Kensington and Chelsea, Westminster and Hammersmith and ......2014/02/12 · Kensington and Chelsea, Westminster and Hammersmith and Fulham 4.3 North West London Reconfiguration Programme

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Kensington and Chelsea, Westminster and Hammersmith and Fulham LOCAL MEDICAL COMMITTEES MEETING

To be held at 1.00 pm on Tuesday 14 February 2012 at The Lighthouse West London, Ladbroke Grove

PART 1 LMC Members only

1.00 – 2.30

AGENDA

1.0 Apologies

2.0 2.1

Declarations of interest Members to declare any conflicts of interest in connection with any items on the agenda or in the light of subsequent debate

3.0 Minutes and matters arising not listed elsewhere on the agenda: 3.1 3.2 3.3

Minutes of LMC meeting Part One on 13 December 2011 (paper attached) Minutes of the Londonwide LMCs and NHS North West London Primary Care Contracting team interim meeting(paper attached) Minutes of the NWL Cluster Meeting 8 December 2011 (paper attached)

4.0 Items for discussion: 4.1 GP Clinical Commissioning Groups – to receive an update of the developments in

Kensington and Chelsea, Westminster and Hammersmith and Fulham 4.3 North West London Reconfiguration Programme (paper attached seperately) 4.4 Enhanced Services 4.5

Once for London Principles - PMS (paper attached) - List Maintenance (paper attached) - Enhanced Services (paper attached)

4.6 PMS issues – to raise any issues 4.7 4.8 4.9

Sessional GP issues – to raise any issues Communication- Imperial College Bulletin Motions to Conference –members to raise items that can be formulated into motions to conference

5.0 Part 2 agenda To discuss the Part 2 agenda

6.0 Items to receive:

6.1 GPC News 5, December 2011 – this can be accessed via the following link: http://www.lmc.org.uk/news/news-detail.aspx?dsid=13532

6.2

LEAD:-to receive a list of forthcoming lead events

7.0 LMC newsletter To identify items for the next newsletter

8.0 Date of next meeting: 10 April 2012

9.0 Any other business:

Draft minutes of the Kensington and Chelsea, Westminster and Hammersmith and Fulham LMC meeting held on Tuesday 13 December 2011

Kensington and Chelsea LMC members

Hammersmith and Fulham LMC Members

Londonwide LMCs

Dr K Aggarwal Dr Moses Dr T Grewal Dr N Rady Mrs A Michaels

Dr P Quilliam Mrs S Beech Dr P O’Reilly (Chair) Ms H Musson

Dr J Pettifer Dr M O’Rawe Dr D Abadi

Dr K Rollinson Ms A Dalal

1.0 Apologies Apologies were received from Dr Lazari, Dr Joshi, Dr Odunuga, Dr Taslaq and Dr Wyatt is on maternity leave. Dr Rollinson and Dr Abadi were welcomed to the committee.

2.0 2.1 2.2

Declarations of interest To note Londonwide LMCs guidance on declarations of interest Dr Abadi questioned whether the LMC represented GPs as providers or commissioners. Dr Grewal responded that the LMC represented the interests of GPs as providers but work with commissioners. There is a recommendation that it might be difficult for someone who is an officer of the LMC to also be an officer of the Clinical Commissioning Group but the Londonwide LMCs view is that we welcome both as long as members are open about their conflicts. Dr Quilliam pointed out this could potentially cause problems, Dr Abadi agreed. Dr Grewal responded that under the pressure of controlling clusters, LMC Chairs and CCG Chairs are working together, the LMC strengths are looking at pathways and working with Clinical Commissioning Groups. Londonwide LMCs are aware of the problems arising from conflicts of interest in the current climate. Members to declare any conflicts of interest in connection with any items on the agenda or in the light of subsequent debate

3.0 Minutes and matters arising not listed elsewhere on the agenda:

3.1 3.2 3.3

Minutes of LMC meeting on 11 October 2011 Clinical Waste (item 3.1.1 refers) Dr Grewal reported that the PCT are not required to dispose of clinical waste under the regulations. PPWT (item 7.4 refers) Dr Quilliam reported that patients are turning up to appointments only to be told they cannot have the procedure. Ms Musson responded that she had attended the PPWT strategy group and Londonwide LMCs are encouraging better LMC involvement in the process. Dr Grewal added Pulse are of the view that PPWT is a bad strategy and will publish bad news stories around this issue. Premises (item 7.7 refers) Dr Grewal warned that practices in PCT owned premises could be responsible for repairs in the future. Minutes of the INWL meeting on 21 September 2011 (paper attached) Minutes of the NWL Cluster Meeting 27 October 2011 (paper attached) ICP Dr O’Reilly commented that the LMC would need to have a serious push back on this issue, especially around the issues of IT functionality, time demands and financing. Each meeting means 120 GP appointments are missed.

3.4 Information Revolution – ‘MyhealthLondon’ website The correspondence between Dr Drage and the Deanery

4.0 Items for discussion: 4.1 GP Clinical Commissioning Groups – to receive an update of the

developments in KCW/HF Dr Quilliam reported his concern about the Clinical Commissioning Groups not understanding the role of the LMC. Dr Abadi added that he was concerned about the capacity of Clinical Commissioning Groups, the demands are very onerous. Ms Dalal added, as a member of the Victoria Clinical Consortia and Central London Health Care Clinical Commissioning Group, that they have been given alot of support from external organisations.

4.5 LMC Annual Conference in Liverpool on Tuesday 22 and Wednesday 23 May 2011 It was agreed that Dr O’Reilly and Dr Aggarwal would attend the LMC Conference.

4.6 PMS issues – to raise any issues Dr Grewal reported that the LMC is going to negotiate on behalf of PMS practices, there are no timescales yet. Clinical Commissioning Groups will not be allowed to negotiate on the practitioner contracts.

4.7

Sessional GP issues – to raise any issues Dr Grewal explained that workforce and education is currently not followed up, he confirmed that he had not received a single communication from his subcluster. Dr Aggarwal agreed, he reported that he had contacted the hospital and they send him regular updates.

6.0 Items to receive: 6.1 GPC News 3, October 2011

6.2 GPC News 4, November 2011 The GPC News was received.

6.3 GPC Negotiators/LMC meeting on 9 November 2011 The slides of the meeting were received.

6.4 Letter from Dr Givans regarding The Cameron Fund The letter from Dr Givans was received.

6.5

LEAD:-to receive a list of forthcoming lead events The list of LEAD events were received.

7.0 LMC newsletter It was agreed that PPWT would be a newsletter item.

8.0 Date of next meeting: The date of the next meeting was confirmed.

9.0 Any other business:

Londonwide LMCs and NHS North West London Primary Care Contracting team interim meeting

Action notes from Thursday 26 January 2012

12.00 – 1.30pm (Room 901, NHS North West London, 9th Floor, Southside, 105 Victoria Street, London SW1E 6QT)

1.0 In attendance: Rachel Donovan (RD) Andy Michaels (AM) Helen Musson (HM) Julie Sands (JS) Ariadne Siotis (AS) Apologies: Kathryn Charles, Karen Clinton, Alison Dalal and Gill Rogers

2.0

3.0

Additional Items not listed on the agenda – It was reported that HM would be moving to cover maternity leave within Londonwide LMCs as Business Resources Manager and AS would be supporting North West London LMCs for a minimum of six months initially. AS was currently supporting SE/SW LMCs and had a lot of experience in PMS reviews. Practice boundaries/GP choice – pilot. Due to time constraints this item was not discussed. Actions from meeting 15 November 2011 – noted. RD would forward the list of practices chosen for PPV QOF visits that were picked out by HM at random for reference and recording purposes. (RD) It was noted that a practice had expressed concern that they had been picked for a QOF review process and the PPV QOF visit. The LMC had been clear that these were different processes. It was unfortunate that a practice would receive two visits but this had been confirmed that this was in the regulations by the Director of GP Support at Londonwide LMCs. Minor Surgery – HM outlined that there appeared to be a difference of interpretation in relation to the minor surgery DES regulations. It was stated that any additions to a DES no matter how small would reconstitute the DES to a LES. HM had sought GPC advice and it was their view that a PCT must offer the DES within the area (although it was recognised that there was discretion in the SFE that it did not have to be offered to all practices). The terms of the DES are nationally agreed and so these must be the terms that are on offer. It is not acceptable for the PCT to create its own LES at the expense of the DES, although there is no reason that they could not offer practices the choice of the DES or a LES. NHS North West London was of the view that the DES was already being offered with only some minor amendments. It was agreed that HM would forward the question that was sent to GPC so that RD could ask the same question of PCC and see their response. It was agreed that this was an urgent issue and that it needed to be resolved before 1 April 2012 as a minimum. (HM/RD) Extended Hours DES claims - A reasonable agreed way forward was still outstanding on where practices were unable to provide extended hours so that they were not unfairly penalised whereby they would lose all their funding for the quarter. It was agreed that NHS North West London would give consideration to what is an acceptable reason for where an extended hours session could not be provided (eg dental contract) and what the threshold would be for what a practice would be paid in relation to the sessions that they may have not provided. This would be shared as a paper via email as soon as possible for comments. (RD)

4.0 5.0 5.1 5.2

Enhanced Services 2012/13 It was noted that the negotiations of the 2012/13 contract had concluded and there was now clarity about what DESs were being offered and the guidance from NHS Employers was awaited to define some of the specifications. It was noted that there continued to be differential and historical rates of pay in different boroughs across North West London for other DESs eg minor surgery/flu etc. It remained NHS North West London’s intention that the DESs and NESs across the cluster should be standardised. It was recognised that it was unlikely that this would be implemented for April 2012 as it would be a big piece of work that required a working group to tease out the different variables of implementation along with appropriate decision making authority. Appropriate representation should be sought for the working group along with LMC representation and would also have to be considered in full and discussed at LMC meetings. It was stated this would not be implemented until a decision had been agreed strategically from NHS NWL and it had been discussed with the LMC. NHS North West London requested support from LMCs that there was a standard payment mechanism to practices for NESs and DESs and their preferred option was that all practices should be paid at the end of each quarter upon submission of the claim form. It was agreed that this would be taken as an item for discussion to all LMCs in February 2012. (HM) It was agreed that the specifications and claim forms for the relevant DESs/NESs would be shared with the LMC at the earliest opportunity for review so that this could be agreed and sent out to practices by mid-March 2012. (RD/HM) JS outlined that LESs were still being commissioned by local borough PCTs for the time being. Framework for Contract Monitoring QOF Review Visits The letters exchanged by Londonwide LMCs and NHS NWL in December 2011 in relation to QOF review visits were received. RD/JS outlined that to address some of the issues in the letter there needed to be specific examples so that these could be addressed. RD noted that the data and interpretation of the data could have been presented in a clearer way. HM queried what training GP Contracts assessors from North West London had to undertake before QOF review visits were arranged. RD stated that all of the contracts team are made aware of the framework and each visit is reviewed in their team meeting. It was also noted that those members of staff that had not undertaken QOF visits before were accompanied by the GP Contracts Manager. AM reiterated that there needed to be consideration of how practices were selected and it was the LMC view that this should be undertaken on a random basis instead of outliers. NHS NWL would be reviewing the process for next year. It was agreed that the process for selection of practices for the QOF 2012/13 visits would be outlined on one side of A4 along with all the documentation to be sent to practices for consideration by the LMC at the interim operational meeting on Thursday 15 March 2012. (RD) Annual Contract Review Visits It was reported that NHS North West London had received the majority of self assessment contractual forms from practices and that any queries had been dealt with along with any necessary timescales for improvement. It was outlined that the two key areas that practices were struggling with most was child protection training and registration policies/process. It was noted that JS had suggested registrations policies and procedures as a once for London project and that a message had recently been sent out in the NWL December 2012 newsletter reiterating the position on patient registration.

