Primary Care Commissioning Committee Committee in Common ... · Jane O’Grady (JO’G) Health &...

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Primary Care Commissioning Committee

Committee in Common Part 1: AGENDA

Thursday 1 June 2017, 3pm – 4.25pm

Bevan Room, Aylesbury Vale CCG, 2nd Floor The Gateway, Gatehouse Road, Aylesbury, Bucks HP19 8FF

Agenda Item Desired Outcome(s)

Contributor Papers/Times

1 Welcome and Introductions: Apologies:

Graham Smith CHAIR 3.00pm – 3.10pm

Paper A 3.10pm – 3.15pm

2 Declarations of Interest Graham Smith CHAIR

3 Questions from members of the public

Graham Smith CHAIR

4 Minutes of the March 2017 meeting and Action Log

Approve Graham Smith CHAIR

5 PCCC Terms of Reference and Scheme of Delegation

Note and Action Helen Delaitre, CCGs Paper B 3.15pm – 3.25pm

6 Primary Care Risk Register Review and Approve

Helen Delaitre, CCGs Paper C 3.25pm – 3.35pm

Primary Care Commissioning 7 Trinity Health / Wellington House

Surgery Merger Approval Helen Delaitre, CCGs

Paper D

3.35pm – 3.50pm 8 Premises Sub-Group Approve Helen Delaitre, CCGs Paper E

3.50pm – 3.55pm 9 Primary Care Development

Scheme Approve Kate Holmes / Simon

Kearey, CCGs Paper F

3.55pm – 4.15pm 10 Hawthornden Surgery in

Flackwell Heath Branch Closure Ratification Helen Delaitre, CCGs Paper G

4.15pm – 4.20pm

Any Other Business

11 Any Other Business Date of Next Meeting: 7 Sept 2017

Graham Smith CHAIR 4.20pm – 4.25pm

For Information Only

12 Report from the Primary Care Operational Groups held in April and May 2017

Paper for information only Paper H

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13 Building Primary Care Resilience: Update

Paper for information only Paper I

14 CQC Update Paper for information only Paper J

Paper A

Primary Care Commissioning Committee (PCCC)

Thursday 2 March 2017, 3.30pm – 5.00pm Bevan Room, AVCCG, The Gateway, Gatehouse Road, Aylesbury, Bucks

PCCC Voting Members Present Graham Smith (GS), Chair Lay Member for AVCCG Governing Body Robert Parkes (RP) Lay Member for AVCCG Governing Body Robert Majilton (RM) Director of Sustainability & Transformation, CCGs (Acting CO) Debbie Richards (DR) Director of Commissioning & Delivery, CCGs Alan Cadman (AC) Deputy Chief Financial Officer, CCGs (Acting CFO) Lisa Beaumont (LB) Associate Director of Quality & Safeguarding, CCGs

In Attendance (non-voting) Dr Graham Jackson (GJ) Clinical Chair, AVCCG Dr Raj Bajwa (RB) Clinical Chair, CCCG Helen Delaitre (HD) Head of Primary Care, CCGs Colin Hobbs (CH) Assistant Head of Finance, NHS England South Central Thalia Jervis (TJ) Chief Executive, Healthwatch Bucks Tony Dixon (TD) Lay Member for CCCG Governing Body Louise Smith (LS) Associate Director Commissioning & Locality Delivery, CCGs Dr Paul Roblin (PR) CEO, BBOLMC Jane O’Grady (JO’G) Health & Wellbeing Board Representative Dr Karen West (KW) Clinical Director for Integrated Care, CCGs Wendy Newton (WN) Primary Care Manager, Bucks CCGs Jessica Newman (JN) Assistant Contracts Manager, NHS England South Central Sarah Edwards (SE), Notes Programme Support Officer, CCGs

Apologies Louise Patten Chief Officer, Bucks CCGs Nicola Lester Director of Transformation, CCGs Nicky Wadely Programme Manager for Co-Commissioning, NHS England South

Central

Item No.

Agenda Item Actions

1 Welcome & Introductions Members of the PCCC were welcomed to the meeting and introductions given. It was noted that no members of the public were present and that the meeting was quorate.

2 Declarations of Interest. No further declarations of interest were made in addition to those declared at previous PCCC meetings. All conflicts of interests were noted on each agenda item.

3. Questions from Members of the Public

No members of the public were in attendance.

4 Minutes and Actions of Committee Meeting 1 December 2016 Minutes of 1 December 2016 agreed with the following amends: Dr Karen West and Dr Graham Jackson attended the meeting as non-voting members of the PCCC. The action log was reviewed and updated accordingly.

5 Primary Care Risk Register The CCG has changed the way it reviews risks and reports these to the Governing Body. A new risk reporting system called Verto has been introduced and each sub-group of the Governing Body is being asked to review the way it monitors and manages risks The PCCC were asked to review and approve the inclusion of the proposed risks onto the Primary Care Risk Register and to review and approve the proposed monitoring arrangements for the Register. On 2 February 2017 the Primary Care Operational Group (PCOG) agreed to recommend to the PCCC the following monitoring arrangements:

• Regular risk monitoring of the PCCC’s risks will become a function of the PCOG and the Risk Register will become a standing item on the PCOG agenda alongside the meeting minutes and action log.

• If the level of risk is deemed to be 12 or above, then these risks will be reported to the PCCC.

• The PCOG will manage risks where the level of risk is deemed to be below 12. • The PCCC will be responsible for agreeing the inclusion and deletion of risks

on the Primary Care Commissioning Risk Register. In the interests of ensuring that risks are added in a timely way, agreement on the inclusion of a risk can be done post-addition.

The Head of Primary Care proposed risks to be added to the Primary Care Risk Register. The PCCC discussed the proposed risks and the mechanism for rag rating identified risks. The PCCC raised the following comments:

• In line with other Programme Boards, the Risk Log should be known as The Risk Register.

• Risk owners need to be clearly identified and involved in the scoring mechanism. Sub owners can be included for managing the mitigation of certain aspects of the overarching risk. The risk owner should be a member of the PCCC to ensure they can be held to account.

• If risks are not appropriately mitigated or actions are not having the desired effect then the risk should be escalated to the PCCC.

• The PCCC proposed an additional risk to be added to the Register to

Draft Primary Care Commissioning Risk Lo

encompass the transformation of primary care. The risk should note the significant change in patient behaviour required within this transformation.

• The Risk Register should be a standing item on the PCCC agenda. • Section the Register into headings i.e. Quality, Workforce & Finance or align

headings to the strategic aims of the CCG. • Axes on the risk scoring matrix need to be made clear.

Actions: The PCCC agreed for the PCOG to further develop the identified risks and to collectively consider the scoring attached to each risk. Accountable risk owners will be appointed to each risk. Risk owners to be members of the PCCC to ensure they can be held to account. The next iteration of the Primary Care Risk Register will be reviewed by the PCCC on 1 June 2017. Approval: The PCCC approved the proposed monitoring arrangements for the Primary Care Risk Register. The expectation is for the PCOG to ensure that risks are appropriately mitigated and resulting actions undertaken, and to regularly report back to the PCCC for oversight and approval.

PCOG

6 Delegated Responsibilities for Primary Care Commissioning Chiltern CCG Delegation Agreement Following prior approval from the Governing Body, the delegation agreement for NHS Chiltern CCG has been formally signed by the Chief Officer and returned to NHS England prior to the deadline of 1 March 2017. The delegation agreement is presented to this Committee for assurance. The PCCC was assured that the agreement did not include any local terms within Section 7. The Memorandum of Understanding (MoU) which outlines the level of support that NHS England will continue to offer the CCG remains in draft form and will be reviewed by the PCOG on 6 April 2017. PCCC Terms of Reference Post Delegation Future NHS Aylesbury Vale PCCC meetings will be held “in common” with NHS Chiltern CCG. The PCCC Terms of Reference (ToR) will be amended to reflect this arrangement. The ToRs will require review by the PCCC on an annual basis. Other CCG Committees already meet in common, with aligned agendas to reduce duplication of work. Following a change to the CCGs Programme Board structure, Nicola Lester, Director of Transformation and who is the Senior Responsible Officer for the Community Services Programme Board will become a member of the PCCC to enhance continuity around discussion and decision making. The Committee discussed representation and asked for the following changes to be made:

• Clinical Director for Integrated Care and CCG Clinical Chairs to be recorded as non-voting members of the Committee.

• Director of Transformation to be a voting member of the Committee.

Delegated Agreement

• Associate Director of Quality & Safeguarding to be recorded as a voting member of the Committee.

• Ensure that the ToRs include a clear distinction between voting members and non-voting members.

The ToRs should make clear that there may be times when different or specific commissioning decisions need to be made in respect of only one of the Buckinghamshire CCGs. RB raised the issue of an offer provided by his predecessor that there would be a member GP representative for the Chiltern practices on the PCCC. This promise has not been rescinded and therefore remains the expectation of NHS Chiltern CCG members. PR advised that in his capacity as CEO of Berkshire, Buckinghamshire & Oxfordshire LMC he was in a position to act as a fair and impartial representative for NHS Chiltern CCG member practices. Action: RB to ask NHS Chiltern CCG members to sanction PR representing their interests on the PCCC. Approval: As further amends are required to the ToRs the PCCC was unable to approve. The PCCC agreed that it would be appropriate for a Chairs Action to be taken to approve changes following amends and for the PCCC ToR to be ratified by the Governing Body when they meet in April 2017.

RB

HD/GS

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QOF/QIS in 2017/18 GJ, KW and RB declared an interest in this item as clinicians – no finances were due to be discussed during the presentation and the Chair agreed to their remaining present for this part of the meeting. LS delivered a presentation on the proposed Primary Care Development Scheme for 2017/18 and 2018/19. The scheme is intended to encompass the Quality and Outcomes Framework (QOF) and current Quality Improvement Scheme (QIS). The PCCC were asked to review and approve the work undertaken to date and the intended direction of travel. The PCCC were further asked to delegate decision making responsibilities for this piece of work to prevent delays. LS advised that the programme is currently in the process of development with clinical input received. The purpose of the scheme is to maintain and improve the clinical quality of primary care services whilst supporting the provision of population-based healthcare within the available financial envelope. The development scheme consists of a 3 tier model:

• Foundation – all participating practices would be required to achieve the Foundation gateway in year 1 – expectations of the Foundation gateway includes EMIS Implementation, increased ERS usage, GP Cluster

Primary Care Development Model

development / Standardisation of protocols and templates and participation in the Grasp AF audit and National Diabetes Audit.

• Delivery – (only available to those practices that have achieved all elements of the Foundation gateway) - expectation for this level includes supported self-care through care & support planning, adherence to local Right Care clinical pathways, meeting directed prescribing, diabetes, AF and EoL targets.

• Care Delivery Alternative – allows alternative metrics to those mandated in

traditional QOF to be delivered including targets for diabetes, heart failure, hypertension and COPD.

The scheme has been developed in consideration of current resources, evidenced-based care, population-based commissioning and in alignment with national and local priorities. The PCCC raised the following comments:

• There is a desire to move all community services onto EMIS during 2017/18 this will exclude Health Visitors who are commissioned by Public Health and not the CCG.

• There are 7 practices in NHS Chiltern CCG who currently use an alternative clinical system to EMIS. Practices have notified the CCG that they are reluctant to change systems due to quality concerns and potential problems caused by the switch. The CCG will need to facilitate and support the transition of the 7 practices in Chiltern and use in-house expertise to make the compelling case for change.

• LMC may be able to support practices with the transition to EMIS. • Practices may require income guarantee arrangements for QOF during the

transitional phase of the programme. • The PCCC acknowledged that not all pathways are currently available on ERS

and therefore this needs to be reflected in the criteria so member practices are not penalised.

• Clinical coding improvements will be required in order to monitor health inequalities efficiently, particularly ethnicity.

A paper will be presented to the Governing Body on 9 March 2017 where the financial envelope for this programme will be discussed. Actions: Updated paper to be circulated to PCCC.

LS LS

8. GP Patient Experience Report: February 2017 GP Patient Experience Report circulated prior to meeting and was taken as read. TJ advised the PCCC of the following:

• Details of the report have been circulated to member practices however; the report has not been published.

• The patient experience survey was undertaken by volunteers. • Only 2 / 3 member practices were unhappy with Healthwatch visiting and

GP Patient Experience Report

undertaking the patient experience survey. • TJ is in the process of attending Locality Meetings to introduce Healthwatch

Bucks. The PCCC considered the opportunity to further highlight the Healthwatch role with practices, by encompassing Healthwatch in an informal inspection process which would help them to prepare for their CQC inspections. PR said it would be useful for the LMC to be involved in this process. Action: TJ and PR to discuss how Healthwatch can support member practices.

PR/TJ

9 Finance Report: M10 CH presented the finance report which sets out the financial position at month 10 of 2016/17 for the delegated primary care services commissioning budget of NHS Aylesbury Vale CCG. There was one point to note in relation to the annual forecast which is that the budget at month 10 is £300,000 below plan.

M10 Finance Report

10 Any Other Business General Practice Resilience Programme GJ, KW and RB declared an interest in this item as their practices are members of FedBucks. It was noted that this paper had not been pre-circulated with the pack therefore declarations were not made at the start of the meeting. The Chair agreed to the conflicted members remaining in the room for this discussion. HD presented a proposal from FedBucks, outlining the use of Buckinghamshire General Practice Resilience Programme (GPRP) funding to work with practices within the county. The proposal outlined the Federation’s intention to support co-ordinated locality discussions and joint working which would enable the formation of GP clusters and plans for local service transformation and integration. Joint GPRP funding in 2016/17 for NHS Aylesbury Vale CCG and NHS Chiltern CCG is £114,000. Funding for the next two consecutive financial years has been agreed at £57,000 per annum. The money available for 2016/17 has to be committed by 31 March 2017. Potential programmes of support which were in line with NHSE Guidance had been discussed at PCOG in January 2017. Following agreement numerous providers were considered to deliver the identified objectives. The PCCC were asked to consider whether the contents of the paper should be recommended to the Governing Body for approval on 9 March 2017. The PCCC did not support the paper being presented to the Governing Body in its current iteration and agreed that further detail was required. The PCCC provided the following comments:

• The FedBucks paper did not demonstrate that the proposed support could be provided within the available financial envelope.

• The CCG would require assurance that FedBucks fully understood the expectations of the CCG with regards to this work.

• The paper needs to include confirmation that all member practices would receive an equitable opportunity to benefit from the packages of support, not just the practices who are members of FedBucks.

• Ensure monitoring and evaluation methods are agreed prior to funding being transferred to FedBucks.

• The updated paper should clearly outline to the Governing Body how FedBucks would be spending the funding and the principles and expected outcomes of the scheme.

Actions: PCCC suggested a commissioning paper be prepared for Governing Body outlining the underlying principles for the use of this funding requesting that PCCC receive delegated responsibility for spending the funding in due course. In anticipation that Governing Body will approve the Commissioning Paper, HD to prepare a specification for this piece of work. Putting these steps in place will ensure a more robust process is followed for the allocation of this funding.

HD

11. Date of Next Meeting: Thursday 1st June 2017, 3pm – 5pm, Bevan Room, AVCCG

Action Log

Action Owner / Responsibility

Status Progress Details

Scheme of Delegation – Forward to Audit Committee Helen Delaitre Open Quality in Primary Care – Amend to remove markers which are difficult to interpret and roll out across Chiltern practices

Karen West Closed KW reported that meetings have commenced.

Primary Care Risk Register - PCOG to further develop the identified risks and to collectively consider the scoring attached to each risk. Accountable risk owners will be appointed to each risk. Risk owners to be members of the PCCC to ensure they can be held to account. The next iteration of the Primary Care Risk Register will be reviewed by the PCCC on 1 June 2017.

PCOG Closed Discussed at PCOG Meetings in April and May. Ready for review and adoption by the PCCC on 1 June 2017

GP Member Representation - RB to ask NHS Chiltern CCG members to sanction PR representing their interests on the PCCC.

Raj Bajwa Open RB has liaised with Paul Roblin re the canvassing of practices and agreement that Paul will represent the interests of members from both Chiltern and Aylesbury Vale CCGs

Primary Care Development Scheme – LS to circulate to the PCCC an update paper on the Primary Care Development Scheme.

Louise Smith Open Agenda Item.

Health Watch - TJ and PR to discuss how Healthwatch can support member practices.

Thalia Jervis / Paul Robin

Open

GPRP Funding - PCCC suggested a commissioning paper be prepared for Governing Body outlining the underlying principles for the use of this funding requesting that PCCC receive delegated responsibility for spending the funding in due course. In anticipation that Governing Body will approve the Commissioning Paper, HD to prepare a specification for this piece of work. Putting these steps in place will ensure a more robust process is followed for the allocation of this funding.

Helen Delaitre Closed Building General Practice Resilience project underway led by KPMG / FedBucks. Update for information on agenda for PCCC on 1 June 2017

PCCC Decision Log

Decision Required Date of Meeting

Record of Decision

Primary Care Risk Register - The PCCC were asked to review and approve the inclusion of the proposed risks onto the Primary Care Risk Register and to review and approve the proposed monitoring arrangements for the Register.

02.03.2017 The PCCC approved the proposed monitoring arrangements for the Primary Care Risk Register. The expectation is for the PCOG to ensure that risks are appropriately mitigated and resulting actions undertaken, and to regularly report back to the PCCC for oversight and approval.

PCCC Terms of Reference – PCCC to approve amendments to their ToR following the delegation of NHS Chiltern CCG and internal restructures within the CCG.

02.03.2017 The PCCC agreed that it would be appropriate for a Chairs Action to be taken to approve changes following amends to the PCCC ToR and for the ToRs to be ratified by the Governing Body when they meet in April 2017.

Primary Care Commissioning Committee Abbreviations and Acronyms Glossary A&E Accident and Emergency K Thousand ACHT Adult Community Health

Team KLOE Key Lines of Enquiry

ACO Accountable Care Organisation

LMC Local Medical Committee

AF Atrial Fibrillation LPF Lead Provider Framework AGM Annual General Meeting M Million APMS Alternative Provider Medical

Services MAGs Multi Agency Groups

AO Accountable Officer MCA Mental Capacity Act AQP Any Qualified Provider MCP Multi-specialty Community Provider AT Area Team MIG Minor Improvement Grant AVCCG Aylesbury Vale Clinical

Commissioning Group MK Milton Keynes Foundation Trust

BAF Board Assurance Framework MusIC Musculoskeletal Integrated Care BCC Buckinghamshire County

Council NHSE NHS England

BCF Better Care Fund NHSi NHS Improvement BAF Board Assurance Framework NOAC New Oral Anticoagulants BHT Buckinghamshire Healthcare

Trust OCCG Oxfordshire Clinical Commissioning

BME Black and Minority Ethnic OOH Out of Hours BPPC Better Payment Practice Code ORCP Operational Resilience & Capacity Planning C4Q Commissioning for Quality

Committee OUH Oxfordshire University Hospitals Trust

CCCG Chiltern Clinical Commissioning Group

PACS Primary & Acute Care Systems

CDIF Clostridium Difficile PAS Patient Administration System CEPN Community Education

Provider Network PB Programme Board

CFO Chief Finance Officer PBR Payment by Results CHC Continuing Health Care PIRLS Psychiatric In Reach Liaison Service CIP Cost Improvement

Programme PLCV Procedures of Limited Clinical Value

COI Conflict of Interest PMS Personal Medical Services COPD Chronic Obstructive

Pulmonary Disease PCCC Primary Care Commissioning Committee

CPA Care Programme Approach PCOG Primary Care Operational Group CQC Care Quality Commission POD Point of Delivery CQRM Contract Quality Review

Meeting POG Programme Oversight Group

CQUIN Commissioning Quality & Innovation

PPA Prescriptions Pricing Authority

CSCSU Central Southern Commissioning Support Unit

PPE Patient & Public Engagement

CSIB Children’s Services Improvement Board

QIPP Quality, Innovation, Productivity & Prevention

CSP Care & Support Planning QIS Quality Improvement Scheme CSR Comprehensive Spending

Review QOF Quality & Outcomes Framework

CSU Commissioning Support Unit RAG Red, Amber, Green DES Directly Enhanced Service

DGH District General Hospital RBH Royal Berkshire Hospital DOLS Deprivation Of Liberty

Safeguards RCA Root Cause Analysis

DST Decision Support Tool (CHC) REACT Rapid Enhanced Assessment Clinical Team

EDS Equality Delivery System RRL Revenue Resource Limit EOL End of Life RTT Referral to Treatment ETTF Estates and Technology

Transformation Fund SCAS South Central Ambulance Service

F&F Friends and Family SCN Strategic Clinical Network FHFT Frimley Health Foundation

Trust SLA Service Level Agreement

FOT Forecast Outturn SLAM Service Level Agreement Monitoring FPH Frimley Park Hospitals NHS

Foundation Trust SRG Systems Resilience Group

GB Governing Body STP Sustainability & Transformation Planning GMS General Medical Services SUS Secondary Uses Service GPFV General Practice Forward

View TDA Trust Development Authority

GPRP General Practice Resilience Programme

TOR Terms of Reference

HASU Hyper Acute Stroke Unit TV Thames Valley HETV Health Education Thames

Valley TVN Tissue Viability Nurse

HWBB Health & Wellbeing Board UECN Urgent Emergency Care Network ICE Integrated Clinical Experience VuPS Vulnerable Practice Scheme ICS Inhaled Corticosteroids YTD Year to Date ICU Intensive Care Unit 5YFV 5 Year Forward View IFR Individual Funding Request IG Information Governance

Primary Care Commissioning Committee - Terms of Reference – May 2017

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MEETING: Primary Care Commissioning Committee Paper B

DATE: 1 June 2017

TITLE: Primary Care Commissioning Committee Terms of Reference (ratified by Governing Body)

AUTHOR: Russell Carpenter, Corporate Governance Lead

LEAD DIRECTOR: Robert Majilton, Deputy Chief Officer

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information For Ratification Summary of Purpose and Scope of Report: The Governing Bodies meeting in common have formally ratified the PCCC Terms of Reference following some changes resulting from:

• NHS Chiltern CCG being formally delegated the responsibility for commissioning Primary Care Medical Services from NHS England on 1st April 2017.

• Internal reconfiguration of Programme Boards within the Buckinghamshire CCGs. From 1 April 2017 it has been agreed that the PCCC for NHS Chiltern CCG and NHS Aylesbury Vale CCG will meet in common. The Governing Bodies were asked to also ratify the following: Changes to Membership:

• Nicola Lester, Head of Transformation will sit on the Committee as a voting member. • Lisa Beaumont, Associate Director of Nursing and Quality will sit on the Committee

as a voting member. Voting Members

• Lay member (PCCC Chair) • Lay member (Deputy PCCC Chair ) • Chief Officer • Chief Finance Officer • Director of Transformation • Associate Director of Nursing and Quality


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Quoracy Five members must be present for the quorum to be established including:

• At least two lay members or one lay member and the Associate Director of Nursing and Quality, and;

• Either the Chief Officer (CO) or the Chief Finance Officer (CFO). Where a required decision is deemed to apply to only one of the two CCGs holding meetings in common, then membership and quoracy will be constructed accordingly. With regards to the Lay Member Deputy PCCC Chair position, the Governing Body considered the appropriate COI guidance (NHSE June 2016) which states: To ensure appropriate oversight and assurance, and to ensure the CCG Audit Chair’s position as Conflicts of Interest Guardian is not compromised, the Audit Chair should not hold the position of Chair of the Primary Care Commissioning Committee. But the guidance also says: Ideally the CCG Audit Chair would also not serve as Vice Chair of the Primary Care Commissioning Committee. However, if this is required due to specific local circumstances (for example where there is a lack of other suitable lay candidates for the role), this will need to be clearly recorded and appropriate further safeguards may need to be put in place to maintain the integrity of their role as Conflicts of Interest Guardian in circumstances where they chair all or part of any meetings in the absence of the Primary Care Commissioning Committee Chair. Therefore the Governing Body approved Robert Parkes or Tony Dixon can undertake the role of PCCC Deputy Chair. In relation to schedule 4 extract of scheme of reservation and delegation, the Governing Body were reminded that it was agreed at their meeting in March 2017 (in public) that the financial thresholds (£50k cap per CCG for all decisions) would be further reviewed following delegation for Chiltern CCG. It was stated at the time that it would be July 2017 at the earliest that the Audit Committee would recommend further changes to the scheme for the Governing Bodies to ratify. The Governing Body has requested that the PCCC consider the appropriateness of the current scheme of reservation and delegation and record any recommended amendments which would assist the PCCC to carry out its duties. The PCCC are asked to note the approved Terms of Reference. The PCCC are asked to review the appropriateness of the scheme of reservation and delegation and recommend any potential amendments which would assist the Committee to undertake its duties. Conflicts of Interest: None in respect of approvals requested. Members should note that Terms of Reference have been designed to ensure that the Committee will be quorate for decision making without any member GP/GP partners present. 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


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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 The Primary Care Commissioning Committee is a

statutory sub group of the Governing Bodies. Prior consideration Committees / Forums / Groups

The Terms of Reference (ToR) were discussed and amendments agreed at the Primary Care Commissioning Committee on 2nd March 2017.

Membership Involvement

Supporting Papers: Primary Care Commissioning Committee Terms of Reference.


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Terms of Reference for Delegated Commissioning Arrangements including Scheme of Delegation and Primary Care Commissioning Committee Document Version Date Version

Number Description of Changes Edited by

10.03.15 2.1 Watermark added Change to paragraph 13 regarding number of votes

Louise Smith

11.03.15 2.2 Reference to Thames Valley area team removed and replaced with NHS England. Full Acronyms explained Change to secretariat from NHSE to AVCCG Change to membership section to read Chief Officer or Chief Finance Officer

Louise Smith Elaine Baldwin

11.03.15 NOTE Sent to Graham Jackson for Chairs action and full Governing Body for approval of sign off. Sent to NHS England (South) as final version.

04.03.16 3.0 Documented updated to delegated commissioning arrangements including scheme of delegation and Primary Care Commissioning Committee.

Elaine Baldwin

22.06.16 4.0 Document updated to take account of joint working arrangements between Aylesbury Vale and Chiltern CCGs.

Helen Delaitre

30.8.16 5.0 Document amended to include draft scheme of delegation at Schedule 4 and

Helen Delaitre

7.11.16 6.0 Document amended to include list of voting members, their deputies and deputising rights.

Helen Delaitre

11.2.17 7.0 Document amended to reflect Committee in Common arrangements starting April 2017.

Helen Delaitre

03.05.17 8.0 Document amended to reflect changes to membership of PCCC and to include 2017/18 MOU for Primary Medical Services Support for Delegated CCGs. ToR reflect arrangements to make a CCG specific decision.

Wendy Newton/ Helen Delaitre/ Russell Carpenter


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Note: the following set of terms of reference was previously in place from 1 April 2016 for Aylesbury Vale CCG. As of 1 April 2017 and with delegated commissioning, the same set of terms of reference is in place for Chiltern CCG. Both committees hold their meetings in common. The only points of variance relate to geographical coverage. Introduction Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that NHS England was inviting Clinical Commissioning Groups (CCGs) to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to a CCG.

1. In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended), NHS England has delegated the exercise of the functions specified in Schedule 1 to these Terms of Reference. The delegation is set out in Schedule 1.

2. The CCG has established the Primary Care Commissioning Committee (“Committee”). The

Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers.

3. The Committee comprises representatives of the following bodies:

• The CCG • NHS England • Healthwatch Bucks • LMC • Health and Well Being Board

Statutory Framework

4. NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 1 in accordance with section 13Z of the NHS Act.

5. Arrangements made under section 13Z may be on such terms and conditions (including terms

as to payment) as may be agreed between the Board and the CCGs. 6. Arrangements made under section 13Z do not affect the liability of NHS England for the

exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including:

a) Management of conflicts of interest (section 14O);

b) Duty to promote the NHS Constitution (section 14P);


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c) Duty to exercise its functions effectively, efficiently and economically (section 14Q);

d) Duty as to improvement in quality of services (section 14R);

e) Duty in relation to quality of primary medical services (section 14S);

f) Duties as to reducing inequalities (section 14T);

g) Duty to promote the involvement of each patient (section 14U);

h) Duty as to patient choice (section 14V);

i) Duty as to promoting integration (section 14Z1);

j) Public involvement and consultation (section 14Z2).

7. The CCGs will also need to specifically, in respect of the delegated functions from NHS England, exercise those set out below: • Duty to have regard to impact on services in certain areas (section 13O); • Duty as respects variation in provision of health services (section 13P).

8. The Committee is established as a committee of the Governing Body of the CCG in accordance with Schedule 1A of the “NHS Act”.

9. The members acknowledge that the Committee is subject to any directions made by NHS

England or by the Secretary of State.

Role of the Committee

10. The Committee is established in accordance with the above statutory provisions to enable the members to make collective decisions on the review, planning and procurement of primary care services under delegated authority from NHS England.

11. In performing its role, the Committee will exercise management of the functions in accordance with the agreement entered into between NHS England and the CCG, which will sit alongside the delegation and terms of reference.

12. The functions of the Committee are undertaken in the context of a desire to promote increased

co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

13. The role of the Committee shall be to carry out the functions relating to the commissioning of

primary medical services under section 83 of the NHS Act.

14. This includes the following:


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• GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract);

• Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);

• Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);

• Decision making on whether to establish new GP practices in an area;

• Approving practice mergers; and

• Making decisions on ‘discretionary’ payments (e.g., returner/retainer schemes).

15. The CCG will also carry out the following activities:

a) To plan, including needs assessment, for primary care services in the CCG’s geographical area .

b) To undertake reviews of primary care services in the CCG’s geographical area.

c) To co-ordinate a common approach to the commissioning of primary care services

generally.

d) To manage the budget for commissioning of primary care services in the CCG’s geographical area.

e) To assist and support NHS England in discharging its duty under section13E of the NHS Act 2006 (as amended by the Health and Social Care Act2012) so far as relating to securing continuous improvement in the quality of primary medical services.

f) To undertake and deliver an estates strategy across the CCG’s geographical area.

Geographical coverage

(Aylesbury Vale)

16. The Committee will comprise NHS Aylesbury Vale CCG. It will undertake the function of NHS Aylesbury Vale CCG commissioning primary medical services for the Aylesbury Vale area, as defined within the Constitution.

(Chiltern)

16. The Committee will comprise NHS Chiltern CCG. It will undertake the function of NHS Chiltern CCG commissioning primary medical services for the Chiltern area, as defined within the Constitution.


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Membership

The Chair of the PCCC should not also chair the Audit Committee. The Chair of the Committee shall be a Lay member of the CCGs Governing Body. The Vice Chair of the Committee shall be a lay member of the CCGs governing body and agreed by the Governing Body.

17. Voting Members of the Primary Care Commissioning Committee shall consist of: • Lay member (PCCC Chair) • Lay member (Deputy PCCC Chair) • Chief Officer • Chief Finance Officer • Director of Transformation • Associate Director of Nursing and Quality

If GP members need to withdraw from decision making for conflicts of interest reasons, the Committee would still be quorate with a lay and executive majority.

