 33,000 Not viable

Total

718,756

433,717

3.5 Directed Enhanced Services

The Primary Care Team leads on securing the sign up and monitoring of all of the Directed Enhanced

Services (DES). Sign up for 2018/19 Directed Enhanced Services is shown below:

Directed Enhanced Service No of Practices (out of 50 in total)

Learning Disabilities 50

Extended Hours 39

Minor Surgery 48

3.6 Locally Commissioned Services

The CCG commissioned 8 Locally Commissioned Services (LCS) in April 2018 as follows: Care Home Medical Service Administering Depo Neuroleptics in Primary Care Insulin Initiation, Monitoring and Restabilisation H. Pylori Testing Near Patient Testing Suture Removal Phlebotomy Venous and Mixed Aetiology Leg Ulcer

Further LCS were commissioned in July and September 2018, to promote health checks for people with severe mental health illness (SMI) and to provide prophylaxis for patients in care homes where there is a confirmed outbreak of flu during key times of the year. Development of a dashboard to cover all LCS scheme aspects has supported both practices and the CCG in monitoring activity levels in each of the services and will continue to support a GP network review of local service delivery. Sign up to LCS in 2018/19 is shown in the table below.

Sign up rates in 2018/19 were similar to 2017/18. The new SMI Health Checks received a good sign up rate of 71% in its first year with 50% of practices also signing up to prophylactic flu. During the year a comprehensive clinical review was undertaken to assess the coverage of all the schemes and whether other elements could be added. A decision to implement further schemes has been deferred, pending the formation of Primary Care Networks.

3.7 The Primary Care Development Scheme

In 2017/18, the CCG approved the launch of the Primary Care Development Scheme as an alternative to the national Quality and Outcomes Framework (QOF). The primary care development scheme was designed to enable primary care to transition to new models of care in line with the 5 Year Forward View, while maintaining clinical quality of services; supporting primary care to develop so that it can provide population-based healthcare within the current and expected financial envelope, maximize opportunities to work together and utilize additional NHS funding where available. A mixture of process and outcomes metrics were developed which practices were expected to meet within the scheme.

Foundation Gateway – These represent process achievements which are regarded as essential

building blocks for primary care to reach its transformation potential in order to support care delivery.

Care Delivery – In this part of the scheme practices were expected to improve specific areas of care delivery around CCG priority areas. This part of the scheme was available to those practices that have achieved all elements of the foundation gateway. Care Delivery Alternative – This part of the scheme allowed alternative metrics to those mandated in traditional QOF to be delivered. These metrics were considered to demonstrate improved patient outcomes of care.

In its second year, the PCDS attracted 100% sign up by practices and elements that were particularly successful were:

Delivery of dementia care planning

Non-steroidal anti-inflammatory drug (NSAID) management

Heart failure management

Referrals to Improved Access to Psychological Therapies

Atrial Fibrillation management. The scheme has been seen to be instrumental in delivering better outcomes for patients during the year and has become a key mechanism of sharing best practice and supporting GPs and practices to work together. Much of the training was geared to supporting this scheme and the amendments made following a review at the end of 2017/18 were welcomed by practices and 2018/19 saw the scheme develop in a number of areas:

Care and Support Planning for all Long Term Conditions

Greater consistency in heart failure management

Extended antibiotic management to cover more areas

Comprehensive Diabetes Education plan for patients supporting self-management of the condition.

The Buckinghamshire scheme and others like it in CCGs around the country, have informed national thinking on how the new QOF scheme for 2019/20 has been developed.

4. Quality Improvement The CCG has a statutory duty to support continuous improvement in the quality of Primary Medical

Care services (Health and Social Care Act 2012).

4.1 GP Patient Survey

The GP Patient Survey was published in July 2018. The GP Patient Survey (GPPS) is an England-wide survey, providing practice-level data about patients’ experiences of their GP practices. For Buckinghamshire CCG, 13,836 questionnaires were sent out, and 5,743 were returned completed. This represents a response rate of 42%. Survey results for Buckinghamshire practices can be found at https://www.gp-patient.co.uk however, overall 84% of patients described their experience at their GP practice as “good”, 7% of patients described their experience as “poor”. This leaves room for improvement in 2019/20 and the Quality Team will continue to monitor survey results and support practices by sharing good practice from elsewhere.

4.2 Quality Improvement Framework The CCG developed a Quality Improvement Framework in 2017 to supplement the overarching Quality Strategic Framework that was in place. This was shared with all GP practices who were asked to reflect on and incorporate elements within their own approach to improving quality. Alongside the framework, a GP Quality Dashboard was created which pulls together a wide range of general practice data and allows comparison against local/national averages and practices, supporting efforts to share good practice and drive improvements. The framework is being further developed to incorporate contractual performance management (see 2. Primary Care Commissioning Governance) and will be utilised to monitor quality improvement activities in General Practice in 2018/19 and to provide committee level assurance regarding the quality of Primary Medical Care Services.

https://www.gp-patient.co.uk/

5. Digital Transformation

5.1 E-Referrals At the beginning of 2018/19 the CCG was achieving around 50% of relevant referrals being made through the Electronic Referral System (ERS). Thanks to the hard work of Buckinghamshire practices, and a switch in referral methods, meaning that fax referrals would no longer be accepted, almost 100% of relevant referrals were being made through ERS in good time for the national deadline of October 2018. 5.2 Online Consultations During 2018/19, the “Ask NHS” application has been developed and promoted to all patients to enable them to access advice and guidance as well as access their GP booking system and patient information. By 31/03/19 the target of 30% (15) practices being live with the Ask NHS application was achieved and roll out is continuing in 2019/20. Findings from the rollout of Online Consultations are that:

Patients are being successfully redirected to self-care

If a face to face or telephone consultation is needed, the practice receives a summary of the triage which is accessible by the clinician from the booked appointment meaning that the clinician has advance warning of the patient’s symptoms and the severity thereof leading to a more efficient and effective consultation. This allows the practice to judge whether the appointment has been booked with the most appropriate clinician and reallocate it as necessary

Regular clinical review sessions have demonstrated that clinicians are confident that the patients are being triaged appropriately and being directed to the right service

Less calls to practices

Imminent developments to be added 5.3 Shared patient records – My Care Record

My Care Record enables data to be shared with authorised care professionals. GP Data is flowing from EMIS Practices with User Acceptance Testing underway, data from one SystmOne TPP site still to be configured. EMIS GP Practices require Single Sign On to be set up, 70% of EMIS sites have been enabled in the background and 100% SystmOne sites enabled in readiness for rollout. 5.4 Patient Online Services Practices were tasked to promote the use of patient online services with the aim of reaching 30% of their patients enabled to use online services. 44% of Bucks GP practices have registered at least 30% or more of their patients for online services. 100% of Bucks GP practices have registered at least 10% or more of their practice population for online services.

