Primary Care Commissioning Committee , Part 1 Held in Public … Care... · Blossom Care Homes Ltd: i) 15% Shareholding ii) Father is Director of Blossom Care Homes Ltd ... Dr Anjan

1

Primary Care Commissioning Committee, Part 1 Held in Public

Wednesday 24th April 2019 2-3.30pm Public Gallery West, Bexley Civic Centre DA6 7AT

AGENDA

Item

Times

Description Enc. Presented by

Standing items

12/19 2.00 Welcome and introductions - Neil Ross

13/19 2.02 Declarations of Interest A Neil Ross

14/19 2.05 Review of Minutes from the previous meeting on 13th February 2019

B Neil Ross

15/19 2.07 Review of action log C Neil Ross

Items for decision

16/19 2.10 Lakeside Medical Practice: Request to change catchment area

D Jill Webb

17/19 2.20 Crook Log Surgery – Partnership and Merger Proposal

E Jill Webb / Nisha Wheeler

Items for information

18/19 2.35 Cairngall Medical Practice : final update report F Nisha Wheeler

19/19 2.45 Primary Care Networks briefing paper G Nisha Wheeler

20/19 2.55 Primary Care Quality Report H Sarah Birch

21/19 3.05 Bursted Wood APMS procurement Verbal update

Jill Webb

22/19 3.15 Primary Care Finance Report I Michael Boyce

Closing items

23/19 3.25 Questions from members of the public Any member of the public who wishes to ask a question at the Primary Care Commissioning Committee should send it in advance to [email protected] Members of the public are reminded that queries relating to individual staff or patients cannot be discussed. The chair

All

12.19 Agenda, welcome & apologies

1 of 87Primary Care Commissioning Commiittee (part 1) Public-24/04/19

mailto:[email protected]

2

Item

Times

Description Enc. Presented by

reserves the right not to respond to queries relating to issues which are the subject of current confidential discussions or legal action or any other matter at his discretion without giving any reason.

Date of next meeting: Wednesday 19th June 2019, 2.00- 3.30pm, Bexley Civic Centre, Watling Street DA6 7AT


2 of 87 Primary Care Commissioning Commiittee (part 1) Public-24/04/19

3

The quorum shall be 50% of the non-GP voting members

Membership: Primary Care Commissioning Committee (part 1) Public

Neil Ross - Chair (NR) Lay member, legal & procurement

Keith Wood (KW) Lay member, governance

Paul Cutler – Vice Chair

(PC) Lay member, patient & public involvement

Neil Kennett-Brown (NKB) Bexley and Greenwich CCGs

Managing Director

Michael Boyce (MB) Bexley CCG Deputy Managing Director

Mary Currie (MC) Bexley CCG Governing Body Nurse

Dr Jhumur Moir (JM) Westwood Surgery

GP Member, Clocktower Locality Lead

Dr Varun Bhalla (VB) Belvedere Medical Centre

GP Member, North Bexley Locality Lead

Dr Sid Deshmukh (SD) Bexley CCG Clinical Chair

Dr Sonia Khanna-Deshmukh

(SKD) Sidcup Medical Centre

GP Member, Frognal Locality Lead

David Maloney Represented by Julie Witherall

(DM) (JW)

Bexley, Greenwich & Lewisham CCGs Bexley CCG

Director of Finance Deputy director of finance

Non-voting members

Dr Anjan Ghosh (AG) London Borough of Bexley Representative for Health and Wellbeing Board, Director of Public Health and Deputy Director of Health & Wellbeing

Dr Richard Money (RM) Local Medical Committee (LMC) Chair & GP

Station Road Surgery

Jane Garfield-Field (JGJ) Healthwatch Bexley Manager

Jill Webb (JW) NHS England Head of Primary Care, South East London, Primary Care Team

Nora Simon (NS) NHS England Assistant Head of Primary Care, South East London, Primary Care Team



NHS Bexley CCG, Primary Care Commissioning Committee members’ declaration of interest, 24th April 2019 - Public

NameCurrent position (s) held in the CCG, i.e., GB, Member practice, employee, Clinical Lead or other

Declared Interest (Name of organisation and nature of interest) From To Action taken to mitigate risk

Update Signature

Dr Sid Deshmukh

Bexley CCG Chair

1. Senior Partner Sidcup Medical Centre PMS Contract -Personal Interest - Materiality 50%2. Shareholder Bexley Health Limited 3. Shareholder Frogmed Limited - Personal Interest (Dormant company)4. Shareholder Blossoms Care Home Ltd - Personal Interest 15%. 5. Clinical Lead - Referral Management and Booking Service (RMBS) - Personal Interest6. Clinical Lead - Dementia7. Shareholder, Bexley Health Neighbourhood Care8. Wife (Dr Sonia Khanna-Deshmukh) is a locality lead for Frognal and on the CCG governing body9. Non-financial personal interest in Inspire Community Trust;a) Wheelchair service b) Joint Equipment Store c) Personal

Health Budgetsd) Information and service support for people with physical

and sensory impairment.

Dr Varun Bhalla GB Locality Lead, North Bexley

1. Partner in Belvedere Medical Practice which holds NHS (PMS) contract Value - Materiality 45% 2. Director of RSVS Ltd a non NHS company - wife is also a Director 3. Bexley Healthcare Services Ltd (wife is also a director) 4. GPCC (Greenwich) Value - Nil so far 5. Shareholder, Bexley Heath Neighbourhood Care 6. Shareholder, Bexley Health Ltd 7. Belvedere Medical Practice is the lead caretaker for Cairngall Medical Practice

Dr Jhumur Moir GB Locality Lead, Clocktower

1. GP Partner, Westwood Surgery2. Shareholder, Bexley Health Ltd3. Shareholder, Bexley Health Neighbourhood Care4. Clinical Lead, Diabetes5. GP Appraiser, NHS England6. GP Trainer, Bexley VTS, HESL

13.19 DO

I

4 of 87P

rimary C

are Com

missioning C

omm

iittee (part 1) Public-24/04/19


Declared Interest (Name of organisation and nature of interest) From ToAction taken to mitigate risk

Update Signature

Dr Sonia Khanna-Deshmukh

GB Locality Lead, Frognal

1. GP Partner at Sidcup Medical Centre2. GP Appraiser for South London,3. Blossom Care Homes Ltd:i) 15% Shareholdingii) Father is Director of Blossom Care Homes Ltdiii) Father and Husband are shareholders4. Inspire Community Trust; Father (Vinod Khanna) is the Chief Executive Officer5. Clinical Lead, 111 &UCC Services for Bexley CCG6. Clinical Lead, Neurology7. Shareholder, Bexley Health Neighbourhood Care; No profit share8. Board Member, Bexley LMC9. Husband, Dr Sid Deshmukh is:i) Senior Partner at Sidcup Medical Centreii) Bexley CCG Chair10. Involved in the developing a pathway for bladder problems in SE London.11. LMC Representative (alternating with Dr Bhadra)

1. I declare all my interests & update the register regularly.2. During meetings I declare my interests separately at the start of discussion of relevant agenda item3. I do not get

involved in decision making where there is a conflict of interest

Keith WoodGB Lay Member for Governance and Audit

None

Paul Cutler GB Lay Member for PPI

1. Director, Paul Cutler Consultancy2. Associate for the National Children's Bureau, Centre for Public Scrutiny, CAN-Invest, Participation Works3. Consultant/ advisor to a variety of charities, social enterprises and local authorities across England (non in SE London)4. Extended family member works for the Alzheimer's Society

Does not take on contracts with organisations within Bexley

Neil RossGB Lay Member for Legal and Procurement

None

13.19 DO

I

5 of 87P

rimary C

are Com

missioning C

omm




Update Signature

Mary Currie Governing Body Nurse

1. Company Director, Quality for Health Ltd - company offering consultancy service in healthcare sector – 50% Shareholding.2. Partner is a Director of Physiological Measurements Ltd (Company delivers NHS clinical diagnostic services in the community, including cardiac diagnostics in Bexley).3. Specialist advisor for the Care Quality Commission (CQC)

Michael Boyce

Deputy Managing Director and Director of Quality

None

Neil Kennett-Brown

Managing Director1. Managing Director, NHS Greenwich CCG2. Trustee, Greenwich Charitable Funds3. Trustee, Fellowship Afloat Charitable Trust

Sept,17Sept. 17Jan. 00

Planning carefully on potential COI particularly cross-charging for staff.

David Maloney

Director of FinanceDirector of Finance;i) Bromley CCGii) Lewisham CCG

Nisha Wheeler

Director of Primary Care, ICT & IG None

Dr Anjan Ghosh

Director of Public Health, LB Bexley

Director of Public Health for LB Bexley 2017

Julie Witherall Deputy Director of Finance None

Dr Richard Money

Member, Medicines Management Sub-Committee

1. GP Partner, Station Road Surgery2. Director & Chair, Bexley Health Ltd3. Director, Bexley Neighbourhood Care4. Chair, Local Medical Committee (LMC)

13.19 DO

I

6 of 87P

rimary C

are Com

missioning C

omm




Update Signature

Jayne Garfield-Field

Member, Commissioning Strategy Committee (CSC)

Manager, Bexley Healthwatch.

Jill WebbPrimary Care Commissioning Committee

Head of Primary Care, South East London Primary Care Team, NHS England

Nora SimonMember, Primary Care Commissioning Committee

Assistant Head of Primary Care, South East London Primary Care Team, NHS England

13.19 DO

I

7 of 87P

rimary C

are Com

missioning C

omm


1

ENCLOSURE: BAGENDA ITEM: 14/19

PRIMARY CARE COMMISSIONING COMMITTEEPublic Meeting

Wednesday 13th February 2019 2018, 2.00-3.30pm Council Chamber, Bexley Civic Centre DA6 7AT

Voting MembersChair:Paul Cutler (PC) Lay member, patient and public Involvement Dr Varun Bhalla (VB) GP Member, North Bexley Locality Lead Keith Wood (KW) Lay member, governance Mary Currie (MC) Registered Nurse Nisha Wheeler (NW) Director of Primary Care, ICT & Information Governance Michael Boyce (MB) Deputy Managing Director Dr Jhumur Moir (JM) GP Member, Clocktower GP Locality Lead

Non-voting members Dr Richard Money (RM) Bexley Local Medical Committee (LMC) Chair Jill Webb (JW) Head of Primary Care, SEL Primary Care TeamDr Anjan Ghosh (AnG) LBB Director of Public Health and Deputy Director of

Health & Wellbeing, Health and Wellbeing Board Representative

In attendance Sukh Singh (item 9/19) Assistant Director of Primary CareLisa Luxford (LL) Primary Care Support Officer (Minutes)

Apologies Dr Sonia Khanna-Deshmukh (SKD) GP member, Frognal Locality LeadMalcolm Hines (MH) SEL CCGs Director of Finance &

Acting Chief Financial Officer Neil Ross (NR) Lay member, legal & procurementDr Sid Deshmukh (SD) Bexley CCG Chair Jayne Garfield-Field (JGJ) Manager, HealthwatchNeil Kennett-Brown (NKB) Managing Director, Bexley and Greenwich CCG’s

Item No1. Standing items

1/191.19.1

Welcome and introductions PC welcomed all to the meeting and apologies for absence were noted.

2/192.19.1

Declarations of Conflicts of Interest The declarations of interest register was passed amongst attendees and signed

14.19 Previous minutes


2

by those present.

3/19

3.19.1

3.19.2

3.19.3

Review of minutes from the Primary Care Commissioning Committee meeting (held in public) on 12th December 2018The committee approved the minutes of the Primary Care Commissioning Committee meeting (held in public) on 12th December 2018, as an accuraterecord, subject to the following amendments

Page 1, Correction: Dr Richard Money is a non-voting member of the Primary Care Commissioning Committee

Page 2, 71.18.2 to read : Conversations regarding the CCG’s proposal, in supporting the local practices within the mile and who would be most affected by the dispersal, took place with LWLMC colleagues who acknowledged the situation but where unhappy with the level of financial support

4/194.19.1

Review of Action Log The action log was reviewed and updated.

2. Items for decision 5/95.19.1

5.19.2

5.19.3

5.19.4

Littleheath Practice: business case for additional partner Dr Thavapalan is a single handed GP with a PMS contract supporting a patient list size of 4550 (as at 1st Oct 2018) in Bexleyheath. The list size is growing steadily and is absorbing the second highest number of patients from the dispersal of a local practice. The practice has no branch sites and is considered to be a “high achieving “practice with consistently high FFT results and 4.5 stars on the NHS choices. A CQC inspection on 5th May 2016 rated the practice as “Good” in all 5 domains of the inspection framework

Dr Thavapalan has submitted a business case to support the proposal that Dr Davies is added as a partner to the PMS contract, with immediate effect. Dr Davies is currently working four sessions at the practice.

Subject to the two conditions detailed in 5.19.4 below , the committee is being asked to approve the addition of a second signatory to the GP contract for the following reasons:

∑ An additional signatory will provide stability to the practice and secure future service provision for the local population

∑ Dr Davies is a female GP and will provide services that are not currently available to patients, such as sexual health services and IUCD & implant services

∑ A partnership will strengthen the clinical team and support Dr Thavapalanin his ambition to reduce his sessions with a view to retiring in 2020.

∑ Patients will receive continuity of care ∑ There is no cost to the CCG

Approval of the business case is subject to the following conditions ∑ The practice must establish a Patient Participation Group (PPG) and

ensure an initial engagement session is in place by April 2019∑ A business case is submitted confirming the remaining contractor’sproposals for continuity of service provisions in the practice and succession plans to coincide with Dr Thavapalan’s notice of intention to retire.



3

5.19.5

5.19.6

5.19.7

RM advised that the LMC supports the addition of Dr Davies as an additional partner at Littleheath Practice and would request the approval conditions are removed. JW advised that the establishment of a PPG is a requirement of the PMS GP contract, and the intention of this requirement is to secure patient care. Further discussion with the LMC would be welcomed outside of the meeting if required.

KW queried if it was in-line with the CCGs Primary Care Strategy to encourage single-handed practices. JW advised that commissioners are required to ensure that practices have sufficient resilience to offer services to their patients. Single handers are able to join Primary Care Networks, which will afford them increased resilience. The intention of Dr Davies to take over the practice when Dr Thavapalan retires will provide patients with continuity and security.