Other non-voting attendees • Invitation to a Healthwatch Bucks representative • Invitation to a Health and Wellbeing Board representative • Local Medical Committee representative • NHS England • Clinical Director for Integrated Care • Clinical Chairs • Head of Primary Care, CCGs • Non-conflicted GPs from other CCGs • Additional Lay members • Subject Matter experts (e.g. premises, workforce)

Provision could be made for the Committee to have the ability to call on additional lay members or CCG members when required, for example where the Committee would not be quorate because of a conflict of interest. It could also include GP representatives from other CCG areas and non-GP clinical representatives (such as the CCGs secondary care specialist). Meetings and Voting 18. The Committee will operate in accordance with the CCG’s Constitution, Standing Orders and

Prime Financial Policies. The Secretary to the Committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than 5 days before the date of the meeting. When the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as s/he shall specify.


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19. Each member of the Committee shall have one vote. The Committee shall reach decisions by a

simple majority of members present, but with the Chair having a second and deciding vote, if necessary. However, the aim of the Committee will be to achieve consensus decision-making wherever possible.

20. The Committee has delegated authority to take decisions in accordance with standing orders

and schemes of delegation (Schedule 4).

21. Where a required decision is deemed to apply to only one of the two CCGs holding meetings in common, then membership and quoracy will be constructed accordingly.

Quorum

22. Five members of the Committee must be present for the quorum to be established including: • At least two lay members or one lay member and the Associate Director of Nursing and

Quality; and • Either the Chief Officer (CO) or the Chief Finance Officer (CFO).

Frequency of Meetings

23. Meetings will take place in public on a quarterly basis.

24. Meetings of the Committee shall: a) be held in public, subject to the application of 25(b);

b) the Committee may resolve to exclude the public from a meeting that is open to the public

(whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

25. Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

26. The Committee may delegate tasks to such individuals, sub-committees or individual members

as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest.

27. The Committee may call additional experts to attend meetings on an ad hoc basis to inform

discussions.


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28. Members of the Committee shall respect confidentiality requirements as set out in the CCG’s Constitution and relevant policies.

29. The Committee will present its minutes to NHS England and to the Governing Body of the CCG

each quarter for information. 30. The CCG will also comply with any reporting requirements set out in its constitution.

31. The terms of reference will be reviewed at least annually with final approval being sought from

the Governing Body. Amendments will be made, where appropriate, to reflect any updated national model terms of reference and local need.

Accountability of the Committee

32. The Committee to have delegated authority from the Governing Body: • To carry out the functions relating to the commissioning of primary medical services under

section 83 of the NHS Act. • To assist and support NHS England in discharging its duty under section 13E of the NHS

Act 2006 (as amended by the Health and Social Care Act 2012) so far as relating to securing continuous improvement in the quality of primary medical services.

• To work with NHS England to agree rules for areas such as the collection of data for national data sets, equivalent of what is collected under QOF, and IT inter-operability.

• To comply with public procurement regulations and with statutory guidance on conflicts of interest.

• To consult with Local Medical Committee and demonstrate improved outcomes, reduced inequalities and value for money when developing a local QOF scheme or DES.

• To approve the arrangements for discharging the group’s statutory duties associated with its GP practice commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, reducing inequalities, improvement in the quality of services, obtaining appropriate advice and public engagement and consultation.

Procurement of Agreed Services The below is taken from the Next Steps in Primary Care Co-commissioning document for further guidance on this please see link below. https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf 33. The Committee must comply with public procurement regulations and with statutory guidance

on conflicts of interest. The committee may vary or renew existing contracts for primary care provision or award new ones, depending on local circumstances. If the committee fails to secure an adequate supply of high quality primary medical care, NHS England may direct the CCG to act.

34. If the Committee is found to have breached public procurement regulations and/or statutory guidance on conflicts of interest, Monitor may direct the CCG or NHS England to act. NHS England may, ultimately, revoke the CCG’s delegation. Any proposed new incentive schemes should be subject to consultation with the Local Medical Committee and be able to demonstrate improved outcomes, reduced inequalities and value for money.

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf


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Consistent with the NHS Five Year Forward View and working with CCGs, NHS England reserves the right to establish new national approaches and rules on expanding primary care provision – for example to tackle health inequalities. Review of Terms of Reference

35. These terms of reference will be formally reviewed by the CCG in April of each year, following the year in which the Committee is created, and may be amended by mutual agreement at any time to reflect changes in circumstances which may arise.

36. The Committee will make decisions within the bounds of its remit.

37. The decisions of the Committee shall be binding on NHS England, and the CCG within the

scope of these TOR and the CCG’s Standing Orders.

Schedule 1 – Memorandum of Understanding (without appendices) Schedule 2 – List of Committee Members Schedule 3 – Primary Care Commissioning Committee Guidance Schedule 4 – Extract from Scheme of Delegation relating to Primary Care


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Schedule 1 MOU without Appendices

NHS England South Central

Primary Medical Services Support

1. Introduction

This offer of support sets out the working arrangements and responsibilities for the delivery of primary care medical co-commissioning in South Central under delegated commissioning (level 3) from 1 April 2017 to 31 March 2018, between:

NHS England South Central and the following clinical commissioning groups: Aylesbury Vale Clinical Commissioning Group

Bath and North East Somerset Clinical Commissioning Group (Level

Bracknell & Ascot Clinical Commissioning Group

Chiltern Clinical Commissioning Group

Gloucestershire Clinical Commissioning Group

Newbury & District Clinical Commissioning Group

North & West Reading Clinical Commissioning Group

Oxfordshire Clinical Commissioning Group

South Reading Clinical Commissioning Group

Slough Clinical Commissioning Group

Swindon Clinical Commissioning Group

Wiltshire Clinical Commissioning Group

Windsor, Ascot and Maidenhead Clinical Commissioning Group

Wokingham Clinical Commissioning Group

2. Purpose

This offer of support is a joint agreement between NHS England and each CCG that has moved to delegated status for the commissioning of general medical services. The offer sets out: the common purpose of the parties in delivering primary medical care functions at

delegated commissioning levels


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the initial period of the relationship and review period the governance arrangements how each party will contribute to the delivery of the primary care functions

3. Key Principles

Delegated commissioning enables CCGs to have greater influence on decisions relating to primary care medical services and enables an integrated approach to improving health care locally, providing opportunities for a more collaborative approach to designing local solutions to support delivery of the CCG Primary Care Strategy and the wider strategic aims of CCGs. In doing so NHS England and Clinical Commissioning Groups need to ensure they are able to share expertise and knowledge to enhance strategy, policy development and decision making working in an integrated way. This ensure contracts and commissioning functions are delivered in line with the Primary Medical Care Single Operating Model (Policy book) https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/01/policy-book-pms.pdf

As outlined in “Next steps towards primary care co-commissioning”

• “Next Steps towards primary care co-commissioning” states that there are no

additional administrative resources available for primary care commissioning services at this time, but individual CCGs may choose to deploy additional resources;

• Pragmatic and flexible solutions should be agreed by CCGs and NHS England local offices to put in place arrangements that will work locally for 2017/18;

• Delegated commissioning (level 3) allows CCGs to assume full responsibility for commissioning general medical services, while NHS England retains responsibility for reserved functions including Section 7A Public Health services, professional performance, complaints and controlled drugs.

It has been agreed with South Central CCGs and NHS England:

• There is an ongoing need for the roles currently performed by staff employed by

NHS England to continue being delivered in 2017/18 as part of the transition to delegated commissioning;

• The safe delivery of core functions is essential – this includes payment processes for practices;

• The expertise to deliver these functions currently resides within the core NHS England team;

• The existing core NHS England team will agree practical and effective working relationships with South Central CCGs during the transition to delegated commissioning for those authorised in 2017, enabling the transfer of expertise to CCG colleagues in a managed way;

• NHS England South Central will set out an offer for the collective tasks involved in the commissioning of general practice;

• The core NHS England team is not relocated and remains within NHS England structures for 2017/18;

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/01/policy-book-pms.pdf

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/01/policy-book-pms.pdf


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• The core NHS England team will respond flexibly to provide escalation support and expertise, working alongside the identified CCG team managing primary medical care commissioning.

4. Objectives

The objectives of this document are to outline the agreed working arrangements for the delivery of primary care medical commissioning in respect of: • CCGs taking on full delegation having access to a fair share of the primary care

medical commissioning team staffing resource during transition, to enable delivery of their commissioning responsibilities.

• NHS England South Central retaining a fair share of existing resource to deliver all their ongoing primary care commissioning responsibilities, in relation to the other areas of primary care commissioning (dental, pharmacy and optometry) which are not currently included in co-commissioning.

5. Primary Care Medical Commissioning Team

The current primary care medical commissioning resource will be co-located as a standalone multidisciplinary team delivering a single service offer across the “mixed economy” of CCG commissioning levels. This includes input from the following teams:

• Primary Care Commissioning • Finance • Nursing and Quality • Communications • Premises

The provisions contained within the Memorandum of Understanding are not intended to be legally binding. Service and staffing levels may vary as a result of unforeseen circumstances or other service requirements.

6. Governance

The governance arrangement for Delegated Commissioning is articulated in the CCG Constitution and in the Terms of Reference for the Primary Medical Services Committee. Monthly operational groups will continue between NHS England and each CCG along with quarterly meetings in public.

6.1. Strategic and Operational Leads

NHS England (South Central) has nominated strategic and operational leads who will act as key points of contact.

• Head of Primary Care will be first point of contact for the MOU and associated support from the NHS England team and will provide the strategic lead.

• Senior manager operational leads – will liaise on all operational matters and advise Strategic Leads

• Senior manager Finance leads will be present at both operational and Primary Care Commissioning Committees


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6.2. Transition

NHS England will arrange to meet with each CCG to provide a summary of all transitional issues currently being dealt with by NHS England that will need to be managed via delegated commissioning arrangements. The GP Contracts Team will also provide a brief document summarising all transitional issues currently being dealt with by NHS England that will need to be managed via these new arrangements. For level 3 delegated commissioning this document will be forwarded to the relevant CCG prior to 30 March 2017.

7. Service Offer

Delivered by an integrated core team (commissioning, finance and nursing & quality) the Primary Care Medical Commissioning Team will continue to enable the contracting and commissioning of general practice to be managed in an efficient and consistent way. Working with CCGs to deliver local commissioning strategies and improve outcomes for patients, through flexible and innovative use of existing contracts and resources. The Primary Medical Care Commissioning Team and CCG Team will agree a high level transition plan from 1st April 2017 onwards. The plan will list the key systems and processes to be handed-over to CCG colleagues. Linked to this will be agreement about which team is the first point of contact for contractual issues. Unless the CCG wants to take this role immediately for all issues, it is expected that this will be phased, in-line with the transition plan. Communication to contractors will be agreed throughout the transition process, ensuring contractors have clear information about who their contact is for different contractual issues. Given CCG established co-commissioning roles to-date, it is recognised the CCG may become aware of issues via local intelligence. During transition, Operational Managers will meet monthly informally, to ensure information is exchanged and teams are informed of issues. It should be noted that issues will fall in to two categories; those which the Primary Care Medical Commissioning Team can deal with as part of everyday business in accordance with NHS England Single Operating policy and procedures and those which require CCGs to make a decision.

7.1 Core Services The Primary Medical Care Commissioning Team will deliver the following, in-line with the transition plan:

• Support the transition of functions detailed in the transition plan; • Ensure functions are delivered in accordance with NHS England

policies or, linking to CCG colleagues in line with CCG policy where appropriate;

• Produce reports and recommendations to the Primary Care Commissioning Committee, attending where appropriate;

• A “named” strategic lead (and deputy) and also a named operational lead to enable the core team to develop a productive working relationship and better understanding of individual CCGs commissioning agendas;


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• A standardised / consistent approach to recommendations on “types of decision” across South Central in line with NHS England Single Operating Policy

• Recommendations in-line with current national regulations and guidance, including associated risks;

• Contracting advice to support delivery of new models of care / bigger primary care / new provider models;

• Advice on Enhanced Services; • Continue to deliver in accordance with NHS England Single Operating Policy

and relevant Regulations; • Advice on proposed changes to GP contracts and QOF.

7.2 Safeguarding

Safeguarding and promoting the welfare of children and adults is the responsibility of everyone who comes into contact with them and their families/carers. All NHS providers including general practice have statutory obligations under Section 11 of the Children Act 2004, Working Together to Safeguard Children 2013 and the Care Bill 2013 to ensure their organisation has arrangements in place to safeguard and promote the welfare of children and adults.

CCGs already have systems in place to monitor compliance with the contractual standards set out in the NHS Provider Safeguarding Audit Toolkit (2015) and Local Safeguarding Policies. It is not anticipated that these arrangements will change post 1 April 2016.

7.3 Primary Care Finance

NHS England will liaise with CCG Finance teams to agree financial reporting responsibilities. The attached document (Appendix A) sets out the detailed working arrangements between the NHS England South (South Central) Primary Care Finance Team and CCGs for the provision of Financial Management, Reporting and Support for GP Services from 1st April 2017. It is proposed that the Primary Care Finance Team will support delegated CCGs in a consistent manner.

7.4 Nursing & Quality

NHS England South (South Central) Nursing and Quality Team will liaise with CCGs for the transition of activity in relation to the delegation of primary care commissioning. The attached document (Appendix B) sets out the functions that will be transitioned; it is recognised that each CCG is at a different stage in their progress towards delegation and therefore the pace of transition in some areas will be negotiated with each CCG.

7.5 Communications and Engagement The NHS England South (South Central) Communications and Engagement Team will liaise with CCG Communications and Engagement teams to support the transition of activity in relation to the delegation of primary care commissioning. The attached document Appendix C sets out the phased approach to the transition arrangements, while Appendix D sets out the functions this relates to. It is recognised that each CCG is at a different stage in their progress towards delegation and discussions will be held with each CCG to refine plans.


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7.6 Premises i. Rent and Rates

Delivery of the three yearly rent review process and payment of rent/rates will be transitioned in-line with local arrangements. This includes liaison with practices and the District Valuer team. NHS England and CCGs will adhere to the Premises Cost Directions.

ii. Premises Development Through their Local Estates Strategies CCGs will continue to lead on the development of commissioning plans, designed to provide health care services for the future with clear priorities for investment in premises, including support for ETTF schemes. NHS England will oversee the Estate Technology and Transformation Fund (ETTF) process, linking to South and National processes, provided advice and guidance to CCG premises leads as appropriate. This will allow each CCG to maximize the investment available through the ETTF scheme.

7.7 Information Governance

As per section E of the Delegation Agreement 7.8 Safety Cul ture and Incident Reporting

NHS England has been actively encouraging General Practice to report patient safety incidents. Nationally via the NRLS GP e-form, offering local support to Practices to learn from incidents and drive improvements. Learning from analysing trends and themes has been shared across South Central as a result. NHS England South (South Central) Nursing and Quality Team will liaise with CCGs for the transition of incident management, including both serious and non- serious incidents. Whilst it is recognised that CCG’s are at different stages in readiness for this, the expectation is that all delegated CCG’s will have taken responsibility by March 2018. The Nursing and Quality Team will liaise with CCG’s on opportunities to maximise shared learning across the STP footprints, whilst helping to develop stronger, positive and more mature safety cultures within Primary Care Medical Services with greater emphasis on patient involvement.

7.9 Team Management

Team management will be provided from existing staffing resource and will oversee all Primary Medical Care Commissioning Team staff management and development. Staff accountability will be via the senior management of NHS England South Central. CCG staff delivering primary medical care will be managed and accountable to the senior management of the CCG.

7.10 NHS England Support Services

It is recognised that NHS England regional and national teams currently provide a range of support services to NHS England employees. Prior to transition to CCGs,


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NHS England employees will continue to access the following functions appropriate to delivery of their role:

Procurement support and advice Legal advice Communications and engagement support and advice Data analytical support GIS mapping GMS contract support and advice from NHS England Central Team CCG employees will access support services in-line with CCG arrangements.

7.11 Primary Care Support Service

Primary Care Support England (PCSE – Capita) are commissioned through a national contract to provide support services to all primary care contractors, include general practice. These arrangements will continue in-line with the contract. NHS England Primary Medical Care Commissioning Team and CCG Teams will continued to support contractors with appropriate escalation of PCSE issues.

7.12 Additional Services In order to support wider primary care commissioning some CCGs may wish to undertake additional or developmental activities related to the commissioning of general practice. This would require appropriate resource from individual CCGs or a pooled resource to provide a common service to all CCGs. Where this incorporates national programs, such as Enhanced Services or QoF, this must be done in consultation with NHS England, to ensure compliance with regulation and guidance. Formal authorization to proceed with changes to national programs will be required from NHS England. Such activities may include: Developing alternatives to QOF; A higher level of input into supporting delivery of new models of care / at

scale primary care / new provider models; LIS/LES development; DES reviews; Development of new contractual models encompassing elements of GMS

services; Input into CCG estates strategies; Strategic planning; Support applications for capital funding;

7.13 Escalation

Following transition of primary medical commissioning and contracting to CCGs, the NHS England Primary Medical Care Commissioning Team will be available to provide escalation support, subject to capacity across the team. This may assist CCGs dealing with an increased number of contractual issues.


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7.14 Reserved Functions Under the arrangements for delegated commissioning, a number of functions are retained by NHS England, as detailed below: i. Complaints: As per the delegation agreement, complaints are a reserved NHS

England function. A quarterly report will be provided by the NHS England South Central complaints team, to inform the Primary Care Commissioning Committees oversight of contractor quality issues. There may be patient enquiries which PALS teams will be involved in managing on behalf of the CCG and NHS England will provide advice as required

ii. Professional Performance, GP Appraisal and Revalidation … iii. Controlled Drugs iv. Section 7A Public Health Services…

8. Key Interactions

In order to ensure the Primary Medical Care Commissioning function can continue to delivered, there are a number of teams / organisations with which strong working links will need to be maintained and strengthened. These include:

• Medical Director, NHS England South Central – for all issues regarding individual practitioner performance

• NHS Property Services • Primary Care Support England • NHS England Assurance Team • Local Professional Networks • Local Medical Committees

9. Service Sustainability

NHS England ability to deliver this offer of support is subject to:

• CCGs agreeing to a standardised approach across all 14 CCGs in South

Central area and that any deviation away from this will result in a decreased level of service delivery and support to transition;

• CCGs agreeing not to fragment the existing staffing resource as this will limit the team’s ability to deliver transition of core functions;

• CCGs agree risk share where appropriate, for example: Violent Patients Service, Discretionary Payments, Clinical Waste contract.

10. Terms of the Agreement

As this is an evolving document quarterly reviews will be undertaken, linked to CCG transitional plans, and any amendments signed off by the CCGs and NHS England at an operational level. These arrangements will be reviewed during the period with a view to either agreeing a continuation of the model into future years or its cessation and movement to a new arrangement.


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The scope of this review would also incorporate a feasibility study into establishing a model for any phase 2 of Primary Care co- commissioning to incorporate Dental, Pharmacy and Optometry services.

11. Signatories Signed For NHS England South Central Signed;__________________________


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Schedule 2 List of Committee Members.

Voting members per CCG = 6. Each CCG has a separate deputy. ROLE Lay CCG NHS

England VOTING RIGHTS

Lou Patten Chief Officer (Deputy - Robert Majilton)

X YES

Nicola Lester Director of Transformation (Deputy - Helen Delaitre)

X YES

Graham Smith Lay Member - PCCC Chair (Deputy - Colin Seaton)

X YES

Robert Parkes (NHS Aylesbury Vale CCG) / Tony Dixon (NHS Chiltern CCG) Lay Member - Deputy PCCC Chair (Deputy - Colin Seaton)

X YES

Lisa Beaumont Associate Director of Nursing and Quality (Deputy - David Williams)

X YES

Robert Majilton, Acting Chief Finance Officer (Deputy - Alan Cadman / Kate Holmes)

X YES

Paul Roblin Local Medical Committee

NO

Dr Graham Jackson NHS Aylesbury Vale CCG Clinical Chair

X NO

Dr Raj Bajwa NHS Chiltern CCG Clinical Chair

X NO

Dr Karen West Clinical Director for Integrated Care

X NO

Helen Delaitre Head of Primary Care

X NO

Dr Jane O’Grady Health & Well Being Board

NO

Thalia Jervis Healthwatch Bucks

X NO

Jessica Newman NHS England

X NO

Colin Hobbs NHS England

X NO

Non-conflicted GP’s from other CCG’s

NO

Additional Lay members

X NO

Subject Matter experts (e.g. premises, workforce)

NO

Additional input ad hoc (e.g. data analyst, contracting etc.)

NO


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Schedule 3 – Primary Care Commissioning Committee Guidance “It is for CCGs to agree the full membership of their primary care commissioning committee. CCGs will be required to ensure that it is chaired by a lay member and have a lay and executive majority. Furthermore, in the interest of transparency and the mitigation of conflicts of interest, a local Health Watch representative and a local authority representative from the local Health and Wellbeing Board will have the right to join the delegated committee as non-voting attendees. Health Watch and Health and Wellbeing Boards are under no obligation to nominate a representative, but there would be significant mutual benefits from their involvement. For example, it would support alignment in decision making across the local health and social care system. CCGs will want to ensure that membership (including any non-voting attendees) enables appropriate contribution from the range of stakeholders with whom they are required to work. Furthermore, it will be important to retain clinical involvement in a delegated committee arrangement to ensure the unique benefits of clinical commissioning are retained.”


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Schedule 4 – Extract from Scheme of Delegation Points to note:

• This set of reservations and delegations was ratified by the Governing Bodies on 9 March 2017.

• Approval is limited to £50k (per CCG) for all decisions listed and delegated. Any decision above that threshold would need to be escalated to the Governing Body with a recommendation from the Primary Care Commissioning Committee.

• Where a decision relates to either an individual practice or award, or more than one practice or award, a separate decision would otherwise need to be taken and managed accordingly on when the delegated limit of £50k comes into effect. E.g. a decision to approve/award affecting 3 practices at £50k each is under the delegated limit individually, but over the delegated limit as a collective at £150,000k.

• However, for the avoidance of doubt, the approval limit of £50k will apply irrespective of the number of contracts or awards underneath.

• In relation to P8 below, most QOF payments are likely to routinely fall above the stated threshold, though this delegation gives a flexibility and opportunity for primary care commissioning committee decisions where it is deemed to be relevant.

No Policy Area Decision P1 PRIMARY CARE

COMMISSIONING Approve arrangements for the review, planning, and procurement of primary care services under delegated authority from NHS England. (up to £50k only)

P2 PRIMARY CARE COMMISSIONING

Approval of the arrangements for discharging the CCG’s responsibilities and duties associated with its primary care commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, reducing inequalities, improvement in the quality of services, obtaining appropriate advice and public engagement and consultation, obtain advice from persons who taken together have a broad range of professional expertise and acting effectively, efficiently and economically. (up to £50k only)


Day to day decisions on provider performance management and risk management associated with Primary Care to provide robust assurance to the Governing Body and NHS England. (up to £50k only)


Approve and ratify Direct Awards (up to £50k only)

P5 STRATEGY AND PLANNING

Approve and ratify practice incentive schemes, having regard to guidance by the Secretary of State. Monitor and review any such schemes. (up to £50k only)


Approve the following primary care services: a. Primary medical care strategy; (up to £50k only) b. Planning primary medical care services (including needs assessment); (up to £50k only) c. Primary Care Estates Strategy; (up to £50k only) d. Premises improvement grants and capital developments; (up to £50k only) e. Practice mergers (up to £50k only)


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COMMISSIONING Approve and ratify proposals for the procurement of primary care services under co-commissioning arrangements: a. The award of GMS, PMS and APMS contracts for primary care services to some or all of the CCG population where they are within CCG budgets (excluding GP contracts for which core contract approval/monitoring and appraisal sits with NHS England Area Team; This includes: the design of PMS and APMS contracts; and monitoring of contracts; taking contractual action such as issuing branch/remedial notices, and removing a contract); (up to £50k only) b. Procurement of new practice provision; (up to £50k only) c. Discretionary payment (e.g. returner/retainer schemes); (up to £50k only) d. 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); (up to £50k only) e. Premises Costs Directions functions. (up to £50k only)


Advise on or approve matters relating to primary care contracting within agreed levels, specifically in relation to commissioning Locally Commissioned Services, Quality Outcomes Framework (QOF - subject to allowances within NHS England's legal framework), Out of Hour services, Walk-in Centres (including home visits as required and for out of area registered patients); (up to £50k only)


Approval proposals for primary care support and development and any associated plans in connection with commissioning and performance monitoring and development within the remit of the CCG. (up to £50k only)


COMMISSIONING Approve arrangements for the review, planning, and procurement of primary care services under delegated authority from NHS England. (up to £50k only)


Approval of the arrangements for discharging the CCG’s responsibilities and duties associated with its primary care commissioning functions, including but not limited to promoting the involvement of each patient, patient choice, reducing inequalities, improvement in the quality of services, obtaining appropriate advice and public engagement and consultation, obtain advice from persons who taken together have a broad range of professional expertise and acting effectively, efficiently and economically. (up to £50k only)


Day to day decisions on provider performance management and risk management associated with Primary Care to provide robust assurance to the Governing Body and NHS England. (up to £50k only)


Approve and ratify Direct Awards (up to £50k only)


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P5 STRATEGY AND PLANNING

Approve and ratify practice incentive schemes, having regard to guidance by the Secretary of State. Monitor and review any such schemes. (up to £50k only)


Approve the following primary care services: a. Primary medical care strategy; (up to £50k only) b. Planning primary medical care services (including needs assessment); (up to £50k only) c. Primary Care Estates Strategy; (up to £50k only) d. Premises improvement grants and capital developments; (up to £50k only) e. Practice mergers (up to £50k only)


COMMISSIONING Approve and ratify proposals for the procurement of primary care services under co-commissioning arrangements: a. The award of GMS, PMS and APMS contracts for primary care services to some or all of the CCG population where they are within CCG budgets (excluding GP contracts for which core contract approval/monitoring and appraisal sits with NHS England Area Team; This includes: the design of PMS and APMS contracts; and monitoring of contracts; taking contractual action such as issuing branch/remedial notices, and removing a contract); (up to £50k only) b. Procurement of new practice provision; (up to £50k only) c. Discretionary payment (e.g. returner/retainer schemes); (up to £50k only) d. 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); (up to £50k only) e. Premises Costs Directions functions. (up to £50k only)


Advise on or approve matters relating to primary care contracting within agreed levels, specifically in relation to commissioning Locally Commissioned Services, Quality Outcomes Framework (QOF - subject to allowances within NHS England's legal framework), Out of Hour services, Walk-in Centres (including home visits as required and for out of area registered patients); (up to £50k only)


Approval proposals for primary care support and development and any associated plans in connection with commissioning and performance monitoring and development within the remit of the CCG. (up to £50k only)

1

MEETING: Primary Care Commissioning Committee PAPER: C

DATE: 1 June 2017

TITLE: Primary Care Risk Register

AUTHOR: Helen Delaitre, Head 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: The CCG has reviewed the way in which it manages risks and reports them to the Governing Body. A new risk management software tool called Verto has been introduced and each sub-group of the Governing Body is being asked to review the way it monitors and manages risks. This includes the Primary Care Commissioning Committee (PCCC). Primary Care Risk Register The PCCC agreed at the March 2017 meeting that the PCOG should further develop the identified risks and to collectively consider the scoring attached to each risk. Accountable risk owners will be appointed to each risk. Risk owners to be members of the PCCC to ensure they can be held to account. The PCCC requested PCOG to carry out a more detailed assessment of the risk register and that it be uploaded onto Verto. The PCOG reviewed the risk register on 6 April 2017 and 4 May 2017 and the register has been amended to reflect recommendations made at that meeting. The PCCC is asked to:

- Review and approve the inclusion of the proposed risks on the Primary Care Risk Register. - Be assured that the identified risks are appropriately mitigated with appropriate actions in

place. - Agree Risk Owners and Delegated Risk Owners (Risk Owner to be a member of the PCCC). - Receive for information and oversight details of risks from other CCG risk registers which

have been identified as impacting upon the Primary Care agenda. Conflicts of Interest: None identified. 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

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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

Prior consideration Committees /Forums/Groups

The management of the risk register has been considered and agreed by the PCCC and the PCOG at monthly meeting since March 2017.


Supporting Papers: Draft Primary Care Risk Register Guidance for Evaluating Risks

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Risk De

Risk Detail

ID Risk Title Raised On

Risk Causes Risk Description (IF)

Risk Effect (THEN) Consequence (LEADING TO)

Project / Corporate 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

RA0000 : Regulatory Affairs Projects

00012 Provision of Primary Care Services

2/3/17 The CCG will be procuring a new provider of primary care services for the population of Mandeville practice during 2017. The risk is that no providers will apply to provide this service.

No provider applies to offer services for the population of Mandeville practice when re-procured in 2017

There will be a patient list not aligned to a member practice

• local unsustain-ability

• loss of reputation

• poor patient

outcomes

Nicola Lester

Helen Delaitre

16 8 More than 6 months

Ensure that the specification is costed appropriately and that the specification will attract providers interested in delivering services in different ways.

00014 Governance 2/3/17 The PCCC needs to be aware of and manage the real or perceived conflict of interest of GPs in specific decisions regarding primary care commissioning.

Conflicts of interest of GPs are not appropriately managed and discharged regarding primary care commissioning

The CCG will be in breach of its conflicts of interest policy

• Poor internal audit report

• Loss of reputation – personal and/or professional

• loss of public confidence and trust in the CCG

• potential legal challenge from providers

• damaged personal reputation of those with potential conflicting interests will be damaged

Nicola Lester

Russell Carpenter

6 6 Immediate Revised conflict of interest policy in place includes strengthened governance arrangements and separation/transparency in decision making.

COI training for GB lay members available.

Assurances: quarterly compliance action plan report to Audit Committees meetings in common

00015 Stability of General Practice

2/3/17 Many practices in Bucks are experiencing difficulty in sustaining core primary care services. The reasons for this are varied and each practice is affected differently. The collective impact risks

A practice informs the CCG that they are experiencing difficulties or are identified as being at risk

There may be difficulties in sustaining core primary care services


• destabilising current delivery of primary care


• poor patient

Nicola Lester

Helen Delaitre

20 10 Immediate CCG to identify and target at risk practices.

Utilise GPRP and VPS funding to encourage practices to build locality-wide resilience. Commissioned FedBucks /

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destabilising current delivery of primary care.

outcomes KPMG to lead on building resilience within Primary Care.

00016 Primary Care Transformation

2/3/17 Lack of appetite by member practices to change current ways of working. A key driver for delegated commissioning is to instigate innovation and redesign services to improve patient outcomes and drive transformation. CCG member practices need to embrace change and see the advantages to them in doing so.

Member practices are not effectively engaged in primary care transformation

CCG will be unable to meet the requirements and expectations of FYFV

• Unable to instigate innovation and re-design services to improve outcomes and drive transformation

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



• poor patient outcomes

Karen West

Helen Delaitre

16 12 KPMG and FedBucks have been commissioned by the CCG to work collaboratively to address the need for change and to develop improvement support plans for individual practices and groups of practices. This work will be divided into two main strands: • Collaborative locality working • Development of a turnaround team / support package This work commenced in April 2017 and is still in the developmental stages. Practice engagement and commitment to the project has so far been positive. However, due to the infancy and importance of this project the score after mitigation has been set at 12 with escalation to the Corporate Risk Register deemed appropriate by the PCCC.

Immediate Clear engagement with the membership will identify the appetite for change. First discussions with localities regarding community hubs and collaborative working beginning to take place. FedBucks / KPMG to lead on building primary care resilience.