NHS NWL expressed concern that some practices had not submitted their self assessment forms despite a number of reminders and they did not wish to issue a breach notice for this. It was noted that the practices that had not undertaken this work could not be shared with the LMC until a breach was issued. It was agreed therefore that a message would be sent to practices reminding them to submit their forms otherwise this may result in a breach notice and to add in information that if they needed any support to contact the LMC office. (HM/RD) HM reminded NHS NWL that Hillingdon practices had already submitted their contract review information to NHS Hillingdon in March 2010 and were therefore not required to resubmit this information. NHS NWL indicated that they would be undertaking a three year rolling programme of annual contract review visits as outlined within the framework. The practices would be selected for a visit on a random basis and this would be chosen by the LMC at an upcoming operational interim meeting. HM queried what evidence would be required by NHS North West London at the practice visit. This would be developed and shared at the meeting with the LMC on Thursday 15 March 2012.

6.0 6.1 6.2

Premises Management of general practice premises issues It was noted that premises contacts for general practice was still outstanding and HM queried where the responsibility for estates would be from April 2012. This was unknown although the integrated FHS service would be responsible for general practice rent reviews from 1 April 2012. Improvement Grants In relation to improvement grants the borough PCTs were still the statutory recipients of the funding and individual borough PCTs had to bit for this funding from the Department of Health and NHS London and was not guaranteed. It was noted that there had been serious concerns about the process that had occurred in the Outer North West London sub cluster particularly regarding communication to practices. It was agreed that the NHS North West London primary care contracting team should work with the sub cluster estates teams and the LMC to agree priorities and strategy for improvement grants. This was particularly in relation to where this investment would be approved for payment to ensure a consistent approach and to discuss further the appropriate protocol and criteria that is suggested that is put in place along with what messages should go out to practices in preparation. It was unknown as to where responsibility for improvement grants and leases would be from 1 April 2012. It was agreed that Sue Hardy and David Cox should be invited to attend the next meeting to discuss the above issues. (RD/JS)

7.0 Communication to Practices HM reiterated concerns that not all practices were receiving communications from the cluster. It was recognised that there had been an issue when sending out the framework however this had been resolved. HM queried that when messages were sent to all practices whether this was sent to all lead GPs as well as practice managers. It was outlined that this may not be the case and it was a priority to ensure that all communications were sent to the senior GP as well as the practice manager.

8.0 8.1

Once for London List maintenance – following the publication of the once for London principles NHS NWL would

8.2

be looking at a process when the integrated service for FHS goes live in April 2012. PMS – following the publication of the once for London principles NHS NWL was looking to undertake a PMS review across all areas in NWL. The governance was currently being discussed and as soon as the proposal was ready it would be shared with the LMC. (JS)

9.0

Practice Vacancies and Procurement It was reported that NHS NWL had received termination notification from two practices in Kensington and Chelsea, one practice in Hillingdon and one practice in Ealing. The LMC office had been notified. The preferred options for the way forward were being discussed at borough level.

10.0

FHS Services JS reported that they were at the recruitment stage following the FHS review and consultation and that it was the aim for the integrated service to be fully operational by 1 April 2012. It was noted that not although this was the aim there may be some delay in timescales. A contact list would be sent to all GP practices but it more realistic that this would be achieved by 1 May 2012.

11.0 Olympics and business continuity for practices

This item was not discussed.

12.0 13.0

Any Other Business There was no other business to discuss. Date of Next Meeting – Tuesday 22 February 11 – 12.30pm, NHS NWL offices

DRAFT

Draft Minutes of the NHS North West London and North West London LMCs Strategic Liaison Meeting held on 8 December 2011 at The Queen’s Club, Palliser Road, W14 9EQ

In attendance LMC Members Dr P Chatlani Dr P O’Reilly Dr A Jenkins NWL Cluster Ms K Clinton Mr D Elkeles Dr M Spencer

Inner North West London Representatives Ms R Carrell Londonwide LMCs Dr T Grewal Ms H Musson Ms R Shaw

1.0 Welcome and apologies

Apologies were received from Nick Relph, Thirza Sawtell, Gill Rogers, Andy Michaels and Dr Helen Clark.

2.0 Declaration of interests Members to declare any conflicts of interest in connection with any items on the agenda or in the light of subsequent debate Dr Grewal declared that he had been appointed the domain expert for London Enterprise Limited Ernst & Young organisational development bid for commissioning groups.

3.0 Additional items Dr Grewal requested that the Minor Surgery DES was discussed under Enhanced Services. Dr Grewal also requested that a 111 Update was provided. Mr Elkeles suggested that the 111 Update is provided at the next meeting because little had changed since the last meeting. Dr Spencer confirmed that the 111 Pilot had been put on hold in Hillingdon and Inner North West London so that the service could be procured.

4.0 Minutes and Matters Arising not listed elsewhere on the agenda 4.1 Confirmation of the minutes from the meeting on 27 October 2011

The minutes of the meeting held on 27 October 2011 were accepted as accurate.

4.2 Matters Arising from 27 October 2011 Item 13.0 – Any Other Business Dr Jenkins queried the following two statements relating to the 111 Service Pilot on page five of the agenda: “Ms Whiting agreed to investigate the LMC concerns about 111:

1) Access to GP appointments and whether a triager for 111 is able to

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book appointments for individual patients 2) The requirement that all practice’s OOH number must be 111”

Dr Spencer confirmed that both of these are part of national guidance and will therefore be required by practices.

5.0 QIPP 5.1 North West London Cluster Finance Report

Mr Elkeles advised that the North West London (NWL) Cluster is the only Cluster in London delivering their financial targets. He advised that within the NWL Cluster, some Boroughs are doing better than others. He outlined that Ealing and Hounslow are in deficit, whereas Harrow and Hillingdon are achieving their target, but are in financial difficulty.

5.2 Delivery Support Unit Update Dr Grewal requested clarification of what pathways are being reviewed in the Ophthalmology Procurement process and queried whether there is a document which outlines the progress of the procurement. Mr Elkeles responded that this procurement was a sub-cluster not a DSU initiative. Mr Elkeles advised that musculo-skeletal specification would be the designated Any Qualified Provider pathways for some of the Borough in the Cluster. Dr Grewal commented that it is important that LMCs are kept updated as they can reassure practices of any changes to services.

5.3 Planned Procedures with a Threshold (PPWT) Dr Spencer advised that PPWT was now to be referred to as “Effective Commissioning” and that the Cluster is currently reviewing how PPWT can become part of pathway development. Mr Elkeles added that PPWT is delivering its financial target.

5.4 Integrated Care Pilot (ICP) Mr Elkeles advised that the Cluster would be extending the ICP by setting up an Integrated Care Pilot for the rest of North West London and increasing the number pathways which are delivered in this way. For example, Cluster will be applying the methodology of a multidisciplinary team to Mental Health services. He added that evaluation of the ICP is currently underway.

6.0 Commissioning Support Ms Carrell advised that Ms Whiting had introduced the North West London Commissioning Support Organisation (CSO) to the LMC Chairs and Londonwide Secretariat at the last meeting. She emphasised that the CSO does not exist at the moment. The organisation is currently being developed by a project team, with Ms Carrell fulfilling the role of Programme Director. She reported that at the moment there are no full-time staff, but they will be looking to make appointments in January 2012 in order for the organisation to take shadow form in March 2012.

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Ms Carrell informed the LMC Chairs and Londonwide Secretariat that the CSO are compiling a policy directory, from which CCGs will be able to choose which elements of commissioning support they would like the NWL CSO to provide them with. She added that CCGs would have a choice where they source their commissioning support from; this could either be done in-house or contracted to private organisations or CSOs. Furthermore, CCGs do not have to choose to source commissioning support from their local CSO. Ms Carrell commented that since commissioning support expertise currently sits within the PCT, it is likely that their commissioning support offering will be competitive and attractive next to other private organisations. Ms Carrell added that the NWL CSO’s competitive selling point will be that it offers all commissioning support services, rather that the private organisations which would specialise in certain aspects of CCG requirements. They also plan to work with the Local Authority to formulate a “One Stop Shop” of services. Therefore, they envisage that their main competitors will be CSOs in other areas of London. Ms Carrell tabled a presentation titled “CSO Development Programme” and talked LMC Chairs through the presentation. One of the key challenges for the NWL CSO was highlighted as being deciding how CCGs can be involved in the governance of the CSO. She requested that meeting attendees refer to page four of the presentation. She outlined that there are three ways of doings this, the CCGs could be shareholder/members, they could be non-executive directors or they could be advisory groups. Dr Grewal commented that there is scope of CCG conflicts of interest for all the options outlined above. The timeline for development of the CSO was outlined, with the prospectus of services being launched in January 2012, the outline business case being completed by April 2012 and the full business case being completed by September 2012. It was advised that page six of the presentation outlined the current products and services which the CSO planned to offer to CCGs. Dr Grewal queried what the envisaged status of the fully formed CSO would be. Ms Carrell responded that the fully formed CSO could be a hosted service, part of the NHS, a community interest company or a social enterprise. She added that this detail would be determined in the outline business case. Dr Jenkins queried whether the CSO was different from the Delivery Support Unit (DSU). Ms Carell responded that both the DSU and the Acute Commissioning Vehicle (ACV) would be part of the CSO in the future. Dr Grewal voiced concern regarding placing the ACV at the centre of the CSO, considering its current performance shortfalls. Ms Carrell advised the CSO team have reviewed the ACV and agree that there are some weaknesses in the organisation and these will be addressed. Dr O’Reilly queried whether CCGs could source all services from the CSO. Ms Carrell responded that they could, but commissioning activity would remain the responsibility of the CCG. Ms Carrell confirmed that the CSO

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would be offering support to the CCGs with needs assessments, costings on contracts, legality of contracts, contract monitoring, HR, resources, pathway design, service redesign, overview and scrutiny. Ms Carrell advised LMC Chairs and Londonwide Secretariat that it is planned that the National Commissioning Board will be a relatively small organisation and will outsource its support for contract management, performance management and management of the performers list from organisations such as the CSOs. The Local Authority will also be able to use CSO services. Dr Grewal requested that if the CSO would be undertaking the responsibility of contract management, then they should draw upon the knowledge of the LMCs when developing this and involve the LMC in the development process. Dr Jenkins requested that the LMC received a copy of the ACV Review for reference. Ms Carrell undertook to provide the LMC with details of the ACV Review.

RC

7.0 Clinical Commissioning Groups 7.1 To receive an update on progress

Dr Spencer reported that CLH and VCC CCGs will merge as discussed at the CCG Lead Workshop on 8 December 2011. He explained that this was a result of the CCGs failing the configuration risk assessment. Mr Elkeles added that the reason these CCGs had failed was because they were too small to be able to finance the management costs and Westminster Council did not support the CCG configuration. Dr O’Reilly advised that there will be a meeting on 13 December 2011 to determine the feasibility of a merger of CLH and VCC.

7.2 Support for CCGs in particular funding stream and payment mechanisms Dr Spencer advised that the PBC funding varied amongst the PCTs. It was noted that some Boroughs in North West London had not made PBC funding available and this was causing some issues.

7.3 2012/13 planning process in particular authorisation process and development of Commissioning Strategy Plans Dr Grewal queried whether any CCGs in North West London are at risk. Mr Elkeles confirmed that all of the CCGs comply with the establishment guidance and the authorisation guidance is due to be published in the near future. The Department of Health will be aiming to authorise CCGs by March 2012. It was noted that the current challenge for CCGs is that the allotted £25 per patient does not cover many of the running and commissioning support costs. Dr Spencer explained that many of the CCGs were now looking into the feasibility of sharing boards and senior staff. Dr O’Reilly queried how much of this £25 per patient was likely to be spent on commissioning support. Dr Spencer responded that this would be around £15 per patient. Dr Jenkins queried whether the issue of patients being discharged from hospitals had been addressed in the commissioning strategic plan. Mr

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Elkeles reported that ACV were deciding with the CCGs which key issues should be of focus. Dr Spencer suggested that the LMC highlight this as an issue with their commissioning group so that they are aware and can consider this for their CSPs. Ms Musson advised that this had been done.