The committee approved in principle the business case, subject to the two conditions detailed in 5.19.4

6/19

6.19.1

6.19.2

6.19.3

6.19.4

6.19.5

Bexley Bid for unspent resilience funding in respect of Cairngall Medical Practice VB declared an interest in the agenda item as the Caretaking provider at Cairngall Medical Practice

The CCG has been successful in a bid to access unspent 2018/19 resiliencefunding to support final dispersal and closedown costs at Cairngall Medical Practice. An award of £104,000 has been made, subject to the following recommendations:

∑ £100,000 - to support patient registration activities∑ £2500 - CCG support work undertaken to assist practices with managing

registrations for vulnerable patients∑ £1500 – subsequent to award notification confirmation of additional funds

from SEL PCT in lieu of slippage from other funds

This amount is in addition to previously allocated resilience CCG funding of £7307, resulting in £111,307 being available to support practices who have been affected by this dispersal.

Members of the committee are asked to consider the need to reduce the proposed sum of £20 to £15 per new patient registration (to support practices in the workload burden involved in the registration of a significant number of new patients) where the practice list size has increased by more than 2%. This would amount to £100,375 which is broadly in line with the sum awarded for patient registration. There are insufficient funds to support a previously suggested figure of £20 per patient.

On-behalf of the LMC, RM raised an objection to the proposed reduction in the allocation of resilience funding from £20 to £15 per patient. The LMC acknowledges the financial constraint on CCG budgets but is of the opinion that the reduction in running costs at Cairngall Medical Practice would balance out any financial shortfall.

JW advised that any savings in regard to premises costs would relate to 2019/20 financial year.



4

6.19.6

6.19.7

6.19.8

6.19.9

6.19.10

MC expressed the view that support to practices should be delivered within available budgets.

If approved, an estimated shortfall of approximately £35,000 would remain in regard to closedown activities. It is expected that the CCG will be able to accrue for these additional costs as part of the year end closedown.

The Chair expressed his thanks to the Director of Primary Care and the Head of SEL PCT whose efforts had resulted in the award of the additional funding to support Bexley practices in the near vicinity of Cairngall Medical Practice and most affected by the list dispersal

The committee endorsed the proposed methodology to implement a consistent process for the distribution of resilience funds.

The committee approved the reduced sum proposed based on limitations of the award received.

7/197.9.1

7.9.2

7.9.3

Cairngall Medical Practice: Caretaking update NW provided a progress update to the committee regarding the current positionon Cairngall Medical Practice since December 2018:

∑ Two further patient letters have been sent out, including easy read versions to patients identified as having protected characteristics. It is anticipated that an additional patient letter will be sent out before the end of February along with an SMS text message.

∑ The CCG is working with Healthwatch and the Caretaking Provider to support vulnerable patients in registering with an alternative GP practice.

∑ Four patient engagement events took place over two dates in December 2018 & January 2019. Attendance levels were low, which may be a reflection of the increased level of patient communications

∑ During December 2018 and January 2019 there have been five patient contacts with the CCG’s patient experience team regarding registration queries and a flu vaccination enquiry

∑ FAQs can be found on the practice website ∑ CCG continues to meet fortnightly with the Caretaking provider to

discuss any issues that arise

As at 31/01/2019, 4127 patients remain on the practice list. It is estimated that in the region of 1000 of these may be ghost patients, i.e. patients who have either died or moved away. When a patient registers with a new practice their medical records are transferred to the new practice.

It is anticipated that some patients will remain on the list when the practice closes on 29th March 2019. The CCG is in discussion regarding the process that will be followed for any remaining patients. The two options being considered are

1. The clinical system remains open for a defined period of time to enable any remaining patients to have their records transferred to their new practice when they re-register

2. Manually print out any remaining records and send them to Primary Care Support England (PCSE) for storage until the patient re-registers with a new practice.



5

7.9.4

7.19.5

JM expressed the view that the CCG and Caretaker Provider had undertaken a great deal of work to manage the closedown process and dispersal of the patient list Cairngall Medical Practice, to have the least impact on patient care as possible.

Update to the minutes: Agreement was reached to pursue a combination of options 1 & 2. The records of any patients remaining on the Cairngall Medical Practice list will be printed out and sent to PCSE for storage until the patient re-registers. In addition, the clinical system will remain open for a period of three months following the closure of Cairngall Medical Practice to allow Belvedere Medical Centre more time to print off the records of the patients that have registered with them and add to their clinical system.

8/198.19.1

8.19.2

8.19.3

8.19.4

Crook Log Surgery: Update briefing JW provided a brief update to the committee ahead of a formal paper being presented at the April meeting of the Primary Care Commissioning Committee

In August 2018 a business case was presented to the Primary Care Commissioning Committee following notification that two, of the three, partners at Crook Log Surgery, intended to resign and retire, leaving Dr Roy as the sole signatory from 14th September 2018. The business case analysed the options available to secure sustainability and resilience of the PMS contract. A partnership model was approved by the Primary Care Commissioning Committee subject to a number of conditions including the implementation of a improvement plan

1. One of the departing partners must remain as a signatory on the contract until October 22nd 2018 when Dr B Chowdhury is added as a signatory

2. The contractor must agree to review and widen its improvement plan, particularly in the area of previous concern regarding FFT and patient access

3. Monthly meetings are held with the contractor to provide assurance to the CCG of the progress made to improve quality and increase the number of partners. Regular updates to be provided to the Primary Care Commissioning Committee

4. If there is no progression in securing additional partners within six months of the business case being approved by the Primary Care Commissioning Committee, the practice will be required to pursue a practice merger

5. The conditions surrounding the business case are contractualised

The six month milestone for the addition of further partners will be reached on February 22nd 2019. A meeting with the practice has been arranged for 11th

March 2019 and the committee will be updated of the outcome of this meeting.

The committed noted the Crook Log update briefing

9/199.19.1

9.19.2

NHS Long Term Plan – Overview and implications for Bexley SS provided an overview to the committee on The NHS Long Term Plan that was published on 7th January 2019 and drew the committee’s attention to the salient points.

GPs will be expected to sign up to network contracts that tie them into practice networks covering 30-50,000 patients. These networks will sit alongside existing



6

9.19.3

9.19.4

9.19.5

9.19.6

9.19.7

GP contracts. On 31st January 2019 GP contract changes were published by NHS England and are considered to be the biggest reform to GP services for 15 years

Key implications for Bexley include: ∑ Funding: The development of Primary Care Networks (PCN’s) will need

to align with current LCN’s to support the work already done and may not fit with existing localities. All three localities in Bexley have in excess of 50,000 patients with North Bexley more than double this figure

∑ Workforce: Existing workforce initiatives in Bexley include GP fellowship programme, mentorship programme to attract and retain newly qualified GPs and those returning to practice, nursing associates, apprenticeships and support for nurses moving from primary to secondary care

∑ Integrated Care: this builds upon the existing LNC work that has already seen the creation of Bexley Care. Issues may arise with the technology to support direct bookings and appointment provision with the implementation of NHS 111 direct booking

∑ Health Inequalities: work to improve the uptake of learning disability health checks, ensure alignment with public health strategy.

∑ Digital: need to ensure there is a straightforward digital access to NHS services. Encourage increase usage of NHS online app and video consultations for all Bexley patients.

RM queried if Connect Care would become more widely available across more hospitals. It is only currently available at one hospital trust.

SS advised that there have been issues with the South East London Virtual care records and the clinical system provider. It is hoped that these issues will be resolved later in the year.

The Chair said he welcomed the emphasis on redressing health inequalities in the NHS Long Term Plan and thought there would be value exploring via a deep dive, how patients would navigate it.

The committee noted the report on the NHS Long Term Plan and the implications for Bexley Clinical Commissioning Group

10/1910.19.1

10.19.2

10.19.3

10.19.4

Delegated Primary Care Finance Report Month 9 2018/19All GPs are potentially conflicted on this agenda item

MB advised the committee that at month 9 the delegated primary care budgets are reported as showing a year to date underspend of £7k, with a year end forecast of an over spend of £96K.

There are two main financial pressures on the delegated primary care budget, the extension of the caretaking arrangements at Cairngall Medical Practice and the General Practice pay award of 2%. The CCG had set aside 1% for GP pay awards. A representation was made to NHSE to bridge the pay award funding gap. However, the CCG has now been advised that there is no further funding available. The predicted overspend risk has been previously highlighted to the committee in a number of papers.

At month 9, £320K of unused accruals have been released from the primary



7

10.19.5

10.19.6

10.19.7

10.19.8

care balance sheet. There is the potential that more may be released in future months.

The planning guidance and allocations have now been published for 2019/20 with a requirement to submit a draft plan by mid-February.

The SEL Primary Care Finance Team are in the process of drafting budgets for 2019/2020. These will be presented at a future PCCC meeting for approval.

Following a query from RM in regard to the outcome of the Demand Management meetings that have taken place with the CCG and practices, NW advised that a report is being drafted and it will be shared with the LMC on completion.

The committee noted the Delegated Primary Care Finance Report as at month 9 (December 2018).

3. Closing items 11/19

11.19.1

11.19.2

11.19.3

11.19.4

Questions from members of the public

Ahead of the meeting a written question had been received regarding services provided by Bluebird Care, for a Continuing Healthcare patient, funded by the CCG.

NW acknowledged receipt of the question on behalf of the committee and expressed the CCGs commitment to providing quality services to its patients. For purposes of confidentiality, and due to patient specific nature of the question, a written response will be provided directly to the person who raised the query. She advised that any shortfall in service would be addressed and the learning shared.

Saby Ghosh said he had seen recent press articles relating to low GP numbers in Bexley, social prescribing and the use of alternative clinicians in primary care. He asked what thoughts the CCG had on these issues and what could be done to attract health workers to work in Bexley.

NW advised that the CCG had been working for some time to try and alleviate the GP deficit in Bexley. Initiatives include participation in the international GP recruitment scheme which has resulted in 2 GPs coming to work in Bexley, a GP mentorship programme to support newly qualified and returning GPs, support for nurses moving from primary to secondary care, paramedics in practices and a variety of apprenticeships.

4. Date of next meeting: Wednesday 24th April 2019 2.00-3.30pm, Public Gallery West, Bexley Civic Centre, DA6 7AT



ENCLOSURE: C AGENDA ITEM: 15/19

Action Meeting Date

Action Agreed Lead Action Taken Date for completion

Status Primary Care Commissioning Committee (public) Action log updated 13/02/2019

15.19 Review

of action log

15 of 87P

rimary C

are Com

missioning C

omm


1

ENCLOSURE: D1AGENDA ITEM: 16/19

Date: 24th April 2019

Title Lakeside Medical Practice - Request to Change Catchment Area

This paper is for decision

Recommended action for the primary care commissioning committee

The Primary Care Commissioning Committee (PCCC) is asked to approve:

1. The request to increase the catchment area of Lakeside Medical Practice with immediate effect.

Potential areas for conflicts of interest

N/A

Executive summary

The purpose of this paper is to inform members of the Primary Care Commissioning Committee (PCCC) of the application received from Lakeside Medical Practice to increase its catchment area. The application was submitted to the South East London Primary Care Team (SELPCT) on 30th January 2019.

The contractor is requesting to increase its current catchment area through Lower Belvedere to the River Thames and states in the application that:

- Following a successful Estates and Technology Transformation Fund (ETTF) bid, the contractor has new clinical rooms available to accommodate new developments locally

- As part of Phase 2 of the ETTF funding, the contractor will have several more clinical rooms available over the new few years to accommodate other developments in the extended area

- Patients from a closed practice (Cairngall Medical Practice) have been requesting to register at Lakeside Medical Practice

The Request to Change Catchment Area application form is in Appendix 1

Primary care commissioning committee (held in public)

16.19 Lakeside MP boundary extension


2

Background

Lakeside Medical Practice is a 6-partner practice with a PMS contract located in Lakeside Health Centre in the Thamesmead East ward. The contractor occupies 40% of Lakeside Health Centre. The raw list size as at 1st January 2019 is 16,356 patients and it operates from a single site which is a modern, purpose built building constructed in 2007 under the Local Improvement Finance Trust (LIFT) initiative. It is one of the largest practices in the borough and is the only Bexley contractor in the Thamesmead East ward.

The contractor’s list size has grown from 16,051 (1.1.2017) to 16,356 (1.1.2019), an increase of 305 patients and is expected to steadily rise due to the planned development in the area (as detailed below). The contractor is located 1.9 miles from Cairngall Medical Practice and as at 28 March 2019, the contractor had registered 55 of its patients.

Proposal

The Business Case confirms that the proposal is for Lakeside Medical Centre to extend its boundary through Lower Belvedere to the River Thames. This area is undergoing redevelopment and would enable the contractor to take on new registrations in this area.

Appendix 1 highlights the contractor’s current and proposed boundary.

At present, only Bexley Group Practice in Bexley covers the proposed extension area.

Local area & developments

Lakeside Medical Practice is located at Yarnton Way in Thamesmead in the Thamesmead East electoral ward. It is the sole Bexley contractor in this area serving a large geographical area.

The application confirms that there is considerable development planned in the area over the next few years. According to the Bexley Growth Strategy, Thamesmead and Belvedere are growth areas in Bexley with significant development potential.

Two of the key infrastructure projects that will trigger a higher degree of cumulative growth to this area will be the completion of a docklands light rail (DLR) extension from Gallions Reach through Thamesmead to Belvedere and the completion of road based river crossings connecting Belvedere with Rainham (Essex) and Thamesmead with Gallions Reach (Greenwich).

Thamesmead is a large housing area. The Peabody Housing Association and



3

the London Borough of Bexley (LBB) Council have approved plans to build 5000 houses within Thamesmead by 2025 with developments in the area already underway. LBB projects 24% housing growth in Thamesmead East by 2025, compared to a London average of 4.6% and regional average of 4.8%. Thamesmead therefore has one of the highest rates of population growth anywhere in the UK over the next eight years.