6. General Practice Forward View (GPFV) The General Practice Forward View, published in April 2016, outlined both the current crisis facing GP practices in England and proposed a number of initiatives (many with attached national funding streams) to support sustainability and transformation in Primary Medical Care. CCGs were required to produce a GPFV plan detailing how the proposals would be operationalised locally and the Buckinghamshire CCG’s Plan 2017-2019 was submitted and signed off by the Primary Care Operational Group on 3 May 2018. Some of the key projects undertaken in the 2018/19 financial year are:

6.1 Reception and Clerical Staff Training As part of the General Practice Forward View and the subsequent General Practice Development Programme, a national fund was created to contribute towards the costs for practices to train reception and clerical staff to undertake enhanced roles in active sign posting and management of clinical correspondence. 6.2 Care Navigation The launch of a Care Navigation Training programme has provided the opportunity for 72 non-clinical practice staff across Buckinghamshire to receive bespoke training by The National Association of Primary Care (NAPC), with 21 of our Primary Care Navigators successfully completing a higher level of training. Primary Care Navigation means assisting patients and carers in identifying and accessing the systems and support that are available to them within health and social care. Further training opportunities will be available in 2019/20. 6.3 Workflow Optimisation The CCG has supported practices in upskilling non-clinical staff in the role of workflow optimisation. Training opportunities will continue throughout 2019/20, to-date 70 practice staff members have received training. Workflow optimisation allows non-clinical staff to work against standard protocols developed in-house and refined through continuous improvement to manage incoming correspondence which does not require clinical oversight and hence release GPs time to care. 6.4 Time for Care Programme The Time for Care programme offers practices the opportunity to access facilitated support from the NHS Sustainable Improvement Team around implementing some of the Ten High Impact Actions (outlined in the GPFV). In July 2018, NHS Buckinghamshire CCG arranged a showcase event for local practices. This resulted in

11 practices undertaking the PGP Quickstart Programme, an on-site, hands-on, short term support package. Alongside the 10 High Impact Actions PGP Quickstart aims to help practices release time for care and build improved capability. Feedback was extremely positive with practices learning proven efficient process mapping skills which enabled them to make tangible differences within their practices in order to release GP time to care and to improve the patient experience. The learning from the programme can be transferred to enable further improvements within practices.

Practices benefitted from the locally hosted Fundamentals of Change and Improvement training which offered attendees an opportunity to receive an overview of delivering change and learn about the application of skills to a local project. Feedback was positive with participants expressing an interest in undertaking further training opportunities in the future.

6.5 General Practice Resilience Programme (GPRP) The General Practice Resilience programme is a national programme which was established to support practices facing resilience issues and to encourage the development of longer term sustainability plans. In Buckinghamshire the programme is administered by the Primary Care Team under the governance of the Primary Care Commissioning Committee. During 2018/19 funding has been utilised by 19 practices for both proactive and reactive purposes. 6.6 General Practice Retention Scheme The Primary Care Team has worked with their Buckinghamshire, Oxfordshire and Berkshire West (BOB) STP partners to secure a significant financial investment to establish a GP Workforce Support Programme. Across the BOB STP, like many other areas, GP recruitment and retention remains a challenge. GPs are increasingly choosing salaried or locum employment rather than traditional GP Partnerships. Delivering a sustainable model of general practice with improved outcomes for the BOB

STP population will mean addressing current supply issues. Practical steps such as paramedic practitioner pilot, supporting patients to self-care, workflow optimisation, primary care navigators and participation in the International GP Recruitment Scheme (IGPR) are already being implemented and networks of GP practices have committed to supporting integrated team development. However more is required to address the current GP recruitment and retention difficulties. The GP Workforce Support Programme aims to support the three BOB STP Training Hubs to establish and embed a workstream to support the GP workforce (both independent and employed in general practice) to maintain and improve local GP services for the local population. The service will provide an administrative support base and pastoral care to support and retain a flexible GP workforce. It is anticipated in time that services offered by the GP Retention Scheme will also be made available to the wider GP Workforce. The programme is based on three workstreams which will include the establishment of a bespoke Locum GP Chambers, a Career Flex Programme and GP Support, which will include dedicated mentoring and career coaching opportunities as well as supporting GPs to return to work after a period of absence. 6.7 Bucks Training Hub Training Hubs are funded by Health Education England and are designed to meet the educational needs of the multi-disciplinary primary care team and bring together NHS organisations, community providers, local authorities and education establishments. Their aim is to provide a much broader education offer than the traditional single professional approach and will support workforce planning. Training Hubs are considered an essential vehicle of workforce transformation due to their ability to engage multi general practice organisations and provide consistent education and workforce planning support. In 2018, the Bucks Training Hub has delivered training and education to over 400 members of staff both within the primary and community care sectors, including, nurses, paramedics, pharmacists, Health Care Assistants (HCAs), front desk receptionists and practice managers and increasingly, the training hub is seen as the first point of contact for training and education needs from local staff. The Hub has not only been focusing on providing education, but also developing and strengthening partnership working with local CCGs, Thames Valley Training Hubs, Higher Education Institutions and local authorities. The Training Hub is currently working on gathering workforce data to inform education strategy, priorities and activities in the upcoming year and the launch of the new lead nurse and HCA forums, amongst others will enable the Training Hub to be in a much better position to respond and deliver workforce needs.

7. Bucks 24/7

7.1 GP Out of Hours The Primary Care Team was involved in the successful transition and transfer to a new provider of GP Out of Hours Services and the Wycombe Minor Injuries and Illnesses Unit in April 2018. Despite a rising demand for urgent care, the new service settled well and has attracted national attention, having one of the first units designated as an Urgent Treatment Centre. This is because it is becoming part of a fully integrated urgent care service in which patients are able to phone NHS 111 to be guided to the most appropriate treatment including booking appointments in the out-of-hours service or the minor injuries and illnesses unit, depending on their injury or illness symptoms. This change is seen as Phase 1 of transforming access to primary care 24/7 and we are beginning to see much more joined up care between healthcare providers to give access to care 24/7 and to share information. The new service is provided by local healthcare and mental health care trusts, the

ambulance service who also provides the NHS111 clinical assessment service and the local GP Federation representing most of the GP practices in Buckinghamshire, all working together to transform the way in which people can access urgent treatment.

7.2 Improved Access to General Practice (IAGP)

Phase 2 of service transformation was the introduction of IAGP on 1st October 2018 whereby each locality has implemented an additional half an hour of bookable appointments per 1,000 weighted population in general practice. IAGP is designed to improve access to routine, bookable appointments outside traditional core GP hours (8am to 6.30pm) and all patients registered with a Buckinghamshire GP are now able to access an appointment up to 8pm on weekdays and at restricted times over the weekend. The service is based on practices working together on a locality footprint to offer improved access and therefore patients may be offered an appointment at a different practice.

The service offers approximately 270 hours of additional access to general practice a week across Buckinghamshire. A number of multi-skilled key transformational workforce models are emerging, for example the use of physiotherapists and paramedics is being piloted along with virtual consultations (QDoctor).

Building on the experience that localities have gained through working together to deliver improved access, practices are beginning to see tangible benefits from working in a more collaborative manner. The next steps are to use the development of the locality plans to further encourage this collaboration in the shape of Primary Care Networks.