7.4 QIPP Priorities Mr Elkeles outlined the QIPP priorities for North West London as the following (these were noted as in line with the priorities of the DSU):

1. ICP of Outer North West London 2. Productivity of Community Health Services 3. Productivity of Acute Hospital (starting with Pathology) 4. Prescribing

7.5 To discuss any further issues There were no issues raised under this item.

8.0 Primary Care Development 8.1 Enhanced Services

Ms Clinton requested that members refer to page five of the agenda. She apologised that the action relating to the Minor Surgery DES had not yet been completed. She advised that Ms Donovan would be sending clarification of this issue to Ms Musson over the next few days. Ms Musson reported that practices in Hounslow feel that they have forced to sign-up to the LES when they really would like to sign-up to the DES. Dr Jenkins queried whether NWL were offering the DES to practices. Ms Clinton advised that the Cluster were offering a DES to practices, but they had written to practices advising that the local PCT are also able to offer a LES for Minor Surgery. She added that since Minor Surgery is not offered to all practices and there is additional training required, it is subject to different regulations to other LESs. Therefore, if a PCT chooses to offer a LES to manage their Minor Surgery Pathway, then practices are able to choose to sign-up to either the LES or the DES.

8.2 Contract Management Ms Clinton advised that the Cluster would continue to be responsible for Contract Management. Mr Elkeles advised that the CCG guidance around this is vague which leaves room for inconsistency. Dr Grewal commented that contract and performance management needed to remain separate.

8.3 Performers List Ms Clinton advised that the administration of the performers list is the responsibility of FHS. Dr Grewal reported that a letter had been sent to practices in Hillingdon advising them that appraisal data had been lost. Ms Clinton advised that it was probably not the case that the appraisal data had been lost, but that Dr

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Hill had been undertaking a stock take of appraisal data and sought confirmation from practices. Ms Clinton undertook to confirm that the GP Appraisal Data has not been lost. Dr Grewal voiced concern that communication to Sessional GPs was still an issue. Ms Clinton responded that the Cluster endeavour to keep GP data up-to-date. Dr Spencer commented that the Performers List is not able to legally be used to communicate to GPs. Dr Grewal referred to the letter recently written by Dame Barbara Haikin, which states that the performers can and should be used to communicate with GPs. Ms Musson undertook to send the Dame Barbara Haikin letter to Dr Spencer. The Cluster undertook to use the Performers List to communicate to GPs in the future.

KC HM

8.4 Quality Outcomes Framework Ms Clinton advised that QOF Visits were currently underway and would be ongoing over the coming weeks. She added that the practices that would be subject to a visit had now been announced. Therefore, if practices have not heard anything, they will not be having a visit. Dr Jenkins queried whether Cluster would be reviewing the way they select the practices that will be visited. Ms Clinton advised that they would be selecting practices at random next year. Ms Clinton added that this would be a logical approach, since these particular QOF visits are voluntary and are not a performance management or punitive process, but a means of support.

8.5 8.5.1

Premises Dr Jenkins queried the short turnaround to compile business cases when practices are advised that improvements grants are available. Ms Clinton advised that the Cluster often get advised that funding is available at short notice. Dr Grewal advised that Londonwide LMCs has advised practices to have their business case ready in our newsletters. The LMC Office undertook to include a warning to practices that improvement grants are often released at late notice, so therefore practices should have business plans ready in the next newsletter. Transfer of PCT-Owned Premises Dr Grewal commented that he had significant concerns regarding the transfer of PCT-owned premises due to the potential for legal difficulties with some practices lease-hold agreements. He advised that the Cluster identify how many premises in NWL have a signed and current lease-hold agreement. Mr Elkeles responded that this had already been completed by Sue Hardy. Dr Grewal requested that a copy of the review is sent to Londonwide LMCs. The LMC Office undertook to contact Ms Hardy to request a copy of this review. Ms Musson asked what strategic plans the Cluster had for Premises. Dr Spencer advised that work relating to premises plans had been undertaken by Sue Hardy.

RS/SB HM

8.6 Procurement – GP Practice Vacancies and other services

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Ms Clinton reported that two practices were currently subject to procurement, since their GPs are retiring. She added that she had advised these practices to inform the LMC. She voiced concern that one of the practices would be closing completely, which would leave a patient list without a practice. Dr Grewal agreed that this needs to be formally communicated to the local LMC. Ms Clinton informed meeting attendees that the review of FHS had been completed and the analysis would be published today (8 December 2012). She reported that KCW FHS is the first FHS to consistently hit 100% screening returns within two weeks. It was reported that the Cluster are experiencing increasing pressure to register patients from Project London. Ms Clinton undertook to send examples of letters from Project London to the LMC Office for review. Dr Chatlani raised the issue of rejected patient registration from the NHS. Ms Clinton responded that NHS should not be refusing to register patients and undertook to look into this issue.

KC KC

9.0 Merger between North West London Hospitals Trust and Ealing Hospital Mr Elkeles advised that the Trust Boards had approved the merger between North West London Hospitals Trust and Ealing Hospital. He added that GPs would be involved in the management of the community part of the hospital. He added that NHS London has approved the outline business case and the full business case would be submitted by the end of February 2012. Dr Elkeles informed meeting attendees that the merger would not result in a service change, it would just be a merger of the management structure. The preferred option for the merger will be announced in April 2012 and the LMC will be consulted at this stage. Mr Elkeles added that the travel time analysis had been completed for Northwick Park, West Middlesex, Hillingdon and Charing Cross hospitals. Dr Jenkins voiced concern that this change will put pressure on other hospitals in the area. Mr Elkeles responded that there is further work and analysis to be done before a decision is made.

10.0 Once for London – Update from Londonwide LMCs Performance and Outcomes Framework Dr Grewal reported that the Performance and Outcomes Framework had been signed off, which will provide guidance on GP performance management. Ms Clinton added that the Primary Care will be discussed at PLG. Dr Grewal informed meeting attendees that appendix two of the Performance and Outcomes Framework includes the Once for London Performance Management Framework. Ms Clinton suggested that she look into this further outside of the meeting and feedback at the next operational meeting with NWL LMCs. PMS Review

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Ms Clinton reported that North West Cluster were developing a paper outlining their approach to the PMS review, to be sent to their senior management team in early 2012. She added that it was planned that negotiations would take place between January 2012 and March 2012. It was reported that NWL would recommend to practices that the LMC negotiate on their behalf. List Maintenance Dr Jenkins queried whether Hounslow and Ealing would be using Experian to conduct their List Maintenance exercise. Ms Clinton advised that Ealing would be contracting Experian to carry out a List Maintenance exercise with patients registered at a different address. She added that patients with dual registrations would be double-checked by Experian also, but List Maintenance programme for deceased patients would not be rolled out. It was noted that the reason that Experian had been contracted to complete this task, was because the contract had been awarded prior to the Once for London List Maintenance Principles being agreed. Ms Clinton undertook to find out whether Hounslow would also be contracting Experian to conduct a List Maintenance exercise. Dr Grewal queried how Experian would be accessing patient data. Ms Clinton responded that Simon Evans-Evans had signed-off the data-sharing agreement. Dr Spencer voiced concern that Simon Evans-Evans is not a caldicott guardian. Ms Clinton undertook to arrange for a copy of the data-sharing agreement to the LMC for review.

KC KC

11.0 Date of the Next Meeting It was noted that the date of the next Cluster meeting will be the 16 February 2012. The Cluster representatives undertook to reserve a room for this meeting.

MT

12.0 Any other urgent business There were no issues raised under this item.

Draft Cover sheet – 21 Dec 2011

Title

NHS North West London Reconfiguration Programme

Lead [CCG Chair]

Summary

� This paper provides an update to NWL Clinical Commissioning Group (CCG) Boards on the proposed service reconfiguration programme.

� This paper also seeks engagement and an indication of commitment from CCG Boards to support the Programme going forward.

� NHS NWL has established the Programme to lead the design of service change for the Cluster. The enclosed paper is an introduction to the programme and outlines programme objectives, approach and governance and how the programme would like CCGs to be involved. It asks specifically for CCG Boards to make a written commitment to participate in the programme.

Key points:

� One of the key aims of this programme is to create a viable healthcare system for North West London. This builds on the key drivers for change that CCGs have outlined in your Strategic Plans.

� CCGs, as commissioners of the future, will be making ultimate decisions (via the Cluster Board) on the options for future service configuration to promote improved quality of care and to improve sustainability of CCGs and provider organisations in NWL.

� As overseers of implementation it is important that CCGs play an active part of the programme and help shape the proposals developed. CCG Chairs are already actively engaged through various Cluster meetings but ongoing participation in the programme from CCGs is important to help ensure any proposals developed are robust and sustainable.

� The Programme SRO (Anne Rainsberry, NHS NWL CEO) has affirmed the need for our involvement in the Programme Board and in the supporting workstreams to ensure that the proposals developed are robust & sustainable.

� As a result, this paper is the request from the Programme asking CCG Boards to confirm their willingness to formally participate.

Implications

Service

� Options for future service configuration are being developed which may impact upon the services or sites within the areas covered by CCGs. It is important that CCGs are involved in, and inform, this process to ensure the programme understands the impact of proposals on the future of health provision and that underlying assumptions are accurate.

� Any service changes that are agreed are likely to require implementation activity, which will need to be overseen by CCGs. The programme wants to work with us from the outset to understand the implementation implications of any proposals.

Other

� This will require significant input from a number of senior leaders (e.g. attending workshops, collating CCG specific data, developing implementation plans). We are asked to make a commitment in writing to offer the necessary support to the programme

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Insert name and Date of Committee (e.g. Directors Meeting December 2011)

Recommendation

� That the Board agree to provide commitment and authorised Chair to complete Appendix B

� That the CCG Chair sits on Programme Board and report back regularly to CCG Board, ensuring that any organisational concerns are raised with the programme and a way forward agreed

� That the CCG Chair nominates leads to support workstream delivery and that these leads report back to CCG leadership team on this involvement to ensure CCG contribution is joined up and that the Chair is sighted on working assumptions.

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NHS North West London Reconfiguration Programme

A briefing for Boards of North West London Clinical Commissioning Groups (CCGs)

Purpose of this paper

1. NHS North West London (NWL) has begun a programme to look at possible proposals

for service change and seeks commitment from local Clinical Commissioning Groups (CCGs), as well as other key stakeholders such as providers, to engage in the programme.

2. This paper sets out details of the programme, including:

• The background to the programme

• The case for service change

• An overview of the programme; including its objectives

• The programme’s approach to delivery

• Programme governance arrangements

• The CCG role in relation to preparing for implementation

• The CCG role in relation to the Programme Board

• The CCG role in relation to programme work streams (Clinical, Out of Hospital, Finance & Business Planning and Communications & Engagement)

• Our request for CCG participation in the programme

3. This programme will be vital both to secure sustainable, high quality services for patients in NWL and to support commissioners and providers in NWL in achieving financial sustainability. However, we understand that it will represent a significant time commitment over an extended period from a range of staff. We are therefore seeking formal agreement to participate in the Programme from CCG Boards.

4. A form is attached in Appendix B for CCG Boards to complete, confirming their willingness to participate in the Programme.

Background to the Programme

5. In its 2010 strategy, NHS North West London set out its overall vision – to localise care close to patients’ homes, to centralise specialist care and to integrate care for people with long term conditions and the elderly. This set out how the activity flows between providers would change to reflect this shift from acute to out-of-hospital settings. It did not explicitly say what the service configuration would look like for each provider but instead asked providers to begin this thinking, based upon likely changes in activity flows.

6. Whilst our existing four year plans described how the financial flows between providers would change to reflect shifts in care from acute to out of hospital settings, the plans did not explicitly say what service changes would be required and how this would impact on

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each provider. Instead, NHS NWL asked providers to take this strategic direction and describe for themselves the implications for the provider landscape. Whilst good progress had been made, NWL commissioners now need to take a role leading these service changes to ensure we deliver the quality improvements that are needed over the next three years.