The Peabody Redevelopment is creating 525 new housing units which means there is an immediate pressure on primary care from this housing development. The site on which Lakeside Medical Practice sits has beendesignated ‘Southmere Village’. This site is expected to be home to an additional 1350 occupants, with 20% of those being children under the age of 18. The presence of a medical centre on site has been articulated as a key part of the development, and new residents moving in will be doing so on the expectation that capacity will be available.

Expanding the Lakeside boundary will help to meet the increased demand for general practice services in this area and will also enable patient choice as currently this area is only covered by one other GP contractor.

Premises and funding to increase capacity

The contractor is situated in a twelve-year-old LIFT building and is contractually and statutory compliant. The CCG has confirmed that the building as a whole is underutilized while the practice space is well utilized.

Lakeside Health Centre is a multi-occupancy building and as well as the practice, houses community and general dental services plus a wide range of community services.

Important context relating to this application is that the CCG was successful in securing ETTF funding in 2017/18 to improve the utilization of Lakeside Health Centre. This funding has enabled the practice to expand capacity by converting void administrative space on the first floor into five new clinical rooms (Phase 1) for the practice with a possible further expansion of three clinical rooms (Phase 2). The contractor has confirmed that the additional five consulting rooms would enable them to accommodate at least 5000 - 7000 extra patients. If ETTF Phase 2 goes ahead, it would allow the contractor to register up to 10000 additional patients, enabling them to deal with the scale of population growth anticipated in the Thamesmead area and some of the population growth planned for Lower Belvedere.



4

Clinical capacity and appointments

The contractor’s list size as at 1st January 2019 is 16,356 patients. The contractor confirmed that it currently has:

- 6 Partners and 4 Salaried GPs (7.6 WTE) - 3 GP Trainees- 2 Nurse Practitioners (1.8 WTE)- 4 Practice Nurses (3.4 WTE)- 3 HCAs (2 WTE)- 22 admin and reception staff

The contractor is also looking to recruit a Clinical Pharmacist and a Paramedic, in line with the new GP contract 5-year framework.

According to the NHS England National General Practice Sustainability and Resilience Data (February 2019), the contractor has 2031 patients per WTE GP which is 783 less (i.e. better) than the Bexley average of 2814. The contractor has confirmed that it offers roughly 1708 appointments per week. Utilisation is approximately 87% which includes the GP on-call in the afternoons. For its list size the contractor would expect to be offering 1177 GP appointments per week. The contractor is therefore offering around 600 more appointments per week than would normally be expected.

The contractor has the clinical capacity to register patients moving into the proposed boundary extension.

Performance

Lakeside Medical Practice was rated as ‘Outstanding’ overall in its recent Care Quality Commission (CQC) inspection on 16th January 2019 and ‘Outstanding’ for ‘Are services caring?’, ‘Are services responsive?’ and ‘Are services well-led?’. It was rated as ‘Good’ for ‘Are services safe?’ and ‘Are services effective?’. Lakeside Medical Practice is the only practice to date in Bexley to receive an ‘Outstanding’ overall rating from the CQC.

According to the national GP Patient Survey, 78% of patients describe their ‘overall experience of the practice as good’ in line with the CCG average of 80%. 89% of patients found receptionists ‘helpful’ (CCG 86%) and 67% of patients were ‘satisfied with appointment times’ (CCG 60%). The CCG Friends and Family Test (FFT) rating average for ‘should the practice be recommended to other people’ is 92%.

Expanding the catchment area would enable a greater population of Belvedere and Thamesmead to access high quality services in central London.



5

Profile

According to the Bexley Strategic Needs Assessment 2016, Thamesmead has a high level of deprivation (30.4%) compared to both the CCG (16.2%) and England (21.8%). Thamesmead East is one of the wards with the highest proportions of the population from BME groups. Almost half the patient population is from a black or ethnic minority group. The population of Thamesmead East is predicted to increase by 300 in 2021 (13050) and by 750 in 2026 (13500).

Lakeside Medical Practice has a greater number of children under 18 years of age (29.9%) compared to both the CCG (22.6%) and England (20.5%) averages. It also has a lower proportion of patients aged over 65 (8.5%, CCG 16.6%), 75 (3.2%, CCG 7.9%) and 85 (0.7%, CCG 2.4%) years.

The contractor is constantly developing and expanding service provision to meet the needs of its young, diverse and deprived population and is regularly visited as a showcase example of innovative primary care. The ‘Outstanding’CQC achievement is partly attributable to responsive services tailored to meet the individual needs of its patients and the flexible way that ensures choice and continuity of care.

http://fingertips.phe.org.uk/profile/general-practice/data

Consultations

The contractor has engaged with its PPG and the LMC, both of which are in support of the proposal.

The contractor has consulted with Healthwatch which confirms that it is “happy to support the proposed extension to include an area of Lower Belvedere not currently covered by other GP practices”.

The contractor has contacted its MP Teresa Pearce who confirms that she supports the boundary change.

Recommendation

The Primary Care Commissioning Committee is requested to approve the extension of the Lakeside Medical Practice catchment area with immediate effect for the following reasons:

- Thamesmead and Lower Belvedere wards are predicted to have considerable housing growth over the next few years and the contractor’s list size is expected to grow considerably over the next few



http://fingertips.phe.org.uk/profile/general-practice/data

6

years- The contractor has the capacity to take on extra patients both in terms of

physical space and number of appointments available- ETTF has enabled the contractor to better utilise vacant space within its

building. It has provided the contractor with additional capacity, relieving pressure on existing services and future proofing Primary Care provision against known housing growth in the area in the coming years

- The LMC, Healthwatch, Councillor and PPG are in support of this proposal

- The contractor’s performance was rated ‘Outstanding’ by CQC at their recent in inspection in January 2019

What are the organisational implications

Key risks

If this is not approved there is risk of insufficient primary care provision to cover the growth anticipated in theLower Belvedere area

Equality

Improves patient choice and enables a larger proportion of the borough to benefit from CQC rated “Outstanding” primary care service. The practice is already making great efforts to address the health inequalities experienced in Thamesmead

Financial No additional costs to the CCG Author: Sally-Ann Sheppard, Commissioning Manager (SELPCT)

Clinical lead: Dr Sid Deshmukh, Chair Bexley CCGExecutive sponsor:

Nisha Wheeler, Director of Primary Care, ICT & Information Governance



Application Notice to Change the Practice Area

01/11/2018

Dear [name]

Application to Change the Practice Area

Please provide the information below to the Commissioner no less than 28 days before the requested contract variation.

1. Affix

practic

e

stamp:

2. Provid

e full

details

of the

propos

ed

practic

e area:

To extend the practice boundary through Lower Belvedere to the river. This

area is not currently covered by any primary facility. (see attached map)

3. Explai

n the

reason

s for

the

chang

e of

practic

e area:

Following a successful bid for ETTF funding, we have new clinical rooms

available for when our list size increases – this is to accommodate new

developments locally. As part of Phase 2 of this ETTF funding, we will have

several (four/five) more clinical rooms available over the next few years to

accommodate other developments in the extended area.

Additionally, patients from a practice which is closing in March 2019

(Cairngall) are asking to register with us as we already provide some services

to them as part of an anti-coagulation service. They also live within this

extended boundary area.

4. Provid

e any

additio

nal

suppor

ting

eviden

ce that

may

be

This is an image of some of the new developments in the extended area from

the Bexley Council planning site.

New developments marked in red.



releva

nt:





Proposed boundary:





Signed by [Dr PK

Anand

_____________________________________

Date _____________________________________

Signed by Dr PA

Milstein

_____________________________________

Date _____________________________________

Signed by Dr H

Williams

_____________________________________

Date _____________________________________

Signed by Dr O

Banerjee

_____________________________________

Date _____________________________________

Signed by Dr FP

Gregory

_____________________________________

Date _____________________________________

Signed by Dr L

Hindley

___

__________________________________

Date _____________________________________

Please note that this application does not impose any obligation on the Commissioner to agree to this application.



1

Chair: Dr Sid Deshmukh | Accountable Officer: Andrew Bland | Managing Director: Theresa Osborne

DATE: 24 April 2019

Title

Crook Log Surgery - Update Paper

This paper is for information *delete as applicable


The Primary Care Commissioning Committee (PCCC) is asked to note:

1. The on-going communication and assurance activities that have been carried out by the partners and management team of Crook Log Surgery since the last update provided to the PCCC on 12 December 2018.

2. That the monthly Improvement Plan assurance monitoring will continue,

subject to review, until such time that all actions have been remedied.

3. That should any further rectification actions be required, following the recent CQC inspection visit and their yet to be published report, the contractor has agreed to add additional actions to its contractualised Improvement Plan.

The Primary Care Commissioning Committee is asked to endorse:

1. The addition of two new signatories to the Crook Log Surgery contract with effect from 1 May 2019, which Crook Log Surgery has initiated.

2. The proposed merger of Crook Log Surgery and Sidcup Medical Centre on 1 April 2020.


Dr Sid Deshmukh will be joining Crook Log Surgery as a partner on 1 May 2019 and he is the Chair of Bexley CCG.

Executive summary

Until such time that all Improvement Plan actions have been remedied, commissioners will continue to hold monthly review and quarterly assurance milestone meetings with the contractor, the latter of which are attended by the Director of Primary Commissioning & IT for the CCG and the Head of Primary Care for SE London. At the request of officers, the contractor has set out the current and prospective

partner’s priorities for the practice, together with their summary action plan and

ENCLOSURE: E1

AGENDA ITEM: 17/18

Primary care commissioning committee (public)

17.19 Crook Log partnership & merger proposal


2

their progress to date in addressing the issues previously identified. These are

attached.

Their priorities are:

To improve patient satisfaction by offering appointments responsive to

the needs of the patient with regular doctors to develop a continuous

relationship with our patients.

To improve staff morale and trust in the organisation by helping to

educate, train and support our staff.

To develop an Organisation that has the corporate and clinical

leadership, management support and infrastructure to be able to

implement proposed changes

To support the NHSE/ CCG strategy of working collaboratively as part of

a larger organisation.

Their action plan addresses all of these priorities.

The contractor received an unannounced, full CQC inspection visit on 27

March 2019. Should any additional rectification actions emerge from the latest

inspection, the contractor has agreed to add additional actions to its

contractualised Improvement Plan.

Progress made to-date since the original PCCC Decision on 22 August 2018

1. The contractor produced an Improvement Plan agreed by

commissioners in October 2018. The latest summary Improvement Plan

is attached.

2. Two partners left the partnership in August 2018 and October 2018.

3. A new half-time (covering 6 session) partner joined the partnership on

22 October 2018.

4. The contractor agreed to contractualise the PCCC conditions and Improvement Plan as a schedule to its PMS contract. The contract variation was sent to the contractor on 28 November 2018, and subsequently signed.

5. The contractor has asked the CCG to endorse two new partners joining

the partnership on 01 May 2019, who will be covering 2 and 3 sessions

respectively per week.

6. A new full-time practice manager will also be joining the practice on 1

May 2019.

7. The attached summary Improvement Plan shows the effort the

contractor is making to reduce the reliance on locum GPs and recruit

more salaried GPs, together with a range of other matters.



3

8. Since December 2018 four salaried GPs have left the practice and four

salaried GP’s have been recruited. Another full-time salaried GP will be

starting on 1 June 2019.

9. From 1 May 2019, Dr Deshmukh will have overall responsibility for

clinical, corporate and management leadership supported by the other

partners and senior management team. Dr Deshmukh will be the

named senior partner, which will occur in any event, on 1 April 2020,

subject to the PCCC’s approval of the proposed merger.

10. Crook Log Surgery (CLS) and Sidcup Medical Centre (SMC) are

proposing to merge on 1 April 2020.o

11. CLS aspires to: improve patient satisfaction by offering appointments

responsive to the needs of the patient with regular doctors to develop a

continuous relationship with our patients; improve staff morale and trust

in the organisation by helping to educate, train and support staff;

develop an organisation that has the corporate and clinical leadership,

management support and infrastructure to be able to implement

proposed changes; and support the NHSE/ CCG strategy of working

collaboratively as part of a larger organisation.

12. The contractor plans to use a wider skill mix of staff including salaried

GPs, nurse practitioner, physician associates and SMC will share staff

with CLS.

13. The Econsult system has been put in place and training provided by Dr

Deshmukh.

14. A revised practice leaflet and a practice newsletter has been developed.

15. A new telephone system, which is the same one as used by SMC, will be installed in April 2019. This is due to be completed by 18 April 2019.

16. The patient participation group (PPG) is now running and has been

holding and has plans to continue with regular meetings, supported by

the contractor.

17. The contractor is engaging more with the CCG by attending locality,

demand and engagement event meetings.

18. The practice holds regular partnership, clinical and admin meetings.

Copies of these meetings are sent to commissioners.

19. Frontline staff have received customer care service training.

20. The introduction of name badges and dress code for reception and

admin staff has taken place.

21. The contractor now has a consultation room on the ground floor.

22. The contractor has commissioned a new cleaning provider to meet the

required cleaning standards.

23. The contractor has upgraded its website and made it more user friendly.

24. The contractor has much still to do, as evidenced by its ongoing

Improvement Plan



4

Areas of improvement still required

25. The contractor is not offering sufficient GP clinical sessions to its

registered patients. This will be addressed by both a new full time GP

starting in June and the wider skill mix proposed by the contractor,

which will also address points 26 and 27 below.

26. The contractor is not offering enough appointments for its list size.

27. There is still reliance on locum GPs.

28. The FFT data is significantly below the CCG’s average and has been

fluctuating on a month by month basis. The contractor has identified

further actions to address this in the attached summary Improvement

Plan.

29. There has been a slow response to complaints from staff and patients.

The new practice manager will be addressing this issue, with support

from an expert HR consultant.

30. Both the CQC and officers have advised the contractor to change the

CQC registered Manager to reflect the current partners. This is in

progress.

31. The Diabetes HbA1c and BP control clinical indicators are below the

CCG average. The contractor has recognised that further progress is

required in these areas.

32. Whilst the PPG is up and running, the contractor is exploring various

ways to increase its PPG membership and make it more representation

of the patients’ population. This has been clearly identified in the

contractor’s action plan.

Whilst the practice statement shows some improvements there are still number

of areas that need to be addressed, which have been captured within the

contractor’s improvement plan and is commended to the PCCC.

