AGENDA - NHS Sutton CCG · AGENDA Chair: Susan Gibbin Report Author Presented by ENC WELCOME &...

PRIMARY CARE COMMISSIONING COMMITTEE

Wednesday 18th September 2019, 1:00 – 3:00pm

Meeting Room 1, Priory Crescent, Cheam, Sutton SM3 8LR

AGENDA

Chair: Susan Gibbin Report Author Presented by ENC

WELCOME & INTRODUCTIONS

1. Welcome & Apologies for Absence

Susan Gibbin

2. Register of Declared Interests

Primary Care Committee members are asked to

declare if their entry upon the Register of

Declared Interests (attached) is not a full,

accurate and current statement of any interests

held.

Jane Walker Susan Gibbin 01

1:00-1:15pm

3. Minutes of previous meeting

To approve the minutes of the Sutton Clinical

Commissioning Group Primary Care

Commissioning Committee meeting held on 20

March 2019

Andrea Merry Susan Gibbin 02

4. Matters Arising

To review any matters arising and the action log

following the meeting held on 20 March 2019

Layla Egwenu

Susan Gibbin 03

FOR APPROVAL

5. Spirometry and Ear Irrigation LCS Sian Hopkinson 04 1.15-1.30pm

6. Robin Hood Health Centre Reconfiguration Geoff Price 05 1.30-1.45pm

FOR UPDATE & DISCUSSION

7. PMS Performance Review 2018/19 Sian Hopkinson 06 1.45-2.00pm

8. Finance Report 2019/20 Month 4 Geoff Price 07 2.00-2.10pm

FOR NOTE

10. Sutton Medical Centre Remedial Notice

Review and CQC Report

Paul Harris 08

2.10-2.20pm

11 Beeches Surgery CQC Report Paul Harris 09 2.20-2.40pm

12. GP Practice Opening Hours William Cunningham-Davis 10 2.40-2.45pm

13. Reports from the:

• PCTOMG

• Quality Surveillance Group

11

Verbal

2.45-2.50pm

14. Risk Register

Sian Hopkinson 12

2.50-2.55pm

15. PCCC Forward Plan

Susan Gibbin 13 2.55-3.00pm

FOR INFORMATION

16. Questions from the Public Susan Gibbin

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Members of the public can submit questions

relating to the agenda if raised with the Chair 48

hours prior to the meeting. The Chair will make

every effort to ensure questions are responded

to at the meeting however there may be

occasions where time constraints preclude this.

If a question cannot be answered at the

meeting, or a fuller response is required, a

written reply will be sent as soon as possible.

ANY OTHER BUSINESS & CLOSE

17. Any Other Business

All 2.55-3.00pm

18. Meeting Close

Date of Next Meeting

The next meeting of the Primary Care Commissioning Committee on Wednesday 18th December 2019,

1-3pm, MR1, Priory Crescent

Closure of Part I To resolve that the public now be excluded from the meeting, on the basis that publicity would be prejudicial to the

public interest by reason of the confidential nature of the business to be conducted in the second part of the agenda.

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Register of Interests

NHS Sutton CCG’s Register of Interests are made publicly available at the Governing Body meetings of the CCG and can be found at

http://www.suttonccg.nhs.uk/News-Publications/publications/Key%20publications/DECLARATIONS%20OF%20INTEREST%20-%20January%202016.pdf

The Register is maintained by the Head of Corporate Governance. The Register is constructed in line with the CCG’s Constitution and Conflicts of Interest

Policy which can be found at

http://www.suttonccg.nhs.uk/News-Publications/publications/Key%20publications/GB%20Approved%20SCCG%20Conflicts%20Of%20Interest%20Policy.pdf

The Register contains details of all members of the CCG’s formal committees and the Governing Body itself. The interests of those individuals that are in

attendance only will be captured in the minutes of the meeting concerned.

Name

CoI Form

Completed / Updated

Position Held Declaration of Interest Membership

Date CoI training

Completed/ Received certificate

Go

vern

ing

Bo

dy

Au

dit

Exec

uti

ve

Fin

an

ce

No

min

ati

on

s

Pri

mary

Care

Qu

ality

Re

mu

nera

tio

n

Su

tto

n &

Mert

on

Ch

ari

tab

le F

un

ds

Pippa Barber 25.09.16 01.12.16 13.11.18 02.05.19

Governing Body – Independent Nurse

• Director THF Health Limited

• Non-Executive Director at Kent Community NHS Foundation Trust

• Media appearances in previous role within NHS

• Trustee Demelza Hospice Care for Children

✓ ✓ ✓ ✓ ✓ 29 May 2019

Sarah Blow 25.01.18 Accountable Officer (1 April 18)