The case for service change

7. Both commissioners and providers in NWL believe that services in NWL will need to change to deliver better quality care more effectively. There are four major reasons underpinning the need to change services; each of which draw upon our case for change, the three overarching principles which underpin our models of care and our quality standards:

• The need to ensure care is delivered in the most appropriate setting – a high volume of patients use acute services who could be treated closer to home by primary care or community care. We need to improve the quality of care in all care settings (as we have set out in our quality standards) and reduce acute care provision.

• The need to make better use of the clinical workforce - a key element of the quality standards is better workforce provision. Research demonstrates that consultant-delivered services achieve better clinical outcomes. Consolidating some services onto fewer sites would enable the consolidation of the associated workforce; improving the service available to patients and, in particular, supporting a move towards 24/7 consultant presence in key specialties (e.g. in A&E, obstetrics ward)

• The need to centralise some services – there is increasing evidence that units with larger volumes of activity achieve better clinical outcomes; greater clinical specialisation leads to better outcomes; Separation of planned and urgent surgery leads to better outcomes and that some new treatments/diagnostics that improve clinical outcomes are only affordable and safe if delivered in sufficient volume.

• Need to make effective use of resources and achieve financial sustainability for commissioner and provider organisations in NWL - budget forecasts suggest that the current configuration of services is unsustainable. Services are fragmented across community and acute sectors and need to be better integrated. Consolidation of some acute services onto fewer sites would enable more efficient use of resources.

8. To be successful, this will need to be complemented by a clear strategy for improvements in out-of-hospital provision (primary care, community care and mental health care).

Programme Overview

9. On 9th November 2011, the NWL Cluster Board approved the establishment of the Reconfiguration Programme. The Programme will be Cluster-wide, commissioner-led and will cover both the acute and out-of-hospital sectors.

10. The Programme will be led by a Senior Responsible Officer (SRO), Anne Rainsberry (NHS NWL Chief Executive). A Medical Director, Mark Spencer (TITLE) and a Programme Director, Daniel Elkeles (NHS NWL Director of Strategy) will also be in place to steer the programme.

11. The overarching objective of the programme is to bring together local commissioners, providers, patients and other local stakeholders to identify, test and refine the optimal


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future configuration of healthcare services across NWL and to transition to implementation of this solution.

12. The Programme will be considered complete and can be closed down when:

• The Cluster Board has approved a final proposal for service change

• It has been identified who will lead implementation of the service change

• Hand-over to the implementation phase is confirmed, including development of provider implementation plans and establishment of provider governance structures to own and drive forward these implementation plans. It is expected that the implementation of service change will take place after the transition to the new commissioning arrangements and that it will therefore need to be overseen by CCGs.

Programme Approach

13. The Programme’s approach will be underpinned by the four tests for service changes set out by the Secretary of State. It is therefore based upon the following principles:

• Clinically led and supported by CCGs – engaging local clinicians from all core settings at each stage of development

• Informed by engagement with the public, patients and local authorities – actively engage with local stakeholders at each stage of development

• Robust and transparent process underpinned by a sound clinical evidence base

• Consistency with current and prospective patient choice – working with local clinicians, PPAG and OSCs to consider how proposals affect patient choice

14. The proposed programme timeline is currently as follows:

Programme Governance

15. The Programme’s governance is designed to ensure all providers and current and future commissioners contribute to identifying the best solutions for NWL patients as a whole.

16. Ultimate decisions will be made by CCGs (with CCG chairs), as commissioners of the future, via the Cluster Board.

17. During the lifetime of the programme, commissioning responsibilities will transition to CCGs. Whilst the Cluster Board/JCPCT will need to retain decision making responsibilities for reconfiguration, the programme has been designed to involve CCGs from the outset to ensure they are bought in and continue to consider it a commissioning priority. This is of particular importance as the commissioning responsibilities transfer from PCTs to CCGs in April 2013 and it is not anticipated that implementation will be completed by that stage.

Key principles underpinning Programme governance arrangements:

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• Ultimate decisions will be made by commissioners (with CCG chairs, as commissioners of the future)

• This decision can only be taken by a legal entity. This is usually a Joint Committee of Primary Care Trusts (JCPCT). It has been confirmed that in NWL delegated authority has been given by the JCPCT to the Cluster Board.

• During the lifetime of the programme commissioning responsibilities will transition to CCGs.

o From October 2012, CCGs can be authorised. This will enable them to take on delegated responsibilities from PCTs but they will not be a legal entity. Therefore the Cluster Board will need to retain decision making responsibility for reconfiguration.

o However, based upon the Secretary of State’s “four tests” and the NHS London Reconfiguration Guidance, the programme should plan to ensure that CCGs have provided written evidence of their support for the consultation before it is launched.

o From April 2013 commissioning responsibilities will transfer from PCTs to CCGs. Although this is expected to take place after formal decision-making, implementation will not be complete at this stage.

o The programme governance has therefore been designed to involve CCGs from the outset to ensure they are bought in and continue to consider it a commissioning priority.

18. The Programme Board is the key mechanism for leaders of provider and commissioning organisations to influence programme recommendations. CCG Chairs represent their organisation on the Programme Board.

19. The Clinical Board is the key mechanism to bring together local clinical leaders to develop service standards and models for high quality care, develop service configuration options and make clinical recommendations to the programme. CCGs have been asked to nominate clinical leaders to contribute to the Clinical Board, both as representatives of their organisation and as senior local clinicians.

20. Working groups will bring together relevant staff from CCGs and providers to take forward delivery of the programme. CCGs will have the opportunity to be involved in all working groups, although their involvement will be key in the Out-of-Hospital Working Group.

21. The governance arrangements are summarised in the diagram below:

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The role of CCGs in overseeing the implementation of service change

22. One of the key aims of this programme is to create a viable, sustainable and safe healthcare system for NWL. It is therefore expected that, following proposed public consultation and subsequent identification of the preferred solution for future configuration, providers will need to take the lead on the actual implementation of many service changes, particularly in acute care.

23. It is anticipated that CCGs, as commissioners of the future, will oversee implementation, building proposals into the relevant contracts and performance targets. We will therefore need the support of CCGs in developing an early implementation plan for inclusion in the Pre-consultation Business Case.

24. Following consultation, we will expect to undertake further implementation planning to help CCGs identify how they will oversee implementation of the changes, so that change can begin as soon as possible following decision-making.

The role of CCGs on the Programme Board

25. Full Terms of Reference for the Programme Board are provided at Appendix A. CCG Chairs have been invited to be members of the Programme Board. Programme Board Members are expected to:

• act as ambassadors for the Programme

• engage their organisations in the development of the Programme, providing views on behalf of their organisation, and feeding back to their Board and staff

• act in the best interests of local patients and the NHS in NWL as a whole




Page 6 of 12

• act as a representative of their organisation

• provide information to the Programme Board, and working groups, to support the undertaking of accurate analysis and well informed decision-making

26. The Programme Board will make recommendations to the Cluster Board (the decision making body). Whilst we will strive to achieve consensus at each step of the programme, where consensus cannot be reached, views which are divergent from the majority view will be recorded and presented with the report/advice to the NWL Cluster Board.

27. We are aware that we are asking CCGs and their representatives to commit a significant amount of time to the programme. We have timed Programme Board meetings to be held alongside CEC meetings to minimise duplication of information and reduce the impact on individuals’ workloads.

The role of CCGs in relation to Programme work-streams

28. Clinical: The Clinical workstream will provide clinical leadership to the programme, ensuring the programme develops robust clinical proposals and making clinical recommendations to the Programme Board. CCGs are asked to nominate a representative to provide clinical input to this group and to support workstream activities if needed.

29. Out of Hospital care: The Out of Hospital care working group will ensure the Programme develops a robust vision and strategy for out-of-hospital care, based upon sound modelling and assumptions. CCGs will give appropriate clinical and executive leadership input, at both the Borough and Cluster level, as required (through both Working Group governance and ad-hoc workshops). CCGs are asked to nominate a representative to provide input to the Out of Hospital care working group.

30. Finance & Business Planning: The Finance & Business Planning group will provide expert financial, capital, estates, productivity and workforce input to the programme, to develop a financial model to capture baseline activity and financials for all acute providers across NW London, and project forward activity and financials under status quo and a range of configuration options. CCGs will not be required to provide nominees for this group as NHS NWL staff will provide commissioning input to this group.

31. Communication & Engagement: The Programme, supported by the Communications & Engagement (C&E) workstream, will need to undertake extensive communications and engagement activity with a wide range of local stakeholders. In particular, as part of the Out of Hospital work-stream, proactive and regular borough-level engagement with CCGs will take place as local Out of Hospital strategies are developed. CCGs will not be required to provide nominees for this group as NHS NWL staff will provide commissioning input to this group.

32. The Programme has also written to the Local Authority Health Overview and Scrutiny Committees in NWL, encouraging them to form a Joint Overview and Scrutiny Committee (JOSC) to scrutinise the programme. .

33. Local clinicians participating in the programme may also be asked to engage with the media or stakeholders directly on behalf of the programme.



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Our request for participation from CCGs

34. CCGs need to actively participate in the programme to help ensure any proposals developed are robust and sustainable. As overseers of implementation it is important that CCGs play an active part of the programme and help shape the proposals developed.

35. This programme will be vital both to secure sustainable, high quality services for patients in NWL and to support providers and commissioners in NWL in achieving financial sustainability. However, we understand that it will represent a significant time commitment over an extended period from a range of CCG staff. We are therefore seeking formal agreement to participate in the Programme from CCG Boards.

36. In return for the commitment of your staff to supporting our programme, we will commit that:

• Where a CCG’s board raises concerns about the recommendations or progress of the Programme, the Programme Director shall support the CCG Chair in engaging their organisation in addressing the concerns.

• Where consensus cannot be reached, views which are divergent from the majority view will be recorded and presented with the report/advice to the NWL Cluster Board.

37. Formal confirmation of agreement to participate - by completing and returning the form at Appendix B – is sought as soon as possible and no later than end January.




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APPENDIX A:

NHS NWL Reconfiguration Programme Board - Terms of

Reference

Purpose of the Programme Board

• The Programme Board is an advisory body to the JCPCT/ Cluster Board which will decide on the option(s) for future configuration of services upon which to consult and commission.

• The Programme Board will ensure that the best possible options are developed in a robust, open and transparent manner and that Programme Board members are given the opportunity to influence each stage in the development, shortlisting and refinement of options to secure the best solution for patients in NWL – and the NHS – as a whole.

• The Programme Board is constituted to bring together local commissioners and local providers to inform and influence the development of the programme. It is not responsible for commissioners’ or providers’ decision making.

• The Programme Board will made recommendations to the NWL JCPCT/ Cluster Board and in particular advise it on:

– Delivery of the programme in line with the scope, aims and timescales set out by Cluster Board

– Development of programme deliverables and progress against agreed timescales, in particular the management of cross-organisational issues, risks and dependencies

Responsibilities

• In order to achieve its purpose, the Programme Board has responsibilities to: – Oversee development of programme deliverables and approve these as

ready to go forward to the JCPCT/ Cluster Board for approval. This should include:

• Case for service change in NWL • Process for options development and appraisal • The Pre-Consultation Business Case • Option(s) for change for public consultation and consultation material • Report on consultation findings and the programme’s proposed

response; and • Decision Making Business Case setting out final recommendations for

the future configuration of services in NWL – Assure itself of the continuing validity of the Vision, the Programme benefits,

and the Programme plans to deliver this Vision and these benefits – Ensure appropriate links are made with other strategic programmes and

groups within NHS NWL, in particular the Ealing/NWLH merger programme team and the Imperial/W Middx strategy project team

– Ensure appropriate links are made with other strategic programmes and organisations outside NHS NWL, including NHS SWL, NHS NCL, NHS London, London Health Programmes

Constitution, Decision-making and Behaviours







Page 9 of 12

• The NWL Reconfiguration Programme Board is established by the NWL Cluster Board and has no powers other than those included in its terms of reference.

• The Programme Board will seek to reach consensus in deciding its recommendations. Where consensus cannot be reached, views which are divergent from the majority view will be recorded and presented with the report/advice to the NWL Cluster Board.