To arrange further workshops to enable practices to work with KPMG and FedBucks to: • Align visions and strategies • Consider options using national examples • Develop a case for change • Agree design principles • Co-create detailed plans and business cases • Implement new operating Models Support FedBucks to continue working with practices to extract value from the new ways of working and to continuously improve, scale and sustain change.

00017 Improved Access to Primary Care

2/3/17 Primary care needs to adapt to the changing needs of the population and streamline the delivery of services so that patients can access appropriate services 24/7. The membership needs to be part of the solution and sign up to improving access.

Primary Care improving access specification is not in place by September 2017

CCG will be unable to meet government expectations on 24/7 access


• poor reputation


Nicola Lester

Helen Delaitre

12 8 3-6 months

CCG to provide leadership so that membership understands the benefits of adapting primary care so that 24/7 services can be provided. Agreed specification to be in place by September 2017.

00018 Quality in Primary Care

2/3/17 All practices in Bucks have now been inspected by CQC. A number of practices “require improvement” while 1 practice is in “special measures”. If a practice fails re-inspection, it creates added pressure on

Member practices already inspected by CQC but in CQC “requires improvement” or “special measures” categories fail future re-inspection

Surrounding member practices will be subject to added/additional pressure


• Loss of reputation


• Patient registration difficulties

Karen West

Lisa Beaumont

16 12 As one practice within Bucks CCGs is rated as Inadequate by CQC and is under Special Measures the PCCC felt that even with all possible mitigation the current risk score should remain at 12 with escalation to the Corporate Risk

Immediate All practices in Bucks have now been inspected by CQC. A number of practices “require improvement” while 1 practice is in “special measures”. If a practice fails re-inspection, it creates added pressure on the remaining practices in the surrounding area.

CCG and NHSE Quality Teams to continue working with the practice to ensure that they are working through a comprehensive and robust action plan which will address all concerns

5

the remaining practices in the surrounding area.

Register. Practice engagement and commitment to working to address concerns previously highlighted by CQC is paramount for a successful reinspection. The practice concerned is in the Wycombe Locality and the risk of the practice failing at re-inspection will add pressure to all neighbouring practices.

previously raised by CQC. The CCGs to offer practices support through the process utilising the RCGP package and other resilience funding as appropriate.

00019 Delegated Responsibility for Primary Care

2/3/17 A Memorandum of Understanding (MOU) is in place between the CCGs and NHSE for the continued provision of support throughout the transition period. However, the CCG needs to plan for how the various functions will be managed once transition arrangements cease.

There are not effective plans in place to discharge the requirements of the MOU for delegated commissioning between the CCG and NHS England

The CCG will be non-compliant with the delegation agreement


• Loss of reputation


Nicola Lester

Helen Delaitre

12 6 3-6 months CCGs across Thames Valley

to agree how best to share limited primary care resources. Solution may involve commissioning some services at scale across the region and outsourcing some transactional functions to other organisations.

ST0008 : My Care Record - GP Access Centre

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

00003 Full potential and benefits may not be realised

6/4/17 The Community Programme and the SMT are currently in the process of deciding on whether the GPAC Proof of concept should be ended or be given an extension of 3 months.

If the GPAC Proof of Concept is not given an extension for the implementation of EMIS Clinical Services (Cross Org appointments & Cross Org Tasks)

Then the implementation of EMIS Clinical Services (Cross organisational Appointments and Tasks will be wasteful of resources and ETTF funding.

Leading to reduced data for evaluation of the benefits of the Clinical Services which are required to inform other EMIS Clinical Services projects and prevent further proposed implementations of EMIS remote consultations to support remote urgent on the day cross organisational appointments (overspill clinics)

Nicola Lester, Helen Delaitre

Helen Delaitre, Anna Lewis

15 12 1 At an SMT meeting a one month extension was approved for the GPAC, enabling the implementation of the Cross organisational Appointments and Tasks (expected 3rd May 2017). This will allow for 6 weeks of data and benefits measuring. This has slightly reduced the likelihood of not getting any measurable outcomes but the impact on the CCG Primary Care strategy is still moderate.

Immediate Controls and assurances are embedded into the project management of the projects that are linked to the Clinical services project for GPAC The project board consists of GPAC members, practice managers, GP's, CCG managers and EMIS The Community Programme Board is currently reviewing an extension of 3 months to the GPAC and has full over sight of this and the GPAC project. SMT are informed of the Community Programmes decisions and request for any approvals required.

tail

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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

Con

sequ

ence

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

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

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

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annum. 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 circumstances

Unlikely to occur

Reasonable chance of occurring

Likely to occur

More likely to occur than 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

Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) complaint Local resolution (with potential to go to independent

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

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

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Consequence score (severity levels) and examples of descriptors standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved

review) Repeated failure to meet internal standards Major patient safety implications if findings are not acted on

Critical report meet national standards

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

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Consequence score (severity levels) and examples of descriptors 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

Paper: D

DATE: Thursday 1 June 2017

TITLE: Trinity Health / Wellington House Surgery Merger Application

AUTHOR: Wendy Newton, Primary Care Manager


Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: Following a full patient and public consultation process, Trinity Health and Wellington House Surgery have made an application to Aylesbury Vale CCG to merge their practices. The practices are proposing a merger as they recognise the difficulties of providing high quality patient care in smaller units. They consider a larger “super-partnership” arrangement will enable them to continue to offer their patients an innovative, sustainable, quality service into the future. Under delegated commissioning arrangements it is the responsibility of the PCCC to approve practice mergers. When carrying out such actions, the CCG is required to act in accordance with the Delegation Agreement which includes but is not limited to:

• undertaking all necessary consultation when taking any decision in relation to GP practice mergers, including those set out under section 14Z2 of the NHS Act (duty for public involvement and consultation). The consultation undertaken must be appropriate and proportionate in the circumstances and should include consulting with the LMC;

• prior to making any decision, clearly demonstrating the grounds for such a decision and fully considering any impact on the GP practice’s registered population and that of surrounding practices. The CCG must be able to clearly demonstrate that it has considered other options and has entered into dialogue with the GP contractor as to how any merger will be managed; and

• in making any decisions, taking account of the CCG's obligations as set out in the Delegation Agreement in relation to procurement, where applicable.

The practices involved have requested assurance from the CCG that as part of the merger process the following will apply:

a) the merged practice will retain the MPIG from the two individual practices; b) the merged practice will retain the dispensing rights currently held by Trinity Health;

c) all enhanced services, direct awards etc. currently commissioned from the two practices will continue to be commissioned on the same, or improved, terms from the merged practice.

This report provides the practice’s application (Appendix 1) and supporting information to help inform the PCCC in their considerations and decision making in relation to this application. The PCCC is asked to:

• Review the application to merge Trinity Health and Wellington House Surgery. • Approve the merger to take effect from 1 October 2017. • Approve to carry over MPIG into the merged budget. • Offer assurance that current enhanced services, commissioned from the two

practices will continue to be commissioned on the same, or improved, terms from the merged practice.

Conflicts of Interest: None known. No member GPs who are Partners at either practice are either voting members of the PCCC or in attendance in a commissioning role. The Managing Partner from Wellington House Surgery has been invited to attend the PCCC as a member of the public, to answer any queries but this is not deemed as material. No further action required. 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






13Q duty to involve the public

Equality Equality Impact Assessment completed

Quality The quality of services provided should be unaffected by plans to merge the two practices.

Financial None – merger should be cost-neutral. Risks None relating to the CCG. Statutory/Legal If the merger is approved then the GMS

contract for Wellington House Surgery will terminate and a contract variation will be issued to Trinity Health acknowledging the 2 additional sites.

Prior consideration Committees / Forums / Groups

Full public and stakeholder consultation undertaken.

Membership Involvement Neighbouring practices have been consulted on the practices’ intentions.

Supporting Papers: Report Appendix 1 - Application to Consider a Practice Merger Appendix 2 – Merger: Reasons and Benefits Appendix 3 - Communications Plan and Feedback Appendix 4 – Equality Impact Assessment Appendix 5 – 13Q Duty Public Involvement Assessment Form

Trinity Health / Wellington House Surgery Merger Application

Purpose of the Paper The purpose of this report is to provide the Primary Care Commissioning Committee (PCCC) with the information they require to make an informed decision on the application from Trinity Health and Wellington House Surgery to merge their practices. Background Trinity Health and Wellington House Surgery both sit within the Aylesbury Vale South Locality. Due to their geographical area both Trinity Health and Wellington House Surgery serve patients residing in both Buckinghamshire and Oxfordshire. Partners at both practices hold GMS Contracts and both use EMIS as their clinical systems. Both practices have been rated as “Good” by CQC (Trinity Health CQC Quality Report published on 10 December 2015, Wellington House Surgery CQC Quality Report published 21 October 2016) . Trinity Health (K82047) currently encompasses three sites: Main Surgery – Thame Health Centre, Thame, Oxfordshire Branch Surgery – Long Crendon Surgery, Long Crendon, Buckinghamshire Branch Surgery – Brill Surgery, Brill Buckinghamshire. Trinity Health has five Partners (all GPs) Wellington House Surgery (K82034) currently comprises two surgeries: Main Surgery – Princes Risborough Surgery, Princes Risborough, Bucks Branch Surgery - Chinnor Surgery – Chinnor, Oxfordshire Wellington House Surgery has 5 Partners (4 GP’s and 1 Managing Partner) The unweighted patient lists as of 1 April 2017 were: Trinity Health – 11,594 Wellington House Surgery – 9,287 Current practice boundaries: Trinity Health:

Wellington House Surgery

Trinity Health currently holds dispensing rights. They are able to dispense from either their Long Crendon or Brill surgeries. Dispensing is not available to Trinity Health patients at Thame Health Centre. The merged practice wishes to retain the current dispensing rights following their proposed merger. The impact of the merger has to be considered and agreed by NHS England South (South Central) Pharmaceutical Services Regulatory Committee (PSRC). The PSRC are expected to do this when they next meet on 28 June 2017. The CCG has received a formal application from the practices requesting approval for the merger with effect from 1 October 2017 (Appendix 1). The merged practice would have a new name, this has not yet been agreed and the practices intend to agree the new name in consultation with their PPGs and staff. The proposal is for the main site to be Princes Risborough Surgery with Thame Health Centre, Long Crendon Surgery, Brill Surgery and Chinnor Surgery as branch surgeries. The merged practice will retain the Trinity Health practice code, K82047. CCG Responsibilities The NHS England Policy Book for Primary Medical Services (January 2016) sets out the process that should be followed when considering a merger: “The underlying principle for the Commissioner to consider when any such proposal is made to them is what the benefit is for the patients and what the financial implications are for the commissioner” (page 78). The Policy Book warns that “merging contracts is a complex matter which should not be approached lightly by either the contractors or the Commissioner. The final commissioning decision on whether contracts should be merged lies with the Commissioner and there are a number of important issues that would need to be considered, prior to giving consent”. The

following are highlighted as items which should be considered by the CCG, although this is noted not to be an exhaustive list: To be Considered by the CCG Comment How patients would access a single service The merged practice will continue to operate

from the 5 existing sites. Patients will be able to visit their current site, or any of the other 4 surgeries.

What would the practice boundary be (inner and outer)

The inner and outer boundaries of the merged practice would reflect the current boundary areas of Trinity Health and Wellington House Surgery (see practice boundary map below).

Assurances that all patients will access a single service with consistency across provision i.e. home visits, booking appointments, essential and additional services, opening hours, extended hours, and so on, single IT and phone system

Assurance received from the practices. There will be a merged clinical system and a single point of access for patients. Services for patients would reflect current arrangements at the practices.

Premises arrangements The merged practice will continue to operate from the 5 existing sites.

Proposed arrangements for involving the patients about the proposed changes, communicating the change to patients and ensuring patient choice throughout

Full patient consultation has been undertaken. See Appendix 3.

Costs / value for money - a contract merger is likely to merge two contracts with differing values, this would have an ‘averaging’ effect, possibly resulting in a higher cost per head of population under a single contract than the Commissioner would have expected

The contract merger will merge two practices with differing contract values and costs per head of population to the sum of the two single contracts. However due to the similarity of the two practices it is not anticipated that the differential in value will be of high significance and the “averaging” cost per head of the population is likely to be similar to the sum of current values. The global sum is calculated using the national Carr-Hill formula and it is not within the remit of the CCG to change it.

Other financial arrangements – the impact of Directions under the Statement of Financial Entitlements, or any specific terms included in the individual contracts

The SFE is a national directive which underpins the way payments are made to practices and not within the remit of the CCG to change. Financial arrangements for the merged practice would remain in line with the SFE and would be equitable with other practices within the CCG. There are no additional adverse financial implications for either the practice or the CCG that we are aware of.

QOF - merging contracts midway through a financial year in respect of QOF achievements and payments is enormously complex and requires significant safeguards to be built in to ensure there is no duplication of payments at year-end. There will also be an averaging of the arrangements and achievements in this respect too.

Both practices have signed up to the local QOF achievement scheme. All practices signed up to the scheme have received an income guarantee for 2016/17. Both Trinity Health and Wellington House are high performing practices and we would expect the newly merged practice to achieve equal achievements. The practices will merge in October 2017 and will have 6 months to

rectify any performance issues relating to the merger by the end of the financial year. Practice payments will be equitable to other practices within the CCG and no adverse impact upon the practice or the CCG is anticipated.

Premises reimbursements The newly merged practice would continue to operate from the existing five premises. Rent reimbursement and pass through costs are expected to remain the same and continue to be based upon the current square footage.

Additional service and out of hours opt-outs

It is anticipated that additional services and extended hours will continue in line with current arrangements.

Patients from the terminating contract are included under the remaining contract through bulk transfer where possible to avoid additional cost pressure

The CCG is working with Trinity Health and Wellington House Surgery to notify PCSE of the proposed merger in a timely manner to ensure that patients are transferred without disturbance to the patient or the practice.

Key Issues The practices believe that they are currently coming from a place of “strength” however recognise the pressures on general practice and the benefits of scale. The practices have provided the following reasoning for the proposed merger along with the expected benefits. See Appendix 2. As part of the merger considerations the practices have requested the following assurance from the CCG:

• the merged practice will retain the MPIG from the two individual practices; • the merged practice will retain the dispensing rights currently held by Trinity Health; • all enhanced services, direct awards etc. currently commissioned from the two


• MPIG (Minimum Practice Income Guarantee)

Previously NHS England has carried over MPIG into the merged budget. However, Aylesbury Vale CCG now holds delegated commissioning responsibilities for Primary medical Services and therefore this is a decision for the CCG.

• Dispensing Rights The continuation of the current dispensing rights held by Trinity Health within the merged practice will require formal agreed by NHS England South (South Central’s Pharmaceutical Services Regulatory Committee (PSRC)), the expectation is for the PSRC to discuss and make a decision on this matter when they meet on 28 June 2017.

• Enhanced Services It is the responsibility of Trinity Health and Wellington House Surgery to consider the impact on payments for a merged practice in relation to QOF, enhanced services etc. However, the CCG expectation is that current commissioning arrangements will be carried over. As the commissioners for primary medical services, the CCG has the right to amend future

commissioning arrangements however; these would be equitable across all CCG practices and would not be varied for the new merged practice.

• Clinical Systems Both practices currently use EMIS as their clinical system, which is the system of choice of the CCG. EMIS will continue to be the clinical system for the merged practice. The plan is to merge the clinical systems on 14/15 October 2017 to ensure that the newly merged practice has a single IT platform. The practice has already liaised with EMIS regarding the planned merger. The phone lines will also be reviewed to ensure a single point of access for patients to the merged practice.

• Financial Consequences There are no anticipated financial consequences for the CCG due to the merger of Trinity Health and Wellington House Surgery. The newly merged practice would continue to operate from the existing five premises. Rent reimbursement and pass through costs are expected to remain the same and continue to be based upon the current square footage. QOF and enhanced services are expected to remain at a similar level to current performance; both practices share a similar patient demographic and are high performing practices. Similarly it is not anticipated that there will be a significant impact on the global sum or impact under the Directions of the SFE.

Supporting Information The proposed practice merger is in line with the CCGs Primary Care Strategy and local delivery of the 5YFV which prioritises practices coming together to produce “at scale” working across larger geographical areas, enabling the sharing of clinical expertise in specialist areas and increased resilience. By working at scale, integrated community services can be wrapped around the larger patient populations enabling increased out-of-hospital services. Patient & Stakeholder Consultation The practices held a full patient / stakeholder consultation prior to formally applying to the CCG to merge Trinity Health and Wellington House practices. The 12 week consultation ran from 1 March 2017 until 31 May 2017. The practices worked with NHS England, the CCG and the CCG’s Communication Team on the consultation process. Full details, including feedback from the consultation, can be found in Appendix 3. The practices widely advertised their plans to merge and also held drop in sessions at each of their 5 premises.

Practice Boundary The proposed merged practice boundary is:

Recommendation The PCCC is recommended to approve the merger of Trinity Health and Wellington House Surgery with effect from 1 October 2017. It is further recommended that the PCCC approve that the merged practice is able to retain their current MPIG arrangements and carry this over into their merged budget. PCCC should assure the practices that the current enhanced services, direct awards will continue to be commissioned on the same terms from the merged practice. Please note that although the CCG has received a request from Trinity Health and Wellington House Surgery for assurance of the continuation of the current dispensing rights held by Trinity Health, the CCG is unable to offer such assurance on this matter. Pharmaceutical responsibilities remain the remit of NHS England, and any discussion regarding the dispensing rights of the newly merged practice will need to be made and communicated by the NHS England’s PSRC.

Appendix 1 Application for consideration of a contractual merger (Please add additional pages if you have insufficient room to complete fully) Practice stamp: Please complete the following: 1. Details of the two contractual agreements you are proposing to merge K82034: Wellington House Practice K82047: Trinity Health We will need assurance from the CCG that as part of the merger process, the following will apply:

a) the merged practice will retain the MPIG from the two individual practices b) the merged practice will retain the dispensing rights currently held by Trinity Health. c) all enhanced services, direct awards etc. currently commissioned from the two


2. Which of these agreements you would prefer to continue with (NHS CB final decision in this respect would be required) K82047 3. Indicate whether you intend to operate from two premises Yes – we will be operating from the existing five premises. a. If yes, which premises will be considered the main and which is to be considered the

branch (if applicable):

Princes Risborough is planned as the main site with Chinnor, Long Crendon, Thame and Brill as branch sites. We have, however, asked the CCG and NHSE for advice/modelling on the financial implications of our choice of main site but have received no response – we may seek to change the main site based on further information received on this. b. If no, which premises do you intend to practice from: ………………………………………………………………………………………………… c. Of which CCG do you propose to be a member? Aylesbury Vale CCG 4. Full details of the benefits you feel your registered patients will receive as a result of this proposed merger:

Merger - reasons and benefits.docx

5. Please provide as much detail as possible as to how the current registered patients from the existing practices will access a single service, including consistent provision across:

home visits; booking appointments; additional and enhanced services; opening hours; extended hours; single IT and phone system; and premises facilities.

WHP and Trinity Health currently both provide excellent patient care; both have recently been rated ‘Good’ by CQC and are high achievers against the Quality and Outcomes Framework. The National Diabetes Audit 2015/16 evidences this further; this records that both practices are amongst the top performing practices nationally for diabetes care. Both provide a comprehensive range of additional and enhanced services and both provide home visits, where required, and extended hours services. We will continue to provide these across the newly merged practice. We will also be pro-actively looking for opportunities to provide additional patient services and move patient services, where appropriate, from secondary care. Our aim is to have a single merged practice from 1st October with common services, processes, protocols and staff providing a consistent, seamless service for patients. We have formed a management board of two partners from each site who meet fortnightly to plan the mobilisation to achieve this aim. Below are some of the key areas: Currently the two practices have different appointment systems; we are developing a common appointment system across the merged practice taking the best of the two current systems to provide an improved appointment system for all patients. The aim of the new system is to redesign the way we handle urgent care across the wider group, using the full range of clinical practitioners, to ensure we create additional resource to more pro-actively manage our frail elderly patients and those with multiple long term conditions. We will merge our clinical systems on the 14th/15th October to ensure we have a single IT platform; discussions are already underway with EMIS on the mobilisation plan. This will provide a single patient database so enabling patients to easily access services at any of the practice sites. We are in the process of reviewing our phone system to ensure a single point of access for patients to the newly merged practice. As training practices, we each already have standardised many core aspects of care so that patients receive same standard from any clinician that is safe and effective. Baseline care will be CKS then practice protocols to clarify pathways and CCG guidelines particularly for meds optimisation and referrals. As part of the merger we are carrying out a full review of all protocols, standardising and updating practice protocols and pathways to current evidence. This will help to develop a multidisciplinary clinical team with common pathways and standards of care.

We are in the process of developing a single governance structure built around ‘seven pillars’ of governance with clear leadership, responsibilities and direct lines of communication throughout the practice. Both practices have proven clinical and managerial expertise in Quality Improvement, leading and implementing improvements both administratively and clinically; on merger we will not only continue to provide consistent care and services but will continually strive to improve this throughout the organisation. 6. Details of the proposed merged practice boundary (inner and outer): Please see embedded document for proposed inner and outer boundary for the merged practice.

Combined Boundary 2017 Final.pptx

7. How you propose to consult with your patients about this proposal, communicate actual change to patients and ensure patient choice throughout: Please see the communications plan together with the patient communication materials used; this was agreed with NHSE and the CCG. Consultation is running for three months from 1.3.17. The communications plan contains the detail of the patient consultation carried out and their feedback.

Communication Plan.docx

Feedback from Patient Consultation

Patient Information Merger Poster Press Release

FAQs Screen information.pptx

To be signed by all parties to both contracts being proposed for merger Signed: ……………………………………………………………………………….…… Print: ……………………………………………………………………………………… Date: ...…………………………………………………………………………………… Signed: …………………………………………………………………………………… Print: ……………………………………………………………………………………… Date: ....…………………………………………………………………………………… Signed: …………………………………………………………………………………… Print: ……………………………………………………………………………………… Date: ...…………………………………………………………………………………… Signed: …………………………………………………………………..……………… Print: ……………………………………………………………………………………… Date: ……………………………………………………………………………………….

Signed: …………………………………………………………………………………… Print: ……………………………………………………………………………………… Date: ....…………………………………………………………………………………… Signed: …………………………………………………………………………………… Print: ……………………………………………………………………………………… Date: ...…………………………………………………………………………………… Signed: ……………………………………………………………………………….…… Print: ……………………………………………………………………………………… Date: ...…………………………………………………………………………………… Signed: …………………………………………………………………………………… Print: ……………………………………………………………………………………… Date: ....…………………………………………………………………………………… Signed: …………………………………………………………………………………… Print: ……………………………………………………………………………………… Date: ...…………………………………………………………………………………… Signed: …………………………………………………………………..……………… Print: ……………………………………………………………………………………… Date: ………………………………………………………………………………………. Please continue on a separate sheet if necessary Note: this application does not impose any obligation on the NHS CB to agree to this request.

Appendix 2 MERGER – REASONS and BENEFITS The following paper provides some information on the reasons we are proposing merger and the benefits we feel will result. Reasons to consider merger Since the NHS was formed there have been enormous changes in the services we are asked to provide, the life expectancy of patients and the complexity of the patients we now manage but the way the services are provided by primary care have not changed a great deal; we are still a large number of small units. Working as small units and still providing excellent patient care has become more difficult; some of the difficulties we face are:

• A significant rise in the number of consultations with General Practice

• An enormous rise in patient expectations including what services we can provide, how quickly we can provide them and ease of access to these services.

• A significant rise in the complexity of the patients we now manage in primary care

• There is a real struggle to balance increased workload with tighter financial constraints

• Increased workload has made clinical recruitment more difficult; we need to make primary care an attractive place to work

• These factors mean that the traditional general practice is very vulnerable – we are generally too small to be resilient

Strengthened, sustainable and resilient primary care is, however, essential to the wider NHS. Primary care currently sees over 80% of all patient contacts with less than 10% of the NHS budget; without a strong, resilient primary care the whole NHS system is vulnerable.

Benefits of Merger We are seeking to create an innovative, resilient model for rural primary care built around:

• Providing a high quality service focused on prevention and self-care

• Ensuring the entire organisation is focused on Improvement; encouraging and facilitating innovation, flexibility and responsiveness

• Developing an efficient organisation built around effective systems and processes

• Ensuring the organisation is financially successful to ensure long term stability and development

• Pro-actively looking for new services and new business opportunities to provide increased services for our patients

• Developing a broader model of integrated primary care – multi-professionals across organisational boundaries.

• Ensuring stability and sustainability – to continue to deliver excellent patient care we need to ensure the survival of our practices – we need to be too big, too innovative, too resilient to fail

• Developing more scope for outward view and new ideas to bring back into the practice to drive further improvement in patient care

• Development of different internal roles will provide more opportunity for staff development and will make it easier to recruit and retain staff

Patient Benefits Patients of both Trinity Health and Wellington House already receive high quality healthcare as reflected in external measures including high QOF achievement, CQC reports and both being established GP Training practices. The National Diabetes Audit 2015/16 evidences this further; this records that both practices are amongst the top performing practices nationally for diabetes care. The merger of both practices will not diminish the current quality of care for patients in any way but into the future patients will benefit from the merger through improved sustainability and resilience, transformation of services and the expansion and education of our primary health care teams. 1. The demographic changes in our population (predominantly elderly) mean that demand

for care in our practices is rising not just for urgent minor illness but to manage the complex acute and chronic needs of an elderly population with multiple comorbidities. Combined with the challenges of recruiting a clinical workforce then, without merger, the care of our patients might be compromised. Through merging, our practices we will have a sufficient population to proactively recruit and train a multi-professional workforce to meet patient’s needs; this will bring other clinical professionals into the practice to protect and further develop the service we can provide. The larger practice will provide the opportunity to develop individual clinical specialist skills and will ensure that resources can be allocated to roles that are impossible to sustain for small populations, for example care navigation specifically targeted to our populations needs. Developing an efficient, merged practice will mean we are less vulnerable and more sustainable and resilient; this will mean we are more likely to be here into the future continuing to deliver excellent care for patients.

2. As the larger population’s needs become clearer we will be in a position to develop new services for patients with a wider primary care team to allow more care for patients to be based around the practice rather than patients needing to travel to other organisations for their care.

This may result from expanding our own team or commissioning others with specialist skills to work for our patients; merger will allow the exploration and development of this for the benefit of our patients.

3. Traditional models of general practice focus on on-the-day management of acute

undifferentiated illness for patients who choose to access the services. The pressure on teams to meet this need leads to a risk, particularly for a population like ours, that those most in need of planned care to prevent acute exacerbations and crises find it harder to access this due to pressures on the workforce in small practices. By merging our practices will be able to provide a more robust infrastructure and larger workforce to meet patients’ needs both for acute on the day care but also for chronic care and preventative management of long term conditions. Developing a more streamlined way of dealing with the ‘acute demand’ we will free up resource to work with our more vulnerable patients in a more pro-active way – looking to develop care plans, prevent problems, prevent hospital admissions and improve quality of life for these patients. It will allow services to be focussed on our own population needs. The scale of the practice will, we hope, once again allow health and social care teams who work with and

know the resources in our specific local communities to more effectively meet the chronic and preventative needs of patients.

4. Finally as two existing GP training practices our patients already benefit from our drive to

be learning organisations. This can be seen in the incorporation of the latest clinical ideas in our patient care that have often been shared by our GP trainees who have just left hospital. It is also reflected in our focus on improving communication and consultation skills throughout the healthcare team. This work has already expanded from training doctors to become GPs, to now include nurse, pharmacist and medical student training all of which broaden our outlook and bring improvements in clinical care. As a larger organisation with education as a core value, patients will continue to be recipients of the breadth of new ideas and professional skills the practice will continue to develop. With the increase in patients with long term conditions and the need to empower them to become proactive in their own health care, we will continue to develop new ways to facilitate this. This could, in future, include the use of group consultations and multi-professional teams including ‘experts by experience’ to support self-management. In doing so we would try to ‘flip healthcare’ (a concept used Maureen Bisognano to the IHI forums in 2014) becoming an organisation where we know what matters to patients, rather than just what is the matter, and that works with them to achieve best results.

Appendix 3

Communication Plan and Feedback

a) Communications plan to support the merger of Wellington House and Trinity Health

Introduction and objectives Wellington House and Trinity are to merge from 1st October 2017 with patients and staff remaining at their respective practices. There are 9266 patients registered with Wellington House and 11612 registered with Trinity. A communications plan will support this merger and needs to be agreed by the two practices, NHS England and Aylesbury Vale CCG. It aims to:

• Identify all the relevant stakeholder groups and ensure they receive timely and relevant information about the plans

• Highlight any potential issues and plan communications to mitigate against these where possible

• Demonstrate how all key partners (practices, CCG, NHSE) are working collaboratively to minimise the inconvenience to patients.

Key messages • Increased pressures on resources in primary care mean that it is not

sustainable, in the long term, for Wellington House and Trinity to continue in their current form.

• The merger is being carefully planned by both practices, NHS England and Aylesbury Vale CCG to ensure there is no inconvenience to patients and so that practice staff transfer smoothly to and settle in quickly to the newly merged practice.

• Patients will continue to receive the same high quality care and treatment that they are accustomed to at their practice. The same GPs and practice staff will still be available to see, and the merger should not affect patients specifically. Patients will benefit from a more sustainable practice, a wider range of services and a more efficient practice.

Potential issues There may be anxiety about the practice merger. People might be concerned that one of the practices may close. It could be unsettling for patients if the practice has plans for other significant developments soon after the merger. Stakeholders

• Patients at both practices • Staff at both practices • PPGs at both practices

• Residential homes that use either practice • Other GP practices in the Aylesbury Vale area • Aylesbury Vale CCG and NHSE • Local health organisations e.g. Buckinghamshire Healthcare, the Council,

pharmacists, Healthwatch • Media • Local MP/councillors/HASC for Bucks • Suppliers at each practice • Other self-employed specialists/groups working from the practices • LMC and other associations

Communications Time Plan Date Activity Who? Target audience Done 19.1.2017 – all staff at PLT session.

Communicate plans and timescale to all staff.

WHP and Trinity Staff Yes. 19.1.17

17.2.17 Draft and agree comms plan

WHP and Trinity to produce and agree with NHSE/CCG

All

Sent to NHSE/CCG 16.2.17

Trinity done WHP 17.2.17

Inform PPG members (ahead of press release and information going on website etc). Gain PPG input to stakeholder comms materials.

WHP/Trinity Patients Completed 17.2.17 Completed 17.2.17

21.2.17 Draft and agree patient comms – information for website, posters, Q&A and A5 flyers

WHP/Trinity to produce and approve all comms material (seek input from NHSE/CCG)

Patients Completed 28.2.17

24.2.17 Update practice websites (place copy on ‘new patient’ page). Display posters/leaflets/flyers in each practice. Text campaign to patients of WHP and TH to alert

WHP/Trinity WHP/Trinity

Patients Patients

Completed 28.2.17 Completed 1.3.17

them to the communication posted on the websites.

27.2.17

Notify Residential homes that use the practices at same time as patient comms sent out

WHP/Trinity Residential Homes and their patients

Completed

27.2.17

Inform all other stakeholders after PPG informed and letter on websites but prior to press release going out

WHP and Trinity Health

See list of stakeholders.