8. Primary Care Budget The table below provides information regarding the budgeted and actual expenditure in relation to the primary care delegated commissioning functions and the wider Primary Care commissioning programme.

Co-commissioning

(SUBJECT TO AUDIT SIGN-OFF)

Summary Description

Annual Budget 18/19

£k

Outturn 18/19

£k

Variance

£k

GMS GMS Contract 42,058 42,213 (154)

PMS PMS Contract 2,427 2,500 (73)

APMS APMS Contract 2,436

3,066

(630)

QOF QOF 7,198 7,198 0

DES Enhanced Services 1,876 1,743 132

PCO Other 3,946 4,202 (256)

Collab Reserves 714 0 714

Premises Premises 7,339 7,521 (182)

Total 67,994 68,442 (449)

Local Commissioning Schemes (SUBJECT TO AUDIT SIGN-OFF)

Summary Description Annual Budget 18/19

Outturn 18/19 Variance

LCS Direct Awards 1,972 1,972 0

(SUBJECT TO AUDIT SIGN-OFF) Annual Budget 18/19 Outturn 18/19 Variance

Out of Hours (BHT 24/7) 7,010 7,010 0

GPFV (Non-Recurrent) 2,064 2,064 0

GPIT 1,780 1,780 0

These figures represent the unaudited 2018/19 position. The majority of the overspend in co-commissioning is related to pressures from GP in year pay award and expenditure from the requirement to support the changes at CHMC and utilisation of section 96 flexibilities to support neighbouring practices to manage patient flows.

2019/20 and Beyond

The main priorities heading into 2019/20 include:

Deliver statutory responsibilities under delegated primary care commissioning.

Achieve financial balance on the primary care commissioning delegated budget.

Development of an STP-wide Primary Care Strategy.

Development of robust and realistic Workforce and Estates strategies for Primary Medical Care Services,

Ensure delivery of Primary Care Networks covering 100% of the Buckinghamshire population.

Build primary care resilience across Buckinghamshire through integrated working at scale within PCNs.

Improved productivity through the roll out of digital solutions and streamlined workload processes.

Implementation of a Primary Care Quality Framework with increased operational support from the Primary Care and Quality teams.

Appendix 1

Membership of Buckinghamshire CCG

Council of Members

Governing Body

Executive Committee

Finance Committee

Audit Committee

Remuneration Committee

Quality and Performance Committee

Primary Care

Commissioning Committee

Locality Meetings

Equality and Diversity Steering Group

Engagement Steering Group

Staff Partner Forum

CHC Exception Panel

Integrated Commissioning Executive Team*

Information Governance

Steering Group

Infection, Prevention and Control Sub-Committee

Individual Funding

Requests Case Review Panel (IFR Panel)

Safeguarding Steering Group

Primary Care Operational

Group

GPFV Oversight Group

Workforce Training &

Development Group

Premises Sub-Group

* These are reporting lines only; the Integrated Commissioning Executive Team is formally accountable to the Health and Wellbeing Board. There are also reporting lines from the Finance Committee to both the Audit Committee and Executive Committee

MEETING: Primary Care Commissioning Committee PAPER: H


TITLE: Primary Care Network Configuration Update

AUTHOR: Helen Delaitre, Associate Director for Primary Care



For Action

For Approval

For Decision

For Assurance

For Information

Summary of Purpose and Scope of Report: This paper provides an update to the Primary Care Commissioning Committee on the establishment of networks across Buckinghamshire in line with the aims of the NHS Long term Plan. PCCC is requested to note and be assured of the process being undertaken to ensure that 100% of the Buckinghamshire population is covered by a PCN by 1st July 2019.

Conflicts of Interest: None arising from this paper – for information and assurance only.

Strategic aims supported by this paper:(please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all







The CCG has requested all PCNs to discuss their proposed configuration with their PPG and confirm that they have done so, with the CCG. PPG involvement has also been a topic at Locality Meetings and at the recent PLT event in May 2019.

Equality

PCNs will have a key role in preventing and reducing health inequalities. It is not expected that there will be any equality issues as 100% of our population will have access to network services.

Quality None arising from this update paper.

Financial None arising from this update paper.

Risks Noted in Risk Register

Statutory/Legal


PCN configuration has been discussed at all Locality Meetings, the ICS PCN Steering Group and PCN Mobilisation Group.


Membership involvement through Locality Meetings.

Supporting Papers:

Primary Care Network Configuration Update.

Buckinghamshire Primary Care Network Configuration Update Introduction The NHS Long Term Plan (LTP) and the 5 Year Framework for GP Contract Reform mark some of the biggest changes to the general practice contract since 2004. They describe Primary Care Networks (PCNs) as the building blocks of Integrated Care Systems. Core to a network is collaboration and integration at community level to enable patients to access services tailored to communities, provided by professionals both in and outside the network. Networks are expected to cover a population size of between 30,000 – 50,000 patients. The new Network Contract Directed Enhanced Service (DES) will see general practice taking a lead role in every PCN. The timescale for establishing PCNs is challenging as all PCNs need to be established by 1st July 2019. This paper updates PCCC on the process the CCG has undertaken to approve proposed PCN configurations together with details of the PCNs themselves and any next steps. Registration Process To be eligible for the Network Contract DES, PCNs needed to submit their completed registration forms to the CCG by no later than 15 May 2019. As part of the approval process, PCNs were requested to provide:

Names and codes for each practice in the network

The network population coverage based on practice list sizes as at 1.1.19

Details of the provider to receive network funding

Details of the PCN accountable clinical director

Initial network agreement signed by each practice in the network. The CCGs Role in Approving Configurations The CCG is responsible for confirming that registrations have been received and ensuring the requirements are met within the timescales. In order to fulfil this role, the Primary Care Commissioning Committee delegated decision making responsibility to the Primary Care Operational Group (PCOG) and this Group held a meeting on 16th May 2019 to review the submissions. The CCG provides approval on behalf of, and with the agreement of, the ICS and STP. Due to the importance of ensuring that PCNs support the wider ICS and STP priorities, colleagues from the STP and ICS were invited to join the PCOG meeting for this item. Before the registration process, it was agreed that all PCNs would be approved at the same time to ensure that every constituent practice of the CCG and 100% of its population were included in a PCN.

National guidance, included in the Network Contract DES specification was used to assist in the decision-making process together with locally drawn up recommendations that were adopted across the Buckinghamshire, Oxfordshire and Berkshire West (BOB) landscape. The CCG designed a checklist to help PCNs respond to all requirements.

Ahead of PCOG on 16th May and after closure of the submission process for PCN registration on 15th May, the CCG convened a panel to review all registration forms received using the approved checklist. Where a registration form submitted substantially met national criteria and local principles, but did not provide evidence requested on the checklist, PCOG were asked to approve the registration form in principle and the primary care team then sought further assurance from the PCN ahead of completing the registration approval process. Outcome A total of 12 PCN registration forms were received by the CCG by 15th May 2019. Following receipt of further information to complete the registration approval process, the following PCNs will be established with effect from 1st July 2019 (subject to Network Agreements being signed).