• Members are expected to act as ambassadors for the Programme and engage their organisations in the development of the Programme. Programme Board members are expected and to act in the best interests of local patients and the NHS in North West London as a whole.

• Each Programme Board member is expected to act as a representative of their organisation. Where an organisation’s board raises concerns about the recommendations or progress of the Programme, the Programme Director shall support the member in engaging their organisation in addressing the concerns.

• Due to the large size of the Programme Board, the Programme Chair/SRO or Programme Director will engage members in agreeing innovative methods to ensure that all parties are able to express their views.

• Members are expected to provide information to the Programme Board, and its groups, to support the undertaking of accurate analysis and well informed decision-making.

• The Programme Board will be advised by • NWL local health Overview and Scrutiny Committees (OScs) and/or a Joint

Overview & Scrutiny Committee (JOSC) • The NWL Patient and Public Advisory Group (PPAG) • NWL shadow Health & Wellbeing Boards

• The Clinical Board will act as the single route for making clinical recommendations to the Programme Board

• The Programme Board shall be dissolved when the Cluster Board confirms that the service configuration option has been decided, and any formal reviews or challenges of that decision have been completed or at any other time when a significant change to either the programme or existing governance arrangements makes it necessary.

Authority

• The Programme Board is authorised: to instigate any activity within its terms of reference and to seek information as necessary; to obtain outside legal or other independent professional advice; to secure the attendance of such persons, including outsiders with relevant experience and expertise, as it considers necessary.

Chair and Senior Responsible Owner

• The NHS NWL Cluster Chief Executive shall be the Programme Board Chair and the Senior Responsible Owner for the Programme.

• If the Chair is unable to attend a meeting, the Programme Director will deputise.

Quorum

• Where the Chair has determined – and has given two weeks’ notice to Programme Board members – that a key decision will be made, then the quorum shall include members (or their proxies) of all organisations that the Chair determines should be present unless that organisation has instead chosen to make a written submission.

• For other meetings, the Programme Board will be quorate when at least two weeks’ notice has been given of the meeting and the Chair (or a Proxy), two clinicians and three other members (or their proxies) are present.









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Membership • The membership of the Programme Board shall be:

– Chair and Senior Responsible Owner: NHS NWL CEO – Programme Medical Director(s) – CEOs of the provider trusts located in NWL:

• North West London Hospitals NHS Trust • Ealing Hospital NHS Trust and ICO • Hillingdon Hospitals NHS Foundation Trust • West Middlesex University Hospital NHS Trust • Imperial College Healthcare NHS Trust • Chelsea & Westminster Hospital NHS Foundation Trust • Royal Marsden NHS Foundation Trust • Royal Brompton & Harefield NHS Foundation Trust • Royal National Orthopaedic Hospital NHS Trust • Central and North West London NHS Foundation Trust • West London Mental Health NHS Trust • Hounslow & Richmond Community Healthcare • Central London Community Healthcare NHS Trust • London Ambulance Service NHS Trust

– Chair of each Clinical Commissioning Group in NWL: • Central London Healthcare • Westminster Commissioning Consortium • West London Commissioning Consortium • Hammersmith & Fulham CCG • Ealing CCG • Hillingdon CCG • Brent GP Federation • Harrow CCG • Hounslow CCG

– NHS NWL Directors – NHS NWL sub-cluster CEOs – PPAG representative

• In addition, the following shall be invited to attend:

– NHS London – South West London PCT Cluster – North Central London PCT Cluster

• The Programme Director and Programme Manager shall also attend Programme Board meetings.

Programme Board Support

• Support and advice to the Programme Board will be provided by the Programme Director and by the Programme Manager as Board Secretary. This support shall include:

– Agreement of the agenda with the Programme Board Chair – The proper and timely preparation and circulation of papers – Keeping a proper record of the meetings and all decisions and actions to be

taken forward – Advising the Programme Board and its Chair on matters of process and

procedure












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Meetings • The Programme Board will meet monthly, and more frequently if required to consider

matters in a timely manner, e.g. to approve key deliverables. Reporting

• A report of the work of the Programme Board and progress of the Programme shall be submitted to each meeting of the NHS North West London JCPCT/ Cluster Board.

Review

• The Programme Board shall keep its membership and responsibilities under review in the light of the development of the Programme, and make any recommendations to the NHS North West London JCPCT/ Cluster Board on changes to its membership or responsibilities.




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APPENDIX B: NWL Reconfiguration Programme - Clinical

Commissioning Group Board Participation Form

It is essential that NWL CCGs actively participate in the NHS NWL Service Reconfiguration Programme from the outset. Your participation is key to ensuring that this programme delivers on its overall objective, which is “To identify, test and refine optimal service configuration to achieve better clinical outcomes and financial sustainability.”

This programme will be vital to secure sustainable, high quality services for patients in NWL and to support commissioners and providers in achieving financial sustainability. However, we understand that it will represent a significant time commitment over an extended period from CCG staff. We are therefore seeking formal agreement to participate in the Programme from CCG Boards.

We would be grateful if you could you indicate your commitment to participating by completing the below:

<CCG Board name > hereby agrees to fully participate in the NHS NWL Service Reconfiguration Programme, to abide by the terms of reference of the Programme Board and to provide the necessary input and support in the delivery of its objectives.

Name:< CCG Chair name> Signature:_____________ ________________ Date:________________

Please return signed forms to [email protected]

‘Once for London’

Pan-London Operating Principles for Primary Care

PMS Contract Review

Once for London

The Once for London Project

• The NHS Commissioning Board will have a direct role in the commissioning of primary care services including medical,

dental, pharmacy and optometry.

• London’s Primary Care Professional Leadership Group (PLG) are developing unified operating models for the commissioning

of primary care services to:

– Support continuing improvement in the quality and productivity of primary care services as part of QIPP

– Ensure fairness, equity and transparency in the way general practice services are being commissioned across London

– Embed best practice approaches across all commissioning organizations

• The output of this work will be a suite of operating principles that can be consistently applied to improve the way we

commission key primary care services. Initially this work programme will focus upon:

– For general practice - List Maintenance, Enhanced Services and PMS Reviews

– For dentistry - End of Year Process, Performance Approach and Contract Changes

• The expectation is that this programme of work will synchronise with transition towards a single operating model for

primary care commissioning nationally. It may therefore extend to looking at all aspects of primary care commissioning and

other contractor groups within London both implementing national operating models and influencing the shape of these by

sharing local operating principles.

Developing the Operating Principles

• A set of task and finish groups have been established to ensure that there is wide collaboration from across London.

• Approximately 70 primary care leaders have participated in this work to date with representatives from clusters, contractors,

LMC, LDC, FHS organisations, clinicians, practice managers, public health, finance and contracting.

• These task and finish groups have provided a forum through which primary care leaders have shared experiences, skills and

knowledge to develop a unified approach to a basket of key QIPP challenges.

2

Summary

• In 2006 the Secretary of State for Health requested that all PCT’s undertake to review PMS contracts to establish value for money and to improve access to services.

• There are clear benefits that flow from renegotiating and updating PMS contracts across London to reflect the changing primary care agenda, ensure value for money, consistent quality and better reflect national and local priorities.

• Many PMS contracts no longer effectively incentivise high quality primary care services and do not contain incentives or provide funding support which will facilitate a reduction in the use of hospital services and deliver more services closer to home in a primary care/community setting.

• In many cases PMS contracts have been superseded by the development of QuOF and enhanced services and as a result there is sometimes little difference between the services provided by PMS and GMS practices

• In 2007/8 an analysis of GP earnings and expenses suggested that the cost paid per patient under PMS agreements was on average 13% higher than the average under the GMS contract

• PMS contracts do not always offer value for money and PMS practices usually (but not always) receive higher payments per capita than GMS practices which creates a perceived inequity in PMS contracts.

• In the case of many PMS contracts the original objectives and allocated growth funds have not been reviewed and there is significant variation in their per capita payments

• This paper sets out an approach to review the above issues and realign the PMS contracts to address the needs of the local population in a cost effective manner.

Background

• Personal Medical Services (PMS) Pilots were first introduced in 1998. The current PMS Contracts have been in place since 2004 and are locally determined contracts with specific objectives that should link to local and national targets.

• The contract was an opportunity to develop more flexible and locally responsive services.

• PMS practices were awarded growth monies attached to the delivery of additional capacity and or locally negotiated services to improve access, encourage the take up of screening programmes, increase the level of childhood immunizations, and improve the management of long-term chronic conditions.

• All PMS practices were expected to have an open list and received additional funding for a planned increase in list size or to attract GPs to the practice in locality areas where GP recruitment was difficult.

• This approach brought a wide range of benefits, being used to develop new services for specific populations, to attract doctors and nurses and to improve services for patients.

3

4

Key Principles

This paper aims to establish a set of pan London principles which provide an operating framework within which commissioners across London

reviewing PMS contracts will operate . The aim is to negotiate equitable PMS contracts which incentivise and reward outcomes which align with

local and national priorities and which meet the needs of the community they serve in line with a set of agreed principles.

A summary of the key principles is as follows:

Process

•The negotiation process, roles, formal processes and representation should be defined and agreed at the start of the process and clearly

communicated to all stakeholders

•LLMC should provide advice and support; local LMCs should lead on negotiations and represent local PMS Practices as mandated by

individual practices and the resulting contract should be offered to all PMS practices

•PMS contract review should be applied to all PMS Practices

•There should be extensive engagement with practices and consultation with LMCs on the renegotiation of PMS contracts and the process,

timeframe and reasons for PMS review should be clearly articulated at the outset

•The commissioner should take all possible measures to reach agreement on PMS contract reviews through timely, well communicated

meaningful and open engagement. Termination should not be part of the negotiation process and where possible all PMS practices should

transfer to the new arrangements. PMS practices should be made aware of their option to return to GMS contracts.

Outcomes

•To provide a consistent framework for PMS contracting

•Funding and pricing should reflect and reward work carried out and represent value for money

•That PMS practices agree and sign up to changes on an individual practice basis

Financial

•Agree an equitable basis for core and enhanced funding, based on services carried out and quality achieved

•Rebasing and funding comparisons and modelling should reflect appropriate, accurate and relevant financial models and assumptions

•Any released savings should be directed into borough Commissioning Strategy Plan (CSP) priorities

5

Managing the change

That the impact of change will receive facilitation and support from the LMC and the PCT in recognising that practices have a varied

start point in capability.

Commissioners should ensure that the pace of change allows a move to the new arrangements with a minimum of disruption to

practices and patients

Performance Management

Performance management arrangements should be

• Specific, measurable, achievable, relevant, time bound.

• Evidence-based

• Not duplicate other schemes such as QOF

• Not be onerous on data collection

• Minimise KPIs

• KPIs should reflect outcomes, processes, or be hybrid.

6

Where are we now? What are we trying to achieve?

There are a number of shortcomings with many current PMS

contracts which include:

•Many PMS contracts have not been subject to regular

systematic review by commissioners and have not been

reviewed or amended since their inception.

•Many contracts have objectives which no longer align with

cluster/CCG objectives or reflect their current priorities.

•The introductions of both Quality and Outcome Framework

(QOF) and Enhanced Services (ES) have superseded some of

the original objectives of PMS contracts (although this has

been offset to an extent by the PMS quality points offset)

•There is potential for practices to be double funded for their

activity under their PMS contract as well as attracting payment

through QuOF.

•There is significant variation in the range, quality and type

of services providedunder PMS contracts and the payments

which they generate.

•There are often significant disparities in the payments per

capita between practices (both PMS and GMS) with little

correlation between the value of the contract and the

performance outcomes which the practice achieves or the

services they are providing.

•In many cases list sizes have not increased in line with

growth projections and commissioners may be funding

patient lists which are significantly less than the contract

allows for.

•A set of pan London principles which provide an operating framework within which

commissioners across London reviewing PMS contracts will operate

•Contracts which maximize the capability and capacity of primary care to support a

shift of services out of hospital and deliver extended services as part of an

integrated care pathway.