Completed

27.2.17 Draft and agree press release

WHP/Trinity to draft NHSE/CCG to approve and send out press release (Neil – to be sent out 1.3.17)

All Sent to NHSE/CCG 16.2.17 Agreed 1.3.17

1.3.17

Send out press release shortly after letter on websites etc.

Neil

Media/All Completed

Trinity 7.3.17 15.3.17 22.3.17 WHP 21.3.17 30.3.17 11.5.17

Hold drop in sessions to gain any patient feedback. PPG to attend if possible. Following letter to parish councils, Trinity attending Brill and Long Crendon meetings. Keep note of numbers attending, key themes and practice feedback. Modify Q&A following this, if required.

Trinity WHP

Patients Trinity drop-in sessions completed 22.3.17. Parish council meetings completed 22.5.17. WHP sessions completed 11.5.17.

6.4.17

Inform Primary Care Operational

Helen Delaitre PCOG members Completed

Group June 2017

Inform HASC Helen Delaitre HASC To be undertaken following approval

b) Feedback from Patient Consultation

Trinity Health and Wellington House Practice have undertaken a 12 week consultation period with patients from 1.3.17 to 31.5.17. The feedback from patients has been positive and supportive with only one objection received (from a Trinity Health patient). Each practice informed and consulted with patients about the proposed merger using the following methods:

• Patient Participation Group meeting to advise of the proposed merger. • Patient leaflet and FAQ sheet which was made available on the Trinity Health

and Wellington House Practice websites and in Brill, Long Crendon, Thame, Princes Risborough and Chinnor waiting rooms.

• Information poster in each site. • PowerPoint slide on the practice information screens. • Text campaign via MJOG to patients who have a mobile number on their

clinical records. • Advertisement of drop in sessions on all merger communications and on

social media. • Email address publicised in all communications to enable patients to feedback

thoughts on the proposed merger WELLINGTON HOUSE PRACTICE FEEDBACK We received feedback in response to our patient communication via MJOG, email and the drop-in sessions. We also received some responses via our patient survey (although this was not designed to seek feedback on merger, patients took the opportunity). The patient feedback was positive; there were questions and discussion but no objections. MJOG and emails • One patient was having difficulty finding the information on the website – advised where

to find • Two patients stated OK with them • One patient didn’t think we should ask patients – if GPs felt it was the right thing then that

was fine • One patient was stating that they didn’t want to stay with the practice if their registered

GP became a specific GP at Trinity • Having moved to Wellington House Practice, Chinnor about 28 years ago when we

moved here, I am a satisfied patient. (patient then gave some specific personal information that has been removed). I can see the benefit of a merger and have no objections and think it realistic and sensible in view of the village expansion over the next few years. I will try and find the time to visit the surgery on Tuesday 21st March.

• Brilliant idea. Look forward to a continuation of the excellent service enjoyed by patients of Wellington House practice.

• One patient raised a specific question asking whether we would now have to follow Oxford CCG guidelines since Trinity are in Oxford – clarified that although some sites are based in Oxford, Trinity are part of Bucks CCG.

• One patient suggested that we hold a drop-in session in the evening which we have done (arranged for 11.5.17).

Drop in Sessions: Chinnor 21.3.17 and Risborough 30.3.17 and 11.5.17 Chinnor drop-in session Tuesday 21st March 2017: 1:00 to 2:30pm Hosted by: Lesley Munro-Faure, Managing Partner 8 people attended the afternoon meeting and most stayed for 1 hour+. We discussed a wide range of topics including: Q. What were the benefits of merger A. We discussed the benefits already communicated in more detail Q. Why Cross Keys were not involved – would it not make sense to merge with them A. We held discussions with all the other practices in our locality but others were not interested in this stage. We have good relationships and will ensure we work closely together with other local practices. Q The location of the three Trinity surgeries and some concerns were expressed about transport links should we decide, in the future, to centralise any services A. The three Trinity surgeries are in Brill, Long Crendon and Thame. Currently we do not plan to centralise any services to run from a single site but this may change in the future, particular if we move the provision of some services from the hospital. We are aware that we have a higher than average elderly population and would need to ensure we kept transport in mind as part of any future plans. Q. Could we, as part of our plans, open a pharmacy to address the poor service they receive from Chinnor Lloyds A. Unfortunately we cannot since NHSE controls the commissioning of pharmacy services and there is legislation on what can be done. Trinity do have a dispensary and can dispense to a large number of their rural patients but, unfortunately we cannot extend this to cover other patients. We are in the process of organising a public meeting in Chinnor with the Lloyds head office team so that residents can feedback their issues with the quality of service provided (this public meeting was held 10.4.17) Risborough drop-in session Thursday 30th March 2017: 1:00 to 2:30pm Hosted by: Dr Michael Mulholland, GP Partner Attendees ranged from 10-14; a total of 17 during the session. Q. Why merge and why now? A. Shared national picture of demand / recruitment / consultation rates comorbidity etc and how these were drivers for the merger. Our population is more elderly and there is a challenge to sustain care we provide. Explained also from the perspective of training/education – there are fewer doctors wanting to train as GPs and fewer wanting to become GP partners. Q. Why WHP and Trinity and not Haddenham, Cross Keys or Rycote practices? A. Explained the discussions we had with all the local practices; only two wished to progress. We spent a lot of work looking at our cultures etc; we have similar values perspectives and aims Q. What next? A. Explained the timeline to merger. There is a three month consultation with patients which ends at the end of May; we will then apply to the local Clinical Commissioning Group who will consider our request. Q. Will this be the end or bigger? A. Explained that we don’t have an end size a mind. We are merging because we want to protect the service for our patients; considering what’s best for patient care and ensuring our sustainability will drive any future decisions. Q. What changes will this mean for patients? A. No change for patients. There was a strong message from patients that they want to maintain personal relationship with own doctor/team and did not want to travel far if needed

care. Explained our potential new model of care and that we are focused on developing that further so those who need have their care provided by the best person closest to home. Q. Will there be cuts in services or staff? A. None are planned; we see it as more opportunity to develop and sustain. Explained our drive for improvement of practice. There was unanimous support to continue and glad we were being proactive. We also discussed opportunities for patient voice in the future and there was one offer to be part of the Patient Participation Group. Risborough drop-in session Thursday 11th May 2017: 6:00 to 7:30pm Hosted by: Lesley Munro-Faure, Managing Partner Attendees: 25 people attended the evening meeting There was general discussion and questions amongst the group; most were questions that had been raised previously. Additional questions were: Q. Will the NHS make more funding available to this larger practice A. We discussed how primary care is currently funded; there is a national funding formula that will apply to the new practice which is the same as the current practice funding. NHSE does not make additional funding available to support merger. We could look to increase funding through economies of scale and/or attracting new services. Q. What new services might be provided? A. The first priority will be to ensure we deliver current patient care efficiently and effectively. Once this is achieved we will look at what new services we might provide; this will depend on the numbers of patients needing that service; equipment costs; skills required etc. Whatever services we provide will need to be assessed to ensure we can provide a high quality and cost effective service. We will also need to produce a business case to persuade the commissioner to commission the service from us. We talked about some general ideas around diabetes and ENT as possibilities. Q. Is there a national standard on the number of patients per GP? A. There is nothing defined in the contract; we need to determine the staffing levels we need to provide the service for our patients. Number of patients per GP is not necessarily the only figure that is important since the number will also depend on what other staffs are involved in delivering patient care eg nurses, paramedics, pharmacists etc. We have around 1500 patients per wte GP which is generally a low number; some can be as high as over 2000. Q. Will we still have a ‘named GP’ and will we be able to see them when we want? A. All patients have a named GP. Our motivation for merging is around patient care and practice sustainability so we need to ensure what we provide in future provides excellent patient care. We know that for some patients speed of access to the service is the most important factor and for some seeing their named GP/continuity is the most important factor. We are completely aware of this and will be looking to design a new service that meets all these needs. Q. Will we keep the name ‘Wellington House? A. We will be looking to come up with a new name for the new merged practice Q. Were all the partners in favour of this proposed merger? A. We explained that, for a merger to go ahead, all partners have to sign a new partnership agreement so all have been involved in the decisions and all were in favour of the merger TRINITY HEALTH FEEDBACK Drop in sessions were held at each site which were hosted by Emira Shepherd, Practice Manager and David Barrow, Trinity Health Patient Participation Group Chair. We also attended evening annual parish council meetings in Long Crendon and Brill.

The drops in sessions were advertised as an opportunity for patients to attend and openly ask questions about the proposed merger. The meetings were open for attendance by all. Brill drop in session. Tuesday 7th March 2017 1.00pm – 3.00pm Two people attended the Brill drop in session, one male in the 75-84 age bracket and one female in the 65-74 age bracket. The following points were raised:

• Concern about the continuity of care in the future for patients and loss of contact with regular GP.

• Travel distance to Princes Risborough and Chinnor. • Mental health provision in General Practice in the future organisation.

Long Crendon drop in session. Wednesday 15th March 2017 1.00pm – 3.00pm Two people attended the Long Crendon drop in session, one female in the 75-84 age bracket and one male in the 75-84 age bracket who was a patient at Wellington House Practice. The following points were raised:

• Difficulty in parking in Long Crendon. • Clarity over home visiting policy. • Wait time to see a GP. • Would like to know more about the Wellington House clinical team.

The Wellington House patient that attended came to find out more about the Trinity Health practice team. Thame drop in session. Wednesday 22nd March 2017 1.00pm – 3.00pm Seven people attended the Thame drop in session, four females in the 45-54 age bracket one female in the 35-44 age bracket, one male in the 75-84 bracket and one female in the 75-84 age bracket who are Wellington House patients that live in Thame. The following points were raised:

Will there still be access to outpatient appointments at OUH. Future development of a new surgery in Thame in light of the population growth in the town. Will there be flexibility to see a GP from Wellington House in Thame.

Brill Parish Council AGM Tuesday 25th April 2017 7.30pm Attended by Dr Stuart Logan, GP Partner and Emira Shepherd, Practice Manager

We gave a brief overview of the proposed merger to the attendees at the Brill Parish Council AGM, and then asked for questions and feedback. The following points were raised:

The merger process, more information about what was happening behind the scenes. Would the Brill practice still operate a full service? Are there plans for improved mental health provision as part of the newly merged organisation? Will there be job losses for employees of Trinity Health? Long term condition management across both practices, how would this work?

Long Crendon Parish Council AGM Monday 22nd May 2017 7.30pm Attended by Dr Anna Furlonger, GP Partner and Emira Shepherd, Practice Manager We gave a brief over view of the proposed merger to the attendees at the Long Crendon Parish Council AGM and then asked for questions and feedback.

The following points were raised:

What additional services would be available to patients in the future? What are the plans for a new surgery in Long Crendon? Would Web GP continue to be used in the newly merged organisation?

Email communications We received a total of seven emails from patients across the three sites. Amongst these one objection was received. C) Patient Information

PROPOSED PRACTICE MERGER

We are delighted to announce that Wellington House Practice and Trinity Health are proposing to merge to form a larger ‘super-partnership’

I am sure that you are aware that over the past few years there have been increased pressures placed upon General Practice. The increasingly elderly population, the growth in long term conditions and the need to move more work from secondary care into the community means that General Practice needs to expand and innovate to absorb this increased workload. Whilst both practices are performing very well against all the national and local targets and have been rated ‘Good’ at recent CQC assessments, we have decided that the best way to continue to offer our patients an innovative, sustainable, quality service into the future is to seek to merge our practices.

Our two practices share the same commitment to quality and to patient care; by merging we would be able to share working arrangements and be more effective and efficient building

on the skills and expertise of a broader pool of doctors, nurses and managers. We have begun to make arrangements for a merger which is planned for 1st October 2017. The first step in the process is for us to communicate our plans with you, our patients and seek your feedback on this proposal.

All of our doctors, our practice nurses and other staff would continue to be available to you under the new planned arrangements at Wellington House Practice and Trinity Health. There would be no changes in premises or phone numbers; but there would be greater flexibility in accessing healthcare and, over time, we would seek to make additional services available in the practice. Your registration would not be affected and you would be able to be seen by one of our doctors or nurses at either practice. In time we would change the name to reflect the fact that we would be a single practice but a new name has not yet been chosen.

We are proud of both of our practices and the quality of care we have maintained over the years and have always been touched by the positive feedback and support from our patients. This proposed merger would see our teams uniting as one like-minded team and would continue to provide care for you at our practices following a seamless and safe sharing of healthcare information and prescribing data.

We understand that you may have questions about the merger and we intend to address your concerns by a number of means.

• We have tried to answer some of the questions we think you may have and these questions and answers can be found on our websites: www.wellingtonhouse.nhs.uk and www.trinity-health.co.uk. This includes information about how to register with another practice if you do not wish to remain at the proposed merged Wellington House Practice or Trinity Health in the future.

• We will hold some ‘drop in’ sessions at Wellington House Practice and Trinity Health when you can call in, have a look around and ask any questions about what a merged practice might mean for you. These sessions will be held as follows: Wellington House Trinity Health Chinnor: Tuesday 21st March 1-2:30pm Brill: Tuesday 7th March 1-3pm Risborough: Thursday 30th March 1-2:30pm Long Crendon: Wednesday 15th March 1-3pm Thame: Wednesday 22nd March 1-3pm

• We very much welcome your feedback on our plans. If you have any specific queries or concerns please contact Lesley Munro-Faure, Managing Partner at Wellington House Surgery or Emira Shepherd, Practice Manager at Trinity Health. Contact details are at the bottom of this communication.

Merger would be a time of change for all of us at Wellington House Practice and Trinity Health and whilst we would all work extremely hard to minimise any disruption, we would be grateful for your understanding throughout the proposed merger process.

http://www.wellingtonhouse.nhs.uk/

http://www.trinity-health.co.uk/

We are excited to be planning on taking this important step to secure the long term future of General Practice and very much look forward to receiving your feedback on our proposal.

Partners at Wellington House Practice Partners at Trinity Health Dr Stephen Stamp Dr Gill Scott Dr Michael Mulholland Dr Stuart Logan Dr Mike Thomas Dr Martin Thornton Dr Swagatika Mohapatra Dr Anna Furlonger Lesley Munro-Faure Dr James Weir Please feedback to us either in person at one of the drop in sessions or via letter or email to: Lesley Munro-Faure Emira Shepherd Wellington House Practice Trinity Health Wades Field Brill Surgery Stratton Road 22 Thame Road Princes Risborough Brill HP27 9AX HP18 9SA [email protected] [email protected]

Merger Poster Press Release FAQs Screen information.pptx

mailto:[email protected]


Appendix 4 – Equality Impact Assessment

Equality and Health Inequalities Analysis: Standard Template for NHS England

Trinity Health and Wellington House Surgery Application to Merge Equality Impact Assessment

May 2017

Equality and Health Inequalities Analysis Standard template for NHS England Version number: 2.0 Prepared by: Equality and Health Inequalities Unit

Equality Analysis

Title: Proposed Merger of Trinity Health and Wellington House Surgery

What are the intended outcomes of this work? Include outline of objectives and function aims Trinity Health and Wellington House Surgery intend to merge. The GMS contract for Wellington House Surgery will cease and a contract variation will be issued for Trinity Health acknowledging the two additional sites. There will be a bulk transfer for patients currently registered with Wellington House Surgery to Trinity Health.

Please outline which Equality Delivery System (EDS2) Goals/Outcomes this work relates to? See Annex B for EDS2 Goals and Outcomes

Better Health Outcomes: 1.1,1.2, 1.3, 1.4,1.5

Improved Patient Access & Experience: 2.1, 2.3

A representative and supported workforce: 3.6

Who will be affected by this work? e.g. staff, patients, service users, partner organisations etc. Patients and staff of Trinity Health and Wellington House Surgery.

Evidence What evidence have you considered? List the main sources of data, research and other sources of evidence (including full references) reviewed to determine impact on each equality group (protected characteristic). This can include national research, surveys, reports, research interviews, focus groups, pilot activity evaluations or other Equality Analyses. If there are gaps in evidence, state what you will do to mitigate them in the Evidence based decision making section on page 9 of this template. • Registered list data: geographical and demographic spread of registered patients at both

Trinity Health and Wellington House Surgery.

• Practice boundaries for the local area. • Evidence to be provided by Trinity Health and Wellington House Surgery through

consultation with patients, local community and stakeholders.

Age Consider and detail age related evidence. This can include safeguarding, consent and welfare issues.

As the merged practice intends to continue to offer services from the existing 5 sites there should be no issues for registered patients. The practices have committed to continue to provide continuity of care to all of their patients. Patients would be able to continue to attend at the site they currently utilise.

Disability Consider and detail disability related evidence. This can include attitudinal, physical and social barriers as well as mental health/ learning disabilities.


Gender reassignment (including transgender) Consider and detail evidence on transgender people. This can include issues such as privacy of data and harassment.

No specific impact.

Marriage and civil partnership Consider and detail evidence on marriage and civil partnership. This can include working arrangements, part-time working, caring responsibilities.

No specific impact.

Pregnancy and maternity Consider and detail evidence on pregnancy and maternity. This can include working arrangements, part-time working, caring responsibilities.


Race Consider and detail race related evidence. This can include information on difference ethnic groups, Roma gypsies, Irish travellers, nationalities, cultures, and language barriers.

No specific impact.

Religion or belief Consider and detail evidence on people with different religions, beliefs or no belief. This can include consent and end of life issues.

No specific impact.

Sex Consider and detail evidence on men and women. This could include access to services and employment.

No specific impact.

Sexual orientation Consider and detail evidence on heterosexual people as well as lesbian, gay and bisexual people. This could include access to services and employment, attitudinal and social barriers.

No specific impact.

Carers Consider and detail evidence on part-time working, shift-patterns, general caring responsibilities.

As the merged practice intends to continue to offer services from the existing 5 sites there should be no issues for registered patients. The practices have committed to continue to provide continuity of care to all of their patients. Patients (and their carers) would be able to continue to attend at the site they currently utilise.

Other identified groups Consider and detail evidence on groups experiencing disadvantage and barriers to access and outcomes. This can include different socio-economic groups, geographical area inequality, income, resident status (migrants, asylum seekers).

No specific impact.

Engagement and involvement

How have you engaged stakeholders with an interest in protected characteristics in gathering evidence or testing the evidence available?

In line with the NHS England’s standard operating procedures, both Trinity Health and Wellington House Surgery have consulted widely on their proposal. The practices have run a robust 12 week consultation for patients, including patients and stakeholders and the results have been included with their application to the CCG. This EIA will be reviewed in light of comments received as part of the consultation.

How have you engaged stakeholders in testing the policy or programme proposals?

N/A operational change.

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

The details of the consultation will be contained within the practice application to close the branch surgery. This EIA will be reviewed in light of comments received as part of the consultation.

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impacts,

if so state whether adverse or positive and for which groups and/or individuals. How you will mitigate any negative impacts? How you will include certain protected groups in services or expand their participation in public life? The impact of the merger would have minimal impact on patients. Services will continue to operate from the existing sites and the practices have committed to ensure a continuity of care for their patients. Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups.

Eliminate discrimination, harassment and victimisation

Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation). No impact.

Advance equality of opportunity Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation). No impact.

Promote good relations between groups Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation). No impact. Evidence based decision-making

Please give an outline of what you are going to do, based on the gaps, challenges and opportunities you have identified in the summary of analysis section. This might include action(s) to eliminate discrimination issues, partnership working with stakeholders and data gaps that need to be addressed through further consultation or research. The 12 week consultation on the proposed merger of Trinity Health and Wellington House Surgery has concluded. The EIA will be reviewed in light of the results of the consultation and any appropriate actions taken.

How will you share the findings of the Equality analysis? This can include corporate governance, other directorates, partner organisations and the public.

Updated Equality Analysis to be included in the decision-making paper to be submitted to the Primary Care Commissioning Committee for Buckinghamshire CCGs on 1 June 2017.

Health Inequalities Analysis

Evidence 1. What evidence have you considered to determine what health inequalities exist in relation to your work? List the main sources of data, research and other sources of evidence (including full references) reviewed to determine impact on each equality group (protected characteristic). This can include national research, surveys, reports, research interviews, focus groups, pilot activity evaluations or other Equality Analyses. If there are gaps in evidence, state what you will do to mitigate them in the Evidence based decision making section on the last page of this template. • What health inequalities currently exist with regard to the health issue that your

policy/procedure aims to address? N/A operational change.

• What factors have created, maintained or increased health inequalities in access to, and outcomes from healthcare services? No impact

• Who will be affected by your work and what are the demographics of the population

affected? No impact

• How is the health issue that your work is aiming to address distributed across different population groups and across different geographical locations? N/A operational change.

Impact 2. What is the potential impact of your work on health inequalities? Can you demonstrate through evidenced based consideration how the health outcomes, experience and access to health care services differ across the population group and in different geographical locations that your work applies to? • How will your work affect health inequalities?

No impact

• Can you demonstrate through evidenced based consideration how the health outcomes, experience and access to health care services differ across the population group and in different geographical locations that your work applies to? N/A operational change.

• Will the work address need across the social gradient or focus on specific groups?

N/A operational change.

• Will the policy/procedure have an unintended differential impact on different population groups and across different geographical locations? N/A operational change.

• Would providing services in an integrated way reduce health inequalities?

N/A operational change. 3. How can you make sure that your work has the best chance of reducing health inequalities? • What can you do to make it more likely that the work reduces health inequalities?

N/A no increased health equalities

• What have you done to mitigate against any failure to reduce health inequalities?

N/A no increased health equalities • Are there any dependencies or interdependencies that may impact on the work’s ability

to address health inequalities? For example, are delivery partners sufficiently engaged in addressing health inequalities? Are there any resource implications that may affect the delivery? N/A no increased health equalities

• Will the work be equitably delivered to all population groups, with a scale and intensity

proportionate to the level of disadvantage? N/A operational change.

Monitor and Evaluation 4. How will you monitor and evaluate the effect of your work on health inequalities? • How will you know whether your work has an impact on reducing health inequalities?

The CCG will ask the newly merged practice to monitor and report any impact the merger has had (if agreed).

• Have you captured the evidence and recorded how the need to reduce health inequalities has been taken into account in the development of this work? Part of practice application.

• Are there any gaps in the evidence that need to be addressed through further

consultation or research? No.

• What will you do based on the gaps, challenges and opportunities you have identified in

the evidence? N/A

• Can you produce both whilst developing this work and at the end of the work, for

assurance and risk mitigation, accessible records of all decisions and the decision making processes? Yes.

For your records Name of person(s) who carried out these analyses: Wendy Newton, Primary Care Manager, Bucks CCGs

Name of Sponsor Director: Nicola Lester, Director of Transformation, Bucks CCGs

Date analyses were completed: 25 May 2017

Review date: April 2018 (6 months after the proposed merger date)

Appendix 5 – 13Q Duty Public Involvement Assessment Form

Section 13Q Duty Public Involvement Assessment Form Step 1 - Details of the commissioning activity Describe the commissioning activity: Trinity Health and Wellington House Surgery intend to merge. The GMS contract for Wellington House Surgery will cease and a contract variation will be issued for Trinity Health acknowledging the two additional sites. There will be a bulk transfer for patients currently registered with Wellington House Surgery to Trinity Health. Step 2 – Identify type of commissioning activity Type of activity: Planning X Proposals for change Operational decision Step 3 – In respect of proposals for change or operational decisions, assess the impact on service users If the plans, proposals or decisions are implemented, would there be:

• An impact on the manner in which the services are delivered to the individuals at the point when they are received by users? Yes X No

• An impact on the range of health services available to users? Yes X No Explain why you have answered yes or no to the above: As the merged practice intends to continue to offer services from the existing 5 sites there should be no issues for registered patients. The practices have committed to continue to provide continuity of care to all of their patients. Patients would be able to continue to attend at the site they currently utilise and access the existing services. Step 4 – Section 13Q duty Does the section 13Q duty apply to the activity? X Yes No Explain why you have answered yes or no to the above: Change in service provider If yes, (a) identify any existing arrangements to involve the public which are already in place (national or local involvement initiatives): Trinity Health and Wellington House Surgery PPGs have been informed of the proposed plans ahead of the formal public consultation. Information for patients will be available in practice waiting rooms, on the practice website and available in hard copy for patients to take

away. There will also be advertised drop in sessions held at every site. This gives patients the opportunity to give their views on the proposed merger. (b) whether it is considered necessary to make further arrangements for this activity and if so what these will be: All patients will have the opportunity to be engaged in the consultation process. NHS England, the CCG and the CCG Communications Team have collaborated to ensure that a robust communication exercise is undertaken as part of the consultation process. Confirm whether a further assessment needs to be carried out in future and, if so, when or in what circumstances that will be carried out: No need for a further assessment identified at present. Name: Wendy Newton Job Title: Primary Care Manager Date: 1 February 2017

If you are unsure as to the answer to any of these questions, seek advice from the

relevant team in your region or the Public Participation Team in the national support centre: [email protected]

or telephone 0113 8250861.

Completed assessment forms must be retained and will be required for reporting and monitoring purposes.


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MEETING: Primary Care Commissioning Committee PAPER: E

DATE: 1st June 2017

TITLE: Premises Sub Group

AUTHOR: Helen Delaitre, Head of Primary Care


Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: Aylesbury Vale and Chiltern CCGs have a challenging Primary Care Strategy to deliver over the next two years. The strategy is closely aligned to the 5 Year Forward View and the GP Forward View and underpins delivery plans across the wider Buckinghamshire, Oxfordshire and Berkshire (BOB) STP footprint. In order to deliver the primary care strategy, a number of key enablers need to be recognised and built into delivery plans:

• Premises development and in particular the development of community and primary care hubs

• IT development and infrastructure • Workforce development • Development of Primary Care led provider clusters • System wide integration.

With the advent of delegated responsibilities for primary care commissioning, decision-making regarding premises development now rests with CCGs. So that the CCG can discharge its duties in an informed way, support was given by the PCOG to establish a Premises Sub Group of the Primary Care Commissioning Committee and HD agreed to draft terms of reference that would be approved by the PCOG before final sign off by the PCCC at the June 2017 meeting. The draft Terms of Reference were reviewed by the PCOG in May and are now presented to the PCCC for final approval. PCCC is asked to agree to the establishment of a Premises Sub Group which will be a sub group of the Primary Care Commissioning Committee. Draft Terms of Reference have been reviewed by PCOG. PCCC is asked to approve the draft Terms of Reference.

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Conflicts of Interest: None in respect of approvals requested. 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






Equality Quality Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups

Establishment of a Premises Sub Group previously discussed at PCOG on 6th April and 4th May 2017.


Supporting Papers: Draft Terms of Reference.

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Premises Sub Group

Terms of Reference 1. Background

Aylesbury Vale and Chiltern CCGs have a challenging Primary Care Strategy to deliver over the next two years. The strategy is closely aligned to the 5 Year Forward View and the GP Forward View and underpins delivery plans across the wider Buckinghamshire, Oxfordshire and Berkshire (BOB) STP footprint. In order to deliver the primary care strategy, a number of key enablers need to be recognised and built into delivery plans:

• Premises development and in particular the development of community and primary care hubs

• IT development and infrastructure • Workforce development • Development of Primary Care led provider clusters • System wide integration.

With the advent of delegated responsibilities for primary care commissioning, decision-making regarding premises development now rests with CCGs. So that the CCG can discharge its duties in an informed way, a Premises Sub Group of the Primary Care Commissioning Committee will be established with the following objectives and responsibilities. 2. Objectives

The objectives of the Premises Sub Group are to:

• Prepare a Primary Care Estate Strategy • Ensure premises are developed in Buckinghamshire to support the implementation of

CCG commissioning plans and in particular the Primary Care Strategy and STP. • Ensure primary care premises are developed to provide the capacity and quality of

premises required to meet needs associated with population growth and new housing.

3. Responsibilities The Premises Sub Group will:

• Review all premises matters and where required, make recommendations to the Primary Care Commissioning and Finance Committees based on informed opinion.

• Review plans for Estates, Technology Transformation Funding (ETTF)/Minor Improvement Grant (MIG) funded developments as well as improvements funded through other sources.

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• Assess capacity requirements for delivering the CCGs’ Primary Care Strategy and develop appropriate premises plans based on GP cluster formations.

• Review rent review management service reports and approve CSU to instigate the local dispute resolution process with practices that appeal their rental assessment. Where this happens the Sub Group will approve increased costs per case up to £5,000.

• Oversee responses to local district and county councils regarding the development of Local Housing Plans, Infrastructure Delivery Plans, Neighbourhood Plans and major planning applications.

• Make recommendations on the application of S106 and Community Infrastructure Levy (CIL) funding.

• Ensure appropriate communication and alignment with other key enabler work streams (e.g. GP IT).

• Provide regular progress and update reports to the Primary Care Commissioning and Finance Committees (and any other committee or board as required).

5. Membership Chair – nominated Lay Governing Body Representative. Deputising duties will be undertaken by the Director of Transformation as and when required. GP Lead Estates Advisor Head of Primary Care Head of Locality Delivery Deputy Chief Finance Officer LMC Other ad hoc members may join the Sub Group as non-voting members as and when required. Ad hoc members will not count towards quoracy. 6. Quoracy A quorum will be the Chair (or their deputy), Estates Advisor, GP Lead (as long as not conflicted) and either the Head of Primary Care or Deputy Chief Finance Officer. Deputies will absolutely be required to cover absences and will be noted in these Terms of Reference. 7. Frequency of Meetings The sub group will meet on an ad hoc basis to ensure the responsibilities of the group are fulfilled. However, at the very least, the group will meet quarterly. 8. Governance

Primary Care Commissioning Committee

Health and Wellbeing Board

Premises Sub Group

CCG Governing Body

Finance Committee

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Document Control

Version control and review date Signatures (approval and review) Date of approval (by who/which committee) These terms of reference will be reviewed annually.

Version (author and date)

Review date (by group/committee)

Reason for amendments

Signature (chair) and date to confirm acceptance and adoption

V 1.0 Helen Delaitre

04/05/2017 First draft, reviewed at Primary Care Operational Group

Graham Smith 04/05/2017

V2.0 Helen Delaitre

23/05/2017 Amendments required following review by members of the proposed Premises Sub Group

Nicola Lester 23/05/2017

MEETING: Primary Care Commissioning Committee PAPER: F DATE: 1st June 2017

TITLE: Primary Care Development Scheme

AUTHOR: Louise Smith

LEAD DIRECTOR: Nicola Lester

Reason for presenting this paper: For Action For Approval X For Decision For Assurance For Information

Summary of Purpose and Scope of Report:

Through the Primary Care Commissioning Committee (2nd March) and the Governing Body (9th

March) the principles, direction and financial envelope of the primary care development scheme (PDS) were approved. The purpose of this paper is to provide the Primary Care Committee with sufficient detail on the PDS including the service specification and finance model to enable them to approve the final scheme.

The primary care development model and associated incentive scheme have been designed to enable primary care to transition to new models of care in line with the 5 year forward view whilst maintaining clinical quality of services. This model is built on the following:

1) Foundation - A robust and reactive infrastructure from which to deliver, to include clustering

of general practice and standardisation of practice 2) Delivery - structured, evidenced based delivery vehicles which have demonstrated improved

clinical outcomes in those areas that are considered a priority to Buckinghamshire because of the health needs of the local population

3) Outcomes – Improved population based outcomes.