PCN Name Practice Name Practice ODS Code

Practice List Size (1.1.19)

Total PCN List Size

Aylesbury North Swan Practice K82007 30,148 66,236

Whitchurch Surgery K82042 3,960

Norden House Surgery K82043 9,578

Ashcroft Surgery K82061 4,009

Waddesdon Surgery K82068 5,295

Wing Surgery K82070 5,295

Edlesborough Surgery K82079 7,951

Westongrove Partnership

Westongrove Partnership K82073 28,945 28,945

Central BMW Berryfields Medical Centre

Y01964 9,113 38,784

Meadowcroft Surgery K82018 15,240

Whitehill Surgery K82040 14,431

Central Maple Mandeville Surgery K82019 15,236 40,698

Oakfield Surgery K82014 5,461

Poplar Grove Surgery K82038 20,001

AVS The Cross Keys Practice K82021 14,254 44,099

Haddenham Medical Centre

K82028 8,556

Unity Health K82047 21,289

Chesham and Little Chalfont

Water Meadow Surgery K82037 12,524 34,656

The New Surgery K82024 10,967

Gladstone Road Surgery K82058 5,432

Little Chalfont Surgery K82621 5,733

Mid Chiltern Hughenden Valley K82049 12,775 42,516

John Hampden Surgery K82035 3,419

Prospect House K82618 3,582

Rectory Meadow K82001 9,500

Amersham Health Centre K82004 13,240

HW Swan Desborough & Hazlemere Surgery

K82017 12,539 45,794

Kingswood Surgery K82022 9,925

Priory Surgery K82053 12,632

Tower House Surgery K82010 10,698

Dashwood Chiltern House Medical Centre

K82020 6,937 53,273

Cressex Health Centre K82603 8,167

Carrington House Surgery K82044 10,913

Riverside Surgery K82036 9,875

Wye Valley Surgery K82030 10,508

Stokenchurch Medical Centre

K82048 6,872

South Bucks Burnham Health Centre K82003 21,611 54,054

Southmead Surgery K82045 6,640

Threeways Surgery K82031 6,340

Iver Medical Centre K82006 9,436

Denham Medical Centre K82005 10,027

Arc Cherrymead Surgery K82029 10,783 84,553

Highfield Surgery K82012 6,676

Bourne End & Wooburn Green

K82066 14,456

Marlow Medical Group K82023 27,228

Milbarn Medical Centre K82011 7,829

Simpson Medical Centre K82046 17,581

The Chalfonts The Misbourne Practice K82051 12,205 30,795

The Allan Practice K82078 8,864

The Hall Practice K82008 9,726

Buckinghamshire has five PCNs that are either larger or smaller than the recommended 30,000-50,000 size. However each has provided their rationale for this, which has been accepted by PCOG. Aylesbury North – The practices in the north of the County cover a large rural area and have already formed their own federation called Medicas. They have a history of working collaboratively and have built strong networks with other health and social care providers as well as local voluntary groups. National guidance suggests that were existing configurations that are more than 50,000 make sense to patients and the local community then they should be approved. Westongrove - On the 1st Jan 2019 the registered list size was 28,945. The Westongrove catchment area will include significant population growth by 2033 (18,000 patients based on AVDC building projections). By April 2020, the practice anticipates reaching 29,700. The practice is spread over three sites and is already recognised as a Primary Care Home site.

Dashwood – this PCN was originally configured to be within the recommended 50,000 limit at 46,401. However, the practices within the PCN agreed to include a stranded practice, which was formerly part of the Wooburn Green locality. South Bucks – all practices in this PCN are either south facing towards East Berkshire CCG or east facing towards Hillingdon CCG. Historically, they have very different referral patterns to the majority of practices within Buckinghamshire. Dividing them into two networks would

create one PCN that meets the recommended size and one that is below 30,000. The proposed configuration will meet the needs of their patients and staff. Arc - While this is a large PCN of 84,553, the CCG has set a condition that the PCN adopts a neighbourhood approach to care delivery. The CCG defines this as one PCN offering two local points of service delivery/co-ordination so that patients benefit from the original intent of PCNs being care teams serving 30 – 50,000 patients with care closer to home. The option of splitting this network was also considered. However, the test of “minimal disruption” would be challenged in that the majority of practices are happy to embrace working at the larger scale and already work well together. Next steps Following confirmation to NHS England of the Buckinghamshire PCN configurations by 31 May 2019, any outstanding issues will need to be resolved by 30 June 2019 in conjunction with the Local Medical Committee (LMC). All PCNs are now actively working on their Network Agreement and Schedules, which need to be completed and signed by all parties by 30th June 2019. Each GP practice in a PCN will also need to sign up to the Network Contract DES through the Calculating Quality Reporting System (CQRS), when available and by recording the agreement in writing with the CCG. The Network DES is expected to commence on 1 July 2019.

Summary

This paper summarises the process undertaken to complete PCN registration formalities. PCCC is requested to note the content of this update and be assured that due process has been followed. Further formal updates on the progress made by each of our PCNs will be presented to both Primary Care Commissioning Committee and to Primary Care Operational Group.

HD 30.5.19

MEETING: Primary Care Commissioning Committee Paper: I


TITLE: Digital Transformation and GPIT Update

AUTHOR: Anna Lewis

LEAD DIRECTOR: Robert Majilton & Balvinder Heran


For Action

For Approval

For Decision

For Assurance

For Information

For Ratification


Primary Care Commissioning Committee is request this report for information.


No decision required.








Not applicable for this paper





Sustainability within Bucks – to contribute to the delivery of a financially sustainable health and care economy that achieves value for money and

encourages innovation





Equality

Quality

Financial

Risks Risks highlighted in report

Statutory/Legal



Supporting Papers:

Digital Transformation and GP IT Update attached.

Progress and Updates against Digital Projects for GPFV requirements, NHS Long Term Plan and Buckinghamshire ICS 2019/20 Operating Plan

Submitted to the Primary Care Commissioning Committee for information and assurance:

Project Governance Update RAG

GP Patient WiFi

GPFV Buckinghamshire CCG identified a requirement for staff and patients to be able to work wirelessly. Deployment of the Egton Practice Wi-Fi solution at all GP practices across Buckinghamshire commenced in 2016 and completed in late 2017. Utilisation statistics were submitted to NHS Digital up to the required end date of 31st March 2019. Objectives of the project were to:

Provide GP Practice staff with Wi-Fi access to the Internet.

Provide patients with Wi-Fi access to the Internet.

Provide GP Practice staff with Wi-Fi access to N3 services e.g. clinical systems.

Enable GP Practices to use emerging mobile technologies.

Complete

Health and Social Care Network (HSCN)

GPFV The Health and Social Care network (HSCN) is a new data network for Health and Social Care organisations which will replace the existing BT N3 network. HSCN will provide a reliable, efficient and flexible way for health and social care organisations to access and exchange electronic information. This project is to migrate Buckinghamshire GP practices from N3 to HSCN. The project is progressing with basic site surveys, and complex surveys where cabinet and cabling upgrades are required. Some delays have been incurred by BT, and NHS Digital is aware of these. The national deadline has been extended to August 2020.