In addition, officers support the proposed interim change in clinical and

corporate governance leadership, pending the full merger on 1st April 2020,

which are likely to stabilise and enable CLS to make further improvements.


Key risks

Practices in the Clocktower locality could be particularly affected if patients choose to register in neighbouring practices should the identified improvements in service provision not be met.

Equality Ensuring patients of Crook Log Surgery receive improved primary care service provision in accordance with the contractor’s agreed Improvement Plan.

Financial N/A

Author: Stella Babudoh, Senior Commissioning Manager

Executive sponsor:

Nisha Wheeler, Director of Primary Care, ICT & Information Governance



5

Enclosures

i. Crook Log Surgery – Statement for Bexley PCCC: April 2019 ii. Updated Plan, as at April 2019 (Power-point) iii. Summary Improvement Plan Table (based on April 2019 intentions.



1 | P a g e

Crook Log Surgery – Statement for Bexley PCCC

April 2019

Key Priorities

At Crook Log Surgery, we have identified the following Key Priorities

1. To improve patient satisfaction by offering appointments responsive to the needs of the patient with regular doctors to develop a continuous relationship with our patients.

2. To improve staff morale and trust in the organisation by helping to educate, train and support our staff.

3. To develop an Organisation that has the corporate and clinical leadership, management support and infrastructure to be able to implement proposed changes

4. To support the NHSE/ CCG strategy of working collaboratively as part of a larger organisation.

Patient Engagement

PPG

We understand the importance of providing patient centred care and empowering our patients to be involved in their care. We have been proactive in recruiting patients to join the PPG, using posters and encouraging patients to join our virtual group. The meetings are being facilitated by Dr Roy and Sharmeen Haque (Assistant practice manager) and take place every 3 months as decided by the PPG. We have been liaising closely with Lotta Hackett (Head of patent engagement and involvement at Bexley CCG) who has been influential in helping us to get patients engaged.

Digital Platform

We have listened intently to our patients and have introduced a number of changes based of their suggestions. In particular, they wanted to be able to access a digital platform and book appointments at a time convenient for them. Consequently, we have employed a web designer who has developed a website which is mobile friendly and secure and allows us to share information with patients and provide them the ability to book appointments online. The website has been developed following CCG guidance and is compliant with all the mandatory requirements. Please see ourwebsite for further details https://www.crooklogsurgery.co.uk/.

Cleaning Standards

The patients identified that the cleaning standards in the practice needed improving and so we have now commissioned a new provider. The early feedback has positive and we will continue to monitor this closely with the PPG.



https://www.crooklogsurgery.co.uk/

2 | P a g e

Reception

The PPG identified the patient experience in Reception needed improvement. We have followed their suggestions of providing the reception staff with customer services training and introducing name badges and a dress code. We do recognise significantly more work is needed in this area; Please see Section ‘Staff and Patient Satisfaction’ for further details.

Access

Telephone Access

Following feedback from the PPG regarding our telephone access we have now signed a contract with a new provider, Premier Choice Telecom, to have a system with increased functionality. This includes more incoming lines, call queuing service and call recording. We will have an intelligent call monitoring package which allows us to identify periods of high demand so we can ensure we have the appropriate level of staffing answering the calls at busy times. A site survey has been carried out and the new system will be installed on 16th April.

Online Consultations

We are actively using Econsult, the online consultation module to improve access. This has been used successfully by Sidcup Medical Centre and Dr Deshmukh has helped us put a similar protocol in place at Crook Log Surgery. He has also trained clinicians and admin staff to effectively use the system.

Recruitment

General Practitioners

We understand patients need to be seen in a timely manner and prefer continuity of care by seeing regular doctors. Our aim is to provide the number of appointments in line with the RCGP guidance of72 appts/ 1000 patients per week. This equates to approximately 600 appointments per week for our patient list size. We have been monitoring this closely and unfortunately, we have struggled to comply with this recommendation. We identified that the number of appointments offered issteadily declining despite our best efforts of working with recruitment agencies and using our own contacts.

We appreciate GP recruitment is an issue for many practices due to the national and local shortage of doctors. In addition to this, we have received feedback that our current transitional phase is an influential factor to why some doctors are reluctant to commit their future to a practice which isunder surveillance by NHSE and the CCG.

Consequently, we realised we needed to think of another strategy to help with our recruitment problem. We are keen to support the NHSE strategy of working collaboratively as part of larger organisations and share resources and workforce. This has been one of the main factors in helping us decide we need to merge with another practice. We will be working in partnership Sidcup Medical Centre (SMC) which has the infrastructure and workforce to support us in achieving good patient access. SMC has successfully merged with Dr Timeyin’s practice, Thanet Road Surgery and Dr Timeyin has been pivotal in developing relations between Crook Log Surgery and Sidcup Medical Centre.



3 | P a g e

We have had open and honest discussions with Dr Deshmukh and he has joined us with some of our Improvement plan meetings with NHSE and the CCG. We have identified ways in which we canbenefit from his clinical leadership and management experience. As a result of these discussions, from immediate effect, we are now sharing a salaried GP who works at Sidcup Medical Centre, DrMuthukaluvan for 1 session per week. In the future, there is scope for Dr Muthukaluvan to provide joint injections and help reduce our referral rates to Orthopaedics.

Dr Deshmukh has helped us recruit a full-time salaried GP, Dr Corbett, who will be starting on 1st

June 2019. This will equate to an additional 120 face to face appointments per week and will help us achieve our target.

We are exploring the options of using a skill mix of staff including advanced nurse practitioners and physician associates to work more effectively.

We are confident that working with SMC will help to alleviate the recruitment issues we have faced over the last 6 months and will help provide the practice with the stability it needs.

Practice Manager

We are pleased to report that we have successfully recruited a full time Practice manager, TinaKhanna. We are fortunate as she also has local knowledge and successful experience of working in a practice that went through similar changes and staff issues a few years ago. Her employment officially begins 1st May 2019 and she has kindly agreed to come every week in April for one afternoon with Charlotte Mead (Sidcup Medical Centre Business Manager) to get a handover from the existing part time Practice manager, Kevin McDonald.

Admin and Reception Staff

We have advertised and are in the process of recruiting reception staff, a medical secretary and senior administrative staff to support Tina Khanna and the team.

Partnership and Practice Merger

In view of the partnership issues we have had at Crook Log Surgery in the past we have been very cautious in selecting a practice which we feel can offer us the support we need and shares a similar ethos to us.

We are pleased to report that following a number of detailed negotiations with Sidcup Medical Centre we have come to a mutual agreement on how the practices can work together. From the 1st

May 2019, Dr Deshmukh and Dr Timeyin will join Crook Log Surgery as partners. Hence, in addition to our two existing partners, Dr Roy and Dr Chowdhury, we will have four partners in total.

Dr Roy will be doing 8 sessions, Dr Chowdhury 4 session from May, Dr Deshmukh 2 sessions and Dr Timeyin 3 sessions. The clinical session will be completed by our team of Salaried GPs and regular locums. A breakdown of these sessions is available on request.

Both practices agreed that we would prefer to work as a partnership initially to give ourselves some time to develop a working relationship and focus on some of the immediate issues. We will be having weekly partnership meetings to ensure we are able to successfully implement the changes we are proposing. Our initial priority will be to ensure we are offering the RCGP recommended



4 | P a g e

number of appointments for clinicians and having regular doctors to help with the continuity care for patients suffering with chronic illnesses.

From 1st May 2019 Dr Deshmukh will have overall responsibility for Clinical, Corporate and Management leadership and will be supported by the other partners and senior management team.

We are currently working with the BMA to draw up a partnership agreement for a 4 partner practicefrom 1st May 2019 and then the practices will fully merge as one organisation from 1st April 2020.

Care Quality Commission (CQC) visit

We had a CQC visit on Wednesday 27th March. A number of areas were identified that needed urgent attention and we have put an urgent action plan in place. We are confident that under the new leadership and senior management structure we will be able to remedy the shortcomings by the end of June.

Staff and Patient Satisfaction

We are aware we need to make significant improvements with patient satisfaction. We havestruggled to make the impact we had hoped for and this is reflected in our fluctuant FFT responsesand from our PPG feedback. One of the main issues identified is the patient experience in reception. As part of the improvement plan we had developed a strategy on educating and supporting the reception and administrative team to help address this issue. We still feel that this is the right approach but unfortunately, we have not been able to implement the changes successfully.

We feel this is partly because we have not had an experienced practice manager who is able to commit enough time in making the changes and monitoring them to ensure the improvement is sustained. We have been aware of this issue for some time but have not been able to find a suitable candidate who could fulfil this role. We did recruit a part time Consultant Practice manager who was not able to implement the improvements or develop the rapport needed to motivate the reception staff. Consequently, we have had reception staff leave and exit interview have identified that poor staff morale and lack of leadership in reception is a significant contributing factor. We have identified that the problems are deeper than we had anticipated and too difficult for one person to influence especially if they are working part time. We need a Management Team who can work together to provide the structure and support needed to build a firm foundation and develop unity amongst the staff. We are aware that forming new teams can be turbulent and this is well documented by Psychologist Bruce Tuckman in his team development theory (forming, storming, norming and performing). We are mindful that we do not want to get stuck in the storming phase and are keen to move on to the more productive stages.

Following discussions with Sidcup Medical Centre, we have developed a plan, where we will be applying a Management Team approach to make the changes needed to improve patient satisfaction. We had underestimated how deep rooted some of the problems were within the team and had focused our attention on improving accountability and achieving results. We realise that building trust amongst the staff is the foundation of improving team work. We are confident that the key to improving staff morale and trust lies in providing support and education to our staff members to help nurture their skills. Hence, we identified that our Practice Manager will need skills to be able to bring people together and work as a team. We feel assured that Tina Khanna has the necessary skills.



5 | P a g e

Clinical indicators

We have made good progress in this area. We are now able to run reports and collate accurate data. Our target manager proactively makes contact with the patients and books them in to the appropriate clinic. We have seen a steady increase in all our clinical indicators. We realise we are still below the CCG requirements for Diabetes HbA1c and BP control. This indicator requires patients to change their behaviour and so will take more time to influence but we feel we are moving in the right direction.

Regarding childhood immunisations we have made a steady increase for all four immunisations, of which one we have now achieved the CCG requirement. For bowel screening we have achieved the CCG Requirement.

We have identified that we do need an experienced clinician to lead on the chronic disease management. Our intentions are to advertise for a Nurse Practitioner as our clinical lead for long term conditions. We are in the process of developing a job specification and will then advertise for this role in the next 6-8 weeks.

Premises improvement

We have converted one of the administrator rooms to a consultation room on the ground floor which means we are disabled access friendly. We have reconfigured the nurse’s room to give us sufficient storage space for our equipment. We have employed a local trades company to help with general repairs and maintenance work.

Primary Care Network

We are actively involved in the discussions with local practices. We have decided to be part of the Clocktower locality primary care network.

Dr Deshmukh will be our lead GP for the PCN and will represent the practice at PCN meetings. We hope to further improve patient satisfaction and care following the establishment of the Clocktower PCN and close working and sharing back office functions with other practices.



THE WAY FORWARD…..1ST APRIL 2019

CROOK LOG SURGERYASSURANCE MEETING

1

17.19 Crook Log partnership &

merger proposal

38 of 87P

rimary C

are Com

missioning C

omm


PARTNERSHIP AND MERGER

•Dr Deshmukh and Dr Timeyin will be joining as partners from 1st May 2019•We have instructed BMA Law to draft

our new partnership agreement•Crook Log Surgery (CLS) and Sidcup

Medical Centre (SMC) will merge on 1 April 2020

2


merger proposal

39 of 87P

rimary C

are Com

missioning C

omm


WE ARE ALREADY WORKING TOGETHER

•Dr Deshmukh already doing 1 session per week helping CLS•New online consultation “Econsult” system put in place at CLS•Dr Timeyin is already working 3 sessions per week at CLS

3


merger proposal

40 of 87P

rimary C

are Com

missioning C

omm



• Dr Muthukaluvan who is a salaried GP at SMC has joined Crook Log for 1 session per week, started on Friday 22 March. Does minor surgery joint injections• Full Time Salaried GP will be joining on 1

June – he has worked at Sidcup Medical Centre covering Dr Khanna’s maternity leave for 11 months

4


merger proposal

41 of 87P

rimary C

are Com

missioning C

omm



• Charlotte Mead (SMC Business Manager) is already doing 1 session per week helping CLS with various policies including Data Protection toolkit.• HR Consultant Mr John Sydney who in

Consultant for SMC has been employed to help us with staff complaints – first meeting last week, next meeting scheduled for this week

5


merger proposal

42 of 87P

rimary C

are Com

missioning C

omm


PRACTICE MANAGER

•Advertisement and interviews concluded on Monday 25 March• Tina Khanna ha accepted job offer for

full time practice manager from 1 May 2019. • Tina Khanna will be coming 1 session

per week in April to help with admin and for handover

6


merger proposal

43 of 87P

rimary C

are Com

missioning C

omm


AND MORE…

• New contract signed with Premier Choice Telecom for new telephone system, install date confirmed as 16 April – same system as at SMC which will facilitate smooth integration at time of merger• New cleaning contract in place•We plan to use a skill mix of staff including

salaried GPs, Nurse Practitioners and Physician Associates

7


merger proposal

44 of 87P

rimary C

are Com

missioning C

omm


AND WE WILL MAKE I T HAPPEN

THANK YOU!

WE BELIEVE THEFUTURE IS BRIGHT.

8


merger proposal

45 of 87P

rimary C

are Com

missioning C

omm


Improvement activity

Achievements to date Actions to be addressed How By when Lead responsibility

Page 1 of 4

Patient Engagement

PPG restarted. Facilitated by Dr Roy and Asst Practice Manager Sharmeen Haque

Created new website

Online appointment booking

New telephone provider with call queueing/call recording/intelligent monitoring

Newsletter developed

New practice leaflet developed

Introduced name badges and dress code for reception and admin staff

Customer services training for receptionists.