•Contracts which incentivise and reward outcomes which align with local and

national priorities and which meet the needs of the community they serve.

•A set of contracts which provides value for public money where greater

investment yields measurably better outcomes and range of services

•A set of broadly equitable PMS contracts which establish a basket of locally

relevant high quality services that patients can expect to receive as a minimum

level of service

•Contracts which support and provide for flexible locally agreed extra service

provisionover and above the basket of services where they offer value for money

and strategic fit.

•Contracts which support the implementation of health care priorities both

national and those identified in local JSNAs and Public Health reports

•A set of KPIs, linked to funding, which are simple to measure, achievable and a

structure for future monitoring arrangements

•An established mechanism for adjusting payment to quarterly changes in the

normalised weighted list population

•Consultation with individual contract holders and a range of stakeholders

including LMC and borough/cluster commissioners as appropriate, bearing in mind

CCGs as their roles and responsibilities are defined.

What are we trying to achieve?

How will we achieve it?

7

Action Summary

Commissioner

carries out an

audit of the

current PMS

landscape.

A first step will be to confirm that current PMS contracts comply with statutory regulations , that they are up to date and in the same

format across all PMS contracts within the health community. Commissioners should complete a comprehensive structured practice by

practice audit of what PMS is currently being delivered over and above GMS and the current levels of per capita funding for each

practice.

This will include:

•An in depth financial review of each practice to establish the range of per capita payments (using the definitions of what to include in the

diagram overleaf). The assessment will also report on the services the practice provides and the outcomes it produces.

•A focus on local health needs outlined public health intelligence in the borough JSNA

•Comparative data on quality outcomes and value for money across different contracts (GMS and PMS).

•Care that comparisons between per capita payments are made on a like for like basis and Clusters should use the Carr-Hill normalised

weighted list (which is used to determine GMS Global Sum Payments) for the denominator in the calculation.

•An audit of additional payments and existing incentive schemes and where there are LIS’s in existence an alternative LES should be

considered to ensure there is a proper contractual mechanism in place.

Financial

modelling

Establishing a robust per capita funding analysis is a crucial part of the process. As part of their financial modelling commissioners should

ensure that:

•Comparative per capita payments are calculated without additional funds such as premises, QuOF and seniority payments (see

diagram on page 6 and appendix 2 for an example of a GMS funding per capita equivalent calculation)

•Determine their commissioning intentions and determine a financial envelope to deliver these intentions which is affordable to the PCT

- delivered through a basket of services over and above the core services

•PMS per capita payments should demonstrate value for money in delivering effective services over and above what an average GMS

practice provides. The commissioner should ensure that the services and standards attached to the additional investment in PMS over

and above GMS delivers measureable cost effective quality outcomes.

•Costing should be calculated for each of services in the basket separately. Once clusters build their basket to reflect local needs , CSP

priorities and financial constraints they can set a per capita value can be set against the services , setting aside a sum for stretch target

payments.

•PMS practices are provided with financial support to manage the transition to the new arrangements within a 12 month period

•Deducted QOF points are noted if they are incorporated into the per capita funding analysis, Out of Hours payments are noted as

included in the per capita funding

• There is a clear process for quarterly list size changes

• Scope of annual reviews is clearly stated

This model provides a

diagrammatic

representation of GMS

and PMS contracts and

the payments made for

the same and different

work that they

undertake.

The basket of PMS

services correlates to the

£s per patient over

Global Sum that all PMS

practices receive for

providing those services.

GMS practices should be

given the option to

provide the PMS basket

of services as individually

priced LES.

Enhanced Services over

and above the basket of

PMS services are offered

to both PMS and GMS

practices

Where PMS practices opt

to provide them they

become part of the PMS

contract

Option for GMS

practices to

provide the PMS

basket of services

as individually

costed/priced LES

Locally agreed

additions to

reflect the

community

need

Essential and

Additional

Services

QOF

Seniority

Premises

Payments

Premises

Payments

Seniority

QOF

GMS PMS

Enhanced Services provided over and

above the basket of services by

practices wishing to provided these

extended services

Essential and

Additional

Services

Variable

practice

income.

Outside scope

of review.

New PMS fixed

practice

income.

Subject to

PMS review.

£

Dependent on actual QOF performance

Dependent on District Valuer’s valuation and actual cost of rates

Essential and additional services as defined in the national contract

regulations.

Includes Out of Hours income unless a

practice has opted out of its providing it

Proposed Pricing Model

PM

S C

on

tra

ctu

al R

eq

uir

em

en

t

Basket of services over which all PMS

practices are expected to deliver. These will

include KPIs and clear rules for

incentives/penalties as a result of

performance against them.

Enhanced services over and above the

basket are offered to all practices (GMS

and PMS) and are agreed with individual

practices .

PPA Payments PPA Payments

Personal, based on length of service

Ad hoc pay e.g.

locums for

sickness,

maternity etc

Ad hoc pay e.g.

locums for

sickness,

maternity etc

Dependent on prescribing activity

Variable from practice to practice and year to year in both GMS and PMS

pracitces

GM

S C

on

tra

ctu

al

Re

qu

ire

me

nt

Fixed

GMS

per

capita

Income

£

9

Action Summary

Establishing

effective

collaboration

There should be extensive engagement with practices and consultation with LMCs on the renegotiation of PMS contracts and the

process, timeframe and reasons for PMS review should be clearly articulated at the outset.

Negotiating a basket of services with the local PMS GP community avoids duplication as broadly one contract is being negotiated

across a group of practices and also provides the opportunity for greater discussion and peer involvement in the negotiation and

agreement process.

The reasons and scope of the PMS renegotiation should be communicated clearly to contractors and their representatives and a

time line established for the renegotiated contracts to go live. Clusters should therefore :

• Clearly set out their plans to renegotiate PMS contracts in line with a set of common principles. Put in place governance

structures in consultation with the LMC and provide opportunities for regular input to the process that reflects the level of

stakeholder collaboration required.

•Should be clear about the reasons for the renegotiation setting out the potential benefits to patients, commissioners and providers

• Establish a clear timeline for renegotiation and the mechanisms for engagement in the process (meeting schedules, participants,

groupings of practices and so on)

•Transitional management planning should take into account the degree to which practices are changing services, contract value

changes and infrastructure requirements and ensure that the pace of change allows a move to the new arrangements with a

minimum of disruption

Governance

Arrangements

•Existing PCTs and their successor body for primary care contracting (planned to be NCB post April 2013) should ensure that there is

Board Level support and accountability through robust and transparent governance arrangements

•The plans for local PMS contract review should be ratified and approved at board level

•A sub-committee of the board should be established to design, steer and deliver the agenda with director level representation and

ownership

•Renegotiation of the contracts will require significant PMS contract expertise, performance data analysis and project management

resources. PCTs should ensure they have a project team in place to deliver from the outset with the capacity and skills to

implement the changes within the time frame they decide on. The project group should be responsible to the PMS Review sub-

committee.

•There should be a clear appeals and local resolution procedure.

10

Action Summary

Establish a

basket of

services

PCTs should:

•Negotiate with their PMS practices to agree a basket of services which their practices should provide and the standards to which they

should be provided. These services/ standards should demonstrate value for money where practices are receiving payments in in

excess of Global Sum / Average GMS payments.

•A percentage of payments should be set aside for stretch target outcomes.

•Agree the basket as far as possible with all their PMS contractors in the borough

•The basket should be reviewed annually and should reflect local and national priorities

•The review should link to the annual Commissioning Intentions process

What might

a basket of

services

look like?

The basket of services is for local determination but in order to achieve a more uniform PMS service provision across London

commissioners may wish to include some of the baskets of services already adopted across London.

For examples of baskets of services commissioned across London see http://www.pathfinders.london.nhs.uk/wider-health-system-

information/

Commissioners should negotiate a per capita payment that reflects individual borough level negotiations and the results in a single

sum payment. Ensuring a clear and simple approach is taken by both the management and calculation of the contract value and

payment due.

Stretch

targets

•Commissioners should attach KPIs to the basket of services which are measurable, challenging and outcome focussed. Where services

are similar to elsewhere in London similar RAG rating and thresholds should be benchmarked as far as possible.

•Commissioners should negotiate a percentage of the payment to be dependent on the contractor being able to demonstrate

compliance with the KPIs/stretch targets

•The capitation payment negotiated for the basket of services should be subject to performance outcomes. The percentage of

payments for performance is for local determination but should be sufficiently high to reward excellence , drive gold standard

performance.

11

Action Summary

Implementation Subject to the overall cost to commissioners being cost neutral;

•Where a practice was being paid less than the negotiated capitation payment their payment should be adjusted upwards

•Where a practice capitation payment was in excess of the newly negotiated capitation payment then the commissioner

will reduce the capitation payment.

•Transitional non recurrent support should take into account the degree to which practices are changing services, contract

value changes and infrastructure requirements and ensure that the pace of change allows a move to the new

arrangements with a minimum of disruption to practices

Enhanced services

and the out of

hospital agenda

PMS contracts allow for significant flexibility and commissioners and providers may decide to negotiate creative and

innovative services which integrate with their local priorities depending on the financial envelope available and the

strategic priorities of the cluster.

The Commissioner will present the opportunities for additional practice income that may be linked to the out of hospital

agenda, or enhanced services that sit outside those identified in the basket of services.

Action where

agreement is not

possible

•The commissioner should take all possible measures to reach agreement on PMS contract review through timely, well

communicated meaningful and open engagement. However where it is not possible to reach a mutually satisfactory

agreement it may be that the provider returns to a GMS contract.

•The contractor has the right to return to a GMS contract through regulation 19.

•There is no legal right for a GMS practice to move to PMS

The Commissioner will

present the opportunities

for additional practice

income that may be linked

to the out of hospital

agenda, or enhanced

services that sit outside

those identified in the

basket of services and core

services.

12

Commissioner engages

with PMS GP community

and outlines their desire

to renegotiate PMS

contracts in line with

QIPP objectives.

Commissioner proposes a

governance structure and

terms of reference

Committee Structure:

-Expert Advisory

Committee

- Project Board

-Set out mandate from

practices

-Representation

includes Public Health

and Business Support

Unit, GP’s, LMC, Primary

Care Management

(Commissioning)

Commissioner carries out

an audit of the current

PMS landscape. This will

include understanding the

investment per patient,

and will assume premises,

seniority and enhanced

services and QOF are

excluded. Information will

present the correlation

between performance

and investment

Commissioner sets out

commissioning

intentions and proposes

a core basket of services

that reflects national

and local priorities.

Commissioner

negotiates RAG rated

KPIs that will be used to

evaluate performance

Commissioner establishes

new per capita payment

for all PMS practices and

sets stretch targets with

performance payments

using the KPIs negotiated

in stage 4.

1 2 4

5

3

Commissioner negotiates time

frame for normalising PMS

capitation payments across

PMS practices.

It is recognised that the

contracts will be signed

by the individual

practices and that

partners will retain the

option of either

agreeing the revised

PMS contract or

reverting to GMS

6 7

PMS Process Summary

Acknowledgements

13

Thank you to all those who contributed to the creation of these operating principles including:

Name Role Organisation

David Sturgeon Task and Finish Group Chair, Director of Primary and Community Services Transformation SEL

Greg Cairns LMC

Dr Paddy Glakin LMC

Claire Hornick Primary Care PMS Contract Manager SEL

Rachel Hawksworth Senior Contracts and Performance Manager (GPs) NCL

William Cunningham-Davis AD Primary Care (GP and OOH) SWL

Edward Ward Head of Primary Care ONEL

Julie Taylor AD Primary Care Contracting NWL

Lee Dolan PMS Practice Manager, Queen’s Medical Centre SWL

Annette Pautz PMS Practice Manager, Holmwood Corner Surgey SWL

Andrew Watson PMS Practice Manger, Fullwell Cross Health Centre ONEL

Mick Lucas AD Primary Care Finance SWL

Rael Gamsu Assistant Director of Finance ONEL

Tony Thomas Associate Director of Finance NWL

Jemma Gilbert AD Primary Care NHS London NHSL

Sean Fenelan PCC

Documents Referenced

Greenwich PCT approach to PMS Review

Harringey PCT Approach to PMS Review

Primary Care Quality and Productivity Challenge: Good Housekeeping Guide – NHS Primary Care Commissioning April 2010

14

Data £/patient

GMS Benchmark £ 64.59

London Weighting £ 2.62

QOF payment £ 2.66

Total £ 69.87

GMS Baseline Payment Calculation

As recommended by the DoH letter

Gateway Ref: 14380

para 6

http://www.dh.gov.uk/

Statement of fees and entitlements

Section 2 para 2.3

(as this payment is based on actual list

size the amount of £2.18 has been

multiplied by the relative list size

adjustment As per QMAS 1.1.11

Payments for chronic disease

management allowance , sustained

quality allowance and cervical cytology

payments included in PMS baselines

but received by GMS in their QOF

payments .