Amber

Clinical System migrations

ICS This programme of work was undertaken to complete GP Clinical System migrations to Emis Web as agreed with practices. Two of the three non EMIS practices have commenced the process of their migration and these will be completed during May 2019. There are currently no agreed plans for the third practice to move to EMIS.

Green

Electronic Document Management (EDM) - Paperless

Paperless by 2020

The Paperless project supports the move to a paperless system. The project’s objectives include:

Supporting the elimination and reduction of paper document communications (including patient discharges) between key NHS & Private Secondary Care organisations and GP practices.

Encouraging the use of existing electronic systems such as EDT (e.g. through Docman) messaging, eRS, eDS, MESH etc.

Reducing lost and mis-directed correspondence, which will reduce clinical risk.

Assisting and supporting the understanding and transformation of current Secondary Provider document processes.

Green

Reducing the duplication of communication methods for the same correspondence, by encouraging secure digital transmission practices.

The project undertook a survey in a number of practices of the amount of paper documentation being sent to practices. Following the survey the project has been working with all main NHS and private provider organisations to assist with their move to electronic communications. In some cases this has been slow as providers are reliant on their own internal plans and systems for paperless working.

Practices using Docman have had regular reports set up within the system to monitor.

Mobile Working

GPFV This project is for the deployment of mobile devices across Buckinghamshire GP Practices. The mobile devices provide remote access to practices' clinical systems and other clinical services such as Electronic Prescribing. To date almost 130 devices have been deployed across 50 practices. These are a mixture of tablets and laptops.

A survey was undertaken after the first phase of deployment and one such comment highlighted the immediate benefits: “GPs can now complete the entire ‘GP round’ whilst in the care home and do not need to return to the practice with a long list of actions that need to be completed. This time delay can lead to errors and omissions as often the GPs return to the practice and need to go into clinic so the action list from the care home can be delayed until much later in the day.”

The project is currently awaiting a decision regarding Buckinghamshire CCG’s future strategy on mobile working and devices before any more devices are procured.

Green

My Care Record (Graphnet Care Centric)

BHT acute data load has been successfully completed. Full sign off of the data load is awaited. A configuration change to My Care Record to have separate ‘tiles’ at the user interface for Community Data and Mental Health Data (thus separating the data views) has been successfully implemented into Live. Oxford Mental Health data load into live My Care Record is completed with report awaited on data quality users. Extract of Community Data from BHT (Rio) is in the early stages with the first extract completed. Errors and data quality issues now need to be resolved. BCC Adult and Children Data content are still to be formally signed off but expected by the end of June. Meetings between BCC Social Care and GP Practices have taken place in April to address questions/concerns around data to be shared through My Care Record with authorised care professionals. GP Data is flowing from EMIS Practices with User Acceptance Testing underway, data from one SystmOne TPP site still to be configured. EMIS GP Practices require Single Sign On to be set up, 70% of EMIS sites have been enabled in the background and 100% SystmOne sites enabled in readiness for rollout.

Amber

Trusted sites to allow GP Practices to access My Care Record portal have been enabled across all EMIS sites. Training material for how to access and navigate Graphnet CareCentric is being developed. Further acceptance testing will be carried out over the next month whilst the Single sign on, policies, support arrangements, communication and training are confirmed/finalised to support a wide rollout. Resourcing of the team is currently under review. Please note that if technical or resourcing issues are experienced these timescales will be impacted.

Online Consultation (Sensely “Ask NHS”)

GPFV Online consultation funding was made available as part of the GPFV & the General Practice Development Programme to support digitally confident practices to explore and successfully embed a model of online consultations. Online consultations are also part of the ‘Time to Care’ initiative to benefit both patients and staff.

The agreed online consultation solution in Buckinghamshire is Sensely’s Ask NHS solution, an online self-triage App & Website providing patients with access to; information (local DOS), self-care (nhs.uk) GP appointments vis triage (EMIS) and Admin requests. Ask NHS is fully integrated with EMIS Web (sending the output of the triage direct into EMIS Web) this allows the clinician the option to respond to the online consultation as deemed appropriate i.e. email, text, phone, GP face to face appointment.

Bucks CCG implementation targets: 30% - 15 practices live by 31/3/19 - Complete 50 % - 25 practices live by 01/06/19 - On track 75% - 38 practices live by 31/10/19 - On track 100% - 50 practices live by 31/03/2020 - On track

Sensely are moving forward with the additional functionality such as web access and responding to patients and staff feedback promptly. A CCG Ask NHS dashboard is being developed by Sensely. Timescales for delivery are under discussion.

Green

Improved Access / 7 Day Working

GPFV In 2015, national proposals to provide all patients with access to 7 day general practice services by 2020 were unveiled. This pledge was reinforced in April 2016 following the publication of the General Practice Forward View (GPFV).

Buckinghamshire CCG has procured improved access as part of the integrated 24/7 model of care which is in itself, aligned to wider transformation in Buckinghamshire.

Improved Access / 7 Day working has been running in Bucks since 1st Oct 2018. Practices (some more than others) are booking regularly into the FedBucks Sunday & Bank Holiday service using EMIS Remote consultations. Practices are also offering improved access appointments across their locality offering registered patients access to primary care during the hours of 8am – 8pm. The uptake for the ‘Cross organisational’ appointments at Locality level is variable. All practices have been audited on Improved Access services being promoted on the practice website.

Green

In order to ensure that GP Practices have the technical capabilities to offer improved access, a programme of work was delivered providing configuration, facilitation, training and guidance.

2 technical solutions were considered, each with limitations.

Issues identified for patients / clinicians attending / providing an Improved Access appointment are:

Cross organisational appointments using ‘Remote Consultations’ do not have access to SPINE services i.e. eRS, EPS

Clinicians are unable to access ICE to order test requests

DXS documents are not visible (the original documents are visible)

Use of cross organisational locality appointments by external patients is poor – Some localities are looking at putting all shared appointments on to the Hub appointment book to make it easier for admin to locate available appointments.

Solutions to these issues are being reviewed.

111 Direct Booking

GPFV 111 Direct Booking into GP Practices Following discussions with NHS England, a 111 Direct Booking pilot was successfully enabled at The Swan Practice in Buckingham in December 2018. The pilot is now running as business as usual.

The new GP Contract requires practices to reserve appointments for NHS 111 clinicians (not lay call handlers) to book patients into. The minimum requirement will be 1 appointment per day, per 3,000 patients (rounded down, with a minimum of 1) e.g:

1500 patients = 1 appointment 5900 patients = 1 appointment 6001 patients = 2 appointments

These should be spread evenly through the day and the practice can decide how to manage patients booked into these appointments. These appointments may be freed up for others to book if not booked within a set period before the appointment (further detail on this will be provided by NHS England).

The roll out of 111 Direct Booking to other Bucks practices was put on hold in January 2019 after SCAS 111 and EMIS declared there was no funding available for the licences to continue with the roll out. Discussions have been had with NHS England to confirm funding for future roll out. Discussions are underway with SCAS to set up direct booking with GP Practices once licences have been procured and practices details (e.g. opening times and locations) are updated on the DOS.