This model is supported by a multiyear development scheme which builds on these three areas. The core principles of which are:

• Encompasses the Quality and Outcomes Framework (QOF) and the current Quality Improvement Schemes (QIS)

• Reduces inappropriate workload, that does not add clinical value • Is built on evidence based care • Is responsive to the population health needs of localities and adds value to patient care • Does not disadvantage practices that take up the proposed scheme • Aligns to national, STP and CCG strategies.

The total budget approved is £1.5m. This will cover the practice support to transition to this way of working as well as the infrastructure within the CCG to provide support, training and technical solutions such as templates and protocols. The model provides practices with a one off payment (£6k) aimed at supporting achievement of the foundation stage. This will be managed as a gateway to the provision of further elements of the scheme because it is accepted that without the fundamentals within the foundation stage practices will not be able to deliver the services in the ‘Care Delivery’ stage and work at scale as part of a new model of care. Care delivery payment is 20% of historic QOF outturn which will be paid at year end.

Practices will be provided with clear performance expectations for the ‘care delivery’ stage of the

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model and these are articulated in the service specifications. As this is a transition year to new ways of working and non-delivery will be picked up by exception where a practice is deemed a significant outlier from its peers. If identified as an outlier a practice will be visited by the appropriate clinical team to understand the issues. The practice will be given the opportunity to engage in the CCG support process but sustained non delivery and unwillingness to engage will result in a reduction of the final 20% payment along a sliding scale. The full financial model is within the attached final paper but the total potential investment is shown below.

Item Total Investment Foundation stage - £6k £312,000 Care Delivery - 20% of historic QOF outturn (Note that the financial envelope available for this payment is £1.2m and therefore the percentage value may change when updated using 16/17 figures)

£1,183,529 (based on 15/16 – only available at this time)

If choosing to deliver the scheme practices will benefit from a suspension of QOF payments being linked to QOF achievement. In reality this means that the practices will still be responsible for maintaining their QOF registers and appropriate clinical care, but that full QOF data collection is not directly linked to the achievement payment. This is to reflect the changes required in general practice in order to deliver the new outcomes. The rationale behind suspending formal QOF reporting and achievement-related payment at Foundation Stage is to enable practices to engage fully in embedding the new model without having to worry about possible dips in QOF performance and related QOF income that might result from diverting energy into this transformational change. At care delivery stage practices are expected to be delivering alternative care achievements that are more relevant to the local population health needs and represent good clinical care and therefore QOF is not required.

Where possible the model tries not to be prescriptive in terms of how it is delivered but focusses on outcomes. This is however a journey and process measures do feature but there is a desire to move to a more holistic patient focus rather than by disease. The aim is to eventually link the clinical metrics with our new models of care with the same clinical expectations across the system. Clinical expectations are documented within the service specification

Patient and public engagement with the scheme is ongoing and has predominately been through existing clinical and locality focused patient groups. Patients will continue to be involved as the scheme progresses and particularly with its evaluation.

Due to the potential for conflict of interest a number of additional measures have been put in place to support the scheme including

• Audit committee verification of monitoring and payment arrangements • Programme board ownership • Monthly monitoring and quarterly reporting using primary care operational group, primary

care committee and the PDS working group as relevant

The final scheme once approved by the PCCC will need to return to the governing body for information as it was recognised that although the principles of the scheme were not expected to change there may be further refinement required to the clinical expectations as a result of ongoing clinical engagement. This in reality has been minimal and has added to the scheme so that all the CCGs priorities are reflected adequately.

General practice cannot afford to remain as it currently is. If the CCG is to support primary care to develop so that it can provide robust and sustainable quality services through new models of care it must also recognise that a financial investment is required. It is genuinely considered that this scheme will meet the population health needs of Buckinghamshire residents and that there will be minimal adverse effects of using this as an alternative to QOF due to the continued use of disease registers, use of templates and protocols and the focus on the clinical areas with the biggest impact.

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Conflicts of Interest:

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

x


x



x



Y PPI as part of the evaluation of current schemes and improvement stands of existing clinical care improvement initiatives which the PDS pulls together.

Equality Y It is the intention that the final scheme will support the levelling of patient inequalities and will be accessible to all practices.

Quality Y The main driver of the scheme is to improve the quality of patient services and is evidenced based.

Financial Y The scheme will require investment of at least £1.5m

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This paper raises a conflict of interest for the CCG clinicians as it relates to a primary care development scheme and its associated payment. Although the paper has been owned by the management team it has involved development with the clinicians due to the clinical content and this has been considered essential. Clinicians have not however been involved in the discussions and conclusions reached regarding financing.

The paper has previously been discussed at Primary Care Commissioning Committee (2nd March 17), Primary care operational meeting (6th April 17) and went to Governing Body on 9th March 17 for sign off in principle including the financial envelope. For the avoidance of doubt, following appropriate contribution of conflicted member GPs at PCCC in discussion on this matter, at Governing Body the GPs did leave the room.

In advance of the meeting it has been agreed with the PCCC lay chair that conflicted clinicians may participate in the initial discussion so that they may be able to contribute appropriately providing clinical guidance but will abstain from the final decision as to whether to approve the roll out of the initiative

The interests of all clinicians in the organisation are recorded on the CCGs register of interests.

The financial outlay is considered reasonable given the additional spend on services from other sectors, the non-investment in primary care for a number of years as well as the QIPP savings that are required some of which will only be possible through the agreement of this scheme. Given the robust governance and monitoring arrangements proposed it is also considered that any potential risk to patients and practices of non-delivery can be managed in order to deliver real transformational change.

The Primary Care Commissioning Committee is asked to approve the PDS including clinical scope and financial model.

which will be made available to practices but will also pay for the supporting structure which will ensure delivery. This investment will support the delivery of QIPP.

Risks Y The scheme attempts to deliver the crucial elements required from general practice in order to move the local health system to new models of care. If the scheme is not thought to be beneficial by general practice and they do not engage the CCG risks not being able to build the new models required in order to create sustainable and resilient primary care or deliver related areas of QIPP.

Statutory/Legal Y This development scheme makes provision for an alternative to the nationally mandated quality and outcomes framework (QOF) this is without prejudice to the rights of practices to their GMS entitlements being negotiated and agreed nationally


Y Clinical work up from 23rd December – clinical locality leads meeting and programme boards as well as one to one discussion Senior management team discussion Primary care operational group - 2 February 2017 Primary Care Commissioning Committee – 2nd

March 2017 Local Medical Committee - 3 January, 7th March & 2nd

May 2017. Governing Body – 9th March 2017 Primary Care operational group – 6th April 2017 Planned Care Programme Board – 16th March & 20th

April h Membership Involvement Y Discussed at all localities during April and May

Practice manager meetings in May PLT session held in May

Supporting Papers:

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Primary Care Development Scheme Final Paper Primary Care Development Scheme Service Specification

Primary Care Provider Development 2017/18 and 18/19

Introduction

The proposal below outlines a two year programme designed to enable Aylesbury Vale and Chiltern Clinical Commissioning Groups (CCGs) to progress primary care services in line with the 5 year forward view and the Buckinghamshire primary care strategy. It is based on the concept of essential building blocks (foundation) required for the delivery of sustainable and transformational primary care services. It recognises the current differences between the two CCGs in terms of the contractual mechanisms and payment by which general practice are currently commissioned and aims to align these without leaving clinical services and general practice disadvantaged. The subsequent commissioning proposals at the end of this document are as a direct response to the current CCG priorities, financial envelope and proposed development model and evaluation of the current commissioned services.

Case for Change

The five year forward view (NHS England, October 2014) and the General Practice forward view (NHS England, April 2016) are starting to change the way in which healthcare is commissioned, contracted and delivered. New models of care are starting to change expectations of healthcare providers and if Buckinghamshire CCGs want our local providers to be successful in their ambitions to improve patient care we must support them to change. As a health and social care system Buckinghamshire is starting to articulate a two year plan (appendix a) but it must also continue to meet a number of competing priorities including

• CCG Improvement and Assessment Framework (IAF) • Value for money and achieving financial balance, including Right Care • Maintain high quality services

One of the greatest areas of challenge is primary care in which multiple contract holders of varying sizes and quality must start to challenge their current business model as without doing so will inevitably lead to a primary care system unable to meet the demands made of it. One of the ways in which primary care can be strengthened is through providers working closely together for a common goal forming GP Networks. These are collaborative arrangements with other practices called federations, networks, collaborations, joint ventures or alliances. Only after making this work can primary care move to forms such as the MCP or PACS.

There is a desire for primary care to transition to new models of care in line with the 5 Year Forward View, it must be given time to do so whilst not allowing service quality to decline.

Challenges

The model below and associated incentive scheme aims to support primary care in its ambition to change. It challenges the current structures that prevent services from delivering and seeks alignment across Buckinghamshire. Such challenges include

• piecemeal payment for additional services or actions in the pursuit of improved patient care and services

• Variation in primary care services and incentive schemes commissioned and the rates at which they are paid (Appendix B)

• A Quality and Outcomes Framework (QOF) that does not take into consideration the particular population health needs of the Buckinghamshire localities and is not consistent with the system wide patient outcomes which commissioners would like to align across all providers.

Opportunities

At the same time the CCG needs to make the most of the opportunities that present themselves. With a potential merger of organisations currently being progressed, now is an ideal time to align these schemes and to see how best the two CCGs can collectively improve general practice services. In addition from April 17 both Chiltern and AV CCGs are expected to assume the status of delegated commissioners of primary care. This will allow for the development of local flexibilities for contracts and incentive schemes without prejudice to the rights of practices to their GMS entitlements being negotiated and agreed nationally. As such it is possible for the CCG to strengthen current service delivery to align it to other locally commissioned services by enhancing specific elements of the existing incentive schemes commissioned nationally by NHS England i.e. QOF and Direct Enhanced Services(DES).

Primary Care Development Model

The primary care development model below is designed to enable primary care to transition to new models of care in line with the 5 year forward view whilst maintaining clinical quality of services; supporting primary care to develop so that it can provide population based healthcare within the current and expected financial envelop, maximising opportunities to work together and utilising additional government funding where available.

Foundation - creating a robust and reactive infrastructure from which to deliver

• Full EMIS economy – ability to share data, utilise same systems across primary care to simplify

booking, recall etc. • Creation of GP networks • Maximising cluster capability - shared protocols, templates, data sharing etc. • Workforce Development - new roles, skill mix and training • Access to risk stratification tool

Delivery - structured, evidenced based delivery vehicles

• Supported self-care (Care and Support Planning) • Clinical pathway development (Right care prioritisation & peerreview) • Use of electronic referral system • Evidenced based prescribing • Extended access including GP Access Centre • Development of new roles, ways of working and multidisciplinary teams (pharmacists

and paramedics in general practice and care navigators)

Outcomes – Improved population based outcomes

• National GMS Quality Outcomes Framework (QOF) • Alternative outcome based scheme to replace QOFexpectations

Development Scheme

Some of the elements shown in the model above will be driven through national incentives and drivers. The CCGs however wish to offer a scheme aligned to local services which supports them to develop further faster. Any such scheme would need to build on the existing incentives open to primary care such as QOF but the local ones such as the current Care and Support Planning scheme in which a leniency around QOF achievement was allowed in return for alternative but linked outcomes. It must also be recognised that the practices may choose not to be part of the scheme and continue with the current nationally mandated QOF as is their right under the GMS contract. A single Bucks wide incentive scheme would meet the following design principles:

• Encompasses the Quality and Outcomes Framework (QOF) and the current Quality

Improvement Schemes (QIS) • Reduces inappropriate workload, that does not add clinical value • Is built on evidence based care • Is responsive to the population health needs of localities and adds value to patientcare • Does not disadvantage practices that take up the proposed scheme • Aligns to national, STP and CCG strategies

Any such scheme would need to be fluid enabling development areas to move to business as usual once achieved. The benefits of having a two year incentive will be in the identification and achievement of steps along the longer development journey.

It is also anticipated for there to be a role for localities to deliver and drive elements of the incentive scheme which can be provided on a wider geography than a single practice.

Clinical Development

CCG Clinical Directors have been involved in the clinical development of the proposed scheme bringing their specific expertise to each domain, identifying clinical priorities for inclusion and recommending outcome targets. Specific challenge was made to consider the following:

• What is currently within QOF and QIS arrangements and theirvalue • How these could change to include clinical outcomes • Prioritisation of each clinical area selected • Targets / metrics to be used that are practical, recordable, do not add extra workload burden

but can demonstrate added value

It was considered that a two year programme would enable phased implementation of clinical areas giving each clinical director associated with the priority area, time to work up their area.

Content of new Scheme

There will be a mixture of process and outcomes metrics which practices will be expected to meet within the scheme. Where possible the expectations made of general practice within the scheme will be explicit simple, achievable, demonstrable and auditable. Engagement with the CCG in order to deliver will also be a general expectation. Clinical targets will be a mix of current targets to be maintained and new targets to be achieved. There are two main areas of the scheme

Foundation Gateway – The aim is for all practices to achieve this in year 1. These represent process achievements which are regarded as essential building blocks for primary care to reach its transformation potential and in order to support care delivery as described below. All elements of the foundation gateway are expected in order to obtain payment and there will be no payment for part achievement. Some practices may have more to do in this section than others but there will be one single payment.

Care Delivery – In this part of the scheme practices are expected to improve specific areas of care delivery around CCG priority areas. This part of the scheme is only available to those practices that have achieved all elements of the foundation gateway and the

Care Delivery Areas of care that practices may

already be delivering but require further focus

• Supported self-care through care and support planning

• Rightcare clinical pathways • Dementia

Care Delivery Plus

Areas of care that practices may already be delivering but require significant continue effort

• Prescribing • Diabetes prevention • AF • EoL • Mental health

Care Delivery Alternative

This part of the scheme allows alternative metrics to those mandated in traditional QOF to be delivered. These metrics are those considered to demonstrate improved patient outcomes of care

• Diabetes triple target • HF • Hypertension • COPD

A summary of key clinical requirements can be found in appendix c with full details in the service specification. Clinical areas excluded from year one of the scheme but for consideration in year 2 can also be found in appendix c.

CCG support to deliver

The CCG will provide additional resource to support this programme. This will be through assigned subject matter experts who will be able to come out to practice and / or engage through an alternative route to assist in the implementation of change through education or facilitation. Where possible the scheme will be monitored through EMIS enterprise with no requirement for separate practice returns.

Financial Model

The total 17/18 budget to be made available to primary care development will be £1.5m. This is equivalent to the incentive funding made available to general practice now and is thought to be a reasonable allocation given that proposals under new models of care have assigned 2.5-4% of contract budget to improvement schemes. When this funding goes to general practice it will be split into two, a one off transitional payment for the foundation stage and a second payment for care delivery achievement.

There will also be a cost to the CCG required in order to facilitate and support the primary care development in practice. Costs will include template and protocol development, CSU support and practice training. Although much of this will be within current costs and contracts an additional budget will be required for elements that the CCG does not currently commission this will be up to £100k.

The financial model observed the following principles

• This is a transition Year therefore the principles around the QOF leniency of the current AV scheme will continue and the relationship between QOF reporting and financial income will be removed

• Foundation stage payment will be £6k this will be a single value to practice as these are

predominately process measures and require doing regardless of practice size and demographics

• Care Delivery payment will be 20% on top of historic QOF achievement, this factors in

practice demographics. Note that the financial envelope available for this payment is £1.2m and therefore the percentage value may change when updated using 16/17 figures. Practices are expected to deliver all aspects of care delivery. The metrics described are associated with current activity and believed to be achievable and therefore there will be no tolerance limit but we will instead look at any non-delivery as compared to peers. A sliding percentage allocation based on the amount of work each area of the scheme represents (care delivery (5%), plus (5%) and alternative (10%)) will be used where significant non delivery is seen

The Financial Flows will be as follows Guaranteed QOF Achievement

• 70% paid monthly as per QOF aspiration currently • 30% balance paid at end of scheme

Foundation Gateway

• £3k paid at beginning of scheme • further £3k paid at end

20% Achievement

• Balance due paid at end of scheme • A sliding Scale of 5% to 10% only to be used in extreme circumstances if significant

deterioration in performance during the year and will be calculated in conjunction with the relevant practice. The sliding scale will relate to the clinical area of non-delivery where care delivery has 5%, care delivery plus 5% and care delivery alternative has 10%.

Total expected expenditure if all practices take up the scheme will be as shown in the table below.

Item Total Investment Foundation stage - £6k £312,000 Care Delivery - 20% of historic QOF outturn £1,183,529 (based on 15/16 – only available at

this time)

Measurement, Monitoring & Reporting

EMIS enterprise will be utilised where possible to obtain the performance data from practices this is so it can be made in as streamlined and time saving way as possible for the practices. This will be made possible through templates where appropriate which will enable automatic population of measures some of which will align to existing read codes.

The risk to the quality of care dropping in any of the clinical areas including those previously in QOF needs to be understood and will be monitored between the CCGs and NHSE. For this reason the CCG will also shadow monitor the original QOF measures through EMIS Enterprise. This process will not add additional burden to general practice.

Data will be pulled from EMIS Enterprise on a monthly basis by the CCG with a quarterly report coming to practices and the primary care committee (see governance). Practices will also be able to run their own reports so that they can map their progress.

Engagement

As delegated commissioners of primary care, AV and Chiltern CCGs will not require NHSE to sign off changes to current or proposed incentive schemes. NHSE will however expect reassurance that there has been adequate health inequalities assessment and patient and public engagement.

Honouring our duty to ensure health inequalities remain at a minimum, it is recognised that the CCG will also need to ensure that the data collection on long term conditions will be maintained and indeed improved in order to ensure the integrity of the national data on conditions such as diabetes.

NHS England guidance is that patient and public involvement will be required prior to a move to service provision in this way because with regards to QOF it is a change to what is available nationally. Thus far this has been carried out in two ways

• the evaluation of current schemes involving patient feedback

• The engagement of patients and public through the current clinical and locality focused patient forums e.g. diabetes, heart failure, dementia, care & support planning, live well stay well, locality patient meetings

It is the intention that as the scheme is launched we will continue to monitor patient reported outcomes and views of the scheme through local practice participation groups and CCG patient forums.

The LMC has received an outline brief on proposals and are aware of the financial envelope and associated principles. Feedback has been received and acted upon but they await the full financial breakdown in order to advise their members fully on the scheme.

Governance Given the potential for conflict of interest there are a number of checks and processes that have been set up to ensure that this is managed robustly.

• Audit committee is to verify the monitoring and payment arrangements

• The individual relevant Programme boards have signed off their associated service

specifications. They will be responsible for the ongoing design of their clinical metrics and validation of practice performance data as well as decisions on what constitutes non- performance and recommend subsequent action to support improvement.

• The working group will continue to be responsible for the monitoring and reporting of the

practice level data highlighting any issues with a continual process of evaluation, development and improvement of the scheme. This will be overseen by a senior manager but with support from IM&T, primary care, performance and localities.

• The primary care operational committee will receive monthly summarised performance data

with a report going to primary care committee on a quarterly basis to include key themes, exceptions and the requirement for any intervention at practice level.

Conclusion

General practice cannot afford to remain as it currently is. If the CCG is to support primary care to develop so that it can provide robust and sustainable quality services through new models of care it must also recognise that a financial investment is required. It is the aim of this paper to provide the

primary care committee with sufficient detail to enable them to approve the PDS and the associated funding to general practice.

It is genuinely considered that this scheme will meet the population health needs of Buckinghamshire residents and that there will be minimal adverse effects of using this as an alternative to QOF due to the continued use of disease registers, use of templates and protocols and the focus on the clinical areas with the biggest impact.

The financial outlay is considered reasonable given the additional spend on services from other sectors, the non-investment in primary care for a number of years as well as the QIPP savings that are required some of which will only be possible through the agreement of this scheme.

Given the robust governance and monitoring arrangements proposed it is also considered that any potential risk to patients and practices of non-delivery can be managed in order to deliver real transformational change.

Appendix A

Our Roadmap….

2017/2018 System Leadership: Preparing for PACS

Leaders establish a year of transition to place based services with outcomes based contracts All transformation projects prioritised for system delivery through a common PMO Further work to scope and share management functions

Commissioners: Clarity on what is commissioned: • As a single team with Bucks County &

• Across Bucks & Oxon & STP • At larger scale (Specialist and Alliance) • Clarity on contracting with PACS for

18/19 including social care provision

Providers: • Strategic & Business case forprovider

• Clusters of GPs (30-50k populations)

supported by the FedBucks ‘umbrella’ working with integrated multidisciplinary teams including MH

PACS model finalised

District Councils

2016/2017 System Leadership: Healthy Bucks Leaders establishes a system-wide Transformation Delivery Group Building trust and transparency across the system

2018/2019 System

Leadership: PACS to ACO

The Provider PACS becomes accountable for the primary, community and general physical & mental health needs of the Bucks registered lists of patients.

Leaders will use this year to establish what areas of commissioning may come into the PACS (as an ACO) and what needs to remain at larger scale

ACO established for 2019/2020

Commissioners: • Working towards smarter /

efficient commissioning with Bucks CC and Oxfordshire CCG

• Working through what STP means for local and at scale commissioning

Providers: • FedBucks, a single

organisation across 80% of Bucks GPs is established

• BHT, OHFT and FedBucks agree to principles of PACS

Appendix B

Current Local Quality Incentives

15/16 Actual

Comment Chiltern AV

GMS QOF

A practice right under the national GMS contract

Local QOF - Care & Support Planning (CSP) Diabetes, Dementia & Respiratory

£113,269

Local AV scheme which has proved successful. Will need to evolve to reflect progress and bring Chiltern in alignment

QIS (Diabetes CSP)

£301,916

Only covers diabetes - There is a need to extend coverage & align with the AV scheme. Need to recognise this is one year behind AV and continued investment to embed is required.

DES+ EoL

£152,944

Alignment required – content is valuable improving quality and reducing A&E contact

QIS End of Life Care

£99,172

QIS Obesity Prevention

£34,352

NA

Reviewed in line with 17/18 QIPP requirements

QIS Attendance at Meetings

£162,000

NA

Not good practice

QIS Prescribing

NA

£279,177

Incudes attendance & cascade of info – as above Successful in improving clinical outcomes

Totals

£597,441

£545390

Practice Populations 280972 195447

Income per patient £2.13 £2.79

Appendix C

Area Expectation

Foun

datio

n G

atew

ay

EMIS Implementation

For non EMIS practices to submit a written commitment to migrating to EMIS Web before end Dec 2017 and book a migration date which should be before end September 2018 at the very latest.

ERS ERS usage - Greater than 60% of GP generated 1st consultant led referrals of available pathways by Jan 18 * Note The national expectation is that all referrals are e-referrals by Nov 18 and acute providers will not accept any other referrals

GP Cluster / Network development

Engagement to move to GP clusters or networks by April 18. GP networks to be of populations of circa 30k+ working together to improve the population health through shared models of care provision and administration, able to provide community hub type services e.g. OOH, and care home services

Standardisation Utilisation of standardised clinical protocols and coding which support clinical decision making and data recording in areas related to the care delivery section of the model. Upload of 100% templates recommended by CCG and/or measure of read codes related to templates. This is an in year requirement acknowledging templates will be developed throughout.

Audit Grasp AF and NDA

Area Expectation

Care

De

liver

y

Supported self- care through care & support planning (CSP)

Year 1 - Practices to embed CSP in diabetes care The CCG will continue to support practices with training and expert resources to include enhanced templates to prompt care pathways Year 2 - COPD and Cardiovascular

Adherence to local Right Care clinical pathways

To adhere to the following right care high use clinical pathways which will include utilising advice and guidance and ERS and responding to clinical audit and peer review as necessary. Pathways will be those expected to deliver against “Right Care” opportunities and will include

• Gynaecology • IFR,

• cardiology, • diabetes,

• cough Pathway, • ophthalmology

• MSK (from three months after •dermatology implementation)

Dementia Structured annual review of dementia patients (Tools / resources which can be adapted for practice use will be provided to support)

Area Expectation

Care

Del

iver

y Pl

us

Prescribing Year 1 • Antibiotic items / STAR-P U (rolling 12 months)

• Trimethoprim items / patient 70 years andover • Trimethoprim : nitrofurantoin item ratio Implementation of

interventions including de-prescribing

AF Review of patients with CHA2DS2-VASc 2 or more not on Oral Anti Coagulants (OAC) and target 90% on OAC

EOL 1. Percentage of practice list adults on a EoL register [maintained quarterly target of 0.5%] 2. Percentage of patients on EoL register with a completed care plan shared on SCR + [expected to be 90% taking into consideration those who refuse consent for SCR + ] After 1 year a review will berequired. 3. Percentage of practice’s annual deaths happening in patient’s preferred place (Consider use of Death audit)

Common mental illness Annual increase in number of patients referred to IAPT within 3 months of diagnosis (coded diagnosis and referral, and based on expected prevalence)

COPD Flu vaccine target 90% of consenting patients living with COPD (not coded as declined)

Standby meds prednisolone and antibiotics – assess for suitability, (read code to be

identified)

Care

Del

iver

y Al

tern

ativ

e

Area Expectation

Diabetes Prevention Maintain prediabetes register

Arrange annual blood glucose / HBa1c

Referral into NHS Diabetes Prevention Programme (NDPP)

Diabetes Triple target

Percentage of patients on diabetes register who meet the triple target Percentage of patients receiving all 8 care processes (NDA) & focus on foot care

Year 1 – create baseline & minimum expectation Year 2 - Practices

increase the percentage

HF Patients with proven LVSD (except those on an EoL pathway or otherwise contraindicated) are up-titrated to a maximum tolerated dose of beta-blockers and ACEI/A2A

year 1 – 50%

year 2 – 75% (A clear HF protocol will be issued by the CCG to support)

Hypertension Year 1 – Identification, increase percentage prevalence against expected practice prevalence. Maintain as per current QOF 80% at 150/90

Year 2 - Better control - BP target level, taking into consideration frail elderly and the need for a looser target in the over 75s

For c

onsid

erat

ion

in Y

ear 2

Area Expectation

Carers Identified carers will be included within CSP approach if they have LTCs

Falls Identification of ‘at risk’ expected through frailty tool in line with

GMS contract requirement (medication review & de- prescribing

expected) Full review of falls service required to make this

meaningful. CKD Covered through CSP – AKI card for patients on ACEI A2A, diuretics, NSAID and metformin

Frailty There is an assumption that this will be picked up in year 1 through core GMS requirements however year two expectations may build on this.

Public Health Year 2/3/4 – Practices in specific localities would be asked to target specific PH issues pertinent to their population as agreed in collaboration with the locality and public health.

Cancer Link with Macmillan on living with cancer project

Focus on screening to improve early diagnosis target

Primary Care Development Scheme 2017-18

Introduction This document details the 2017/18 Primary Care Development Scheme (PDS), a programme which will evolve on a yearly basis designed to enable practices within Aylesbury Vale and Chiltern Clinical Commissioning Groups (CCGs) to progress service provision in line with the 5 year forward view (NHS England, October 2014) and the Buckinghamshire primary care strategy, thereby expected to improve the quality of clinical care and patient outcomes.

For those that take up the PDS it will replace the national Quality and Outcomes Framework (QOF) and the Quality Improvement Schemes (QIS) previously commissioned by the CCGs. Practices may choose not to be part of the scheme and continue with the current nationally mandated QOF as is their right under the GMS contract. However in doing so, they would not be eligible for funding via the PDS.

All clinical areas identified in this scheme have been chosen due to their importance both nationally and locally as part of the identified population health needs.

Aims The PDS aims to

• Support primary care to change the way in which care is delivered and to embed these changes

• Encompass the national QOF and the local QIS • Reduce inappropriate workload, that does not add clinical value • Be responsive to the population health needs of localities and adds value to patient care • Does not disadvantage practices that take up the proposed scheme • Aligns to national, STP and CCG strategies

Service Summary The Primary Care Development Scheme (PDS) is based on the concept of essential building blocks.

The Foundation gateway - A mandatory set of five key delivery areas (insert link) that all practices that choose to take part will be expected to achieve in Year 1. All elements of the foundation gateway are expected in order to obtain payment and there will be no payment for part achievement. Some practices may have more to do in this section than others but there will be one single payment.

Care Delivery - In this part of the scheme practices will be expected to improve specific areas of care delivery around CCG priority areas as summarised below

Care Delivery Areas of care that practices may

already be delivering but require further focus

• Supported self-care through care and support planning

• Rightcare clinical pathways • Dementia

Care Delivery Plus Areas of care that practices may already be delivering but require significant continue effort

• Prescribing • Diabetes prevention • AF

1 Please note that due to the innovative approach outlined in this document the CCG is part of national discussions on the future of QOF and the development of alternatives therefore all content is subject to alignment to national initiatives and NHSE approval.

• EoL • Mental health

Care Delivery Alternative

This part of the scheme allows alternative metrics to those mandated in traditional QOF to be delivered. These metrics are those considered to demonstrate improved patient outcomes of care

• Diabetes triple target • HF • Hypertension • COPD

Traditional QOF will not need to be delivered in these areas but practices will need to utilise specific templates and read codes.

This part of the scheme is therefore only available to those practices that have achieved all elements of the foundation gateway.

Levels of PDS Practices are asked to choose their preferred level of delivery from the options below Status Quo

QOF only • Practice will get payment upon QOF delivery as per the national guidance

• No option to gain additional income Level 1 Foundation stage

& QOF • Practice will be able to gain £6k for delivery of the

foundation stage • Practice will get payment upon QOF delivery as per the

national guidance Level 2 Foundation stage

& QOF leniency • Practice will be able to gain £6k for delivery of the

foundation stage • Practice QOF will be paid on 16/17 achievement or 17/18

actuals if higher regardless of actual QOF achievement. This is being allowed as it is recognised that foundation stage actions may impact a practices ability to maximise QOF. Please note that practices will still be responsible for maintaining disease registers for prevalence purposes and quality clinical care.

Level 3 Foundation stage & care delivery

• Practice will be able to gain £6k for delivery of the foundation stage

• Practice QOF will be paid on 16/17 achievement or 17/18 actuals if higher regardless of actual QOF achievement. This is being allowed as it is recognised that the CCG are expecting alternative care delivery from general practice. Please note that disease registers must still be maintained in order to record prevalence

• An additional payment to practices will be made to practices based on the new care delivery requirements.

Level 3 provides the highest level of income for practices with no additional risk, compared to levels 1 and 2.


Process This document provides links to the individual clinical service specifications which make up the scheme. Practices are asked to sign up to the PDS through June ready for a 1st July start date. Participating practices are required to

• sign up to Calculating Quality Reporting Service (CQRS) and the General Practice Extraction Service (GPES)

• use the clinical ‘smart’ templates supplied by the CCG designed to make prompts to care, and automatically collect specific data fields which will be reported via EMIS Enterprise

• agree to allow CCGs to run EMIS Enterprise reports relevant to the clinical metrics within this scheme

• allow CCGs access to historical QOF data held by NHSE. This is for the purposes of ensuring correct payment under the scheme but also for understanding the clinical value of the scheme

Resources – Support for delivery The CCGs will continue to support practices to overcome challenges of implementation by

• Offering support to adapt the ‘smart’ template on EMIS that enables reporting data to be collected automatically

• Establishing clinical nurse leaders to support practice nurses in their delivery of elements of the scheme

• Develop training resources where required • Providing access to clinical and management expertise locally and nationally • Working with practices to identify common issues, and finding ways of addressing these. • Phasing the release of templates with the first lot to be sent out before 1st July upon

practice sign up to the scheme. 2017/18 is considered to be a transition year during which practices will implement the changes necessary in order to embed this new way of working. It is therefore considered a good base from which to develop in 2018/19 and the CCG will have a clear plan of action for the progression of the local scheme or an exit strategy should the scheme be deemed unsuccessful following year-end review.