£13,050/5,891 (PMS points deduction

divided by national average list size)

multiplied by relative list size

adjustment factor as per QOF 1.1.11

Appendix 2



List Maintenance

Once for London


• The NHS Commissioning Board will have a direct role in the commissioning of primary care services including medical,

dental, pharmacy and optometry.

• London’s Primary Care Professional Leadership Group (PLG) are developing unified operating models for the commissioning

of primary care services to:




• The output of this work will be a suite of operating principles that can be consistently applied to improve the way we

commission key primary care services. Initially this work programme will focus upon:



• The expectation is that this programme of work will synchronise with transition towards a single operating model for

primary care commissioning nationally. It may therefore extend to looking at all aspects of primary care commissioning and

other contractor groups within London both implementing national operating models and influencing the shape of these by

sharing local operating principles.



• Approximately 70 primary care leaders have participated in this work to date with representatives from clusters, contractors,

LMC, LDC, FHS organisations, clinicians, practice managers, public health, finance and contracting.

• These task and finish groups have provided a forum through which primary care leaders have shared experiences, skills and

knowledge to develop a unified approach to a basket of key QIPP challenges.

2

Operating Framework for List Maintenance

Primary Drivers for Undertaking List Maintenance:

London is a world city, with a diverse population and many health issues. However, London has some of the worst health

outcomes in the country in some key areas, and poor performance in prevention activity. Gross inequalities exist across the

capital, both in the quality of preventive services and in health outcomes. London is an extreme outlier for all indicators based on

GP registrations.

The accuracy of a practice’s registration list is important for:

– the efficacy of ill-health prevention / screening programmes and total population capture

– the assessment of performance and clinical outcomes which are often compared on a ‘per patient’ denominator

– the appropriate use of public funds, as allocations are made on a £ per patient basis

Improving GP list accuracy would:

– reveal the true picture of London prevalence of ill health and public health performance – showing that London is not

the outlier it is currently presented to be;

– ensure the design of effective interventions to reach local priority groups and impact on priority programmes;

– contribute to the delivery of regional and local QIPP Health & Wellbeing outcomes;

– have a positive impact on many clinical outcome measures for example, cancer, long term conditions, heart disease,

communicable disease, respiratory disease.

3


Why do inaccurate lists occur?

• The patient list is a changing register reflecting population movement. This is particularly true in London where turnover of

patients is high and can be marked for some practices serving a transient population.

• Ongoing and effective maintenance of lists is essential to ensure that they are accurate. However, even with the most

effective list maintenance procedures in place, a practice list can hold 3-8 % of inaccuracy due to patient turnover alone.

• It is estimated that in London the level of list inaccuracy can range from 3-35 %. Whilst some of this is accounted for by

population turnover, high levels of list inaccuracy have also resulted from:

– list maintenance being one of many competing priorities for improvement

– low awareness of the importance of list maintenance and the link to both service outcomes, public health and the use

of public funds

– attention not being given to this over time but list maintenance has become more critical as a result of QIPP

� Practices have an important role to play in maintaining accurate lists. Practices with robust systems in place to verify and

record patient details at the point of registration ,as well as regular systematic checking of details when patients contact the

practice, have more accurate lists.

• Commissioners, patient registration authorities and GP practices will be effective in reducing list inaccuracies sustainably, if

they work collectively to addresses these factors.

4

Stage 1 of a List Maintenance Exercise

Commissioner identifies

cohort of patients and

sends details to the practice

for verification (see page 7)

After 4 weeks a second

letter is sent

Pa

tien

t

Re

spo

nd

ed

Pa

tien

t

Re

spo

nd

ed

No

Response

No

Response

Pa

tien

t

Re

spo

nd

ed

Pa

tien

t

Re

spo

nd

ed

No

Response

No

Response

After 4 weeks an FP69

activated on the

practices IT system

List action taken by the

patient registration

authority



authority

See STAGE 2 overleafSee STAGE 2 overleaf

FP

69

Activ

eF

P6

9 A

ctive

Practice identifies any patients that have a

record of contact with the practice in the last 15

months, removes them from the cohort and

returns list to the commissioner. Practices will

have 4 weeks to do this after which time the

letters will be sent out.

Contact would include an appointment,

telephone consultation, collection of a

prescription or any other interaction which has

been noted in the patient record.

First letters sent to

patients that have had no

contact with their

practice in the last 15

months

5


Stage 2 of a List Maintenance Exercise

FP69 Active

If the practice still believes the

patient is an active registration,

they have 6 months to establish

contact with the patient directly

to confirm their registration

requirements.

Practice declares patient

resident and eligible for

general medical services

from the practice



authority

Pa

tien

t

Co

nta

cted

Pa

tien

t

Co

nta

cted

Pa

tien

t

No

t

Co

nta

cted

Pa

tien

t

No

t

Co

nta

cted

Patient deregistered by

the patient registration

authority

6 month long pause,

Commissioners do not hold attendance

information. Advance screening of the

cohort by practices should minimise the

removal of any vulnerable patients on

chronic disease registers, as the 15

months time frame coincides with many

of the QOF recall standards for patients

with chronic diseases.

Commissioners should not request any

more than a verified list from the practice

– practices should not be required to

produce screen shots or other

documentation.Return to sender

The patient registration

authority will inform the

practice of any letters which

are “returned to sender.”

The practice would then be

responsible for contacting

the patient and establishing

their new/correct address.

They should then inform the


authority so that the FP69

can be removed.

6


Pan-London Operating Principles:

• List maintenance processes should be designed with the proactive engagement of commissioners, registration authorities,

LMCs on behalf of GP’s and practice managers.

• List maintenance should be undertaken as a continuous rolling programme for example working through the list

alphabetically over a one to three year period.

• A rolling programme could also include phased targeting of specific patient cohorts

Examples of this approach include:

i) choosing a patient cohort that supports a screening programme e.g. childhood immunisations, flu or cytology

ii) addresses with apparent multiple occupancy

iii) practices with particular circumstances which dictate a local bespoke approach to maintaining accurate lists e.g.

University practices

• A ‘one hit’ approach in which a single practice is targeted should be avoided except in exceptional circumstances. This might

include for example; due diligence when transferring a full list to a new practice. In all cases this should be carried out in

consultation with the LMC.

• When responding to FP69 flags in the practice IT system, a practice declaration will be sufficient - additional evidence such

as screen-shots would be unnecessarily bureaucratic and may breach patient confidentiality. The practice is responsible for

ensuring all declarations made are accurate and should be made aware that these can be challenged where any

inconsistencies are highlighted through cluster-wide audit.

• A list maintenance exercise is not designed to address performance failures. Where there are reasonable grounds for

believing that list inflation is particularly high at an individual practice then concerns about this should be handled separately

and in accordance with the performance management directions. Good performance management guidance has been

agreed pan-London (weblink to be inserted).

7


Minimising inconvenience to patients

• Advance screening of the proposed cohort by practices means that less patients will be inconvenienced by having to respond to

the letter. It will also reduce postal costs associated with the exercise.

• The commissioner should ensure that where the registration authority disputes the practice declaration, the practice is made

aware of the reason why, and is advised of any list actions that have been taken.

• The commissioner should maximise awareness in the patient population of list maintenance procedures an effective patient

communications strategy should be in place. The strategy should be tailored to local needs and build upon examples of what has

worked well for example:

– Branded NHS envelopes are more likely to be opened as they are clearly related directly to the patients health

– Alerting patients to registration checks well in advance – as part of the registration conversation, through display notices in

a practice

– Making the process clear to patients through any letters and posters for example - what the letter looks like, what to do

when you get one, the steps in place to minimize de-registration errors, what to do if there is a de-registration error, what

to do if a letter arrives for someone not living at that address.

– Communications tailored for different languages and consideration of other support for patients who’s first language is not

English

– Letters to be addressed to named patients and not the occupier

NHS London will work with patients and community groups to develop recommended templates which provide clear simple

accessible messaging on all patient correspondence

• Commissioners should ensure that practices have access to training and IT support to undertake validation - identifying FP69’s and

flagged patients on the practices system

• Practices have a crucial role to play in ensuring that their staff access the training, are familiar with the FP69 process and are

proactive partners in the list maintenance process.

• List maintenance is also an opportunity to improve other aspects of patient registration including the accuracy of patient

information held on the register. Practices should verify the details of patients contacting the practice on a systematic basis as

part of routine on going maintenance.

• Practices should always re-register patients who have been removed under this process, but who are still resident , with a

minimum of inconvenience to the patient.

8



Local Enhanced

Services

Once for London


• The NHS Commissioning Board will have a direct role in the commissioning of primary care services including medical, dental, pharmacy

and optometry.

• London’s Primary Care Professional Leadership Group (PLG) are developing unified operating models for the commissioning of primary

care services to:




• The output of this work will be a suite of operating principles that can be consistently applied to improve the way we commission key

primary care services. Initially this work programme will focus upon:



• The expectation is that this programme of work will synchronise with transition towards a single operating model for primary care

commissioning nationally. It may therefore extend to looking at all aspects of primary care commissioning and other contractor groups

within London both implementing national operating models and influencing the shape of these by sharing local operating principles.



• Approximately 70 primary care leaders have participated in this work to date with representatives from clusters, contractors, LMC, LDC,

FHS organisations, clinicians, practice managers, public health, finance and contracting.

• These task and finish groups have provided a forum through which primary care leaders have shared experiences, skills and knowledge to

develop a unified approach to a basket of key QIPP challenges.

2Draft Work In Progress

Local Enhanced Services

Context and Background

• LESs are a key commissioning tool for delivering care closer to home and to shift services out of hospital.

• This document sets out a range of pan-London operating principles for the commissioning of enhanced services. These principles

will provide a framework for local bodies to make best use of local enhanced services mechanisms.

• PCTs have commissioned a broad range and number of enhanced services. There is great variation in the number, scope, format and

type of Local Enhanced Services (LES) within each cluster as well as across London.

• The benefits and outcomes of many LESs have not often been systematically evaluated for value for money, impact and strategic fit.

A number of PCTs are completing reviews of enhanced services as part of Primary Care QIPP programmes.

• Enhanced services can make up to 20% of practice income. The historical variation in PCT commissioning , reporting, auditing and

payment arrangements for different enhanced services can be counterproductive and a significant burden for both commissioners

and providers.

• Directed Enhanced Services (DES) remain outside of the scope of this document as they have national specifications which cannot

be altered and which must be offered to all practices. Commissioners may wish to replace a National Enhanced Service (NES) by

developing a LES to make it more locally applicable.

• The document is structured around 4 parts of a cycle that all commissioners of enhanced services need to explore as key elements

of the commissioning and contracting process.

4

Key Enhanced Service Commissioning Principles

•This document provides principles for Clusters, CCGs, Public health and LMCs in the commissioning of Local Enhanced Services

•LESs are a key commissioning tool for delivering care closer to home and to shift services out of hospital.

•LESs should be locally led and developed in consultation with the Local Representative Committee (LRC)

•LESs should have clear notice periods, termination dates and the facility for annual review.

•Clinical engagement in audit and outcomes should be a key part of this process.