Friends and Family Test (FFT) needs improvement

Increase number of appointments

Improve processes e.g. incoming post/prescriptions/checking diagnostics

Recruitment – regular clinicians to improve continuity of care and patient satisfaction

Improve staff morale and further customer training for staff so patients have a positive experience

30.6.19 Dr Deshmukh

Tina Khanna

Dr Deshmukh

Tina Khanna


merger proposal

46 of 87P

rimary C

are Com

missioning C

omm




Page 2 of 4

Access New telephone system contract signed, installation on 18 April

Econsult – online consultations

Regular clinicians and long term locums

Provide number of GP appointment in line with RCGP guidelines

Increase number of salaried and partner sessions

Monitor demand and adjust workforce reflect busy periods

New full time salaried GP starting employment

Use intelligent monitoring system of new telephony to identify busy periods

Use Econsult more effectively for on the day appointments

01.06.19

30.05.19

30.06.19

Dr Deshmukh

Tina Khanna

Dr Deshmukh

Recruitment 2 additional partners will be joining on 1.5.19

Dr Muthukaluvan started doing 1 session per week

Dr Hanson doing 3 sessions per week – salaried GP

Dr Tazneen doing 6 sessions per week

Dr Bhalani doing 2 sessions per week

To reduce orthopaedic referral/MSK referrals

Increase regular GPs doing clinical sessions

Improve management team

Dr Muthukaluvan will be doing minor surgery and joint injections

Dr Dave will be doing 4 clinical sessions per week

New full time practice manager Tina Khanna will be joining the team

Collaborate with Asst Practice Manager and Business Manager from Sidcup Medical Centre

30.09.19

01.05.19

01.05.19

01.05.19

Dr Deshmukh

Tina Khanna

Dr Deshmukh

Tina Khanna


merger proposal

47 of 87P

rimary C

are Com

missioning C

omm




Page 3 of 4

Be part of a larger organisation in line with NHSE strategy

Recruit more reception staff

Crook log surgery will merge with Sidcup Medical Centre

30.05.19

01.04.20

Tina Khanna

Dr Deshmukh

Leadership (Clinical, Corporate, Management)

Dr Roy has been the lead GP since the departure of Dr Kwan and Dr Chowdhury. He identified the potential benefits of working as part of a larger organisation to help stabilise the practice

Patient satisfaction, staff morale needs improvement

Clinical processes need to be more efficient

The new management team includes Dr Sid Deshmukh who has successfully merged with Thanet Road Surgery in April 2018 and Tina Khanna who is an experienced practice manager with local knowledge.

Dr Deshmukh will be responsible for clinical, corporate and management leadership

01.05.19

30.06.19

Dr Deshmukh

Dr Deshmukh

Premises New cleaning contract n place

Converted 1 admin room on ground floor into consultation room to facilitate disabled access

Maintenance work completed to make

To improve security and efficiency

Reconfiguration of ground floor admin room

30.07.19 Tina Khanna


merger proposal

48 of 87P

rimary C

are Com

missioning C

omm




Page 4 of 4

property safe

Clinical Indicators

Developed reports and now able to collate data

Steady increase in all indicators in improvement plan

Achieved CCG recommendation for bowel screening, cervical cytology, DTAP/IPV/HiB

Improve Diabetes HbA1c and BP control

Childhood imms – PCV booster/Hib/Men C Booster/MMR – uptake needs to be improved

Arrange Diabetes virtual clinics via GP federation

Increase nursing sessions

Review call/recall system

30.06.19

30.06.19

30.06.19

Tina Khanna

Tina Khanna

Tina Khanna


merger proposal

49 of 87P

rimary C

are Com

missioning C

omm


1

DATE: 24th April 2019

Title

Cairngall Medical Practice update

This paper is for information *delete as applicable


That the primary care commissioning committee note

1. Actions since the last update to PCCC 2. Updates on patient engagement 3. Practice closure activities 4. Communications with the current caretaking provider 5. List size changes 6. Timeline of activities to date

*delete as applicable


Local practices who may take on registration of Cairngall patients and caretaking provider

Executive summary

The following paper provides an update on Cairngall Medical Practice (CMP) since the last Primary Care Commissioning Committee in February 2019. This update is the last in the series of regular briefing reports to the PCCC in relation to the progress of the CMP closure on the 29th March 2019 and the subsequent dispersal of patients.


Key risks

Actions taken look to mitigate risks that patients and local practices may not be sufficiently supported to ensure adequate general practice provision.

Equality

Ensuring equitable support and access available to all patients registered at Cairngall Medical Practice.

Financial

Communications and engagement processes may incur financial and resource costs.

Author: Sukh Singh, Assistant Director of Primary Care Service Delivery

Clinical lead: Dr Sid Deshmukh, Chair Bexley CCG

Executive sponsor:

Nisha Wheeler, Director of Primary Care ICT and Information Governance

ENCLOSURE: F1

AGENDA ITEM: 18/19


18.19 Cairngall Medical Practice final update report


1

ENCLOSURE: 18/19 AGENDA ITEM: F2

Cairngall Medical Practice update – April 2019

The following paper provides an update on Cairngall Medical Practice (CMP) since the last Primary Care Commissioning Committee in February 2019. This update is the last in the series of regular briefing reports to the PCCC in relation to the progress of the CMP closure on the 29th March 2019 and the subsequent dispersal of patients.

Patient engagement A final letter reminding patients of the impending closure of the practice and the actions they need to take to re-register at alternative practices was sent to all CMP registered patients on 6th March 2019, including an easy read letter version to those patients on the learning disabilities register. A further set of text messages were sent to patients following this letter. The CCG has been working closely with CMP and Healthwatch to identify vulnerable patients who may need additional assistance in registering with a new practice. At the end of March, 20 patients on the child protection register were remaining un-registered. All of these patients’ parents/carers have been contacted by the practice care-taker (Belvedere Medical Centre) and are all in the process of registering with other practices. All other patients with the following characteristics had been supported and fully registered with another practice.

Learning Disabilities

Mental Health

Dementia

Frailty diagnosis

Palliative care

Housebound

Homeless or living in Hostel

Practice closure On Friday 29th March CMP formally closed. The practice care-taker (Belvedere Medical Centre), expended a significant amount of time and resource to ensure that all the remaining unregistered patients (of which there were 2011), electronic records were printed and securely transferred to Primary Care Support England (PCSE). They will securely store these records until these patients register at another practice and will forward the records on to their new practice at this time.



2

The CCG, together with the SEL Primary Care team, fulfilled the information governance assurance process on the last day to ensure that there was no patient identifiable data (PID) remaining at the premises.

On-going communications with the current caretaking provider A fortnightly contact with the caretaker continued to take place throughout the dispersal process with the final contact meeting taking place on the 4th April 2019. This process allowed the practice to raise any questions that had arisen in the month and enable officers to address and support as necessary. Where urgent matters arose in between this period, the caretaker made direct contact with the primary care team who provided support as necessary. In addition, the CCG submitted a bid for additional 18/19 London GP unspent resilience funding to support those practices undertaking significant work in the registration processes, patient communications and registration support for vulnerable patients. Payments will continue to be reconciled for patient registrations until the end of May 2019. The caretaking provider has agreed to continue to monitor the CMP clinical system for 3 months until the end of June 2019, ensuring that any clinical correspondence received post-practice closure will be appropriately managed. The CCG is working with the caretaker to ensure that any providers continuing to send correspondence for patients registered at CMP are contacted directly to ensure that their systems and processes are updated to recognise that CMP has now closed. The CMP phone line has an automated message added, stating that the practice is now closed and patients should register elsewhere, or if their need is urgent to contact 111 or UCC.

List size changes for Cairngall

Cairngall Medical Practice G83005

Quarter Raw Patient list

size

01/07/2018 Q2 18/19 8868

05/07/2018 Q2 18/19 8868

19/07/2018 Q2 18/19 8739

02/08/2018 Q2 18/20 8588

16/08/2018 Q2 18/21 8414

30/08/2018 Q2 18/22 8181

13/09/2018 Q2 18/23 7892

27/09/2018 Q2 18/24 7658

11/10/2018 Q3 18/19 7383

25/10/2018 Q3 18/19 6967



3

08/11/2018 Q3 18/19 6596

22/11/2018 Q3 18/19 6191

06/12/2018 Q3 18/19 5766

20/12/2018 Q3 18/19 5266

03/01/2019 Q4 18/19 5041

17/01/2019 Q4 18/19 4567

31/01/2019 Q4 18/19 4127

14/02/2019 Q4 18/19 3655

28/02/2019 Q4 18/19 3090

14/03/2019 Q4 18/19 2624

28/03/2019 Q4 18/19 2011

11/04/2019 Q1 19/20 1563

The July data above is for July 1st 2018 (8868), latest figures available for 11th April 2019 show 1563 patients registered at the practice – 7,305 patients have registered elsewhere.

Timeline of activities - all actions have been completed

Date Event

December 2017 Sole partner resigns with 1 months’ notice

December 2017 Caretaker procurement launched publication of the procurement documentation for the caretaking contract took place on the 22nd December 2017 with the subsequent contract award being notified on the 25th January 2018 to Belvedere Medical Centre. The temporary contract started on the 1st February 2018

January 2018 In parallel to caretaking procurement, the CCG had been working with NHS England colleagues leading the London APMS Tranche 6 procurement programme for the substantive contract for Cairngall Medical Practice due to commence from 1st October 2018

February – June 2018

Various discussions with landlord representatives to align on-going lease or sale of property to GP property services company

February 2018 – present

Monthly meetings with caretaker to ensure PC provision being maintained

April 2018 Caretaker puts forward business case to close Cumberland Drive branch surgery with effect from 1st July 2018



4

May/June 2018 Several meetings with Stuart Rowbotham to advise of estate issues and what CCG was doing

12th June 2018 Meeting with Councillor Diment (Councillor Newton on leave)

18th June 2018 PCCC urgent planned meeting

18th June 2018 Meeting with landlords

22nd June 2018

Meeting with Councillors Diment and Newton

26th June 2018 All Belvedere ward councillors sent an email and letter

28th June 2018 Email and letter sent to Councillor Ogundayo (OSC leader of opposition and Teresa Pearce MP

2nd July 2018 Letter sent to all patients of CMP advising of decision made

5th July 2018 Meeting with Cairngall Medical Practice Patient Participation Group (PPG) to discuss decision made and approach for engagement of patients

10th July 2018 Easy read letter sent to 43 patients identified by practice

26th July 2018 Meeting with Belvedere ward councillors (councillor Putson joined very near the end and therefore missed the conversation)

1st August 2018 Email from Councillor Francis – responded to when Director of Primary Care returned from leave 4th September

18th September 2018

Further meeting held with PPG to discuss additional letter that has been developed to give to routine patients of Cairngall Medical Practice highlighting nearby practices and support available to them for registering with a new practice in the local area

10th October 2018

CCG meeting with clinical system supplier to agree approach to managing the practice closure

9th November 2018

CCG meeting with Londonwide LMCs to discuss Cairngall Medical Practice dispersal and support available for local practices



5

14th November 2018

CCG Information Governance Officer met with Cairngall Medical Practice to discuss plans for secure closure of site

19th November 2018

Practice identified list of Cairngall Medical Practice vulnerable patients to be supported in re-registration

22nd November 2018

Final version of patient letter agreed

1st December 2018

Patient letter despatched to Cairngall Medical Practice patients, including easy read letter version to those patients on the learning disabilities register

7th December 2018

SMS message sent to patients regarding closure and need to re-register

10th December 2018

Primary care paper including Cairngall Medical Practice update presented to Overview and Scrutiny Committee

17th December 2018

Two patient engagement sessions held at 2pm and 6:30pm at Cairngall Medical Practice, providing patients with the opportunity to discuss and raise any questions regarding the practice closure

10th January 2019

Meeting with Cairngall Medical Practice provider to discuss and agree closure plan and actions

10th January 2019

Two patient engagement sessions held at 2pm and 6:30pm at Cairngall Medical Practice, providing patients with the opportunity to discuss and raise any questions regarding the practice closure

25th January 2019

Meeting with councillors Francis, Putson and Hinkley to update on current position at Cairngall Medical Practice

1st February 2019

CCG update to LMC liaison meeting regarding current position at Cairngall Medical Practice and impact on neighbouring practices

15th February 2019

CCG communication to local health care providers informing them of the pending practice closure

26th February 2019

Meeting with Councillors Diment and Newton

6th March 2019 Final patient letter despatched to Cairngall Medical Practice



6

patients, including easy read letter version to those patients on the learning disabilities register

29th March 2019 Final collection of records (for unregistered patients) from Cairngall Medical Practice to Primary Care Support England (PCSE)

29th March 2019 Information Governance assurance of site completed to ensure no patient identifiable information remained in the premises.

29th March 2019 Final closure of the practice



1

DATE: 24TH April 2019

Title Primary Care Networks (PCNs) Briefing Paper

This paper is for information


That the primary care commissioning committee approve

1. An extraordinary meeting to be convened to endorse the recommendations being made by the Local Care Partnership Board (LCPB) and Commissioning Strategy Committee (CSC) prior to the 20th May

That the primary care commissioning committee note

1. The contents of this briefing paper which seeks to provide a high level guide on the national expectations of CCGs in meeting the requirements for the development and coverage of primary care networks (PCNs) and in so doing, ensuring 100% full coverage of the patient population.

2. The role of commissioners, the Local Care Partnership Board and the LMC in supporting and approving networks

3. The additional network workforce for 2019/20 and funding available 4. The role of the PCN Clinical Director5. Extended Hours Access requirements6. Engagement activities to date7. Local risks and challenges identified in meeting the requirements8. Next steps


Primary Care Networks have implications for all GP’s, however this is a high-level briefing paper for information only with no sensitive details that would cause any conflicts to GPs in this meeting

Executive summary

The NHS Long Term Plan and GP contract were published January 2019. The plan endorsed the broad approach set out in the Bexley CCG primary care strategy and aligns with the Local Care Networks (LCNs) within Bexley. The NHS Long Term Plan nationally committed £4.5 billion more

ENCLOSURE: G1

AGENDA ITEM: 19/19


19.19 Primary Care Networks briefing paper


2

for primary medical and community health services by 2023/24.

The contract increases investment in primary care with more certainty around funding and looks to reduce pressure and stabilise general practice. It will ensure general practice plays a leading role in every Primary Care Network (PCN) which will include bigger teams of health professionals working together in local communities. It will mean much closer working between networks and their Integrated Care System (ICS).