Practices will be kept informed of the scheme’s success and future intentions for the service.

Measurement & Reporting Data collection for monitoring and audit purposes will be made in as streamlined and time saving way as possible for the practice. Practices will be expected to identify patients for inclusion in existing disease registers as these will still need to be maintained in order to understand prevalence.

Where relevant the CCG will issue EMIS ’smart’ templates which will automatically populate measures some of which will align to existing read codes.

The risk to the quality of care dropping in any of the clinical areas including those previously in QOF needs to be understood and will be monitored between the CCGs and NHSE. For this reason the CCG will shadow monitor the original QOF measures through EMIS Enterprise. This process will not add additional burden to general practice.


Payment and Validation Commissioners will seek to invite practices to participate in PDS by 2nd June 2017. Practices wishing to participate will be required to sign up to this service by no later than 30th June 2017.

Funding for the foundation stage will be provided to general practice via two payments of £3k, one (component 1) at the beginning of the year and sign up to the scheme and a second (component 2) at year end on confirmation of achievement of the foundation stage requirements.

Practices will receive an additional payment (component 3) if they have chosen to complete the foundation stage and move to the service delivery aspect of the service. This will be at a value of 20% of historic QOF achievement. Note that the financial envelope available for this payment is £1.2m and therefore the percentage value may change when updated using 16/17 figures. This will be paid at year end upon achievement of the service requirements as described in the service specifications.

Practices are expected to deliver all aspects of care delivery. Any associated metrics are associated with current activity and considered achievable. Non-delivery will be picked up by exception where a practice is deemed a significant outlier from its peers. If identified as an outlier a practice will be visited by the appropriate clinical team to understand the issues. The practice will be given the opportunity to engage in the CCG support process but sustained non delivery and unwillingness to engage will result in a reduction of the final 20% payment calculated in conjunction with the relevant practice along a sliding scale. The sliding scale will relate to the clinical area of non-delivery where care delivery has 5%, care delivery plus 5% and care delivery alternative has 10%.

QOF association If practices agree to participate in the PDS there will be a suspension of payment being linked to QOF during 17/18 i.e. full QOF data collection is not directly linked to the achievement payment however practices will still be responsible for maintaining their disease registers and appropriate clinical care.

The rationale behind suspending formal QOF reporting and achievement related payment is twofold

• At foundation stage to enable practices to engage fully in embedding the core foundation stage requirements without which they cannot move to the additional care delivery stages of the scheme and earn additional income. This enables practices to make service changes without having to worry about possible dips in QOF performance and related QOF income that might result from diverting energy into this transformational change. The CCG expects practices to continue to demonstrate good clinical care.

• At care delivery stage practices are expected to be delivering alternative care achievements that are more relevant to the local population health needs and represent good clinical care and therefore QOF is not required.

QOF will continue to be paid as the monthly QOF aspiration payment (70%) and will be reconciled (30%) to 16/17 achievements at year end or as actual 17/18 achievement whichever is the greatest. For Aylesbury Vale practices the highest QOF achievement over the previous three years will be taken reflecting the previous CSP scheme also aligned to QOF.


Appendix A - QOF Requirement Comparison with Primary Care Development Scheme (PDS)

Atrial fibrillation

Ref 17/18 QOF Requirement Points 17/18 Alternative Rationale for change

AF001 Records - Contractor establishes and maintains a register of patients with atrial fibrillation

5 Maintain a register of patients aged 17 or over with diabetes mellitus in order to record prevalence

Mandated public health marker

AF006 Ongoing management The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHA2DS2-VASc score risk stratification scoring system in the preceding 12 months (excluding those patients with a previous CHADS2 or CHA2DS2-VASc score of 2 or more) NICE 2014 menu ID: NM81

12 Not monitored

AF007 In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated with anti-coagulation drug therapy Patients with a previous score of 2 or above using CHADS2, recorded prior to 1 April 2015 will be included in the denominator. NICE 2014 menu ID: NM82

12 QOF+ Review of patients with CHA2DS2- VASc 2 or more not on OAC and target 90% on OAC

Grasp AF twice a year supports monitoring CCGs have a high prevalence rate and anticoagulation rate. AF project initiated to support practices to review the small number of anticoagulated patients. Anticoagulation reduces stoke rate NNT 37 (lower in higher risk patients) Local target – through Right Care identification


Secondary

Ref Indicator Points 17/18 Alternative Rationale for change

CHD00 1

Records - The contractor establishes and maintains a register of patients with coronary heart disease

4 Use CSP approach • Maintain a register of patients

aged 17 or over with CHD in order to record prevalence

• Annual review clinical and CSP outcomes recorded

Evidence of meeting YOC Quality Assessment outcomes

CHD00 2

Ongoing management The percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less NICE 2015 menu ID: NM86

17

CHD00 5

The percentage of patients with coronary heart disease with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti- coagulant is being taken NICE 2015 menu ID: NM88

7

Heart failure



HF001 Records The contractor establishes and maintains a register of patients with heart failure


aged 17 or over with CHD in order to record prevalence


• Evidence of meeting YOC Quality Assessment outcomes

Patients who do not have optimised treatment are more likely to be admitted and have poorer outcomes

HF002 Initial diagnosis The percentage of patients with a diagnosis of heart failure (diagnosed on or after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment 3 months before or 12 months after entering on to the register NICE 2015 menu ID: NM116

6

HF003 Ongoing management In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, the percentage of patients who are currently treated with an ACE-I or ARB

10 Outcomes

Uptitration to maximum tolerated betablockers and ACEI/A2A, % of patients on register at maximum tolerated dose HF004 In those patients with a current diagnosis of heart

failure due to left ventricular systolic dysfunction who are currently treated with an ACE-I or ARB, the percentage of patients who are additionally currently treated with a beta-blocker licensed for heart failure NICE 2015 menu ID: NM90

9


Hypertension


HYP00 1

Records - The hypertension contractor establishes and maintains a register of patients with established

6

Use CSP approach • Maintain a register of patients

aged 17 or over with HYP in order to record prevalence



Outcomes Year 1 – identifcation - % prevalance against expected practice prevalance Year 2 - Better control - BP target evel, taking into consideration frail elderly and the need for a looser target in the over 75s

The CCGs have poor prevalence compared to expected prevalence and poorer than average BP to target. Poor control of BP leads to CVD including HF and stroke

HYP00 6

Ongoing management The percentage of patients with hypertension in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less NICE 2015 menu ID: NM91

20

Peripheral Arterial Disease



PAD00 1

Records The contractor establishes and maintains a register of patients with peripheral arterial disease NICE 2011 menu ID: NM32


aged 17 or over with PAD in order to record prevalence



PAD00 2

Ongoing management The percentage of patients with peripheral arterial disease in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less NICE 2011 menu ID: NM34

2

PAD00 4

The percentage of patients with peripheral arterial disease with a record in the preceding 12 months that aspirin or an alternative anti-platelet is being taken NICE 2011 menu ID: NM33

2

Stroke and transient ischaemic attack (STIA)


STIA00 1

Records The contractor establishes and maintains a register of patients with stroke or TIA


aged

STIA00 8

Initial diagnosis The percentage of patients with a stroke or TIA (diagnosed on or after 1 April 2014) who have a record of a referral for further investigation between 3 months before or 1 month after the date of the latest recorded stroke or the first TIA NICE 2015 menu ID: NM92

2 17 or over with STIA in order to record prevalence • Annual review clinical and CSP outcomes recorded • Evidence of meeting YOC Quality

Assessment outcomes


STIA00 3

Ongoing management The percentage of patients with a history of stroke or TIA in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less NICE 2015 menu ID: NM93

5

STIA00 7

The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti- platelet agent, or an anti-coagulant is being taken NICE 2015 menu ID: NM94

4

STIA00 9

The percentage of patients with stroke or TIA who have had influenza immunisation in the preceding 1 August to 31 March NICE 2015 menu ID: NM140

2

Diabetes mellitus (DM)


DM017 Records The contractor establishes and maintains a register of all patients aged 17 or over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed NICE 2011 menu ID: NM41


aged 17 or over with diabetes in order to record prevalence

• Annual review clinical and CSP

Link to IAF Improved targets and care process reduces complications and reduces morbidity and mortality Evidence from BHT of cohort of patients

DM00 2

Ongoing management The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less NICE 2010 menu ID: NM01

8


DM00 3

The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less Based on NICE 2010 menu ID: NM02

10

DM00 4

The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less

6

DM00 6

The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with an ACE-I (or ARBs) NICE 2015 menu ID: NM95

3

DM00 7

The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months NICE 2010 menu ID: NM14

17

DM00 8


8


DM00 9


10

DM00 2

Ongoing management The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less NICE 2010 menu ID: NM01

8

DM012 The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4)

4

DM014 The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register NICE 2011 menu ID: NM27

11

DM018 The percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 August to 31 March NICE 2011 menu ID: NM139

3

Asthma



AST001 Records -. The contractor establishes and maintains a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma- related drugs in the preceding 12 months


aged 17 or over with Asthma in order to record prevalence



AST002 Initial diagnosis The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months before or any time after diagnosis NICE 2015 menu ID: NM101

15


AST003 Ongoing management The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using the 3 RCP questions

20 Outcomes Year 2 – await respiratory pathway development

AST004 The percentage of patients with asthma aged 14 or over and who have not attained the age of 20, on the register, in whom there is a record of smoking status in the preceding 12 months NICE 2015 menu ID: NM102

6

Chronic obstructive pulmonary disease (COPD)


COPD0 01

Records The contractor establishes and maintains a register of patients with COPD


aged 17 or over with COPD in order to record prevalence



Outcomes Year 1 • flu vaccine target • Standby meds prednisolone

and antibiotics prescribed

The most cost effective interventions against COPD exacerbations are flu vaccine followed by pneumococcal vaccine and availability of standby medicines. Reducing risk of exacerbations reduces unplanned admissions and improves quality of life

COPD0 02

Initial diagnosis The percentage of patients with COPD (diagnosed on or after 1 April 2011) in whom the diagnosis has been confirmed by post bronchodilator spirometry between 3 months before and 12 months after entering on to the register

5

COPD0 03

Ongoing management The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 12 months NICE 2015 menu ID: NM104

9


COPD0 04

The percentage of patients with COPD with a record of FEV1 in the preceding 12 months NICE 2015 menu ID: NM105

7

COPD0 05

The percentage of patients with COPD and Medical Research Council dyspnoea grade ≥3 at any time in the preceding 12 months, with a record of oxygen saturation value within the preceding 12 months NICE 2012 menu ID: NM63

5

Year 2 – await respiratory pathway

COPD0 07

The percentage of patients with COPD who have had influenza immunisation in the preceding 1 August to 31 March NICE 2015 menu ID: NM106

6

Dementia (DEM)


DEM00 1

Records The contractor establishes and maintains a register of patients diagnosed with dementia


aged 17 or over with dementia in order to record prevalence


• Evidence of meeting YOC Quality

DEM00 4

Ongoing management The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face- to-face review in the preceding 12 months

39


DEM00 5

The percentage of patients with a new diagnosis of dementia recorded in the preceding 1 April to 31 March with a record of FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded between 12 months before or 6 months after entering on to the register Based on NICE 2010 menu ID: NM09

6 Assessment outcomes

Enhanced review template to be developed

Depression (DEP)


DEP003 Initial management The percentage of patients aged 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March, who have been reviewed not earlier than 10 days after and not later than 56 days after the date of diagnosis Based on NICE 2012 menu ID: NM50

10 Keep as is

Mental Health


MH001 Records The contractor establishes and maintains a register of patients with schizophrenia, bipolar affective disorder and other psychoses and other patients on lithium therapy

4 Keep


MH002 Ongoing management The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive care plan documented in the record, in the preceding 12 months, agreed between individuals, their family and/or carers as appropriate NICE 2015 menu ID:

6

MH003 The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 12 months NICE 2010 menu ID: NM17

4

MH007 The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 12 months NICE 2010 menu ID: NM15

4

MH008 The percentage of women aged 25 or over and who have not attained the age of 65 with schizophrenia, bipolar affective disorder and other psychoses whose notes record that a cervical screening test has been performed in the preceding 5 years NICE 2010 menu ID: NM20

5

MH009 The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 9 months NICE 2010 menu ID: NM21

1

MH010 The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range in the preceding 4 months NICE 2010 menu ID: NM22

2


Cancer (CAN)


CAN001 Records The contractor establishes and maintains a register of all cancer patients defined as a ‘register of patients with a diagnosis of cancer excluding non - melanotic skin cancers diagnosed on or after 1 April 2003’

5 Maintain a register of patients aged 17 or over with Cancer in order to record prevalence

CAN003 Ongoing management The percentage of patients with cancer, diagnosed within the preceding 15 months, who have a patient review recorded as occurring within 6 months of the date of diagnosis Based on NICE 2012 menu ID: NM62

6

Chronic kidney disease (CKD)


18

Please note that due to the innovative approach outlined in this document the CCG is part of national discussions on the future of QOF and the development of alternatives therefore all content is subject to alignment to national initiatives and NHSE approval.

CKD005 Records The contractor establishes and maintains a register of patients aged 18 or over with CKD with classification of categories G3a to G5 (previously stage 3 to 5) NICE 2014 menu ID: NM83


aged 17 or over with CKD in order to record prevalence



Epilepsy (EP)


EP001 Records The contractor establishes and maintains a register of patients aged 18 or over receiving drug treatment for epilepsy

1 Use CSP approach Maintain a register of patients aged 17 or over with epilepsy in order to record prevalence • Annual review clinical and CSP

outcomes recorded • Evidence of meeting YOC Quality

Assessment outcomes

Learning disability (LD)



LD003 Records The contractor establishes and maintains a register of patients with learning disabilities NICE 2015 menu ID: NM73

4 Maintain a register of patients aged 17 or over with LD in order to record prevalence Use CSP where individual has LTCs

Osteoporosis: secondary prevention of fragility fractures (OST)


OST004

Records The contractor establishes and maintains a register of patients: Aged 50 or over and who have not attained the age of 75 with a record of a fragility fracture on or after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan, and Aged 75 or over with a record of a fragility fracture on or after 1 April 2014 and a diagnosis of osteoporosis NICE 2011 menu ID: NM29


aged 17 or over with a diagnosis of osteoporosis in order to record prevalence



OST002 Ongoing management The percentage of patients aged 50 or over and who have not attained the age of 75, with a fragility fracture on or after 1 April 2012, in whom osteoporosis is confirmed on DXA scan, who are currently treated with an appropriate bone- sparing agent NICE 2011 menu ID: NM30

3

OST005 The percentage of patients aged 75 or over with a record of a fragility fracture on or after 1 April 2014 and a diagnosis of osteoporosis, who are currently treated with an appropriate bone-sparing agent NICE 2011 menu ID: NM31

3


Rheumatoid arthritis (RA)


RA001 Records The contractor establishes and maintains a register of patients aged 16 or over with rheumatoid arthritis NICE 2012 menu ID: NM55

1 Use CSP approach Maintain a register of patients aged 17 or over with a diagnosis of RA in order to record prevalence Annual review clinical and CSP outcomes recorded

RA002 Ongoing management The percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face review in the preceding 12 months

5

Palliative care (PC)


PC001 Records The contractor establishes and maintains a register of all patients in need of palliative care/support irrespective of age

3 QOF plus 1 %age of practice list on a EoL register [quarterly target of 1%] %age of patients on EoL register with a completed care plan shared on SCR + [should be near to 100%, excepting those who refuse consent for SCR+] %of practice’s annual deaths happening in patient’s preferred place

QIPP potential - improving the Quality of care and preventing A&E attendances and admissions **Need to consider variation in death rates

PC002 Ongoing management The contractor has regular (at least 3 monthly) multi-disciplinary case review meetings where all patients on the palliative care register are discussed NICE 2015 menu ID: NM111

3


Primary Care Development Scheme 2017-18

Contents:

1. Foundation Stage a. EMIS b. ERS c. GP Cluster Network Development d. Standardisation e. Audit (Grasp AF and NDA)

2. Arterial Fibrillation (AF) 3. Care & Support Planning (CSP) 4. Common Mental Illness 5. COPD 6. Dementia 7. Diabetes Prevention 8. Diabetes Triple Target 9. End of Life (EoL) 10.Heart Failure (HF) 11.Hypertension 12.Prescribing (Priority) 13.Right Care

Primary Care Development Scheme

Title: AF Clinical Lead: Shona Lockie

Lead Manager: Maria Smith

Year: 17/18

1. Context AF patients with a CHADSVASc score of 2 or more should be considered for Oral Anti Coagulants (OAC) to reduce the risk of stroke.

2. Overall Objective For all practices to have anticoagulated 90% of AF patients with a CHADSVASc score of 2 or more.

3. Proposed Scheme Outline Many practices have already reached or are close to this target and the number of patients that need review is relatively small. An Academic Health Science Network (AHSN) supported project is available to review these patients in practices at no additional cost to the practice.

4. Aim

To review patients with CHADSVASc score of 2 or more not on OAC and aim to increase the proportion of them on OAC to 90% of those consenting.

5. Patient cohort

AF patients with a CHADSVASc score of 2 or more and not on OAC

6. Process Search for and review all AF patients with CHA2DS2-VASc 2 or more not on Oral Anti Coagulants (OAC). This can be done with the support of the AHSN project and aim to get 90% of those consenting on OAC.

7. Link with Existing Work Schemes AHSN project which sits under Med Management

8. Timetable/Milestones Patient group to have been reviewed and put on OAC as appropriate by March 31 2018

9. Measurement and Reporting

Data to be coded as per current practice

10. Method of Monitoring EMIS Enterprise – Monthly reports run and reported back to practices on a quarterly basis

11. Thresholds 90% of AF patients with CHA2DS2-VASc 2 or more on Oral Anti Coagulants (OAC) by 31st March 2018.

12. Appendix

a) Baseline Data (if appropriate) Levels by Practice (to be provided)


Title: Supported self-care through care and support planning (CSP) in Type 2 Diabetes Clinical Lead: Dr Stuart Logan Lead Manager: Steve Goldensmith Year 17/18

1. Context Care and Support Planning (CSP) supports both the 5 Year Forward View and the Primary Care Strategy in promoting self-care and patient empowerment. In recognition of the different starting points diabetes will be the focus in year one but in year two COPD and CVD will follow.

2. Overall Objective

To increase patients and carers confidence in and ability to self-care

3. Proposed Scheme Outline Utilising a CCG provided template, the practices will follow the two stage CSP process allowing patients and carers time to reflect prior to their C&SP appointment

The CCG will continue to support practices with training and expert resources to include enhanced templates to prompt care pathways

4. Aim • Year 1 - Practices to embed CSP in Type 2 diabetes care. Patients and carers

confidence increases their ability and engagement in self-care

• Year 2 - Extension to and embedding of CSP in other long term conditions in particular COPD and Cardiovascular

5. Patient cohort

Year 1 – all patients with Type 2 diabetes Year 2 – As above and those with COPD & Cardio vascular disease

6. Process Patients identified with Type 2 diabetes will be eligible for Care & Support Planning

7. Link with Existing Work Schemes

Further embeds the current CSP schemes in both AVDCC and CCCG Diabetes Transformation Work

8. Timetable/Milestones 80% of patients with type 2 diabetes to have a care plan by March 31st 2018, allowing for exceptions.

9. Measurement and Reporting Please use current templates until new ones are developed and provided. CCG will run search on read code on 8CS.

10. Method of Monitoring

EMIS Enterprise – Monthly reports run and reported back to practices on a quarterly basis

11. Thresholds

80% uptake (allowing for exceptions) in Year 1 90% uptake (allowing for exceptions) in Year 2

12. Appendix

a. Baseline Data (if appropriate)


Title: Common Mental Health; Anxiety and Depression Clinical Lead: Dr Sian Roberts Lead Manager: Caroline Hart Year: 17/18

1. Context

• Mental illness accounts for 23% of the health burden in the UK- (next is cardiovascular at 16% and then cancer at 15%).

• 1 in 4 people in any one year suffer with mental ill health. • The Mental Health Five Year Forward View supports parity of esteem

and mandates increased patient access to the appropriate mental health support by 2020.

• This includes a specific target that at least 25% of adults with common mental illness (anxiety, depression etc.) will have timely access to IAPT (Improving Access to Psychological Therapies) services by 2020.

• In Buckinghamshire, the aim is to work towards this national target, with at least 19% of adults with a common mental illness accessing IAPT services by 31st March 2018.

The NICE guidelines on common mental health disorders makes recommendations about the care and treatment for people living with a common mental health problem.

Psychological treatments that may be offered include, but are not limited to: counselling, psychotherapy and cognitive behavioural therapy. GPs and their teams should know how to access these therapies in their local area and how to help people decide what may or may not be helpful for their individual needs.

In Buckinghamshire, IAPT provides services via Healthy Minds and the Live Well Stay Well service. The performance of the local IAPT service is excellent with well over 60% of patients showing a full recovery following support from the service. The service has been awarded funding to expand its service further, particularly for patients with a co-existing physical long term condition.


This indicator aims to ensure that people with a new diagnosis of a common mental illness are offered referral for psychological treatments (IAPT).

3. Proposed Scheme Outline

The scheme is twofold: 1. To identify patients with a common mental illness ; anxiety, depression,

Obsessive Compulsive Disorder , Post Traumatic Stress Disorder , phobia, panic disorder, Generalised Anxiety Disorder, Social Anxiety Disorder

2. Treatment options should be discussed, and to include signposting to IAPT.

Newly diagnosed patients will be added to a new Common Mental Health Register. For each newly diagnosed patient, the signposting to IAPT will be recorded via an approved local template.

Please note that “low mood” and “stress” are symptoms of potential mental health issues, and not diagnoses. Clinicians are encouraged to make an appropriate diagnosis in patients with ongoing symptoms of low mood and/or stress, in order that they are appropriately signposted to IAPT services.

4. Aim

To measure the percentage of patients with a new diagnosis of a common mental illness in the preceding 1 July 2017 to 31 March 2018, who have been signposted to IAPT.

5. Patient cohort

All patients with a new diagnosis of these common mental illnesses: anxiety, depression, Obsessive Compulsive Disorder (OCD), Post Traumatic Stress Disorder (PTSD), phobia, Panic Disorder, Generalised Anxiety Disorder ( GAD) , Social Anxiety Disorder, between July 1st 2017 and March 31st 2018

6. Process

Practices will be provided with a template with appropriate codes, to be used when a patient receives a new diagnosis of a common mental illness

This will include • Relevant diagnostic code • Signposting to IAPT code

The CCG will calculate the % of patients signposted to IAPT between July 1st

2017 and March 31st 2018 7. Link with Existing Work Schemes

• To link with the Live Well Stay Well services; the integration of IAPT services with physical health services for patients with mental health issues related to their Long Term Condition ( LTC)

• To continue screening patients at risk of depression at their Long Term Condition annual reviews, perinatal women etc.

8. Timetable/Milestones

• Practices to upload the appropriate Common Mental Illness template to their clinical system by 1st July.

• At least 60% of new patients diagnosed with a common mental illness between 1st July 2017 and 31st March 2018 to be signposted to IAPT.

• (NB 60% threshold selected to allow for patients who may choose to access alternative therapies to IAPT and for patients with self-limiting mental health issues who will recover without the need for IAPT services e.g. bereavement)

9. Measurement and Reporting • IAPT will report patient access rates as part of their contract monitoring. • The CCG will monitor the Common Mental Illness prevalence and IAPT

referrals via EMIS Enterprise. 10. Method of Monitoring

• EMIS Enterprise ; Number of IAPT referrals offered; quarterly • IAPT benchmarking data; Access rates to IAPT; quarterly

11.

12.

13.

Thresholds • At least 60% of new patients diagnosed with a common mental illness

between July 2017 and 31st March 2018, to have been signposted to IAPT.

1st

Appendix NICE Guidelines; Common mental health problems: identification and pathways to care https://www.nice.org.uk/guidance/cg123 Baseline Data (if appropriate)

To include benchmarking IAPT data; March 2017; practice level data indicating patient access to IAPT services

https://www.nice.org.uk/guidance/cg123


Title: COPD Clinical Lead: Dr Stuart Logan Lead Manager: Steve Goldensmith Year 17/18

1. Context Flu vaccination is one of the most beneficial interventions for our patients with COPD. Provision of standby medication has been shown to reduce the need for hospital admissions and also empowers patients to self-care more easily.


We want to continue high levels of vaccination in this group and enable a proactive self-help response so as to reduce the risk of exacerbation and hospital admissions.


Identify and immunise patients with COPD against Flu Supply standby medication to patients with COPD with clear instruction as when to use

4. Aim To achieve the Flu vaccine Target: 90% of consenting patients living with COPD (Patients declining vaccinations will not be included). Provision of COPD Rescue Pack (standby meds prednisolone and antibiotics) code 8BMW

5. Patient cohort

All patients on COPD register

6. Process To promote and provide Flu vaccination for known COPD patients from September onwards. Assessment & Provision of standby medication


Both currently in QOF and supports existing Buckinghamshire guidelines.

8. Timetable/Milestones Achievement by March 31st 18 is expected although the majority of the work will need to be happen ding through the months prior to winter.

9. Measurement and Reporting

Issue of COPD Rescue Pack - Read code 8BMW Flu (Qtr 3 / 4 results) - Read Code 65E

Medicines Management Monthly Monitoring and outliers discussions 10. Method of Monitoring


11. Thresholds – (in consenting patients)

Issue of COPD Rescue Pack 80% Flu vaccination 90%

12. Appendix a. Baseline Data (tbc)


Title: Dementia Clinical Lead: Dr Sian Roberts / Dr Stuart Logan Lead Manager: Maxine Foster Year 17/18

1. Context Dementia is a syndrome characterised by a progressive decline in multiple areas of function, including memory, reasoning, communication skills and the skills needed to carry out daily activities. The prevalence of dementia increases with age and is estimated to be approximately 7% in those over 65. Alzheimer’s disease accounts for around 62% of cases of dementia with vascular dementia accounting for around 17%.

Nationally, the ambition is that two thirds of the estimated number of people with dementia has a formal diagnosis in order to receive post diagnostic support. Aylesbury CCG has successfully exceeded the 67% target whilst Chiltern CCG has made significant progress and as of March 2017, has reached 64.5% . Efforts will continue for both CCGs to exceed the national target.

The Prime Ministers Challenge on dementia 2020, outlines Every person diagnosed with dementia should have meaningful care following their diagnosis, which supports them and those around them, with meaningful care being in accordance with published National Institute for Health and Care Excellence (NICE) Quality Standards.


Supporting patients with dementia (and their carers) by effective advanced care plans will enable patients to live well with their dementia. This will result in people with dementia remaining independent for longer and improve their quality of life.


To identify patients with dementia . Where a patient does not already have a care plan or an advanced care plan in place, it is expected that the practice will develop a care plan. The face-to-face care plan or advanced care plan review focuses on support needs of the patient and their carer. In particular the review should address the following:

In addition, focus should be provided on the carer; • obtain appropriate permissions to authorise the practice to speak directly to

the nominated carer(s) • as appropriate, the carer should be included in the care plan or advanced

care plan discussions, • offer the carer support including signposting to other relevant services to

support their health and wellbeing. 4. Aim

To continue to identify patients who have dementia and to measure the percentage of patients with dementia whose care plan has been reviewed with a structured face-to-face review in the preceding 12 months

5. Patient cohort

All patients on the Dementia Register 6. Process

Practices will be provided with a Dementia Care Plan template for a detailed annual review for patients with dementia. The practices will invite the patient and their carer to attend for a joint review. The review will be holistic and person centred;

The care plan will be mutually agreed and a copy will be provided to the patient/carer. The clinician will refer onto appropriate services if this is appropriate (Alzheimer’s Society, Memory Support Services, Social Services, Carers Bucks etc)

The CCG will calculate the percentage of dementia annual reviews performed between March 2017 and March 2018


• To continue the work on identification of patients who are at risk of dementia by GPCOG screening; ( those with other Long Term Conditions; diabetes, stroke, ischaemic heart disease, increasing age, frailty, housebound)

• To continue using the Memory Support Service to provide both screening in at risk patients, but also post diagnostic support.

• To continue work with the Carers Bucks to provide Carers support. 8. Timetable/Milestones

• Practices to upload the appropriate Dementia Care Planning Template to their Clinical system by 1st July.

• To complete the Annual Reviews on 80% of their register between 1st July 2017 and 31st March 2018.

9. Reporting and Measurement

• Baseline DDR from NHSE March 2017 • Measurements will be calculated by the CCG using NHSE DDR data and

EMIS Enterprise searches for Annual Health Checks completed 10. Method of Monitoring

• NHSE Dementia Diagnosis Rates; monthly • EMIS Enterprise; Number of completed Annual Reviews; quarterly

11. Thresholds

• Practices to improve on their DDR from baseline (31st March 2017), or to maintain the 67% if they have already exceeded this target.

• To complete an annual review in 80% of patients on their Dementia Register

12. Appendix

• NICE CG42. Dementia. Supporting people with dementia and their carers in health and social care. 2006: http://guidance.nice.org.uk/CG42/NICEGuidance/pdf/English

• NHS England Dementia: Good Care Planning: https://www.england.nhs.uk/wp-content/uploads/2017/02/dementia-good- care-planning.pdf

13. Baseline Data (if appropriate)

The dementia calculator spreadsheet and dashboard data shows practice figures for the end of March 17 G:\PCT\Chiltern CCG - TO BE KEPT AND TRFD\Localities\Dementia\Dementia Calculator - Figs Updated to End March 2017.xlsx

http://guidance.nice.org.uk/CG42/NICEGuidance/pdf/English

https://www.england.nhs.uk/wp-content/uploads/2017/02/dementia-good-care-planning.pdf




Title: Diabetes Prevention Clinical Lead: Dr Stuart Logan

Lead Manager: Steve Goldensmith

Year 17/18

1. Context Diabetes prevalence rates are a significant and growing challenge to the health economy. Buckinghamshire is now a successful wave 2 national diabetes prevention site and is rolling out the provision of Structured Education for people at risk of Type 2 diabetes.


By referring patients at high risk of developing diabetes into the National Diabetes Prevention Program (NDPP) it is hoped that we can achieve a 30-60% reduction in progression to diabetes.


As patients are found in the “at risk” group they should be read coded on the practice system and referred into the Live Well Stay Well Single point of access (SPA) who will then contact the patient and enrol them on the NDPP Structured Education course. The provider (Ingeus) will record and feedback to practices participation/ completion/ decline and drop-out rates so practices can understand patient engagement and target patients accordingly in future.

4. Aim

For Practices to maintain a pre-diabetes register & structured education participation. Referral in to NHS Diabetes Prevention Programme (NDPP)

5. Patient cohort

All patients in year found to have non-diabetic hyperglycaemia (formerly prediabetes)

6. Process

An initial data search to identify existing at risk patients to be referred to the NDPP scheme via a direct mail and referral process. Subsequently as new patients at risk are identified this will be as per normal SPA referral process


Diabetes Transformation Links to our STP which requires expansion of prevention work.