• Trust Governor for Greenshaw Learning Trust ✓ ✓ Held by SWL Alliance

Dr Robert Calverley

08.12.17 11.10.18 01.05.19

GP Board Member Wallington Locality Lead

• GP partner at Manor Practice (1.11.16)

• Member of Sutton GP Services Ltd

• GP Trainer. Non voting member on PCCC

✓ ✓ ✓ 25 June 2019

Dr Imran Choudhury

22.02.18 02.05.18 02.05.19

Director Public Health

• Commissioner of GP services via London Borough of Sutton Public Health budget

✓ ✓

Dr Jonathan Cockbain

01.12.17 08.11.18

GP Board Member Carshalton Locality Lead

• GP Partner

• Joint Clinical Director of Carshalton Primary Care Network

• Member of Sutton GP Services Ltd

• Wife is a tutor at Sutton College (ESOL)

• GP extended access hub sessions

✓ ✓ ✓ 15 July 2019

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Reviewed: 09 September 2019 Jane Walker, Head of Corporate Governance

Name

CoI Form

Completed / Updated

Position Held Declaration of Interest Membership

Date CoI training

Completed/ Received certificate

Go

vern

ing

Bo

dy

Au

dit

Exec

uti

ve

Fin

an

ce

No

min

ati

on

s

Pri

mary

Care

Qu

ality

Re

mu

nera

tio

n

Su

tto

n &

Mert

on

Ch

ari

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ds

Non voting member on PCCC

Dr Jeffrey Croucher

25.01.17 31.10.18

Clinical Chair • GP Partner at Benhill and Belmont GP Centre

• Benhill and Belmont GP Centre is a Member of the Sutton GP Federation

• Received a research grant from the Health Innovation Network in 2015/2016 for Musculoskeletal clinical services in Sutton

• Project Lead for the Belmont surgery, in developing the new Belmont GP Centre

• GP Trainer at Benhill & Belmont GP Centre.

• Partner is a Consultant Gynaecologist/Infertility Services at Epsom & St Helier NHS Trust.

✓ ✓ ✓ 16 May 2019

Susan Gibbin 09.06.17 11.04.18 19.11.18 22.05.19

Lay Member - Performance

• Owner/Director – Susan Gibbin Consultancy Ltd

• Freelance consulting with Carnall Farrar Ltd – Health and Care Consultancy Firm

• Trustee/Director for the Bourne Education Trust

• Governor at St Mary’s Primary School, Oxted.

• Management Consultancy, Susan Gibbin Consultancy Ltd

✓ ✓ ✓ ✓ 30 May 2019

James Murray 25.01.18 Chief Finance Officer

• Director, MPL

• Associate Director, Prolex Consultancy

✓ ✓ ✓ Held by SWL Alliance

Dr Dino Pardhanani

08.02.17 31.08.18 20.12.18

Joint Clinical Director

• GP Practice representative

• Practice is a member of GP Federation

• GP WSI ENT – work on ad hoc basis Epsom & Kingston Community Non voting member on PCCC

✓ ✓ ✓ ✓ 18 June 2019

Stephanie Phillips

07.03.19 Governing Body – Patient & Public Involvement

• Member of Sutton Healthwatch ✓ ✓

✓ ✓ 06 May 2019

Michelle Rahman

01.05.18 10.05.19

Acting Managing Director

• No interests to declare. ✓ ✓ ✓ 09 July 2019

Karol Selvey 01.10.16 16.11.17 10.09.18 13.05.19

Joint Clinical Director

• Partner – Dr Grice & Partners

• Practice is member of Sutton GP Services Federation Non voting member on PCCC

✓ ✓ ✓ 29 May 2018

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David Smith 27.03.19 Governing Body – Audit & Governance

• Director – D Smith Partnership Ltd

• Trustee – Active Oxfordshire

• Senior Advisor – Newton Europe

• Associate – Oxford Centre for Triple Valve Healthcare

• Lay Member & Lay Vice Chair – Merton CCG

• Independent Chair – Sussex & Kent CCGs 111 Procurement Joint Committee

✓ ✓ ✓ ✓

✓ Held by Merton CCG

Dr A Hervey Wilcox

11.03.19 22.07.19

Governing Body - Independent Secondary Care Doctor

• Governor, Homefield Preparatory School, Sutton ✓ ✓ ✓ 26 June 2019

Lucie Waters 01.05.18 Managing Director

• No interests to declare. ✓ ✓ ✓ ✓ ✓ 15 May 2018

David Williams

24.02.17 18.11.17 04.03.18 14.05.18 16.07.18 24.01.19

Chair - Healthwatch (Participating Observer)

• Member of Old Court House Surgery Patient Participation Group

• Chair, Patient Reference Group

• Chair Healthwatch Sutton

• Vice Chair (Substitute) for Health & Wellbeing Board

• Appearances on Radio St Helier

• Son is Senior Planning Officer with the London Borough of Sutton.