The Network Contract DES Directions begin on the 1 April 2019, and following sign-up to the Network Contract DES, the requirements on GP practices will apply from 1 July 2019. The Network Contract DES is intended to remain in place for five years until 31 March 2024, with the Network Contract DES specification evolving over time, subject to annual review and development.

The focus of the Network Contract DES in 2019/20 is to support the establishment of primary care networks (PCNs) and the recruitment of new workforce, with the bulk of service requirements coming in from April 2020 onwards.

This paper provides an overview of the key components for establishing PCNs, the engagement that has taken place with stakeholders, the local risks and mitigating factors that have been identified in relation to establishing PCNs in Bexley together with next steps in the development and implementation of PCNs.

What are the organisational implications Key risks

∑ Ensuring adequate provision of services if 100% network coverage is not achieved or PCNs are not geographically contiguous

∑ Development of network configurations which parties (CCG, LCP, LMC, practices) cannot come to agreement on

∑ Future viability of GP federation if they are not chosen for hosting arrangements, and impact on the on-going provision such as extended access hubs then needing to be managed from within networks

∑ Challenging timescales in which to implement PCNs

Equality∑ Ensuring that all patients receive equitable

access to primary care services across Bexley and ensuring that variations to services are minimised or eradicated altogether

Financial∑ Funding has been committed nationally, but

the size of each network may require more funding to be available, particularly in 19/20 when some funding is based on networks,



3

rather than list size∑ CCGs need to allocate £1.50 per head for the

development of PCNs in their areas, this will be paid to the PCN’s single nominated practice or provider

Author: Sukh Singh, Assistant Director of Primary Care Service Delivery

Clinical lead: Dr Sid Deshmukh, Chair Bexley CCGExecutive sponsor:

Nisha Wheeler, Director of Primary Care, ICT and Information Governance



1

Primary Care Network Briefing paper

Introduction The NHS Long Term Plan and GP contract were published January 2019. The plan endorses the broad approach set out in the Bexley CCG primary care strategy and aligns with the Local Care Networks (LCNs) within Bexley. The plan nationally committed £4.5 billion more for primary medical and community health services by 2023/24. It sets out the ambition for CCGs to actively encourage every practice to be part of a local primary care network so that these cover the whole country as far as possible by the end of 2018/19. Primary care networks will be based on GP registered lists, typically serving natural communities of around 30,000 to 50,000 however not limited to this upper limit. They should be small enough to provide the personal care valued by both patients and GPs, but large enough to have impact and economies of scale through better collaboration between practices and others in the local health and social care system. Primary care networks will build on the core of current primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care. The GP contract released in January 2019 increases investment in primary care with more certainty around funding and looks to reduce pressure and stabilise general practice. It will ensure general practice plays a leading role in every Primary Care Network (PCN) which will include bigger teams of health professionals working together in local communities. It will mean much closer working between networks and their Integrated Care System (ICS). The Network Contract DES is the contractual framework which supports delivery of the ambitions set out for PCNs. Following general practice engagement and agreement to sign up of local PCNs and the Network Contract DES, requirements on GP practices will apply from 1 July 2019 and intended to remain in place for 5 years until 31 March 2024. The focus of the Network Contract DES in 2019/20 is to support the establishment of primary care networks (PCNs) and the recruitment of new workforce, with the bulk of service requirements coming in from April 2020 onwards.

ENCLOSURE: G2 AGENDA ITEM: 19/19



2

Eligibility for sign-up to the Network Contract DES GP practices signing up to the Network Contract DES must hold a registered patient list and be offering in-hours (essential services) primary medical services. By the 15 May 2019, PCNs must complete and return their registration form to the CCG. During the period 16th May 2019 to 20th May 2019, CCGs will seek to confirm and approve all PCNs and their associated network areas in a single process that ensures that all patients in every GP practice are covered by a PCN and that there is 100 per cent geographical coverage. Final approval and feedback of PCN’s will be provided by 31st May once regional and national assurance has been received Governance and Due Diligence The challenging national timescales set around establishing PCNs will mean that a considerable amount of governance and due diligence will need to take place with a number of committees in a short period of time. Local Care Partnership Board (LCPB) PCNs have already been presented to the LCP board together with the challenging timescales, and the LCP Board has already signalled that it will convene an extraordinary meeting to enable proposals to be presented for approval within the timeframes set. Commissioning Strategy Committee (CSC) This paper is also due to be presented to the Commissioning Strategy Committee (CSC) on the 23rd April and a request for approval to convene an extraordinary meeting to consider and approve the proposed networks by the 20th May will be made. Primary Care Commissioning Committee (PCCC) PCCC members will be asked to endorse the recommendations being made by the LCPB and CSC and therefore are asked to approve for an extraordinary meeting to be convened to provide this endorsement – again prior to the 20th May. By 31 May 2019, it is expected that CCGs will confirm that registration requirements have been met, including discussions and agreement of the PCNs and their associated network areas across the CCG and key members of the Local Care Partnership board. After CCG confirmation of networks has been received and prior to 30 June 2019, each GP practice in a PCN will sign-up to the Network Contract DES through the Calculating Quality Reporting Service (CQRS), when available, and by recording the agreement in writing with the commissioner. CCGs will work closely with Local Medical Committees (LMCs) during the registration period to resolve any issues in order to secure 100 per cent geographical coverage of PCNs. This will include ensuring any patients with a GP practice not participating in the Network Contract DES are covered by a PCN.



3

Description of Primary Care Network and Network Area The CCG and practices will agree Network Areas which are sustainable for the future, taking account of how services are delivered by wider members of the PCN beyond the practices and with a view to the evolution of PCNs as described in Investment and Evolution framework. They should also seek to minimise disruption to any pre-existing Primary Care Networks that have already been locally agreed with their CCGs and wider partners if these also satisfy the Network Contract DES criteria. PCNs will typically serve populations between 30,000 to 50,000, however it is accepted that the upper limit is not fixed. When setting the Network Area, consideration must be given to the future footprint which would best support delivery of services to their patients in the context of the ICS or Sustainability and Transformation Partnership (STP) strategy. The Network Area must cover a boundary that makes sense to its: (a) constituent members (b) other community-based providers who configure their teams accordingly and (c) the local community, and would normally cover a geographically contiguous area. PCNs will not normally cross CCG, STP or ICS boundaries, but there may be exceptions to this such as where the practice boundary, or branch surgery, crosses the current CCG boundaries. Practices have been working within LCNs as part of the vision and strategy evolving from the work of the LCP. Bexley have developed three Local Care Networks on locality footprints; North Bexley, Clocktower and Frognal. LCNs are a framework in which partner organisations can plan and deliver health and care services in an integrated way that delivers benefits to the whole system by planning and managing services based on the population need in each LCN. Addressing the wider determinants of physical and mental health alongside care delivery and scaling prevention are key components in a place-based LCN model. LCNs bring together commissioners and providers of health and care services in a variety of formal and informal structures to improve services in the local areas in which they are based, and to provide care that is person-centred, accessible and coordinated. Each localities population coverage (based on January 2019 list sizes) is as follows: North Bexley 105,750 Clocktower 83,218 Frognal 53,951 The following map indicates the current location and list size (as of January 2019) of practices along with their branch sites in Bexley. The map depicts where practices are members of their current localities, but is not the PCN’s which they may be agreeing to be members of.



http://www.bexleynet.nhs.uk/Our-Changing-NHS/templates-and-branding-guidance.htmhttps:/www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf

http://www.bexleynet.nhs.uk/Our-Changing-NHS/templates-and-branding-guidance.htmhttps:/www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf

4



5

Role of CCG’s and LMCs in PCN formation CCGs and LMCs will need to work closely and in partnership to support PCN formation and development at a local level in order to ensure 100 per cent geographical coverage. CCGs will:

Liaise with the South East London STP to ensure each PCN Network Area supports delivery of services within the wider ICS/STP strategy.

Identify any issues with the proposed PCNs, both within individual PCN submissions, and when considering their registered population area as a whole.

Engage with LMCs and bring practices together to resolve issues to ensure 100 per cent population coverage is achieved.

Approve the submission, ensuring that the registration requirements have been met and that all PCN footprints make long term sense for service delivery and in the context of the GP contract framework.

Support PCN development via investment and development support outside of the DES.

During June 2019, this collaborative working will focus on resolving any issues and supporting practices in forming PCNs and signing-up to the DES. LMCs will bring practices in their area together, mediate where required and help ensure 100 per cent coverage. In Bexley, meetings with the LMC have already been taking place with PCNs now being a standing agenda item on both the informal and formal LMC meetings.

Primary Care Network workforce and requirements PCNs will be able to access funding as part of the Network Contract DES, to support the recruitment of new staff to deliver health services across the PCN, as agreed by members of the PCN and set out in the Network Agreement. Every network of at least 30,000 population will be able to claim 70% funding for one additional whole-time equivalent (WTE) clinical pharmacist and 100% funding for one additional WTE social prescribing link worker. Beyond 100,000 network size, the 2019/20 reimbursement scheme doubles to two WTE pharmacists and two social prescribers; with a further WTE of each, for every additional 50,000 network population size.



6

Additional workforce being introduced from 2020/21 over the period of the contract include physician associates, first contact physiotherapists and paramedics. No reimbursement will be made in 2019/20 for physiotherapists, physician’s associates and paramedics under the Additional Roles Reimbursement Scheme. Any physiotherapists and physicians associates who are employed after 1 April 2019 will not be eligible for reimbursement until April 2020. The same applies to paramedics from April 2021. To provide clarity on what is meant by new additional staff, the Network Contract DES introduces a principle of ‘additionality’. To receive the associated funding, a PCN needs to show that the staff delivering additional services for whom funding is requested comply with this principle of additionality. The additionality rule serves both to protect pre-existing local investment in primary care, as well as to expand capacity. Additionality will be measured on a 2018/19 baseline of staff supporting GP practices as taken at 31 March 2019. The baseline will be determined by combining information from the National Workforce Reporting System (NWRS) as at 31 March 2019 and a survey of commissioners during April 2019 according to subsequent guidance. The baseline will be set against all five staff roles in March 2019 – clinical pharmacists, social prescribing link workers, physician associates, physiotherapists and paramedics. The only exception to this baseline, will be those clinical pharmacists employed via the national Clinical Pharmacist in General Practice Scheme or those pharmacists employed via the Medicines Optimisation in Care Homes Scheme. For this exception to apply the employee must be in post prior to 31 March 2019.



7

PCN Clinical Director The Clinical Director is to be agreed by PCNs by 15 May 2019 and their name submitted to the commissioner as part of the Network Contract DES registration timetable.

The PCN will be required to appoint a named clinical director.

The clinical director will be a practicing clinician from within the PCN member practices.

The post will be held by an individual (or job share) from within the PCN, but cannot be shared across PCNs.

PCNs may wish to consider rotating the clinical director within a reasonable term.

It is the responsibility of the PCN to agree who their clinical director will be and to evidence the process for selection in their application.

Clinical directors will work collaboratively with clinical directors from other PCNs within the ICS/STP area.

Extended Hours Access Provision of extended hour’s access appointments is a requirement of the Network Contract DES from 1 July 2019. This is separate from the CCG commissioned extended access services. An additional period of routine appointments that equate to a minimum of 30 minutes per 1,000 registered patients per week will be required for each PCN

Communications and Engagement to date

Learning Event The CCG arranged a primary care network learning event on 14th March for practices, governing body members and local care partnership leads to hear from Dr Nikki Kanani, NHSE Medical Director of Primary Care on the national requirements and expectations of PCNs and Mark Edgington, SEL STP Director for Community Based Care Program on the SEL STP process in the development of an SEL vision and shared principles framework as well as progress to date of developments across SEL for borough wide integrated care systems. Engagement with stakeholders The CCG has also met with LCN clinical leads and GP federation to explore possible configurations and plans to ensure 100% coverage across Bexley and presented PCN requirements to LCP Board on the 20th March. The GP Federation (Bexley Health Neighbourhood Care CIC) are engaging in practice and locality discussions to facilitate network modeling including workforce, clinical director appointments and hosting arrangements. Discussions are underway to understand the social prescribing model from 1st July 2019, recognising that the BVSC model is well advanced across Bexley.



8

A communications and engagement plan has been developed for staff, the public and wider stakeholders with critical timelines identified. See appendix B Meetings with Bexley LMC have been held on the 13th and 21st March, with PCNs agreed as a standing agenda item for future meetings. SEL STP vision and shared principles issued on 28th March via CCG chairs to practices and LMC. See appendix C NHS England guidance issued on 29th March with details of additional resources. Engagement with Bexley patient council planned for 30th April 2019. Bexley PCN event planned for 2nd May 2019, bringing together proposed networks and local providers to ensure agreement and alignment in advance of formal submission due by 15th May 2019. LCP and CCG discussions with emerging network proposals have been offered to those PCNs wanting to have early conversations to determine levels of support from wider stakeholders for their proposed networks.

Local Risks

Risk Mitigating action

Not enough Bexley GP practices sign up / fail to meet national timescales for agreeing PCNs

Support/information offered to practices through wide variety of channels including CCG, GP federation and LMC

Regular and on-going engagement

Public concern from patient groups/influencers about PCNs

Regular and repeated comms activity

Make use of supportive patient council and PPG representatives to disseminate positive messaging

Meetings with specific stakeholder groups to provide info/address concerns

Positive case study

High or low performing practices all form within one network, causing variation in quality of services between PCNs, impacting on patient outcomes and driving demand for other services (eg. A&E)

Engagement activities with the practices to discuss rationale and alignment to local strategies supported by the CCG, LCP board and LMC

Make use of supportive patient council and PPG representatives to disseminate positive messaging

Meetings with specific stakeholder groups to provide info/address concerns

PCNs do not align with other health and care services (i.e. community, social care, mental health)

CCG PCN event highlighted need to align

SEL Vision and Framework document to support



9

LCP board required to sign-off proposals – offer of supportive conversations with the LCP and CCG.