• 70% of consenting “at risk” (i.e. HbA1c 42-47 or FBG 6-7) population

• Patients identified, referred recorded by practices patient data system) 9. Measurement and Reporting

Practices will identify and code non-diabetic hyperglycaemia patients so that the CCG can view the data for monitoring purposes (Code: C317)

These patients to be referred to Pre Diabetic Structured Education (Code: 679m4)


practice 11.

12.

EMIS enterprises on a monthly basis and reported quarterly to the

Thresholds 70% of the “at risk” population.

Appendix



Title: Diabetes Triple Target plus 8 Care Processes & footcare Clinical Lead: Dr Stuart Logan Lead Manager: Steve Goldensmith Year 17/18

1. Context Buckinghamshire has been achieving improved outcomes in diabetes care over the last three years with the work of the Diabetes Transformation Programme. There remains a broad variation in achievement levels of the Triple Target & 8 Care Processes as identified through the National Diabetes Audit.


To continue the success of the current diabetes transformation programme, addressing inequalities and improving care wherever possible. The data will allow us to target input to where it is needed but also allow further improvement where good outcomes are already being achieved.


To try and reduce variance & increase achievement levels of these 2 key targets in diabetic care.

4. Aim Increase percentage of patients on diabetes register who meet the triple target Increase percentage of patients receiving all 8 care processes (NDA) & focus on foot care. • Year 1 – Create baseline & minimum expectation • Year 2 - Practices increase the percentage

5. Patient cohort

All patients with diabetes mellitus.

6. Process Practice and NDA data recording, as using CSP & CCG templates data should be recorded automatically.

7. Link with Existing Work Schemes Links with diabetes transformation programme and supports the planned shift of care form hospitals to the community. NDA data recording

8. Timetable/Milestones Annual measurement and continues existing national monitoring.

9. Measurement and Reporting Data to be coded as per current practice


NDA Annual Monitoring using existing QoF codes (HbA1c, Blood Pressure & Cholesterol) EMIS Enterprise – Monthly reports run and reported back to practices on a quarterly basis

11. Thresholds

Lower third of Bucks practices to improve by an additional 7.5%, middle third by 5% and upper third by 2.5%

12. Appendix

a. NDA Data Sheet for AV & CCCGs

Microsoft Excel 97-2003 Worksheet


Title: EOL (Priority) Clinical Lead: Dr Malcolm Jones Lead Manager: Ian Cave Year 2017/18

1. Context In any given 12 month period, approximately 1% of the population will die. The majority of these deaths are expected and predictable. In the case of expected deaths, patients typically have 3 unplanned hospital admissions in their final year of life. While recognition of terminal decline in patients with end stage cancer is usually straightforward, predicting the timing of death in patients with other end- stage conditions, such as heart failure, COPD, severe frailty and dementia can be much more challenging. Nevertheless, all of these patients have end of life and palliative care needs. If a patient’s primary care physician feels death in the next 12 months would not be surprising, then that patient is at significant risk of dying soon – in other words, a primary care physician’s general impression of a patient’s likelihood of death has good positive predictive power.

National work looking at Advance Care Planning (ACP) in those likely to be nearing the end of their lives has shown that ACP significantly increases a patient’s chance of dying in their preferred place. ACP also reduces the number of days of unscheduled hospital admission that EoL patients suffer in their final year of life. Furthermore, there is good evidence that the bereavement process for surviving relatives and carers is enhanced by ACP.

The effectiveness of Advance Care Planning is amplified through electronic sharing of the ACP with any health care providers who may become involved in a patient’s end of life journey.

2. Overall Objectives

To enhance dignity and facilitate choice for those patients likely to be nearing the end of their lives, through Advance Care Planning. To focus clinicians’ minds on the end of life needs of their patients.

To provide momentum for the CCG to commission more specialist and non- specialist end of life care.


Practices will maintain an End of Life register of at least 0.5% of their population throughout the 17/18 financial year. At least 90% of patients on the practice EoL register will have completed ACPs, with consent to share via SCR Additional

The EoL register, consent to share via SCR Additional and the ACP will be recorded through a CCG provided EoL template.

v1.3 May 2017

4. Aim To improve end of life care for patients in Buckinghamshire and to enable the CCGs to identify system requirements for improving EoL care.

5. Patient cohort

0.5% of practice population who are most at risk of dying within the next year. 6. Process

• Practice identifies 0.5% of their practice population most at risk of dying within the next year and adds these to the practice End of Life Register. (See provided population data below for required minimum targets).

• Advance Care Plans are completed for 90% of patients on the End of Life Register using the CCG provided clinical template, and by completing the relevant fields within.

• Practices are required to maintain both the 0.5% EoL register target and the 90% ACP target each quarter.

Please note that these Read codes will be automatically assigned when a practice selects the appropriate drop-down box within the provided template. If a patient is appropriately coded, but either dies or transfers to another practice on or prior to 31st March 2018, the coding practice will still receive payment. It is acknowledged that completing the ACP template may not be possible or desirable to complete during one clinical encounter. Clinicians are able to partially complete a template, and return at a later date. It is therefore the responsibility of the clinician to self-monitor completion of the ACPs and ensure that an ACP, once started, is fully completed as soon as possible and prior to the end of the quarter. In order to help EMIS practices monitor this a search called XXTO FOLLOWXX has been created to identify those patients on the EoL Register that have no, or a partially completed, ACP. This can be found in the End of Life EMIS search folder detailed below.


This scheme is a direct continuation [albeit, simplified] of the 16/17 EoL QiS [Chiltern CCG] and the 16/17 EoL DES+ [AVCCG]. It uses the same electronic template for recording a patient’s ACP and consent to share via SCR Additional. Please click here for national guidance for clinicians regarding SCR consent for patients who lack capacity. For SCR Additional quick guide and frequently asked questions specific to EMIS Web, please click here. If a patient refuses to share their information via the SCR Additional (Read code 9NDN), they will not be eligible for inclusion under the EoL scheme. It is confirmed that practices can be signed up to both the Care Home Direct Award and the End of Life scheme.


To commence on 3rd July 2017, continuing until 30th March 2018 inclusive. v1.3 May 2017

https://digital.nhs.uk/summary-care-records/additional-information#Patients%20who%20can%27t%20consent

http://systems.hscic.gov.uk/scr/additional/emis

9. Measurement and Reporting • The provided clinical templates have the correct Read coding and

performance will be calculated by generating a report based on the number of ACPs created with the relevant template fields completed (see Appendix 2)

• For EMIS users clinical system searches are available for practices to run as and when they wish to monitor their progress against scheme. These are located on EMIS under ‘NHS Chiltern Enterprise Search and Reports’ CCCG Primary Care Development Scheme End Of Life. The CCGs will use EMIS Enterprise to assess practice performance. Clinicians will be expected to complete the 10 mandatory fields details detailed in Appendix 2; however to count towards a practice’s achievement a patient will only need the following three Read codes in place:

o SCR Additional consent status – 9NDN o On End of Life register – 9NG7 o Tick here to code 'Has end of life care plan' - 8CME

These specific Reads have been chosen to ensure a minimum standard of information sharing via the SCR Additional.

• Non-EMIS users will be provided with a copy of the EMIS template to import into their own clinical system and use for measuring achievement. This will allow non-EMIS users to undertake the required coding whilst they are preparing to move to EMIS. For support in importing the template into your clinical system, please contact the CSCSU training team via cscsu.training- [email protected]

• The CCG endeavours to ensure that the searches and templates are accurate, however it is recognised that errors can occur. Practices are asked to review the provided clinical searches and templates, check for inaccuracies in the search results, and feedback to [email protected] by 31st

July 2018. After that date no changes will be accepted and the data will be used to calculate EoL scheme achievement.

10. CCG Contacts and Leads

• Malcolm Jones, End of Life Lead Chiltern and Aylesbury CCG [email protected]

• Ian Cave, Head of Community Models of Care, [email protected] • For clinical system queries and administrative assistance: cscsu.training-

[email protected]

11. Support • Clinical template developed and made available to practices. Please see

above. • Training videos are provided on the Primary Care Development scheme

section of the Members websites. • Tools to support practices in identifying and supporting End of Life

patients: o Dying Matters – Find Your 1% campaign – includes resources, case

studies and training materials)

v1.3 May 2017










http://www.dyingmatters.org/gp

o Last Year of Life presentation – given by Dr Jo Withers at May 2015 PLT

• Clinical system SCR Additional Quick guides and FAQs here. • CSCSU Training team for clinical system queries and assistance:

[email protected]

v1.3 May 2017

http://www.chilternccgmembers.co.uk/?sc=libext&id=27030&acc=10217357

http://systems.hscic.gov.uk/scr/additional/emis


Appendix 1

Practice Code

Practice Name

Locality

List size EoL Register target (0.5%) - this is the

minimum number that must be maintained each

quarter

90% of EoL Reg - this is the minimum number that

must be maintained each quarter

K82004 Amersham Health Centre Amersham & Chesham 13043 65 59 K82058 Gladstone Surgery Amersham & Chesham 5119 26 23 K82049 Hughenden Valley Surgery Amersham & Chesham 12631 63 57 K82035 John Hampden Surgery Amersham & Chesham 3309 17 15 K82621 Little Chalfont Surgery Amersham & Chesham 5678 28 25 K82618 Prospect House Amersham & Chesham 3612 18 16 K82001 Rectory Meadow Surgery Amersham & Chesham 9085 45 41 K82024 The New Surgery Amersham & Chesham 10876 54 49 K82037 Water Meadow Surgery Amersham & Chesham 12411 62 56 K82014 OAKFIELD SURGERY AV Central 5116 26 23 K82018 MEADOWCROFT SURGERY AV Central 14664 73 66 K82019 THE MANDEVILLE PRACTICE AV Central 15678 78 70 K82038 POPLAR GROVE SURGERY AV Central 18871 94 85 K82040 WHITEHILL SURGERY AV Central 14233 71 64 K82073 WESTONGROVE PARTNERSHIP AV Central 28177 141 127 Y01964 BERRYFIELDS MEDICAL CENTRE AV Central 7350 37 33 K82007 THE SWAN PRACTICE AV North 28801 144 130 K82042 WHITCHURCH SURGERY AV North 4017 20 18 K82043 NORDEN HOUSE SURGERY AV North 9460 47 42 K82061 ASHCROFT SURGERY AV North 3931 20 18 K82070 WING SURGERY AV North 5014 25 23 K82079 EDLESBOROUGH SURGERY AV North 7679 38 34 K82021 CROSS KEYS SURGERY AV Southern 14199 71 64 K82028 HADDENHAM MEDICAL CENTRE AV Southern 8093 40 36 K82034 WELLINGTON HOUSE SURGERY AV Southern 9255 46 41 K82047 TRINITY HEALTH AV Southern 11566 58 52 K82068 WADDESDON SURGERY AV Southern 5318 27 24 K82033 Burnham Health Centre Southern 21823 109 98 K82055 Denham Medical Centre Southern 9607 48 43 K82045 Southmead Surgery Southern 6578 33 30 K82078 The Allan Practice Southern 8775 44 40 K82008 The Hall Practice Southern 9541 48 43 K82006 The Ivers Practice Southern 9483 47 42 K82051 The Misbourne Practice Southern 12087 60 54 K82031 Threeways Surgery Southern 6327 32 29 K82029 Cherrymead Surgery Wooburn Green 10524 53 48 K82005 Hawthornden Surgery Wooburn Green 6950 35 32 K82012 Highfield Surgery Wooburn Green 6135 31 28 K82011 Millbarn Medical Centre Wooburn Green 7712 39 35 K82066 Pound House Surgery Wooburn Green 7216 36 32 K82048 Stokenchurch Medical Centre Wooburn Green 6831 34 31 K82023 The Marlow Medical Group Wooburn Green 27226 136 122 K82046 The Simpson Centre Wooburn Green 17090 85 77 K82044 Carrington House Surgery Wycombe 10178 51 46 K82020 Chiltern House Medical Centre Wycombe 8639 43 39 K82603 Cressex Health Centre Wycombe 8181 41 37 K82017 Desborough Surgery Wycombe 11323 57 51 K82022 Kingswood Surgery Wycombe 10065 50 45 K82053 Priory Surgery Wycombe 12286 61 55 K82036 Riverside Surgery Wycombe 9784 49 44 K82010 Tower House Surgery Wycombe 10144 51 46 K82030 Wye Valley Surgery Wycombe 10221 51 46 551912 2758 2484

v1.3 May 2017

Appendix 2

EMIS Web 1. SCR Additional consent status – 9NDN 2. On End of Life register – 9NG7 3. DNACPR decision & location of document 1R10 or 1R00 4. Discussion about DNACPR – 67P0, 67P1 or 8CN3 5. 1st Choice Preferred place of death (Mandatory) – 94Z1, 94Z2, 94ZC, 94Z5,

94ZE, 94Z4, 94Z8 6. In relation to their health, what has been happening to the patient? – 8CMe 7. Is there anything the patient would like to avoid happening to them? – 8CMe 8. Are there any comments or wishes the patient would like to share with– 9NGJ

others? – 8CN4 9. Does the patient have any special request or preferences regarding their future

care? – 8CN 10. Tick here to code 'Has end of life care plan' - 8CME

v1.3 May 2017


Title: Heart Failure (HF) – Optimisation in Primary Care - CLOUD

Clinical Lead: Dr Raj Thakkar

Lead Manager: Ojalae Jenkins

Year 17/18

1. Context The key objective for this scheme is to increase the quality of life of patients living with Heart Failure in Buckinghamshire. The proposed model, (acronym ‘CLOUD’), optimises care around patient Co-morbidities, Lifestyle, Out-patient management, Up-titration of drugs and Drugs adherence.

2. Overall Objective To reduce morbidity, hospital admissions and mortality of patients with Left Ventricular Systolic Dysfunction (LVSD). To improve engagement, disease ownership, functioning and quality of life of patients with LVSD. To recognise that patient with LVSD need to be medically optimised prior to a hospital procedure in order to improve outcomes.

To adopt a systemic approach to collect and analyse data, using fact-based evidence to plan, to effect implementation and to measure outcomes using appropriate qualitative and quantitative data including patient experience feedback to support the whole pathway for CVD whilst tackling health inequalities across Buckinghamshire.


This scheme aims to control the progression and prevalence of heart failure and thus ameliorate the consequence of heart failure on those patients identified as being at risk. While other planned care projects are addressing morbidities including diabetes, COPD and stroke through service redesign; patients who have any of those morbidities who have underlying heart condition require a holistic approach. Diagnosis and treatment of heart failure complements these projects and schemes under the primary care development programme.

The Urgent Care work streams of the CCG seek to prevent and reduce emergency admissions. The CLOUD project supports that aim by proactively managing patients who would be a greatest risk of emergency admission due to heart failure. This scheme is based on a patient-centered philosophy of optimising care for the individual patient, in the community and thus ‘closer-to- home’ with appropriate self–management.

4. Aim • To increase awareness of HF in Buckinghamshire and to recognise that it is

under-diagnosed • To optimise the care of patients with diagnosed chronic stable left ventricular

systolic dysfunction (LVSD) within primary care using evidence-based medicine

• To reduce disease progression • To reduce morbidity, hospital admissions and mortality of patients with LVSD • To reduce the inequality gap • To learn from unplanned admissions in order to prevent future events • To improve engagement, disease ownership, functioning and QOL of patients

with LVSD • To recognise that patients with LVSD need to be medically optimised prior to

a hospital procedure in order to improve outcomes.

Patients with proven LVSD (except those on an EOL pathway or otherwise contraindicated) are uptitrated as per protocol to a maximum tolerated dose of beta-blockers (or to pulse 60 BPM) and ACEI/A2A Year 1 - 50% of patients with LVSD Year 2 - 75% of patients with LVSD (A clear HF protocol will be issued by the CCG to support)

5. Patient cohort

All patients with a proven diagnosis of left ventricular systolic dysfunction (LVSD) unless on an end of life pathway or otherwise not appropriate. We would anticipate the majority of patients would be eligible.

6. Process

Uptitration of betablockers and ACEi/ARBs according to the cloud model of heart failure care: • Optimising doses of ACE-i (or ARB) and β-blockers to maximum tolerated

doses significantly reduces morbidity, hospital admissions and mortality. • Traditionally QOF doesn’t incentivise uptitration of drugs to maximum

tolerated doses, however this primary care development scheme does aim to achieve uptitration

o Note β-blockers have a “striking and early reduction in overall mortality”

CLOUD model details – See Appendix 1


All patients with LVSD should be educated about lifestyle, avoiding drugs such as NSAIDs, should have co-morbidities optimised, should have drug adherence checked and be taught to weight themselves daily such that if their weight increases rapidly or they get breathless, early intervention can be initiated where possible (ideally in primary care with diuretics and managing the cause, or if required the heart failure day unit or admission if no alternative). The primary care development scheme for heart failure details a lot of this work.

8. Timetable/Milestones 1st July 2017 – All resources will have been developed and ready, this includes the EMIS CLOUD template.

9. Measurement and reporting

Number of patients being up-titrated will be captured using codes in EMIS 10. Method of Monitoring

• Specific read codes in EMIS will be used as method of recording and monitoring, in line with the New York Heart Association Classification, they are:

o Association Classification – Class I EMIS CODE (662f) o Association Classification – Class II EMIS CODE (662g) o Association Classification – Class III EMIS CODE (662h) o Association Classification – Class IV EMIS CODE (662i)

Patient on maximum tolerated beta blocker therapy (Code 8B6V) AND Patient on maximum tolerated ACE inhibitor therapy (Code 8B6Q)

11. Thresholds

The first year target is 50% of patients up-titrated for both drugs.

12. Appendix 1

Cloud Model

The HF toolkit is a care delivery framework based on the “CloudeC” model:

• This simple and practical model should be used in conjunction with NICE and local guidelines

• The model draws together key achievable concepts from the evidence-base and provides a delivery framework for use within primary care that will significantly improve patient outcomes

• It assumes a diagnosis of LVSD has been confirmed using echocardiography (BNP not currently available in Bucks – pilot pending) and treatable causes for LVSD have been considered (e.g. CHD, hypertension, valvular disease, arrhythmia)

• If there are diagnostic or management doubts, expert advice (e.g. consultant, heart failure nurse) should be sought

Multi-pronged approach focusing on and optimising:

➢ Co-morbidity management

➢ Lifestyle management

➢ Outpatient monitoring (usually within primary care)

➢ Uptitration of ACE-i/ARBs and β-blockers to max tolerated dose

➢ Drug adherence maximization

➢ education and enablement

➢ Care plans


Title: Hypertension Clinical Lead: Dr Stuart Logan Lead Manager: Steve Goldensmith Year 17/18

1. Context Good control of blood pressure in hypertensive patients is one of the most effective interventions in reducing cardiovascular disease. There is a gap between patients diagnosed with hypertension and the real prevalence. Even in patients diagnosed with hypertension treatment could be further optimised to achieve evidence based targets.

2. Overall Objective The objective of this scheme is to increase prevalence recording and optimise treatment (including reducing the over treatment in our frail elderly population).


Recording blood pressures and if raised manage in line with local & national guidance.

4. Aim • Year 1

Identification: increase percentage prevalence by practice against expected practice prevalence.

• Year 2 Identification, increase percentage prevalence against expected practice prevalence.

Better control, BP target level, taking into consideration frail elderly and the need for a looser target in the over 75s

5. Patient cohort

Patients with blood pressure of >150/90.

6. Process Identification of Patients with Hypertension Provide optimum treatment Link to protocol for Hypertension

7. Link with Existing Work Schemes – N/A

8. Timetable/Milestones Quarterly Prevalence & Reported Rate of Hypertension by Practice

9. Measurement and Reporting Identify & Code Hypertension Patients using existing QoF Search for ‘HYP001 Patients on Hypertension Register’.



11. Thresholds/Targets

Aiming for 80% of the cohort <150/90

http://webarchive.nationalarchives.gov.uk/20170302112650/http://yhpho.org.uk/ncvinintellpac ks/pdf/10Y_slidePack.pdf

http://webarchive.nationalarchives.gov.uk/20170302112650/http://yhpho.org.uk/ncvinintellpac ks/pdf/10H_slidePack.pdf

above links to Cardiovascular networks data packs (scroll down to hypertension and practice level data on current versus expected prevalence so for example Waddesdon in AV 0.77 of expected i.e. 23% undiagnosed)

12. Appendix


http://yhpho.org.uk/ncvinintellpac

http://yhpho.org.uk/ncvinintellpac


Title: Prescribing (Priority) Clinical Lead: Shona Lockie Lead Manager: Maria Smith Year 17/18

1. Context There is a national drive to ensure appropriate antibiotic use to slow the rise in antibiotic resistance.


This is a 2 year quality premium (QP) scheme. The QP measure for 2017/18 is specifically around the appropriate use of antibiotics in the management of urinary tract infections (UTIs) in primary care, the sustained reduction in use antibiotics in primary care and to reduce the incidence of gram negative blood stream infections (BSI) across the whole health economy especially in at risk groups. The selected measures are those identified by NHSE and which the CCG and practices will be monitored against.


To promote the appropriate diagnosis and management of UTIs in primary care especially in the older population and reduce the use of trimethoprim prescribing as 1st line in the empirical treatment of UTIs and to continue the program of sustained reduction of prescribing of antibiotics in primary care

The driver for this is that both nationally and locally, the pattern of trimethoprim sensitivity is less than for nitrofurantoin ( locally for example rates of trimethoprim sensitivity for all isolates is only around 68%, ie 32% of cases are resistant to trimethoprim whilst nitrofurantoin sensitivity level remains high at 92%). This strategy is expected to facilitate a corresponding reduction in E.coli bacteraemias’ that may in part be attributable to treatment of infections associated with antibiotic resistant organisms.

4. Aim

The primary aims in year 1 are to: • increase the appropriate use of nitrofurantoin as 1st line choice for the empirical

management of UTI in primary care settings and achieve at least a 10% reduction in the number of trimethoprim prescription items esp in the at risk elderly population

• Sustain reduction of prescribing of antibiotics in primary care • Reduce incidence E coli BSI reported at CCG level by at least 10% based on 2016

performance data (indicative and final targets to be made available in due course) • reduction of gram negative blood stream infections across Buckinghamshire

5. Patient cohort

• Nos of Patient prescribed antibiotic therapy in relation to population demographics • Patients prescribed empirical treatment with nitrofurantoin vs trimethoprim • Patients aged 70 years or over prescribed nitrofurantoin vs trimethoprim

6. Process Implementation of interventions including: • de-prescribing of antibiotics for asymptomatic bacteriuria in older people • strategies to reduce use of antibiotic prophylaxis • increasing use of nitrofurantoin 1st line for empirical treatment of UTIs instead of

trimethoprim. • a reduction in prescribing of trimethoprim in ‘at risk’ groups reported to have a

significantly higher rate of nonsusceptibility • Tools to facilitate identification diagnosis and appropriate management of patients at

high risk of E. Coli blood stream infections • Reducing use of antibiotic prescriptions issued for viral infections

7. Link with Existing Work Schemes Not applicable


Within year 1 9. Measurement & Reporting

• Target 1 Measure: Ratio of Number of prescription items for trimethoprim within the CCG to Number of prescription items for nitrofurantoin within the CCG

• Target 2 Measure: Number of prescription items for trimethoprim with identifiable NHS number and age 70 years or greater within the CCG

• Target 3 Measure: Antibiotic items/STAR-PU (rolling 12 months). • Target 4 Measure: For this part of the QP, data will be taken from PHE DCS system

to both collect data for gram negative BSI and monitor progress on E coli BSI. CCGs need to collect the primary care data set for all cases of E. coli bacteraemias and use it locally to identify opportunities to reduce the risk of E.coli bacteraemias. The CCG will need to provide evidence of primary care data set capture to NHS England via local assurance processes. CCG cannot submit the data set to DCS directly, but can do so via the Trust DCS portal if this has been agreed within the local health economy

Feedback on prescribing given at prescribing and locality forums as well as via bulletins / interventions & updates


• Monthly prescribing trend analysis (epact data).that will be fed back to practices • Regular enterprise searches and feedback to outlying practices on prescribing trends • PHE Antimicrobial Resistance (AMR) Fingertips benchmark data

11. Thresholds

1. a 10% reduction (or greater) in the Trimethoprim: Nitrofurantoin prescribing ratio based on CCG baseline data (June15-May16) for 2017/18.

2. a 10% reduction (or greater) in the number of trimethoprim items prescribed to patients aged 70 years or greater on baseline data (June15-May16) for 2017/18.

3. sustained reduction of antibiotic prescribing in primary care equal or below NHS England 2013/14 mean performance value of 1.161 items per STAR-PU.

4. 10% reduction of gram negative blood stream infections across the whole health economy

12. Appendix



Title: Adherence to local Right Care clinical pathways

Clinical Lead: Dr Raj Thakkar

Lead Manager: Neil Flint

Year 17/18

1. Context Recent years have seen the development of many clinical pathways covering a range of conditions. These pathways reflect evidence based best practice and are designed to help clinicians deliver a consistent approach to patient care. Of course any pathway should allow for deviation from it for individual patients.

2. Overall Objective To promote patient care in accordance with locally and nationally developed guidelines.


The scheme promotes the compliance with published pathways, in particular with reference to standardising care and improving the quality of referrals important pathways include:

• Gynaecology intermediate service and appropriate pathways, • Cardiology intermediate service and appropriate pathways, • Cough Pathway, • MSK (from three months after implementation of the new integrated “iMSK”

service), • IFR and procedures of limited clinical value, • Diabetes clinical pathway, • Ophthalmology intermediate service and appropriate pathways, • Dermatology appropriate pathways when new advice and guidance goes live,

4. Aim To adhere to the clinical pathways which will include utilising advice and guidance and ERS (Electronic Referrals System).

5. Patient cohort

Patients identified under the following clinical specialities: • Gynaecology, • Cardiology, • Cough Pathway, • MSK IFR

• Diabetes • Ophthalmology • Dermatology

6. Process Implementation of practices and interventions including: • Support with Advice and Guidance provided • Adherence to IFR process and policies • Adherence to pathways including the use of intermediate services (where they

are in place). 7. Link with Existing Work Schemes

ERS, IFR process, Advice and Guidance 8. Timetable/Milestones

Referral activity, 9. Measurement and Reporting

• Where an intermediate service is in place - appropriate referrals to intermediate care.

• Use of Advice and Guidance

10. Method of Monitoring • Monthly trend analysis on referrals to secondary care that will be fed back to

practices • Monthly trend analysis on referrals to intermediate care that will be fed back

to practices • Monthly trend analysis advice and guidance available by pathway • Regular searches and feedback to outlying practices on referral

11. Thresholds This gateway area does not have specific measurable targets. It is included as a means of practices demonstrating commitment to adhere with local pathways.

This area may be audited to help to understand referral practices.

12. Appendix


1

MEETING: Primary Care Commissioning Committee PAPER: G

DATE: 1st June 2017

TITLE: Hawthornden Surgery Branch Closure in Flackwell Heath

AUTHOR: Jessica Newman, NHS England Anne Ronan, Practice Manager Hawthornden Surgery


Reason for presenting this paper: For Action For Ratification For Decision For Assurance For Information Summary of Purpose and Scope of Report: The Hawthornden Practice in Bourne End has made an application to close its branch practice in Flackwell Heath. This application has been made following a CQC inspection that rated Hawthornden Surgery as overall Requires Improvement with an inadequate rating in the Safe domain. These ratings are due in large part to the CQC’s concerns about the Flackwell Heath branch surgery.

Whilst the CQC felt that Hawthornden Surgery itself was of a good standard it raised several concerns regarding Flackwell Heath branch surgery:

• Risks around fire safety and legionella were not managed adequately.

• An infection control audit had not been completed and cleanliness and hygiene were not always managed appropriately.

• There were no arrangements to manage an emergency. In particular, there was no oxygen and the GP lone working meant there are no other staff to assist in an emergency or act as chaperone.

Following the visit, the practice took the decision to close the branch immediately and to follow due process in order to apply for permanent closure. This report provides NHS England supporting information, map of Practice Boundaries and Flackwell Heath residents, Hawthornden Surgery application to close branch premises, 13Q and Equality Impact Assessment, letter sent to Flackwell Heath patients and public Q&A document. PCOG on 6 April 2017 reviewed the application to close the Hawthornden branch surgery and recommend that Chair’s Action be taken to approve the application. The PCCC is asked to ratify the closure of the Hawthornden Branch Closure.

2

Conflicts of Interest: None known. 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






13Q Duty to involve the Public.

Equality Equality Impact Assessment completed. Quality CQC Inspection Report makes reference to

branch surgery. Financial N/A Risks Risk that patients living in Flackwell Heath have

difficulty attending main surgery in Bourne End. Risks will have been considered as part of duty to involve patients in decision to apply for closure.

Statutory/Legal Requirement to engage patients before application to close is made.


Primary Care Operational Group on 6 April 2017 reviewed the application to close the Hawthornden branch surgery and recommend that Chair’s Action be taken to approve the application.


Neighbouring practices have been informed of the practice’s intentions.

Supporting Papers: G1 NHS England supporting information, presented to PCOG on 6.4.17 G2 Map of Practice Boundaries and Flackwell Heath residents G3 Hawthornden Surgery Application to Close Branch Premises G4 13Q and Equality Impact Assessment G5 Letter sent to Flackwell Heath patients G6 Public Q&A Document

3

Aylesbury Vale CCG and Chiltern CCG

Date 6 April 2017

Title Branch closure: Flackwell Heath surgery, branch of Hawthornden Surgery, Bourne End, Buckinghamshire

Author Jessica Newman

Hawthornden Surgery Hawthornden Surgery is a practice of 6,827 patients with a main practice in the village of Bourne End and a branch surgery in Flackwell Heath, a village situated some 2 miles away from Bourne End.

Flackwell Heath Branch Surgery Flackwell Heath is a small village 2 miles from Bourne End and 4 miles from High Wycombe, located within the Flackwell Heath and Little Marlow ward of Wycombe District Council.

Until 05.12.16, Flackwell Heath branch surgery was open on 4 sessions per week, on Monday, Tuesday, Wednesday and Thursday mornings for the duration of the GP consultations. A GP consulted alone at the surgery with no reception or nurse support. The surgery comprises a small bungalow with two rooms being used as waiting and consultation rooms. Due to the size of the Flackwell Heath site and lack of adequate facilities, all nursing care, diagnostics, additional and enhanced services are provided at the main site at Hawthornden Surgery.

Of the 6,827 patients registered at Hawthornden Surgery about 1700 patients have a Flackwell Heath address. The practice report that the majority of patients seen at the branch surgery are not local but go there to see the GP consulting.

The residents of Flackwell Heath surgery also fall within the practice boundaries of Cherrymead Surgery and Riverside Surgery in High Wycombe, and Pound House Surgery in Wooburn Green. The latter practice works jointly with Hawthornden Surgery. All these practices are further away than Hawthornden Surgery in Bourne End. A map of neighbouring practice boundaries and Flackwell Heath residents by practice is at F2.

The Flackwell Heath surgery building is owned by the Partners of Hawthornden Surgery.