• Owner of Alexander Grant Management Consultancy

• Chair of the IHT SRG with SWL

✓

Mary Hopper 21.09.16 13.11.17 10.04.18 03.05.19

Director of Quality

• No interests to declare. ✓ ✓ 25 June 2019

Sean Morgan 15.11.17 01.05.19

Director of Performance & Delivery

• No interests to declare. ✓ 08 April 2019

Geoff Price 19.09.16 31.01.17 17.03.17 10.04.18

Director of Finance

• Daughter working in a nursing post with Epsom and St Helier NHS Trust at Epsom hospital.

• Daughter working as a GP but not in Sutton.

✓ ✓ 05 Jun 2019

Mike Procter 10.10.18 Programme Director – Commissioning (Interim)

• Owner/Director Mike Procter Consulting Ltd ✓

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LEAVERS

Sally Brearley (Left Feb 2019)

07.12.16 16.11.17

Lay Member – Patient & Public Engagement and Chair of the Quality Committee

• Fellow in Patient & Public Involvement Kingston University

• Patient registered at Old Court House Surgery

✓ ✓ ✓ ✓ 31 May 2018

Dr Senthooran Kathirgama Kanthan (Left Feb 2019)

26.09.16

25.04.18 GP Board

Member

Sutton and Cheam Locality Lead

• GP Partner Well Court Surgery – James O’Riordan Medical Centre

• GP Tutor St George's Medical School

• Member of Sutton GP Service Ltd (Sutton Federation).

✓ ✓ 10 May 2018

Dr Les Ross (Left Mar 2019)

21.09.16

10.04.18 Lay Member – Secondary Care Consultant

• Honorary Treasurer for Sutton & District Medical Society

• Honorary Treasurer for Gynaecological Study Group

• Daughter is a Consultant at St Mary’s (Imperial College) potentially giving

tertiary service

• Registered as a patient at Carshalton Fields Surgery.

✓ ✓ ✓ ✓ ✓ ✓ 27 Feb 2018

Paul Sarfaty (Left Mar 2019)

05.10.16

03.04.18

31.10.18

Lay Member – Governance and Audit, Vice Chair and Chair of the Audit Committee

• Director and Consultant - Feughside Limited

• Trustee of St George's Hospital Charity from 09/17

• Interim Consultant St George’s Hospital Charity (10/18 – 03/19)

✓ ✓ ✓ ✓ ✓ ✓ ✓ 28 May 2018

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MINUTES OF THE SUTTON CLINICAL COMMISSIONING GROUP

PRIMARY CARE COMMISSIONING COMMITTEE

Wednesday 19 June 2019, 11:00am – 1:00pm Meeting Room 1, Priory Crescent

Present

Voting Members:

Susan Gibbin SMG Lay Member, Performance (Chair)

Pippa Barber PB Governing Body Member, Independent Nurse

Stephanie Phillips SP Lay Member – Patient and Public Involvement

Dr Dino Pardhanani DP Joint Clinical Director

Geoffrey Price GP Chief Finance Officer

Non-voting Members:

William Cunningham-Davis

WCD Head of Primary Care, SWL Alliance

Dr Lindsey Roberts LRo LMC Representative

David Williams DW Healthwatch Representative

In Attendance

Andrew McMylor AMM Director of Primary Care Transformation, SWL

Paul Harris PH SWL Primary Care Team

Lou Naidu LN Head of Primary Care Commissioning

Sian Hopkinson SH Associate Director of Primary Care

Dr Chris Elliott CE Associate Clinical Director of Primary Care

Andrea Merry AM Executive Assistant (Minutes)

Apologies

Dr Simon Elliott SE Independent GP Advisor

Michelle Rahman MR Acting Managing Director

Lucie Waters LW Managing Director

Welcome & Introduction

1. Welcome and Apologies SMG welcomed members, both voting and non-voting, to the meeting in public of the Primary Care Commissioning Committee (PCCC). Apologies were noted as detailed above.

2. Register of Declared of Interest The Register of Interest was agreed as a correct and accurate record.

3. Minutes of previous meeting The minutes of the Sutton CCG PCCC meeting held 20 March 2019 were agreed as a true record.