Further local discussions required to agree plans and next steps. 111 Direct Booking into the Improved Access Hubs Improved Access appointments 9am – 1pm on Sundays and Bank Holidays are to be made available to 111 (GP Connect to be utilised) and for FedBucks OOHs to book into.

Red

A draft process has been mapped out to enable the OOH’s GP to identify patients suitable for an Improved Access GP appointment. Patients that have been booked into appointments at one of the OOHs bases directly by 111, or those that require a call back by OOHs (added to the clinical assessment pool) can be (traced in) registered from the SPINE into an available EMIS GP Improved Access slot. The process is due to be presented to the FedBucks senior management team for approval in May 2019.

In order to progress this, licences will be needed for all GP practices and the Hub. Plans and resources to be agreed.

Discussions are underway with Primary care and Digital Transformation to agree an offering to support the delivery of GP contract requirements.

NHS App GPFV The NHS App is due to be activated for Bucks practices in early May 2019. As Bucks are part way through implementing Online Consultations in the form of Ask NHS from Sensely, Bucks have held discussions with NHS England as to how to phase the rollout and promotion of the 2 apps to give maximum benefits to Primary Care and patients whilst minimising confusion with multiple apps.

Findings from the roll out of Ask NHS have indicated potential to increase quality of care for patients and reduce demand on practices. Therefore, whilst the NHS App has huge potential, Bucks CCG believes that in this early iteration, Primary Care and patients will see more benefits from a clear focus on implementing and promoting the use of Ask NHS online consultations.

The NHS App will be available to Bucks residents but will not be actively promoted across Bucks until the national communications campaign in the autumn.

Green

MEETING: Primary Care Commissioning Committee PAPER: J


TITLE: Performance Review of the Primary Care Development Scheme 2017/18 & 2018/19

AUTHOR: Simon Kearey, Head of Locality Delivery



For Action

For Approval

For Decision

For Assurance

For Information


Primary Care Commissioning Committee will receive a presentation evaluating the two-year Primary Care Development Scheme to provide assurance regarding the performance of this scheme during that time. PCCC is requested to note content of the presentation.

Conflicts of Interest: None arising from this paper.







Governance requirements: (Please tick each box as is relevant to the paper) Governance Element Y N N/A Comments/Summary


N/A

Equality N/A

Quality

The PCDS supports practices to deliver high quality services.

Financial

Financial aspects of this scheme are not covered by this paper.

Risks

Risks associated in delivering this scheme are not covered by this paper.

Statutory/Legal N/A


PCCC and PCOG are involved in the decision-making process for agreeing new terms for the PCDS and receive regular updates.

Membership Involvement N/A

Supporting Papers:

Presentation slides will be made available after the Committee meeting.

MEETING: Primary Care Commissioning Committee AGENDA ITEM: K


TITLE: Report from the Primary Care Operational Groups: 4th April and 16th May 2019

AUTHOR: Dawn Bing-Lowe, Executive Administrator



For Action

For Approval

For Decision

For Assurance

For Information

For Ratification


To provide the PCCC with an update from the PCOG meetings held on 4th April and 16th May 2019.


N/A

















Equality

Quality

Privacy

Financial

Risks

Statutory/Legal



Supporting Papers:

Report from the Primary Care Operational Groups: 4th April and 16th May 2019.

Report from the Primary Care Operational Group Meetings held on 4th April 2019 and 16th May 2019

Terms of Reference - Primary Care Operational Group There was an annual review of the Terms of Reference at April Meeting and the following amendments were approved:

Added standing invitees - Estates Development Manager and Associate Director of Digital and IM&T

A clear statement regarding quoracy in the event of voting members being unable to attend meeting.

South Bucks Out of Hours Service. PCOG were updated on the South Bucks GP Out of Hours (OOH) Service which as part of Buckinghamshire 24/7 Primary Care Access is due to mobilise on 29 May 2019. The new service will operate from Threeways Practice in Stoke Poges. A preliminary Outline Mobilisation Plan has been developed to indicate actions required for successful delivery of the OOH service. Transport links, location and travel from practice premises have been assessed and although it was acknowledged that public transport may prove challenging in this geographical area, it was noted that this would be the case in most areas of Buckinghamshire during the Out of Hours period. It was also noted that the new service will not just be available to patients from Threeways, Southmead and Burnham, but will be open to patients from practices in the Chalfonts and Iver to attend and the patient survey revealed that patients were happy to travel up to 6 miles. The equality impact assessment did not identify any major issues. QOF Plus. PCOG recommended Buckinghamshire practices to sign up to the national QOF scheme for 2019/20. A new QOF+ scheme will be made available to member practices to sign up to. The CCG has allocated approximately £200k for the new QOF+ scheme which aims to improve outcomes for patients and support member practices in. The main elements of the scheme focus on prevalence, ethnicity recording and antibiotic management. Terms of Reference for the General Practice Forward View (GPFV) Oversight Group and Workforce, Training and Development Group. PCOG approved the terms of reference for the Workforce, Training and Development Group and GPFV Oversight Group. The GPFV Oversight Group will report directly to PCCC and will provide assurance and progress reports on all aspects of the GPFV workstreams. The Workforce Training and Development Group meeting will be held in conjunction with the Bucks Training Hub. It was apparent that the Bucks Training Hub required an operational group to sit under the Training Hub Board and that the attendees at this meeting would be very similar to invited members of a GPFV Workforce Group, therefore it seemed more efficient to establish a joint meeting which will focus on GPFV and Training Hub Projects. It is hoped that this joint forum will enable more collaborative working and prevent duplication of effort and resources.