Conflicting messages between local, regional and national communications and stakeholders

SEL Vision and Framework developed

Letter sent to practices from CCG chairs

On-going practice, federation, CCG and LMC discussions

National guidance available from 29th March 2019

Detrimental impact on existing social prescribing and extended access services

BVSC and BHNC to be included in discussions on PCN development

Opportunities for service provision of both social prescribing and extended access to be scoped

Not enough time or capacity to have required level of discussion on development and leadership of PCNs

CCG and federation to support with PCN events

Time to be made for discussion at

existing forums and locality meetings

Risk to future sustainability of GP federation

Federations to play key role in PCN discussions

Federations to provide clear information on the benefits of federations hosting PCN’s

Cairngall dispersal will impact on payments to networks, as the registered list for PCN’s is taken from January 2019 when the practice still had 5,013 patients registered

Working with NHS England on re-basing list sizes to April 2019

100% network sign-up is not achieved across Bexley

On-going practice, federation, CCG and LMC discussions

Commission Local Incentive Scheme



10

Next Steps Members are asked to note the contents of this paper and to approve to convene an extraordinary meeting to take place in line with the schedule below:

Practices to declare expressions of interest to the CCG by 30th April (internal deadline) to broadly indicate likely PCN configuration.

CCG to carry out workforce survey in April, once guidance released, to provide a baseline stock-take on roles in general practice (focusing on additional roles).

Meeting with practices and local health and social care providers on 2nd May to ensure support for proposed networks.

PCN applications submitted to the CCG by 15th May.

CCG due diligence, governance and submission process on PCN applications from 15th – 20th May.

Proposals to be presented to the LCP Board for approval on the 16th May at an extraordinary meeting.

Proposals to be presented to the CSC for approval at an extraordinary meeting to be scheduled on or prior to the 20th May.

Extraordinary PCCC meeting to take place in line with the LCPB and CSC extraordinary meetings to provide endorsement of the decisions made.

Completion of PCN data sharing agreements to take place once national templates published.

Provision of extended hours access appointments is a requirement of the network contract DES from 1st July 2019, including a minimum of 30 minutes per 1000 patient population.

Contract start date -1st July 2019.



11

Appendix A Further Guidance documents PCN FAQs PCN DES Spec PCN DES Guide PCN DES registration form PCN DES MOU PCN DES network schedules PCN DES VAT info QOF guidance QOF QI info QOF QI case studies QOF QI safe prescribing QOF QI EoLC Enhanced service details also available at: https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/



https://www.england.nhs.uk/gp/gpfv/redesign/primary-care-networks/pcn-faqs/

https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-des-specification-2019-20/

https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-des-guidance-2019-20/

https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-des-registration-form/

https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-network-agreement/

https://www.england.nhs.uk/wp-content/uploads/2019/03/network-agreement-schedules.docx

https://www.england.nhs.uk/publication/the-network-contract-des-and-vat-information-note/

https://www.england.nhs.uk/wp-content/uploads/2019/03/1920-gms-contract-qof-guidance.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/03/an-introduction-to-quality-improvement-in-general-practice.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/03/1920-qof-quality-improvement-case-studies.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/03/1920-qof-quality-improvement-reporting-template-safe-prescribing.docx

https://www.england.nhs.uk/wp-content/uploads/2019/03/1920-quality-improvement-module-documentation-eol-care.docx

https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/

https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/

12

Appendix B Timelines / Milestones / stakeholder meetings Date Milestone

27th February NHSE Supporting the development of PCN’s workshop

13th March LMC Liaison meeting

14th March Bexley PCN Workshop & GP engagement event

19th March SEL Discussion on Approach (SEL Exec Meeting)

20th March Meeting with LCN clinical leads

20th March LCP Programme Board

21st March Bexley LMC meeting

21st March Frognal Locality Meeting

22nd March Development of Comms and Engagement Plan

27th March Final SEL vision and framework document shared to support discussion with local providers and stakeholders

27th March NHSE PCN workshop

28th March SEL Vision and Framework for PCN Contract agreement taken to OHSEL Board

28th March North Bexley Locality Meeting

28th March Clocktower Locality Meeting

29th March Meeting with LCN clinical leads

29th March Network agreement and additional information available from NHSE

2nd April NHSE PCN development support event

4th April CCG Primary Care Development Working Group

4th April Update to Governing Body Seminar

18th April Frognal Locality Meeting

23rd April Update to CSC Meeting

24th April Update to PCCC meeting

24th April LCP Programme Board

25th April CCG/LMC Liaison Meeting

25th April North Bexley Locality Meeting

25th April Clocktower Locality Meeting

26th April OHSEL board sighted on progress to date on local PCN agreement

27th April BHNC Federation – Members PCN event – first indication of potential PCNs

29th April Health and Wellbeing Board

30th April Federation to inform CCG of PCN proposals

30th April Bexley patient council

1st May Bexley Inter-faith forum

2nd May CCG Primary Care Development Working Group

2nd May Primary Care and LCP meeting – early assessment of PCN viability

2nd May ** Bexley CCG Governing Body meeting

8th May Bexley Voice (parent/carer group SEND)

9th May Bexley LMC

15th May PCN submission deadline

15th May Agreement of support to developing PCN arrangements with SEL DASS group.

16th May Frognal Locality Meeting



13

16th May ** LCP meeting on PCNs

21st May Bexley PPG network meeting

21st May ** CSC briefing on network submissions and approval

21st May Local CCG/Place based lead to present rational for PCN agreement for approval by the SEL ICS development board.

22nd May SEL Submission to be approved at OHSEL Board

23rd May North Bexley Locality Meeting

23rd May Clocktower Locality Meeting

29th May ** LCP Programme Board

31st May CCG submission to national and regional team

6th June Update to Governing Body Seminar

13th June GP engagement event

19th June Update to PCCC meeting

20th June Frognal Locality Meeting

26th June LCP Programme Board

27th June CCG/LMC Liaison Meeting

27th June North Bexley Locality Meeting

27th June Clocktower Locality Meeting

1st July Contract start date

Recurring meetings Monday Weekly PCN update with GP federation (BHNC) Wednesday Weekly SEL Network Contract oversight group calls Key

NHS England / SEL STP guidance and engagement

Early indication milestones

Engagement Events/Activities - Patient Awareness - LMC Meetings - Locality Meetings

Governance Meetings

Network Submissions and Go Live

** decision meeting



14

Appendix C - Vision and framework for the agreement of the Primary Care Network (PCN) Arrangements for South East London



1


Title Primary Care Quality Dashboard



That the primary care commissioning committee note.1. The contents of the enclosed quality dashboard and accompanying

highlight report


The dashboard includes practice level information and quality data which is already publically available.

Executive summary

Over the last few months much work has been undertaken on developing a primary care quality dashboard (PCQD) that can be presented to the public meeting of the primary care commissioning committee.

The dashboard has been developed with practice and stakeholder input (including Healthwatch) to ensure that metrics included are meaningful to the public.

The purpose of this is to provide an overall impression of quality at a practice level that encompasses patient experience, patient safety and clinical effectiveness.

The PCQD has been refreshed with the latest available data and this highlight report discusses primary care quality for each metric included. All practices have access to a more comprehensive set of performance and activity data that shows how they compare to their peers, the borough average and London average. It aims to be a useful support tool to help raise awareness of quality improvement areas and discussions on the mechanisms and support available for practices in raising quality and disseminating best practice.

What are the organisational

Key risks None. Data already public.

ENCLOSURE: H1

AGENDA ITEM: 20/19


20.19 Primary care quality report


2

implicationsEquality

Serves as a tool to assess variation in primary care quality. Highlights opportunities for improvement to raise standards to a more consistent level across the borough

FinancialNone

Author: Sarah Birch, Head of Primary Care, Bexley CCG

Clinical lead: Dr Sid Deshmukh, CCG ChairExecutive sponsor:

Nisha Wheeler, Director of Primary Care, ICT & IG



1

ENCLOSURE: H2AGEDNA ITEM: 20/19

Primary Care Quality Dashboard Highlight Report

Background and IntroductionOver recent months Bexley CCG has been working to develop a public facing primary care quality dashboard (PCQD) to give an overall impression of the quality of individual practices in Bexley. A dashboard has been developed that includes a set of publically available metrics that relate to patient experience, patient safety and clinical effectiveness. CQC ratings are also included which span all areas. By triangulating a broad range of data sets it is hoped that a holistic picture of quality is presented where decline and concerns can be identified earlier and addressed.

The purpose of this dashboard is:∑ To serve as a robust, comprehensive, evidence based method for reporting on primary

care quality at a practice level∑ Enable practice staff to better assess how they are performing so they can focus efforts on

areas most in need of improvement but also recognise positive performance∑ Enable the CCG to better identify and spot trends in practice performance so that

problems can be identified early and solutions or support offered to practices∑ To make quality reporting more transparent to the public as many of the data sources that

are available publically are not easy to find and interpret ∑ Inform broader quality improvement work that could be supported at a borough level.

It is proposed that the quality dashboard and accompanying highlight report is brought to the PCCC every other meeting, (i.e. every 4 months) as this should provide sufficient time to see notable changes in performance. The dashboard has been designed in such a way to make comparison and trends easy to identify at a practice level. It is important that the dashboard is reviewed alongside this accompanying report that aids interpretation of the dashboard figures.

In addition to this dashboard, practices also have access to an online activity reporting tool that includes a much more comprehensive set of indicators and data, some of which is not in the public domain. Practices receive monthly hot spot reports that flag their performance and how this compares to other practices.

MetricsThe dashboard includes the following metrics which are explained in the table below:

Data ExplanationList sizes This is the registered number of patients at the practice and is collected

quarterly



2

CQC The Care Quality Commission are the independent regulator of health and adult social care in England. They make sure health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve. They inspect practices at least every 5 years as a maximum interval although can inspect a service at any time irrespective of rating. For practices they appear to do a local area at a time.

Quality & Outcomes Framework

The Quality and Outcomes Framework (QOF) is a voluntary scheme within the General Medical Services (GMS) contract. It aims to support contractors to deliver good quality care. It is a pay for reward scheme that plays a major part in standardisation of long term condition care. It is regularly reviewed and is based on clinical evidence to ensure that incentives are appropriate and beneficial to patients.

Patient Online This relates to the proportion of patients that are signed up for online services, the system that allow patients to book appointments, order repeat prescriptions and access their medical record online. There is a national target that 20% of a practices population are registered for online services.

Friends & Family Test

Practices are required to ask patients whether they would recommend their surgery to friends and family. This is collected monthly and is a contractual requirement that practices have to report to the South East London Primary Care Team.

GP Patient Survey

This is an annual survey that is operated by Ipsos Mori on behalf of NHS England and gets sent out to a sample of patients in every practice across the country. It provides a standardised collection method for gathering patient feedback.

Primary Care Quality Dashboard – Key Findings

The enclosed dashboard is included in appendix A. This section summarises key messages relating to the dashboard and helps to explain the findings and work underway to address this. Practices are grouped together in localities which are historical groupings that broadly align to geography and hence have different demographic features.

List size changes

Key findings to note include:∑ Cairngall Medical Practice – this shows significant list decline as the practice closed on 29th

March following a list dispersal and prior to this patients were encouraged to re-register in surrounding practices.

∑ Surrounding practices have also shown significant growth as a consequence of the Cairngall dispersal, most notably Belvedere Medical Centre, Dr Thavapalan and Bulbanks

∑ Other changes in list size are largely driven by demographic factors (birth rate versus death rate), housing growth, and patients choosing to register at other practices.



3

∑ The average list size of a practice in Bexley (10,122) exceeds the England average (8,507). There is a general trend for practices with larger lists to benefit from economies of scale.

CQC ReportsCQC inspections are a comprehensive assessment of the quality of GP services. Inspections are usually announced approximately two weeks ahead of an inspection and involve a team of inspectors visiting the surgery, asking questions of staff and patients and also looking for policies, processes and documentary evidence to be able to assess the following:

∑ Are services safe?∑ Are services effective?∑ Are services caring?∑ Are services effective?∑ Are services well led?

Each area is given a rating of either:∑ Outstanding∑ Good∑ Requires Improvement∑ Inadequate

The rating given to the five areas then informs the overall rating.

They also assess the quality of services received for the following population groups:∑ People with long-term conditions∑ Families, children and young people∑ Older people∑ Working age people (including those recently retired and students)∑ People experiencing poor mental health (including people with dementia)∑ People whose circumstances may make them vulnerable

All reports are published so are publically available and practices are required to include the rating on their website.

Most Bexley practices had their last CQC inspection during 2015 to 2016. Where a practice is rated as either good or outstanding they are rated every 5 years as a maximum interval but if they are rated as Requires Improvement they will be re-inspected in 12 months or within 6 months for an Inadequate rating to ensure that appropriate actions have been taken to improve the quality of services received.

In recent months CQC has been back in Bexley and so far there have been three recently published reports as follows:



4

1: Lakeside Medical Practice

This is the first Bexley practice to achieve this rating and the inspectors praised the following as areas of outstanding practice:

∑ The practice had a partnership with a local charity and a housing association, called Positive Steps Thamesmead. This provided a very wide range of social prescribing. It provided support to patients and non-patients alike in areas such as housing immigration and debt.

∑ Reception staff at the practice provided drinks and snacks for homeless patients and invited these people to sit inside, away from extreme weather. They were able, for example, to charge their mobile telephones at the practice.

∑ There was a Patient Liaison Officer who was in regular contact with patients who were deemed to be particularly vulnerable.

∑ The practice used technology innovatively, there was a tablet computer in reception so patients contact their GP or access other electronic practice services. The practice had obtained tablet computers for two homes for elderly patients to improve communication.

∑ The practice had set up a sexual health clinic in direct response to the lack of such provision in the area. It was open to patients and non-patients alike.

2: Northumberland Heath



5

3: Ingleton Avenue Surgery

The CCG routinely monitor the publication of CQC reports and summarise emerging themes of success and areas for improvement. Once a greater number of reports have been published, these themes will be discussed with practices more broadly to help inform areas that would benefit from a borough wide response or support. There is also a GP Federation, Bexley Health Neighbourhood Care who are well placed to assist any practices who may need support to improve following a CQC rating.