•Commissioners should give due consideration to the provision of reasonable notice periods and appropriate contract lengths to facilitate budgeting

and planning. Many LESs will be annual contracts, but where a LES may require the purchase of equipment or employment of additional staff, a LES

may be commissioned with a contract length of 2 or 3 years as appropriate.

•LESs should be outcome based as far as possible and the costs required to provide a service covered by the income which the LES provides.

•Commissioners should systematically review their LES portfolio for value for money, impact and strategic fit. It may be that there are opportunities

to decommission some services of limited value & strengthen the specifications and outcome measures of those that remain. Commissioners should

consider opportunities to consolidate their LES into a fewer number to deliver measurable health outcomes within a financial envelope .

•Enhanced services should add value and offer a measurable enhanced level of care and not duplicate services provided under other contractual

provision

•For reasons of equity, commissioners should give due consideration to cover any gaps in service so that complete population coverage is achieved.

Non-specialist LESs should normally be offered to all practices which satisfy accreditation criteria. Where specialist skills or equipment are needed to

provide a LES (such as minor surgery or anticoagulation therapy) , it may be that a cohort of appropriate practices are commissioned to provide the

service to the local population. Commissioners could also consider opportunities to achieve economies of scale through a network of practices

combining to employ particular staff (such as an additional nurse to provide immunisations and vaccinations) or share a piece of equipment.

• The data requirements for LESs should be as simple and straightforward as possible. They should not be onerous to produce or analyse. By involving

general practice IT system suppliers early-on, it is possible to develop a set of enhanced service read codes. This places a marker on all enhanced

service activity so that searches can be conducted to provide information for audit requirements.

5

Governance arrangements

It is likely that the new NHS architecture will present commissioners with challenges to ensure there are clear and transparent governance

arrangements.

Commissioners must ensure that there are robust and transparent governance arrangements to manage any potential conflicts of interest

within Clinical Commissioning Groups (CCGs) in the LES commissioning and provision process, to ensure that services commissioned are

genuinely enhanced and that a robust pricing process has been followed which ensures that LES provide value for money.

We do not know the precise nature of roles and responsibilities for enhanced services commissioning post transition but transparent

governance mechanisms will need to be in place to demonstrate probity and stewardship.

It is expected that the LMC will have a key role to play in establishing them and that public and lay representation will be involved in this

process.

Deciding if a LES is the best contractual vehicle for the service

As part of the process of defining a service need, understanding the options for provision will enable commissioners to decide whether a

local enhanced service contract is the right approach.

Considerations such as the time of day and number of days a week the service would be best provided and the skills required may lead the

commissioner to consider a range of providers for whom an alternative contractual vehicle would be more appropriate.

For example ,local community services or pharmacists may be best placed to provide some services rather than GP practices.

6

Governance Arrangements

Governance Arrangements

Framework for

Local Enhanced

Services

Development

Stage One:

Identify the outcomes to be achieved by the service you are commissioning and the service specification that will deliver it.

Stage Two:

Agree an appropriate financial model for the service

specification

Stage Three:

Deciding which providers should provide the service

Stage Four:

Review and Evaluation

7

Stage One:

Identify the outcomes to be

achieved by the service you are

commissioning and the service

specification that will deliver it.

Stage One: Identify the outcomes and service specification required by the service

Having identified a health need, the commissioner should consider the outcomes that they wish to

achieve, the service required to address it and the service specification to support it.

Service specifications for enhanced services should be based on clearly defined and measurable

service outcomes, outputs and processes depending on the service commissioned which should be expressed in clear KPIs.

In order to facilitate impact assessments, service specifications should contain outcome measures where possible. They may also contain some output

measures where appropriate. A smoking cessation LES, for example, will pay for the number of smoking cessation consultations held (‘outputs’) , as

well as the number of quitters achieved (‘outcomes’).

The specification should be appropriately quality assured to fit with the local enhanced services portfolio, including testing quality, effectiveness and

efficiency of a specification.

LES services specifications should include:

•What the LES aims to achieve and how that will be evaluated

•Any eligibility and exclusion criteria

•Service outline

•Pricing for the service

•Data requirements and payments schedule

•Length of contract prior to service review and audit

•Monitoring arrangements and audit process (PPV arrangements for example)

•Length of notice required for termination of agreement or variation of agreement (it is recommended that this should not be less than 3 months)

•Arrangements for patient participation/feedback where appropriate

The commissioner should consult with the LRC on all aspects of the specification

For a LES model template see appendix 1

8

Stage One:

Identify the outcomes to be

achieved by the service you are

commissioning and the service

specification that will deliver it.

Length of contract

Due consideration should be given to the period of time that the service will be commissioned

before review and evaluation. Where a service requires, for example, the purchase of equipment or

employment of additional staff, commissioners may consider an agreement of two years

or more appropriate as providers may need to make significant investments to provide the service.

This should be clearly outlined in the LES specification and SLA/contract.

Notice period for variation and termination

Similarly, the notice period to be given to providers for variation or termination of a LES should be considered on a case by case basis and should usually

be no less than 3 months. When considering notice periods ,commissioners should take account of the requirements of providing the service and the

ability of providers to make necessary operational adjustments within a reasonable time frame, as well as the health and clinical outputs and outcomes.

Considerations similar to those given to contract lengths will need to be given to LES notice periods as those which require the employment of

additional staff, for example, are likely to require longer periods of notice than those where the operational impact on providers is less significant.

Commissioners may also want to include the period of notice providers need to give should they no longer want to provide a LES.

Contract length, notice periods , termination and variation arrangements should be clearly outlined in the service specification and contract/SLA and

are subject to consultation with the LRC.

Contract monitoring

The contracting body should carry out suitable audit ,such as undertaking regular reviews of payments and activity. Anomalies/changes in patterns of

provision should be queried and where there are ongoing concerns , a post-payment verification check may be appropriate. Contract monitoring should

also provide assurance on compliance with service delivery and achievement of outcome measures.

Commissioners should carry out systematic post payment verification at a sample of practices as a matter of routine. Arrangements for contact

monitoring/PPV should be made clear in the service specification.

Draft Work In Progress 9

Stage 2: Agree a financial model for the service specification

Recorded activity

Recorded activity for local enhanced services should be based on clearly defined, valid and measurable

service outcomes, outputs and processes which should be reflected in the service specification and

payments.

For example, where a practice provide chlamydia screening , the LES may reward the number of screenings carried out

Smoking cessation may include ‘outcomes’ (i.e. the number of quitters) , as well as ‘outputs’ (the number of patients seen).

Where a LES is largely process-focused, outcomes such as health improvement and patient satisfaction may be considered for inclusion.

The service specification will include the methodology for undertaking review and audit locally – outlined in stage four.

Price setting and payments

In determining the price ,commissioners may look at a number of considerations. These could include a calculation of the costs to the provider of

delivering the service, how that cost compares to any tariff price that it might substitute and benchmarking of prices paid elsewhere for the same or

broadly similar activity.

Professional Local Representative Committees (LRCs) must be consulted on the service specification, including the pricing.

Payments for enhanced services should be identifiable on practice budget statements where possible. Where this is not feasible, alternative

solutions should be considered such as an annual statement of enhanced service £sum totals.

By involving general practice IT system suppliers early-on, it is possible to develop a set of enhanced service read codes. This places a marker on all

enhanced service activity so that data searches can be conducted to provide audit/evidence that the service has been delivered according to the

specification.

Stage Two:

Agree an appropriate financial

model for the service

specification

Stage Three: Identify who should provide the enhanced service

Deciding on service providers

The commissioner may wish to offer their local enhanced services to all providers or practices for

“generalist” services or for more specialist services to a select group of providers with the

necessary skills, staff, equipment or premises.

Having due regard for professional and medical opinion, commissioners should decide if there are any minimum eligibility/quality criteria for the

provision of each local enhanced service and, if so, what they are and how they will be assessed.

The process through which providers are selected should be transparent, fair and equitable.

Commissioners could also consider opportunities to achieve economies of scale through a network of practices combining to employ particular

staff (such as an additional nurse to provide immunisations and vaccinations) or share a piece of equipment that can be used by a network of

neighbouring practices. Commissioners will also need to consider the number of providers required to deliver a LES in order to address the health

needs of the population.

All patients should be able to access the service

For reasons of equity, commissioners should have an alternative strategy in place to cover any gaps in service so that complete population

coverage is achieved.

Where a practice is not providing a LES, either through choice or accreditation, then whole population coverage for the service can be achieved by

commissioning a neighbouring provider to deliver the service to the non-participating provider’s patients.

Commissioners may want to consider identifying host sites for enhanced service delivery with inter-practice referrals so that provision is via a care

network.


Stage Three:

Deciding which providers should

provide the service


STAGE FOUR:

Review and evaluation

Stage 4: Review and Evaluation

Commissioners should undertake a regular review, evaluation and update of each of their enhanced

services.

LESs should be subject to periodic review and impact assessment. Clinical engagement in audit and outcomes should be a key part of this process. A

robust process would take into account a review of the evidence of impact of each LES, its value for money and strategic fit with local and national

priorities. The LRC must be consulted as part of this process.

To facilitate this task, commissioners may consider setting-up a group to review their LES portfolio, which includes stakeholders from finance, IT, public

health, pharmacy, primary care, contracts, LRCs, GPs and Practice managers. A LES review process may require significant time input from group

members and a commissioning resource to oversee the process and deliver any contract changes.

Following the review of a LES, the commissioner may decide to make modifications (for example, strengthening the service specification, payment

thresholds, adapting the outcome measures) or to decommission the service depending on the review outcome.

Modifications to LESs should be subject to consultation with the LRC and arrangements made for due process, in line with governance frameworks.

Undertaking a formal review and evaluation of enhanced services can help commissioners to identify opportunities for improving the administration of

these contracts. For example, this could include establishing read codes or having a single enhanced services contract to cover a number of related

existing enhanced services.


Enhanced ServicesFuture Roles and Responsibilities

The precise commissioning

arrangements for enhanced services

are not yet known.

As we move towards transition CCGs

already have an important role to

play in deciding on the ability of

practices to provide enhanced

services and which services should

be commissioned and it is likely that

their role will broaden further.

Ensuring that the LES offer

effectiveness, value for money,

quality and impact as well as

processes for governance, audit and

patient involvement will be a key

challenge for the new architecture.

Context and Background

A national operating model for the development of enhanced services post-transition has not yet been designed however the known organisations

and their interactions are outlined below.

Learning Education and Development (LEAD)

CURRENT EVENTS FOR 2011/2012

http://www.lmc.org.uk/uploads/files/member%20community/events/2011/leadannualpro

gramme201112v2.pdf

Medical Records in Primary Care

(the importance of good record keeping)

• Tuesday, 21 February 2012

• 1.00-4.30pm • Medical Protection Society, 33 Cavendish Square, London W1G 0PS • Delegate fee £90.00 for Londonwide delegates and £108.00 for other areas • Maximum capacity 25 per workshop

General Practice Nurse and Healthcare Assistant Events

Family Planning: Contraception

• Tuesday, 20 March 2012 (1.00-5.00pm) • Hamilton House Meeting & Conference Centre, Mabledon Place, London WC1H 9BD

• Delegate fee £50.00 for Londonwide delegates and £60.00 for other areas

• Maximum capacity 40

Practice Manager Events

Risk Management

• Tuesday, 24 January 2012 (1.00-4.30pm) • Woburn House Conference Centre, 20 Tavistock Square, London WC1H 9HQ

• Delegate fee £79.00 for Londonwide delegates and £108.00 for other areas • Maximum capacity 40

Employment Law ‘Hot topics’

• Tuesday, 23 February 2012 (1.00-4.30pm) • General Chiropractic Council, 44 Wicklow Street, London WC1X 9HL • Delegate fee £49.00 for Londonwide delegates and £60.00 for other areas • Maximum capacity 70

If you, or a member of your practice team, are interested in any of these events please contact the

LMC office ([email protected]) to register or request more information.

The New LEAD programme for 2012/13 will be available shortly so please look out for it!

Booking Form