GPFV Funding 2018/19. For 2018/19 NHS England awarded NHS Buckinghamshire CCG £75,799 as their share of the GPRP fund. In addition in March 2019, NHS England informed the CCG that additional funding had been made available for 2018/19 totalling £50,000 and plans are being made for spending this additional funding. The CCG is required to regularly report to NHS England on the utilisation of this funding. PCOG also noted GPRP spend to-date. Tier 2 Care Navigation Training. Over the past 12 months the National Association of Primary Care (NAPC) has worked with Buckinghamshire CCG to deliver training and development in non-clinical care navigation to almost 100 staff from general practice. This included foundation training in signposting (Tier 1) and more skills based health coaching. (Tier 2). The evaluation and feedback from the training has been positive. At April PCOG £9,600 funding was approved to enable NAPC to continue to work with practices to upskill non-clinical staff in the role of care navigation. Front-line Non-Clinical Staff Development Session. Reception staff are often the first to encounter patients within general practice, both by phone and face to face. When a patient or carer is experiencing anxiety, pain, illness, stress, substance misuse or mental health problems these interactions have the potential to become highly charged or challenging. The CCG wants to support practices by hosting a development session which would help equip frontline non-clinical members of the primary healthcare team to avoid conflict and manage these interactions to gain the best outcome for all. PCOG approved £4,920 of dedicated non-clinical training funding to run the development session for reception staff and practice managers. PCOG also approved up to £5,000 of dedicated non-clinical training funding to support venue and catering costs for planned events and training in 2019/20. Primary Care Networks (PCN) Update. In May 2019 PCOG received an update on the formation of PCNs within Buckinghamshire, representatives from the ICS, STP and LMC were invited to attend. PCNs were requested to submit their registration applications to the CCG by 15 May 2019. The CCG received 12 PCN applications. PCOG noted that there was one stranded practice in the Wooburn Green Locality. Applications were reviewed via a checklist, an approach approved by PCCC on 9 May 2019. PCOG noted that the CCG is expected to submit the PCN recommendations to NHS England and ensure that 100% of the population were covered by a PCN by 31 May 2019. The CCG intends to use the intervening time to receive clarification on any areas of concern. Wye Valley Surgery Contract Variation Wye Valley Surgery is moving to the Wycombe Hospital site on 17 June 2019. The new location is less than a mile from the original site and the increased capacity at the new premises offers the potential to provide improved facilities for patients, including disabled parking. PCOG approved the GMS contract variation. Chiltern House Medical Centre (CHMC) Practice Payments When the Partnership at CHMC dissolved and the branch surgery closed, local practices asked the CCG for financial assistance anticipating re-registering patients who had chosen to de-register from CHMC. A fixed payment of £17.50 was agreed, the payment being per patient registered from CMHC between the date of the partnership dissolution and the date the CCG made a decision regarding longer term plans for the practice (6 December 2019). Due to the low number of patients registering with neighbouring practices in January and February PCOG approved the cessation of payments from 31st December 2018.

Cross Keys Practice Boundary Change PCOG approved an application from Cross Keys Practice to marginally reduce their practice boundary by removing three small rural areas. The Partners requested the boundary area change due to the future housing expansion plans in Princes Risborough and Chinnor where approximately 3500 new homes are expected to be built. The practice has stated that they feel unable to continue to provide services to the same geographical area with this anticipated increase in demand. Prior to approval the practice consulted with their PPG and neighbouring practices, none of whom raised an objection to the boundary change. Mandeville Practice Boundary Change The Management team from The Mandeville Practice in Aylesbury approached the CCG to request their contracted boundary is extended to cover some of the new housing growth adjacent to Stoke Mandeville Hospital. PCOG approved the boundary change to the Mandeville Practice noting this enhances patient choice for residents moving into the new developments. The practice had consulted with neighbouring practices who raised no objections to the boundary change. Syrian Refugee Scheme Following the expansion of the national Syrian Refugee Vulnerable Persons Resettlement (VPR) programme in September 2015, the LMC requested that Buckinghamshire CCG develop a Service Specification which will enable local practices who register Syrian refugees to access the funding associated with this scheme. Practices providing this service will be expected to assess the physical and mental health of all patients as soon as possible following registration (and ideally within 5 working days of arrival) and give appropriate treatment and/or support as required. Participating practices will be paid £600 per individual patient registered under this scheme. This is a one-off payment in recognition of the additional clinical, administrative and communication needs of the patients concerned and is funded by central Government. PCOG approved the service specification, Special Allocation Service (SAS) Review and Proposal for 2019/20

In 2018, Buckinghamshire CCG commissioned a Special Allocation Service to provide primary medical services for patients who have been removed from a practice due to an incident of violent or threatening behaviour. The service was commissioned in line with NHS England’s Primary Medical Care Policy and Guidance Handbook (PGM) and Bassett Road Surgery in Leighton Buzzard have provided the service as an Enhanced Service since July 2018. Regular contract review meetings have been held, with clinical support being provided by the CCG Clinical Chair. Both commissioner and provider are happy with the way the SAS is working and the provider has indicated they would be happy to continue provision for 2019/20. PCOG noted the activity that has happened in this first year and that the SAS is operating within budget. Procurement advice has been obtained on the advisability of awarding the Enhanced Service without testing the market and waiver with publication of a transparency notice being the preferred route. PCOG approved the maintenance of the budget at £34,250 for 2019/20 including a 1.7% uplift to the Retainer element.

MEETING: Primary Care Commissioning Committee AGENDA ITEM:

L


TITLE: Premises Sub Group Notes: 1 March 2019

AUTHOR: Vicki Parker, Business Support Manager



For Action

For Approval

For Decision

For Assurance

For Information

Summary of Purpose and Scope of Report: Notes of the Premises Sub Group, which is a sub-group of the Primary Care Commissioning Committee, chaired by Tony Dixon, Buckinghamshire CCG Governing Body Lay Member. The PCCC is asked to note for information.

Conflicts of Interest: None arising from this paper.








☐

Equality ☐ ☐

Quality ☐

Financial ☐

Risks ☐

Statutory/Legal


Membership Involvement ☐

Supporting Papers:

Notes from the Premises Sub Group held on 1 March 2019

Premises Sub-Group

1st March 2019, 10am – 11.30am Large Meeting Room, Amersham Site CCG

Minutes

Voting Members:

Tony Dixon (TD), Lay Member and Finance Committee Chair (Chair of this meeting)

Helen Delaitre (HD), Associate Director of Primary Care, CCG

Kate Holmes (KH), Deputy Chief Finance Officer, CCG

In Attendance:

Nicola Lester (NL), Director of Transformation, CCG (Deputy Chair)

Jessica Newman (JN), Senior Primary Care Manager, CCG

Vicki Parker (VP), Business Support Manager, CCG (Minute Taker)

Peter Redman (PR), CCG Estates and Development Manager

Apologies:

Dawn Bing-Lowe, Executive Administrator, CCG

Simon Kearey (SK), Head of Locality Delivery, CCG

Agenda No. Agenda Item Action

1 Welcome and Introductions

2 Declarations of Interest No additional declarations other than those standing on published registers.

3 Notes from Last Meeting Minutes from the 25th January 2019 meeting were agreed as an accurate record.

4 Action Log The action log was updated accordingly.

5 Outstanding Lease Issues Mandeville Surgery: The CCG understands work on the lease negotiations is on-going and we have not been made aware of any delays or issues. Wye Valley: BHT and the practice should have signed the lease on 28/2/2019 since both parties have now agreed the outstanding issues. The CCG is supporting the practice to establish a patient communications pack and this engagement will commence shortly. The practice is planning to move at the end of April 2019. BHT is carrying out the refurbishment work and ETTF funds have been secured to fund this. Cressex Health Centre: The CCG will be supporting a meeting scheduled on 21/3/2019 to work through the outstanding points on the lease negotiations. At its meeting in December 2018, the PCCC approved the novation of the APMS contract for Cressex Health Centre, High Wycombe from CV Health to

Better Health Bucks (BHB) from 1 April 2019. The approval was given provided the necessary registrations for CQC had been completed and there is a signed sub-lease in place for the main site at Hanover House by 31 March 2019. It is noted this timeframe may not be met and a novation agreement may be needed to resolve the issues by the end June 2019. Carrington House: This has been referred to the DV to undertake a rent assessment and review appropriate terms of a lease due to forthcoming GP Partner retirements.