Quality Outcomes Framework

This shows practices overall achievement in the Quality Outcomes Framework for the 17/18 financial year compared to the 16/17 financial year. The results of QOF are not published until the October following the previous financial year. Key findings are as follows:

∑ The Bexley average was 96% in 2017/18 compared to an England average of 97%. Bexley’s performance declined when compared with the previous year when the average (98% for Bexley) exceeded the England average (96%)

∑ The Cairngall performance at 53% in 17/18 will largely explain the drop in Bexley’s average performance. This practice has experienced a range of issues over the last few years which have been reported on separately to PCCC

∑ 9 practices have scored 100% in both years∑ 5 practices improved their QOF performance compared to the previous year and 5 saw a

decline (one being Cairngall) but four of these practices only reduced by 1-2%.Recent published changes to the GP contract from April 2019 onwards have included improvements to the Quality and Outcomes Framework (QOF) to bring in more clinically appropriate indicators such as diabetes, blood pressure control and cervical screening. In addition there will be the introduction of quality improvement modules for prescribing safety and end of life care where the GP Federation will be well placed to assist in the arrangements of this so that maximum value is achieved through these requirements which includes sharing best practice and peer review activities.



6

Patient Online

There is a national target that practices should have 20% of their patients registered for patient online services and the CCG has dedicated resource that has assisted practices in maximising the benefit of this technology. Key findings to note:

∑ A number or practices have switched clinical systems over the last year and the two patient online systems do not have interoperability to enable the transfer of this switch from one system to another. This means patients have to re-register for online services. This explains why Westwood Surgery, Welling Medical Practice and Bexley Medical Group are below the target – all of whom were above the 20% target prior to their system migrations. These practices are actively encouraging their patients to re-register with online services and patients do not need to show ID again.

∑ There are only two practices (Crook Log and Ingleton Avenue) that have not achieved the target of 20% but are taking active steps to sign up more patients for online services.

Friends & Family Test Results

The dashboard shows friend and families test results for the last 3 months and in brackets the number of responses is included which provides an indication of how representative the sample size is. Key findings to note are:

∑ Crook Log surgery has the lowest FFT results and the issues and actions to address performance improvement are being discussed separately at PCCC

In addition to the ratings, practices receive qualitative feedback from patients that they have the opportunity to review and take corrective action to address patients’ feedback.

Latest GP Patient Survey

The GP patient survey is administered in January of every year and the results are not published until the following July/August. This means the data included in the dashboard is based on patient feedback from January 2018. A comprehensive report was taken to the PCCC meeting held in October 2018 about GP patient survey results for Bexley practices. It was also discussed with the patient council at their meeting in November 2018. The headlines to note were:Key findings worth noting are as follows:

∑ Overall experience of GP surgeries has improved marginally from 79% to 80% but compared to a national average of 84%.

∑ Access to GP surgeries on the telephone has had a notable increase of 5% from 58% last year to 63% this year.

∑ Patients’ experience of making an appointment has dropped by 2% compared to last year, remains below the national average and is at the lowest point since 2013. The national average also declined dropping from 73% in 2017 to 69% this year.



7

To support practices with this, an online consultation tool has been deployed across the borough and there is also NHS Online Bexley app that enables patients enables patients to communicate in a new way with their GP by requesting an online consultation, to manage appointments, order prescriptions and view their medical records.

Conclusion

The dashboard seeks to summarise a range of quality information in a single place to show how primary care performance varies across practices and over time. Raising quality and addressing variation is not a quick fix but there are a wide range of projects and initiatives underway in the borough that help to raise the quality and sustainability of primary care services such as:

∑ Nine Bexley practices recently participated in a Productive General Practice Quick Start Programme which was an on-site, hands-on, short term support package for practices that forms part of a local Time for Care programme and aims to help practices release time for care and build improvement capability. Practices who participated have reported significant time savings for staff allowing time to be reinvest in patient care

∑ Over the last year practices have had protected time with facilitated support to identify changes they wish to make to their practices. They set actions that were followed up six months later.

∑ Workforce challenges is one of the key areas which challenges practices and there has been a range of initiatives to support greater role diversification (e.g. clinical pharmacists)

∑ There is an active GP retention scheme underway that seeks to bring qualified GPs back into the workforce as well as providing mentorship for GPs in their first 5 years of practice

∑ Bexley has benefited from the International GP recruitment scheme whereby two GPs are now working in the borough who relocated from abroad

Practices are also in the process of forming primary care networks which will involve practices working in larger groupings to deliver some services. It is hoped that this provides additional resilience and sustainability for practices in the long term and helps to ensure that all patients receive a high quality and consistent service offering.

The primary care strategy and previously presented implementation plan provides a more comprehensive overview of all the areas of work that collectively aim to raise quality locally.



Locality October 2018 January 2019%

change

Last CQC

report

publication

date

CQC

Rating

QoF

Achievement

16/17

(Maximum 559

point)

QoF

Achievement

17/18

(Maximum 559

point)

%

change

November

2018

December

2018

January

2019

January

2019

February

2019

March

2019

Overall, how would

you describe your

experience of your GP

surgery?

Generally, how easy

is it to get through to

someone at GP

surgery on the

phone?

Overall, how would

you describe your

experience of making

an appointment?

England average 8444 8507

Bexley average 10112 10122

Bexley total list size 242676 242919

Clocktower Bellegrove Surgery 11909 11989 1% 05/11/15 Good 100% 100% 0% 29% 24% 30% 96% 98% 92% 90% 87% 72%

Clocktower Bexley Group Practice 11898 12086 2% 24/07/18 Good 99% 100% 1% 31% 31% 33% 94% 91% 93% 71% 51% 47%

Clocktower Bursted Wood Surgery 5162 5229 1% 29/09/16 Good 90% 94% 4% 23% 22% 23% 94% 94% 96% 93% 93% 84%

Clocktower Crook Log Surgery 8287 8206 -1% 18/11/16 Good 100% 100% 0% 16% 16% 16% 77% 43% 37% 70% 53% 49%

Clocktower Dr Thavapalan & Partners 4550 4808 6% 18/07/16 Good 99% 99% 0% 21% 20% 21% 92% 88% 100% 86% 97% 85%

Clocktower Ingleton Avenue Practice 5116 5135 0% 27/03/19 Good 95% 95% 0% 9% 9% 10% 98% 100% 92% 93% 74% 87%

Clocktower The Albion Surgery 14401 14527 1% 29/04/17 Good 100% 100% 0% 45% 44% 44% 90% 100% 88% 92% 58% 70%

Clocktower The Westwood Surgery 9282 9341 1% 22/09/16 Good 99% 98% -1% 8% 8% 9% 87% 67% 76% 68% 55% 43%

Clocktower Welling Medical Practice 11970 11897 -1% 01/04/16 Good 98% 100% 2% 0% 1% 1% 65% 71% 63% 65% 42% 46%

Frognal Barnard Medical Group 14846 14799 0% 22/04/16 Good 99% 98% -1% 20% 20% 21% 86% 88% 84% 70% 37% 41%

Frognal Plas Meddyg Surgery 7205 7174 0% 06/04/16 Good 100% 100% 0% 46% 41% 47% 94% 90% 88% 95% 91% 75%

Frognal Sidcup Medical Centre 11887 11896 0% 05/10/17 Good 100% 100% 0% 21% 20% 22% 80% 85% 77% 81% 67% 72%

Frognal Station Road Surgery 10181 10128 -1% 03/09/15 Good 98% 100% 2% 43% 39% 44% 92% 80% 92% 79% 41% 54%

Frognal Woodlands Surgery 9979 9954 0% 15/10/15 Good 100% 100% 0% 31% 28% 31% 94% 92% 90% 85% 51% 47%

North Bexley Belvedere Medical Centre 12044 13732 14% 05/11/15 Good 99% 99% 0% 37% 17% 37% 86% 90% 88% 94% 90% 85%

North Bexley Bexley Medical Group 17208 17353 1% 29/04/16 Good 100% 98% -2% 7% 8% 7% 83% 88% 89% 77% 71% 60%

North Bexley Bulbanks Medical Centre 3671 3773 3% 15/10/15 Good 100% 98% -2% 23% 22% 24% 96% 95% 93% 92% 74% 76%

North Bexley Cairngall Medical Practice 7507 5013 -33% 16/10/17 Good 96% 53% -43% 23% 8% 20% 72% 73% 100% 61% 54% 45%

North Bexley Crayford Town Surgery 8991 9049 1% 20/05/16 Good 100% 100% 0% 24% 22% 24% 92% 85% 84% 85% 65% 61%

North Bexley Riverside Surgery 9039 9018 0% 01/10/15 Good 99% 99% 0% 22% 21% 23% 81% 83% 71% 69% 51% 51%

North Bexley Lakeside Medical Practice 16245 16355 1% 16/01/19 Outstanding 98% 98% 0% 26% 26% 26% 94% 94% 91% 78% 55% 61%

North Bexley Lyndhurst Medical Centre 9154 9233 1% 05/11/15 Good 100% 100% 0% 26% 25% 28% 96% 94% 100% 90% 77% 81%

North Bexley Northumberland Heath M.C. 13827 13916 1% 03/01/19 Good 100% 100% 0% 25% 25% 25% 88% 88% 86% 85% 58% 72%

North Bexley Slade Green Medical Centre 8317 8308 0% 16/08/17 Good 85% 86% 1% 25% 24% 26% 84% 83% 81% 79% 60% 56%

Latest GP Patient Survey (GPPS)

July 2018Patient Online

% patients enabled for e-Bookings

Quarterly Monthly Monthly

List size overview CQC Reports Quality Outcomes Framework Friends & Family Test (FFT)% Recommended (Responses)

Annual Annual Rolling programme

CCG Average 63%

National 70%

CCG Average 62%

National 69%

Practice

Data frequency

Benchmarking

England

average

Good

England

average

96%

England

average

97%

N/AN/A N/ACCG Average 80%

National 84%

(50) (49) (50)

(161) (162) (167)

(50) (49) (50)

(56) (46) (46)

(48) (51) (50)

(48) (50) (49)

(48) (50) (50)

(61) (52) (49)

(48) (49) (48)

(50) (48) (49)

(50) (49) (50)

(49) (48) (48)

(50) (49) (50)

(50) (49) (50)

(50) (48) (50)

(98) (65) (70)

(47) (44) (44)

(29) (15) (5)

(48) (48) (49)

(47) (46) (42)

(107) (97) (98)

(50) (50) (50)

(50) (49) (49)

(49) (42) (47)

20.19 Prim

ary care quality report

83 of 87P

rimary C

are Com

missioning C

omm


ENCLOSURE: I1

AGENDA ITEM: 22/19

1



Title Delegated Primary Care Finance Report on Month 12 2018-19



That the primary care commissioning committee;

1. NOTE the update on the Month 12 2018-19 position including the final overspend position of £48k.


There may be a conflict of interest for any Bexley GP on this committee as this report concerns payments to GP practices in respect of their contractual arrangements for GMS, PMS and APMS.

Executive summary

The committee has previously received a number of papers regarding the 2018/19 budget setting process and the fact that there is a negative budget included in the overall budget to ensure that the budget allocation of £29,321k is not exceeded; this is even taking into account the allowable contingency.

As indicated in the previous report to PCCC, there are two main financial issues which will put additional pressure on the delegated primary care budget. The first is the requirement for the caretaking arrangements at one of our practices to continue to the end of the financial year, following which there will be the potential costs of the dispersal of this substantial patient list plus some admin costs related to additional capacity linked to the re-registration process and also potential redundancy costs for staff at the closing practice. This issue has been eased to some extent by the receipt of some additional resilience funding which has been attributed to cover a number of these costs. The second issue has been the announcement of the General Practice Pay Awards which equate to approximately 2%, the

22.19 Primary care finance report


2

CCG set aside 1% for pay awards and so there is a funding gap at present of circa £113k. Representation has been made to NHS England for additional funding to bridge this gap but the CCG has now been advised that there is no further funding available for this.

There have not been any primary care QIPP schemes in place for 2018/19 as the budget was already under pressure prior to the two issues above being raised. However, it should be recognised that primary care colleagues have become more involved and supportive in a number of the QIPP schemes for 2018/19 and those being developed for 2019/20. In fact the primary care team is leading on the requirement from NHS England to visit all GP practices to discuss referral management following the national and local increases in referrals to secondary care. The initial round of meetings has now been completed and generally primary care colleagues have been positive about the work required and action plans for practices have been constructed and agreed with them. The second tranche of visits has also now been completed, the purpose of these visits was to obtain an update on progress with the practice action plans, and discussions on 2 week wait referrals and also mental health referrals. The initial feedback from the second round of visits has been that the GPs are using the tools available more (Consultant Connect and Advice and Guidance), additional support has been requested from some on the use of DXS. Also, there has been some evidence that the rate of referrals from GPs has started to decrease as these additional tools are being utilised more.

In 2018/19, any payments relating to 2017/18 should be offset by year end accruals. At month 12, the primary care team had been able to release £320k of unused accruals into the financial position. A number of pre 2017/18 creditors have also been settled and these have been recharged to NHS England which provided a cash benefit to the CCG.

At month 12 (see Appendix 1), the delegated primary care budgets are reported as showing an overspend of £48k which is an improvement on previous forecasts reported at this committee. This overspend accounts for the extension of the caretaking arrangements for one of our practices plus the unfunded 1% of the pay award. The additional costs of closing the practice have also been included within the overall CCG budget with the additional resilience income received being used to mitigate this impact. Given the negative budget included in the primary care budgets to balance the books, this small overspend shows that the budget has been well contained and managed during the year.

A separate paper will deal with the 2019/20 planning and budget setting arrangements for primary care.

What are the organisational

Key risks There are no further risks relating to the 2018/19 financial position as the year is now closed and the



3

implications CCG will be reporting within the £10m deficit position which has been forecast for some months.

EqualityN/A

FinancialThere are no further risks relating to the 2018/19 financial position as the year is now closed and the CCG will be reporting within the £10m deficit position which has been forecast for some months.

Author: Julie Witherall, Deputy Director of Finance

Clinical lead: Dr V BhallaExecutive sponsor:

Malcolm Hines, Director of Finance





Documents

Primary Care Commissioning Committee , Part 1 Held in Public … Care... · Blossom Care Homes Ltd: i) 15% Shareholding ii) Father is Director of Blossom Care Homes Ltd ... Dr Anjan