CQC Inspection and Report The full CQC Inspection Report for Hawthornden Surgery at can be seen at

Hawthornden Surgery CQC inspection report

The final CQC report, published on 30.01.17, rated Hawthornden Surgery as overall Requires Improvement with an inadequate rating in the Safe domain. These ratings are due in large part to the CQC’s concerns about Flackwell Heath branch surgery although the CQC has credited the practice on their swift actions in response to the concerns raised.

Whilst the CQC felt that Hawthornden Surgery itself was of a good standard it raised

Paper G1

http://www.cqc.org.uk/location/1-554084482

4

several concerns regarding Flackwell Heath branch surgery:

• Risks around fire safety and legionella were not managed adequately.

• An infection control audit had not been completed and cleanliness and hygiene were not always managed appropriately.

• There were no arrangements to manage an emergency. In particular, there was no oxygen and the GP lone working meant there are no other staff to assist in an emergency or act as chaperone.

The extent of the CQC’s concern was such that it advised the practice manager that they were considering imposing an Urgent Compliance Notice on Flackwell Heath. To avoid this, the practice closed the branch surgery on a temporary basis immediately.

For the temporary closure, all appointments offered at Flackwell Heath branch surgery have been re-located to a ground floor consulting room at Hawthornden Surgery.

The practice contacted NHS England who advised on the process for applying to close a branch surgery (NHS England Policy Book for Primary Medical Services, paras 15.7-15.26) including the requirement to consult patients and stakeholders on the proposed closure.

Initial estimates of the refurbishment work to bring the branch surgery up to required standards were about £15k. The cost of employing an additional receptionist and associated cover for leave etc. also needs to be included as the current reception team at Hawthornden Surgery do not have capacity to cover Flackwell Heath.

Taking all factors into consideration, the Partners decided they wish to close Flackwell Heath branch surgery and start a consultation process and submit an application to NHS England/Chiltern CCG. The application is at Paper F3.

Consultation Process In line with the NHS England SOP for managing the closure of branch surgeries, Hawthornden Surgery has run an extensive consultation process about the potential closure of Flackwell Heath branch surgery and the available alternative options.

The practice has worked with NHS England and Chiltern CCG Communications Teams, NHS England South Central Primary Care Team and the Head of Primary Care at Chiltern CCG on the consultation process.

On 06.01.17, Hawthornden Surgery PPG meeting discussed the proposal to close and considered a draft patient letter. The PPG supported the proposal and agreed to lead the patient engagement aspects of the consultation. This meeting date was agreed as the start of the consultation process.

The letter agreed by the PPG was made available in Hawthornden Surgery waiting room and on the website.

An article was been published in the community newsletter and Bucks Free Press.

A letter to patients was sent to all those with a Flackwell Heath postcode.

Drop-in sessions for patients were held on 09.03.17.

The CCG briefed the councillor for Flackwell Heath & Little Milton and he met with the practice on 02.02.17.

The proposal was discussed at the Wycombe and Wooburn Green locality meetings in March.

The consultation period ended on Friday 31 March.

5

Key Issues

• The CQC inspection on 05.12.16 required the practice to take urgent action regarding the safety of patient services provided at Flackwell Heath branch surgery. As a result, the practice closed the branch surgery on a temporary basis.

• All appointments previously provided at Flackwell Heath have been re-provided at the main site. Patients have always had to travel to the main site at Hawthornden Surgery, Bourne End (2 miles away) for services other than GP consultations and when the branch is closed.

• After consideration, the Partners decided they wish to close Flackwell Heath branch surgery permanently as it is not cost effective for them to put in place the measures required by CQC.

6

Paper G2

7

Dear Anne, Application to Close Branch Premises Please provide the information below to the Commissioner no less than 28 days before the requested contract variation. Affix practice stamp:

Details of branch surgery address proposed for closure:

Lyndhurst 47 Straight Bit Flackwell Heath Buckinghamshire HP10 9NE

1. Do you have premises approval to dispense from the branch surgery? If yes, how many patients do you currently dispense to?

No N/A

2. Do you have premises approval to dispense from any other premises? If no, do you intend to give three months’ notice of ceasing to dispense as required by Paragraph 10 of Schedule 6 of the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 as amended?

No N/A

3. How have you involved patients regarding this proposal?

Letter sent to Flackwell Heath patients and distributed in surgery inviting comments.

Paper G3

Anne Ronan Practice Manager Dr S Buxton & Partners Hawthornden Surgery Wharf Lane Bourne End SL8 5RX

Primary Care NHS England

5510 Jubilee House Cowley Oxford

OX4 2LH

07824 302891 [email protected]

28 March 2017

8

Coverage arranged in local magazines. Morning and afternoon drop in sessions for patients. Engagement with the PPG. Information on website. Information on Facebook page. GPs having opportunistic conversation with patients during consultations.

4. How will you be communicating the actual change to patients, ensuring that patient choice is provided throughout, should the Commissioner approve this application

As above: notices in main surgery, making a letter available explaining options, notices on website and Facebook page, further PPG engagement, articles in local magazines.

5. Please provide a summary of the patient involvement feedback and confirm that you will supply evidence of this consultation should it be requested:

FH FAQs final.docx

6. Please provide as much detail as possible about how this proposed closure will impact on your current registered patients, including: • access to the main surgery site i.e. public transport, ease of access; • capacity at main surgery site; • booking appointments; • additional and enhanced services; • opening hours; • extended hours; and • dispensing services (if applicable)

170214 EIA Flackwell Heath.docx

7. From which date do you wish the branch closure to take effect? 10/04/2017

9

Signed by Dr Sarah Buxton

Date: 28/03/17

Signed by Dr Mike Wolfin

Date: 28/03/17

Signed by Dr Sarah Abbas

Date: 28/03/17

Signed by Dr Peter Newman

Date:

Signed by Dr Maneeza Siddiqui

Date: 28/03/17

Signed by Dr Pavan Bhargava

Date: 28/03/17

Where an application to close premises is granted by the Commissioner, the contractor shall remain fully responsible for cessation or assignment of the lease for any rented premises and any disposal of owner-occupied premises . In both cases, payments under the premises directions will cease from the day of closure.

Please note that this application does not impose any obligation on the Commissioner to agree to this application

Yours sincerely, Anne Ronan Practice Manager

10

13Q Assessment Form Flackwell Heath

170214 EIA Flackwell Heath.docx

Paper G4

11

HAWTHORNDEN SURGERY Tel: 01628 522864 Fax: 01628 533226

Dr S.H. Buxton Wharf Lane Dr M.B. Wolfin Bourne End Dr P.W. Newman Buckinghamshire Dr S Abbas SL8 5RX

Dr M. Siddiqui Dr P. Bhargava

Future of Flackwell Heath Branch Surgery Dear Patient You may be aware that our branch surgery at Flackwell Heath has been closed since early December. We have not lost any appointments through this action – all doctor sessions that would have normally run from Flackwell Heath have continued in Bourne End. The practice partners took the decision to temporarily close the branch surgery following a Care Quality Commission (CQC) inspection which determined that we are “failing to comply with the relevant requirements of Regulation 12, (1) and (2), Safe care and treatment, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 due to the fabric of the building and its constraints and the practice of a sole clinician operating from the branch surgery”. Our partners have carefully considered whether they could improve the structure of the practice and premises to an acceptable level (with advice sought from NHS England). The partners have concluded that the issues raised by the CQC inspection are insurmountable and the best overall solution is to close the branch surgery. The practice is planning to apply to NHS England and NHS Chiltern Clinical Commissioning Group to withdraw from providing services there. The Practice has a long history of providing GP services in Flackwell Heath and has built strong bonds with the local community. We recognise that many patients will share our disappointment that the surgery plans to close, but very much hope that they will stay with us and continue to use Hawthornden surgery, less than two miles away in Bourne End. We do firmly believe, however, that this decision is in the best interests of patient care at both of our surgeries. The Partners will be working closely with the Hawthornden Patient Participation Group and would welcome your views on how you feel we might ensure that you continue to receive the best patient care.

Paper G5

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Why are we planning to close Flackwell Heath Branch Surgery? • The building has become inadequate. Flackwell Heath Branch Surgery is a converted

private house, has limited patient parking, inadequate disability access and no reception area.

• Modern General Practice is provided by more than just GPs. Space constraints mean it is impossible to offer the full range of services that our patients need. Often patients seen at Flackwell Heath need to be seen a second time at our main site, where there is access to additional equipment and staff. We also cannot offer additional services at the branch, for example nurses, counsellors or midwives.

• General Practice increasingly needs to work with external teams such as Health Visitors, District Nurses etc. Due to space constraints, these services are not available at Flackwell Heath.

• The service to all our patients would be improved by concentrating GP, Practice Nurse and management resources at Hawthornden Surgery.

• There is a single doctor working on their own at Flackwell Heath Branch Surgery. This could lead to personal risk, and unacceptable professional isolation. The CQC also note that this means that there are no other staff available to assist in an emergency or act as a chaperone.

How will this affect you as patients? • You can continue to access the wider range of GP services at Hawthornden Surgery. Your

registration will be unaffected. • Access to Hawthornden Surgery is straightforward. It is just under two miles from

Flackwell Heath (six minutes without traffic) and there is car parking both at the surgery and across the high street, in Wakeman Road. For those using public transport, there is a direct bus route between the two sites.

• Doctors will continue to provide home visits to housebound patients who remain registered.

• Patients can continue to have prescriptions sent electronically to the chemist of their choice without interruption

• Appointments that were offered at Flackwell Heath are now being offered at Hawthornden Surgery in a ground floor consulting room that we have made available. This will also help to increase accessibility for all our patients.

What happens next? We are extending the time frame for patients to provide feedback to the Practice, to 31 March 2017. Following this, the Partners will include detailed feedback in a submission to NHS England and NHS Chiltern Clinical Commissioning Group for their consideration. We firmly believe that we have explored all options available to keep Flackwell Heath Branch Surgery open but have not been able to find a sustainable solution that will enable us to provide safe, high quality patient care from that site and continue with our plans to develop our general practice. We are also seeking new premises for our main site to improve services for our patients in the future. We are keen however to gather patient feedback on our plans to close our Flackwell Heath branch and concentrate our services at Hawthornden Surgery to ensure we have captured as far as possible our patients’ views and needs; and will consider these when discussing future options with NHS England. How can you get involved?

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We would like to hear your views and invite you to write to Anne Ronan, Practice Manager at Hawthornden Surgery, Wharf Lane, Bourne End, Buckinghamshire, SL8 5RX or email [email protected]. You can also contact our Patient Participation Group Chair, Mr David Lunn by leaving a note with reception. You can also share your views with us in person at a drop in session with the partners and Patient Participation Group representatives between 9:30 – 11:30 and then 12:30 – 2:30 at the Bourne End Library on 9 March, 2017. For further information visit our website (www.hawthorndensurgery.co.uk) or follow us on Facebook (HawthorndenGP). Yours faithfully The Partners of Hawthornden Surgery


http://www.hawthorndensurgery.co.uk/

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HAWTHORNDEN SURGERY Tel: 01628 522864 Fax: 01628 533226

Dr S.H. Buxton Wharf Lane Dr M.B. Wolfin Bourne End Dr P.W. Newman Buckinghamshire Dr S Abbas SL8 5RX Dr M. Siddiqui Dr P. Bhargava

Below are some of the frequently asked questions and comments we have received from patients who have given Hawthornden Surgery feedback on its decision to apply to close its Flackwell Heath branch surgery. In total, nine emails were received along with two written letters. Eight patients also visited the drop in sessions.

- The Flackwell Heath surgery has been operating for many years in the same way and

has always been fine – why is it a problem now? While this is true, regulations for GP services have changed and the site has now been deemed as inadequate for use as a branch surgery. We also must be mindful of the drive by the NHS to move more services into the community from hospitals, and to federate small practices into larger ones in order to achieve cost savings and reduce waste. Small branch surgeries that provide very limited services are unlikely to figure into this new model of services.

- Patients were able to visit the Flackwell Heath surgery on foot – would a new building let them do this? We understand that it has been lovely for Flackwell residents to have been able to walk to the branch surgery, and we wish all 7040 of our patients had this option. Unfortunately the size of the area that we cover means this simply is not possible for everyone. We are obviously looking at appropriate areas for the new site for our surgery, but some people will inevitably have to travel further than others.

- Has the old Budgens site in Flackwell Heath been considered for use? This site has been mentioned many times by our patients. The intention is to build a practice large enough to house both Hawthornden Surgery and Pound House Surgery (currently based in Wooburn Green) as well as to deliver more services for our patients and with room to meet the demands of planned growth in the area. We currently believe the old Budgens site does not have the space to meet these needs; however, we have passed the suggestion on to the developers we are working with for their fuller consideration.

- The bus service between Flackwell Heath and Bourne End is not ideal – can this be

addressed? We understand the limitations of the bus service and have raised this with the council. We have been working with patients to book appointments that correspond to the bus schedule. One of the requirements for the new site will be adequate public transportation.

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- Parking wasn’t a problem in Flackwell Heath, but it is difficult in Bourne End. Is the parking situation there being addressed? The parking situation at the Bourne End surgery is not ideal, and is similar to most GP surgeries in the area. This is another reason why the Bourne End surgery has become outdated. One of the criteria for finding a new site will be that it has adequate car parking space. Several patients have pointed out that some people abuse the car parking at Bourne End by using it when popping to the shops. This is an issue that we do address when we are aware of it occurring, and we are planning to work with the Patient Participation Group to help us educate our patients about how crucial it is to vacate their space after an appointment.

- Why is the disability access at Flackwell Heath such an issue when not many disabled

people even need to use the specific facilities which are causing the problems? The toilet facilities at Flackwell are inaccessible to wheelchairs and the emergency exit to the rear of the building is inadequate for people with limited mobility. We appreciate people may not need these facilities most of the time, but it is essential that we can provide them to our patients with disabilities.

- Why would there be a difference to the current service as second appointments would

be needed at Bourne End as well. Why not be seen at Flackwell first? Some critical services, particularly ECGs are routinely given to patients by our nursing staff when a doctor is concerned. This cannot happen at the Flackwell Heath branch.

- Why isn’t emergency assistance available from the doctor at the FH branch? On the day of the CQC inspection, there was an incident in which a patient experienced respiratory arrest at Bourne End. The response of the team to this very serious medical emergency was flawless, but did involve two doctors attending the patient, a nurse readying the emergency equipment, and a receptionist calling for an ambulance. With just a single doctor present at Flackwell Heath such a response is not possible.

- No one would go to Flackwell Heath with an emergency, so why should the lone doctor

issue matter? It is true that we did not see ‘urgent’ cases at the branch. However we have had several instances of patients arriving for a routine appointment and becoming acutely unwell in a short space of time. In these instances (which was the case in the aforementioned respiratory arrest at Bourne End) having the facilities and staff available (to set up a nebuliser or perform an urgent ECG, for example) is critical.

- Have chaperoned appointments only been available at Bourne End?

In the main, chaperones are required for intimate examinations. Often the patient will not inform the receptionist of the nature of the problem and the doctor isn’t always aware that they will need to perform such an examination. Therefore the initial appointment is wasted and the patient has to re-book in Bourne End where a chaperone can be made available.

- Why is the lone working issue such a problem? There is a panic alarm for the GP at

Flackwell Heath and even at Bourne End, reception staff and nurses may be of little help if a doctor is attacked. There has always been a panic alarm for the doctor working from Flackwell. However, there would be no way of getting immediate assistance to them. The CQC’s principal concern about lone working was the lack of assistance in an emergency, the lack of an available chaperone, and professional isolation (for example it is often useful for GPs to confer between patients).

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- Is it likely that the new surgery will be in a location between Bourne End and Flackwell Heath? It will be a challenge to find space for new premises, but our developers are optimistic. As we will be sharing the new build with Pound House Surgery and other services, the priority will be space. However we will consider the location of the majority of our patients as part of the site search.

- Could there be a register of drivers able to escort less able patients to appointments?

This is an excellent suggestion. We have also been considering how we might be able to support volunteer driving organisations already in the area which would ensure that requirements of such a service (such as insurances) are adequate.

- People with disabilities may find it difficult to travel and will be greatly impacted by the closure. How are they being considered? Again, we are considering how we might be able to support driving organisations to help patients with transportation. We will, of course, continue to provide home visits for the house bound. We have always only provided nursing appointments from Bourne End, so many of our less mobile patients already have support systems in place to help them get safely to Hawthornden.

- Why can’t the Flackwell branch be kept open in the short term whilst seeking new premises? Sadly this is not an option. The CQC inspector, on the day of the inspection, told us that the problems at the branch must be sorted “immediately” - the only means of doing that was to stop seeing patients there. The nature of the problems cited required long term solutions, including hiring new staff and major building works. As we were already working towards new premises for the surgery’s long-term future, to commit to the level of work required as a temporary solution was not tenable.

- Will funding for this new practice be available?

There are several potential streams of funding that we are considering. It is a complicated process but we are certain that it is achievable.


Paper H

DATE: 1 June 2017 TITLE: Report from the Primary Care Operational Group (PCOG) AUTHOR: Wendy Newton, Primary Care Manager 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 provide the PCCC with an update from the PCOG meetings held on 6 April 2017 and 4 May 2017. Conflicts of Interest: None. 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






Equality Quality Financial Risks Statutory/Legal Prior consideration Committees / Forums / Groups

Primary Care Operational Group.


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Report from the Primary Care Operational Group Meetings held on

6 April 2017 and 4 May 2017

Primary Care Development Programme The PCOG were updated and given the opportunity of comment on the development of the Primary Care Development Programme. Agenda item for PCCC on 1 June 2017. Primary Care Risk Register At the PCCC meeting on 2 March 2017 the monitoring arrangements for the Primary Care Risk Register were agreed. At the request of the PCCC the PCOG have reviewed the risks noted on the Primary Care Risk Register and have collectively considered appropriate scorings. Accountable risk owners and delegated risk owners have been appointed to each risk. The risk register will be a standing item for the PCOG and PCCC. Cressex Health Centre Contract The PCOG reviewed the results of a deep dive into the current and projected financial position for Cressex Health Centre, with all income and expenditure reviewed in detail, including details of the financial consequences incurred by the practice as a result of the decision to keep Lynton House Surgery open. A financial proposal was presented to the PCOG to enable the continuation of the Cressex Health Centre contract for 2017/18 and the steps to be taken to achieve sustainability for the remainder of the contract term. The PCOG recommended that the Chief Officer and Chief Finance Office approve this proposal outside of the PCCC due to the urgent timeframes involved. Hawthornden Branch Closure The small Flackwell Heath branch surgery of Hawthornden Surgery was closed by the practice in December 2016, following a CQC inspection which highlighted concerns around the condition of the premises and identified lone working arrangements. An application was received from the practice to permanently close the branch surgery following a full patient consultation. The PCOG recommended Chairs Action to approve the closure of the surgery which will formally closed from 1 June 2017. The PCCC will be asked to ratify this decision at the public meeting on 1 June 2017. Mandeville Surgery The PCOG noted that the current APMS contract provider (TPG) for Mandeville Surgery has signed an extension to their temporary contract which allows them to continue providing primary care medical services at Mandeville Surgery until 31 March 2018. The reprocurement process for the new APMS 5 year contract from 1 April 2018 has commenced. The PCOG raised concerns over the inclusion of the Gender Dysphoria service in the specification as they considered it inappropriate to procure this specialist service using GMS funding. The PCOG and the PCCC will be kept updated on progress. Building Practice Resilience in Buckinghamshire The PCCC in March 2017 requested a commissioning paper to be presented to the Governing Body outlining proposals for the use of General Practice Resilience Programme (GPRP) funding, awarded to the CCG in 2016/17 by NHS England. Following approval by the Governing Body and the Clinical Locality Directors, the specification was sent to five providers. An Evaluation Panel was convened to consider the proposals received and it was proposed that a blended approach utilising the skills and knowledge of two of the providers would be optimum for Buckinghamshire member practices. FedBucks and KPMG have agreed to work in partnership to deliver this piece of work. By working with both providers it is envisaged that the

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local knowledge held by FedBucks will be beneficial. It is further anticipated that the joint working relationship will enable KPMG to impart their knowledge and expertise to the emerging Federation. The PCCC will receive an update on the progress of the programme on 1 June 2017. General Practice Resilience Programme The PCOG approved the following GPRP spending for Kingswood Surgery: • Ex-Practice Management Support (3 days) - £1,500 • Improvement Plan from PCC (following earlier diagnostic work) - £2,478 • Data Support Assistant (2 days) - £700

Primary Care Premises Sub Group The PCOG were asked to support the establishment a Primary Care Premises Sub Group of the PCCC. The meeting noted the lack of local premises expertise following loss of advisory support from NHS England with the transition to delegation. The PCOG acknowledged that the sub group would require alignment to the Finance Committee as well as being a recognised sub group of the Primary Care Commissioning Committee. Due to timelines, the PCOG approved for the Sub Group to hold an inaugural meeting prior to formal agreement for the establishment of the sub group by the PCCC. The PCCC on 1 June 2017 will be asked to approve the establishment of the Sub Group. NHS Property Services Billing NHS Property Services have formulated tenancy agreements and moved to implement market rent. CCGs received an allocation of funding to offset rent increases (which is less than the increase in charges received by the practice). Norden House Surgery has contacted the CCG to request reimbursement for the additional rent and service charges. Practices residing in NHS Property Service premises had not previously been charged for their lease or associated service costs with these being borne by the PCT and more recently NHS England. Two practices within Bucks CCGs (Norden House and Amersham Health Centre) are currently accommodated in NHS Property Services premises. NHS England are due to schedule guidance on the recommended process regarding these increased fees, however this has not been published as yet. Other practices that have private landlords have always been responsible for the payment of their service charges. This issue is recommended as an agenda item for the Primary Care premises Sub-Group (if the establishment of the Sub-Group is approved by the PCCC). CSU Provision of Rent Review Management Service The PCCC had previously agreed that the CCGs would commission SCWCSU to continue to manage the primary care rent review management process for 2017/18 so long as the other CCGs within the BOB footprint continued to do the same. However Oxfordshire CCG has decided to bring this service in-house. The CSU has confirmed that despite Oxfordshire’s decision, the cost to Bucks for this service (£21k) would remain as originally quoted and that there would be no TUPE implications. If stranded costs are to be applied they would be no more than 27% of the value of the contract with Bucks. In the longer term this is something the CCGs could continue to commission or provide at scale across BOB but these discussions are yet to be had with Oxfordshire and Berkshire CCGs. It was noted that the costs had been budgeted for and that this service would almost certainly cost more if brought in-house for 2017/18. The PCOG agreed to continue commissioning SCWCSU to undertake the management of the rent review process for a further 12 months. Violent Patient Scheme The PCOG noted that despite the CCGs move to delegated commissioning status, NHS England are proposing to maintain management of this service for the remainder of this year and have agreed an extended service agreement with the current provider to March 2018. This will allow time for a service review and procurement of a new service. CCGs will be involved in the procurement of a new service. Unfortunately Warneford Hospital and the Whiteleaf Centre have given notice to the VPS service and plan to withdraw from offering use of their premises

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from 3 July 2017. This will leave a lack of premises for Buckinghamshire patients registered with the VPS. Quality Dashboard The PCOG received an overview of the Quality Dashboard and were reassured that there was nothing unexpected in the data contained. Future clinical markers will to coincide with the markers in the Primary Care Development Scheme. The collection of Friends and Family Test Data remains an issue. This will be reviewed again by the PCOG when they meet on 6 July 2017.


Paper: I

DATE: Thursday 1 June 2017

TITLE: Building Primary Care Resilience Update

AUTHOR: Christopher Rowland, KPMG Karen Gill, FedBucks


Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: The CCGs have commissioned KPMG and FedBucks to provide an intensive support programme to all localities across Buckinghamshire, the objectives being to:

- Provide an evidence-based case for change upon which to develop collaborative arrangements for the formation of primary care clusters within Buckinghamshire.

- Encourage collaborative locality working in clusters, underpinned by agreed business plans, heads of terms, care and local principles and estates strategies that overcome challenges and promote the opportunities for improvement.

- Develop a model of care with respect to primary care services in Buckinghamshire, using multidisciplinary, integrated, community-based teams to serve the GP practices, their patients and their care.

- Develop a turnaround team/support package by working with clinical and management leaders from FedBucks to help them build capacity and skills for working with individual practices.

Conflicts of Interest: None. All GP practices are encouraged to participate in this programme. 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 outcome of this programme will result in patient engagement over 3 sessions planned for 2017.

Equality None relating to this paper. Quality None relating to this paper. Financial None relating to this paper. Risks None relating to this paper. Statutory/Legal None. Prior consideration Committees / Forums / Groups

This programme is being delivered in full consultation with the Localities and the Clinical Locality Directors.

Membership Involvement Full membership involvement planned through 3 workshops and locality meetings.

Supporting Papers: Buckinghamshire GP Resilience Project: Weeks 3 to 5

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MEETING: Primary Care Commissioning Committee PAPER: J

DATE: 1 June 2017

TITLE: Summary of CQC Inspections

AUTHOR: Wendy Newton, Primary Care Manager


Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: The purpose of this paper is to provide the PCCC with an update on CQC inspections and awarded ratings for practices within NHS Chiltern CCG and NHS Aylesbury Vale CCG. Conflicts of Interest: No conflict of interest noted. The information contained is within the public domain. 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






Equality Quality Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups


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Practice Name Branch Surgeries 1st Inspection date Report date Follow up inspection Follow Up Report Date

Outcome of Follow Up

Overall rating

K82007 The Swan Practice Steeple Claydon SurgeryMasonic House Verney Close Surgery

27.10.2015 26.11.2015 N/A NFA Good

K82042 Whitchurch Surgery 27.10.2015 26.11.2015 N/A Awaited NFA GoodK82043 Norden House 17.12.2014 31.05.15 N/A NFA GoodK82061 Ashcroft Surgery 27.09.16 07.11.16 27.03.2017 06.04.2017 Safe, Effective and

Overall RI to GoodGood

K82070 Wing Surgery 19.04.15 27.05.16 01.11.16 22/11/2016 Safe RI to Good GoodK82014 Oakfield Surgery 12.08.15 01.10.15 N/A NFA GoodK82018 Meadowcroft Surgery 20.01.2016 11.02.2016 N/A NFA GoodK82019 Mandeville Surgery 02.07.2015 27.08.2015 05.04.2017 Awaited RI

K82038 Poplar Grove Practice 12.01.2016 18.02.16 N/A NFA GoodK82040 Whitehill Surgery Fairford Leys 17.11.2015 17.12.15 N/A NFA GoodK82073 Westongrove Partnership Wendover Health

CentreAston Clinton SurgeryBedgrover Surgery

25.02.16 10.03.16 NFA Good

K82079 Edlesborough Surgery Pitstone Surgery 23.06.15 21.07.16 25.01.2017 28.02.2017 Safe, Effective and Well Led and Overall rating RI to Good

Good

Y01964 Berryfields Medical Centre 04.12.14 19.03.15 DTR - 16.04.16 14.06.16 Safe RI to Good GoodK82021 The Cross Keys Practice Lincoln House Surgery

Cross Keys Practice03.02.16 03.03.16 Reassessed do not

know date? Good

K82028 Haddenham Medical Centre 10.12.14 19.02.15 N/A NFA GoodK82034 Wellington House Practice Chinnor Surgery 17.12.2014 31.03.15 DTR - 16.04.16 09.06.16 Safe RI to Good GoodK82047 Trinity Health (Long Crendon) Thame Health Centre

Bril l Surgery07.10.14 10.12.15 N/A NFA Good

K82068 Waddesdon Surgery 02.09.15 29.10.2015 N/A NFA Good

Awaiting ReportTo be Re-inspected Good or above rating (no reinspection)Inadequate Rating

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Practice name 1st Inspection date Report date Follow up inspection Follow Up Report Date Outcome of Follow Up Overall ratingRectory Meadow 29.04.15 18.06.15 DTR - 04.12.2015 11.02.16 Safe Domain RI to Good GoodAmersham Health Centre 07.06.16 03.08.16 N/A NFA GoodThe New Surgery 09.08.16 27.09.16 N/A NFA GoodJohn Hampden Surgery 27.01.16 01.04.16 N/A NFA OutstandingWater Meadow Surgery 12.05.16 03.06.16 N/A NFA GoodHughenden Valley Surgery 23.03.16 17.06.16 No Revisit 30/12/2016 Safe - RI to Good GoodGladstone Surgery 01.06.16 30.06.16 N/A NFA GoodLittle Chalfont Surgery 02.03.16 12.04.16 N/A NFA GoodIver Medical Centre 26.05.16 21.07.16 N/A NFA GoodThe Hall Practice, Calcot 02.04.15 28.05.15 N/A NFA Outstanding

02.08.16 12.10.16 No Visit 24.04.2017 Safe RI to Good GoodBurnham Health Centre 21.07.16 05.11.16 21.07.16 09.08.16 RI to Good GoodSouthmead Surgery 18.08.16 22.09.16 13.03.2017 04.05.2017 Overall - Inadequate to Good

Safe - Inadequate to GoodResponsive - RI to GoodWell-Led - Inadequate to Good

Good

The Misbourne Practice 28.10.16 14.12.16 N/A NFA GoodDenham Medical Centre 20.04.16 25.05.16 DTR - no date given 04.04.2017 Safe and Effective RI to Good GoodThe Allan Practice, Calcot 20.07.16 27.09.16 undertaken 19.04.2017 Effective RI to Safe GoodHawthornden Surgery 05.12.16 30.01.17 TBA (l ikely July 2017) RIMillbarn Medical Centre 26.07.16 14.09.16 DTR - 01/03/2017 16/03/2017 Safe Domain RI to Good GoodHighfield Surgery 18.07.16 19.08.16 DTR - 02.11.16 09.11.16 RI to Good GoodThe Marlow Medical Group 15.04.15 09.07.15 DTR - 17.12.15 21.01.16 Safe Domain RI to Good Good

Cherrymead Surgery 14.06.16 14.07.16 N/A GoodThe Simpson Centre 14.09.16 01.11.16 No revisit 28.04.2017 Safe RI to Good GoodStokenchurch Medical Centre 25.05.16 23.06.16 N/A NFA GoodPound House Surgery 28.10.2016 16.12.2016 TBA (l ikely DTR June 17) GoodThe Practice, Prospect House 21.09.16 21.10.16 N/A NFA GoodTower House Surgery 22.06.16 09.09.16 N/A NFA GoodDesborough Surgery 16.05.16 02.08.16 08.02.2017 13.03.2017 RI in Overall, Safe, effective and

well led changed to goodGood

Chiltern House Medical Centre 25.02.16 10.05.16 18.10.16 and 24.10.16 29.12.2016 and 16/03/2017 RI to Inadequate InadequateKingswood Surgery 18.11.16 18.01.2017 TBA (l ikely July 2017) RIWye Valley Surgery 15.04.15 07.04.16 DTR - 25.01.16 08.04.16 RI to Good GoodRiverside Surgery 16.09.16 31.10.16 N/A GoodCarrington House Surgery 16.06.16 05.08.16 20/02/2017 21/03/2017 RI Overall, Safe and Well Led to

GoodGood

Priory Surgery 25.07.16 12.10.16 N/A NFA GoodCressex Health Centre, CV Health 18.08.16 27.10.16 26.04.17 awaiting report RI

Awaiting ReportTo be Re-inspected Good or above rating (no reinspection)Inadequate Rating

Threeways Surgery

Primary Care Commissioning Committee Committee in Common ... · Jane O’Grady (JO’G) Health &...

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