6 Water Meadow Surgery

The Practice Manager at Water Meadow Surgery has advised that the Pharmacy no longer occupy the first floor room that was previously excluded from their rent reimbursement (review date 10 Nov 2016), with effect from the 18th January 2019 . Since the 10 Nov 2016, the practice has received £104,700 p.a., and are now seeking an additional £2,235 (for the room previously occupied by the Pharmacy) to be included in their rent reimbursement taking the annual reimbursement to £106,935 with effect from the 18th February 2019. Action: The premises sub group agreed to the additional £2,235 p.a. increase, subject to the practice providing confirmation of what GMS services are now being offered out of this space.

HD/VP

7

Ownership Models for GP Premises using S106 Monies NL explained the CCG continues its work with AVDC planners to negotiate S106 contributions for pooled arrangements to support new primary care infrastructure. The two main areas of challenge are:

1. Negotiating changse to old S106 agreements which now offer inadequate provision;

2. The flow of S106 monies into another public body and GP Ownership models.

The purpose of this paper is to inform members of the challenges to each potential ownership model and the actions being taken to mitigate financial risk to the CCG and to assure an adequate provision of general medical services is in place for the increasing population. A recommendation within the paper is to seek legal advice to check these options are robust. It was agreed any costs associated with instructing a planning lawyer must be capped at £10k (including VAT). Action: PR to write a brief to scope out the request for legal advice. Action: NL will take this discretionary spend request to SMT for approval. Action: HD will note these recommendations from the premise sub group to the PCCC. Action: Members of the Premise Sub Group confirmed this paper can go to the PCCC meeting on 6th March 2019.

PR NL HD VP

8

Strategy for Health Provision in South Aylesbury NHS Buckinghamshire Clinical Commissioning Group and Aylesbury Vale District Council Planning Department (the Planners) are currently discussing the need for new health infrastructure in response to housing and employment growth in Aylesbury (South of A41). The developments in this strategy include Hampden Fields, Woodlands, Aylesbury Garden Town1 and RAF Halton. The paper presented to the Premises Sub Group sets out the CCGs strategy for this population growth and notes work to date and future actions. Action: Members of the Premise Sub Group confirmed this paper can go to the PCCC meeting on 6th March 2019.

VP

9

Update on Hubs and the BHT Estate Strategy BHT have competed their strategy and this has been shared with partners.

10

Update on OPE and MIG applications HD advised Buckinghamshire has been successful in the award of £375k of OPE funding the following:

Pre Project Costs for the new hub at Buckingham

A feasibility study for Stoke Mandeville Hospital

A Mapping exercise and Feasibility study for Bourne End

Programme management for OPE at County level. MIG: Bucks CCG was awarded £428K from NHSE for minor improvement grants in 2018/19. Projects were identified and work needs to be either completed or be well underway by the end of March 2019. Action: VP to request a status update from NHSE and report back at the next Premises Sub group meeting.

VP

11

Current consultations South Bucks and Chiltern Councils are in the early stages of drafting their Local Plans. The CCG has been consulted and provided comments on the draft plan. The Wycombe local plan is with the Inspectors and the CCG has reviewed the recommendations with no further comment required.

12 Any Other Business

Alton House in Aylesbury is an office block being converted into flats. AVDC have approached the CCG to see if we wish to go ahead and bid for a S106 financial contribution. This increase in 77 new dwellings

will affect Meadowcroft and Whitehill surgeries. It was agreed we would struggle to meet the CIL regulations to invest in either of these 2 sites (Meadowcroft is moving to a new build in 2022 and Whitehill has capacity at their sister site at Fairford Leys). It was agreed not to pursue this particular S106 request.

It is agreed we need to undertake a piece of work to agree a methodology for calculating land values and S106 contributions for health provision.

Action: PR agreed to work up a scope for this work with an estimated cost. We will approach colleagues at Oxford CCG to see if they will consider sharing the cost.

PR and VP met with the Poplar Grove Practice and their Landlords to discuss the infrastructure changes needed to take on the increase in population from the neighbouring Kingsbrook Estate. The landlords have indicated they will consider two options with option 1 being their preferred option:

1. Landlord covers cost of the infrastructure changes but would request practice enters into a new 25 year lease (currently 20 years) to increase the value of their asset. The S106 would not be utilised in this option and CCG would need to approach AVDC to see if this sum can be added to the sum being negotiated for the permanent facility.

2. Practice carries out work using landlords recommended contractors and S106 funds to cover costs. This would be subject to landlord consent and may require reinstatement back to original state at the end of the lease Action: VP will present a paper at the 26th April meeting listing the options available and the associated risks.

The CCG is being approached by practices affected by population growth for funding for pre project planning costs to scope out the work required to move these projects forward. The CCG has approached NHSE for any slippage funds but has not been successful. Action: HD will escalate this request to NHSE to see if there is anything that can be allocated from existing Bucks projects. Action: KH to discuss this further with GH and then take the request to SMT. We estimate £10k per project is required.

HD explained the practices based at Calcott in Chalfont St Peter have requesting support from CCG and BHT in light of new housing developments in the Chalfonts. PR will be involved and this will be a priority piece of work for Bucks.

PR

VP

HD

KH

Date of Next Meeting

Friday 26th April 2019, 1.30pm – 3.00pm, Large Meeting Room, Amersham.

ALL

MEETING: Primary Care Commissioning Committee PAPER: M


TITLE: Contract Variations (for information)

AUTHOR: Wendy Newton, Primary Care Manager



For Action

For Approval

For Decision

For Assurance

For Information

Summary of Purpose and Scope of Report: Report highlighting approved contract variations.


None – paper is for information.






Governance requirements: (Please tick each box as is relevant to the paper) Governance Element Y N N/A Comments/Summary


Equality

Quality

Financial

Risks

Statutory/Legal Practices must inform the CCG of any changes to the terms of their contract.



Supporting Papers:

Contract Variation Log.

Contract Variations– Report Dated 24 May 2019

Dr Gwenlaid Williams 2655079 GP Partner

Retirement 21/12/2017 K82073 Westongrove Partnership PMS

Dr Nicola Dickinson 7020415 Salaried GP

Partner GP

01/11/2018 K82051 The Misbourne Surgery GMS

Dr Rupinder Pardesi 6147501 Salaried GP

Partner GP

01/11/2018 K82051 The Misbourne Surgery GMS

Dr Greg Simons 4158763 Partner GP

Salaried GP

01/01/2019 K82007 The Swan Practice GMS

Dr Katherine O'Brien 4211280 Partner GP

? 05/05/2019 K82058 Gladstone Surgery GMS

Dr Isabel Taylor 3057067 Partner GP

? 01/01/2018 K82051 The Misbourne Surgery GMS

Dr Sutapa De 4069373 ? GP Partner

01/04/2019 K82044 Carrington House Surgery GMS

Dr Kate Grint 6135457 Partner GP

? 01/05/2019 K82046 The Simpson Centre GMS

Buckinghamshire Primary Care Commissioning Committee · Dr Stephen Burr (SB), Clinical Locality...

Documents

Transcript of Buckinghamshire Primary Care Commissioning Committee · Dr Stephen Burr (SB), Clinical Locality...