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4. Matters Arising New GP Contract and Primary Care Network Directed Enhanced Services (DES) – to ensure key decision milestones are outlined in the work plan and define the role of the PCCC in assuring the GB on its successful implementation – work plan on the agenda for approval. Locally Contracted Services (LCS) Review – LN to communicate with the LMC, to advise Practices only need to audit on certain drugs as the others are not routinely supplied – LR advised that the LMC was uncertain as to whether this information has been received from LN. Action: SH to follow up with LN

SH/LN

For Approval

5. Extended Access and Primary Care at Scale Programme Plan 2019/20 SH presented the Extended Access and Primary Care at Scale Programme Plan 2019/20 to the Primary Care Committee and advised that it sets out the progress achieved in 2018/19 in the delivery of the Extended Access and the Primary Care at Scale Programme. SH advised that key points to note include:-

• In 2018/19, SCCG received a combined budget for the

extended access and primary care at scheme which was the

first year of a two year programme. The funding comes to

SWL and it has been agreed that it will be divided equitably, at

£6.27 per head for 2019/20.

• The funding is for the extended access service which is

delivered from two hubs: Wrythe Green and the Old Court

House surgeries by the GP Federation. The hubs deliver a

service 6.30 p.m – 8.00 pm weekday evenings and 8.00 a.m –

8.00 p.m on the weekend. The remainder of the funding is for

the second year of the primary care at scale programme.

• In 18/19, SCCG was required to make a top up to the service,

however it is proposed that this arrangement will not continue

for 19/20. The rationale behind this decision is that the entire

budget will ultimately transfer to the Primary Care Networks by

April 20/21 and needs to be able to fully fund the service.

• The extended access service has performed well in 18/19, with

90% utilisation of slots achieved by year end. 20,000

additional GP and nurse appointments have been offered to

patients.

• Direct bookings are being taken from ED and NHS 111 in

addition to direct bookings from patients.

• The service has expanded over the course of the year and

cervical screening appointments are now being offered at the

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weekends. The CCG is in discussion with the GP Federation

to determine if there are other services which could be

provided.

• With regard to Primary Care at Scale, a number of projects

have been developed in 18/19 focussing on the planning and

mobilising of those services. Work carried out in 19/20 will

involve ensuring a sustainable roll-out of services is achieved.

• The key focus initially with PCAS was regarding proactive MDT

care planning for patients with complex needs. There has

been a delay in the roll out of this initiative due mainly to

recruitment issues. Discussions are ongoing with Epsom & St

Helier as to how to achieve an interim solution.

• MDT meetings which have taken place have been positive.

The GP Federation has been successful in organising and

coordinating meetings and ensuring that the locality nurses are

undertaking comprehensive assessment of patients.

• Acute home visiting commenced in March. It has been

acknowledged that further work is required to ensure that the

correct model is in place.

• Work is ongoing with Sutton Health and Care around the

proactive and preventative business case, specifically

regarding the development of the social prescribing support for

the Proactive Locality MDTs in partnership with the Primary

Care Networks and their link workers.

• The Federation has been involved in developing the model for

triaging online consultations of patients where the outcome is

the need to speak to a clinician urgently.

The Committee discussed the report at length and the following

questions/comments were raised:-

• PB asked for clarity regarding the current arrangements for the

measuring of impact and outcomes of services described and

whether a year on, there is evidence of the impact of the

funding which has been invested. SH advised that monitoring

is ongoing through the recording of patients going through the

MDT process, those using the acute visiting and through the

coding of patients receiving social prescribing support. Future

monitoring will include reviewing the activity of these cohorts of

patients both before and after intervention by looking at both

hospital and primary care activity. A new measuring tool will

be provided by the CSU, however it should be noted that there

has been a delay in the introduction of the tool due to issues

regarding the data sharing agreement.

• SH confirmed that monitoring of outcomes has been agreed,

however the impact on patients will not be immediately

available due to the need to monitor activity for at least 6

months after intervention

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• CE commented that a discussion was held at the last

Operational Management Group regarding MDTs as there has

been a challenge as to how efficiently the meetings are being

run and it has been agreed that CE will be attending some

meetings as an observer.

• CE advised that it is hoped that the issue regarding diverting

patients from A & E to Primary Care can be resolved by

providing one number to A&E for all patients going forward.

The federation could then become responsible for managing

those patients and arranging a Primary Care appointment for

patients if required.

• RC queried the funding for 19/20, specifically the

arrangements for services which started halfway through the

year and if they would still receive two years’ of funding. SH

confirmed that the funding is ongoing however it was initially

introduced as a two year programme and will be transferred to

the PCNs by April 2021.

• SMG asked how moving forward into the second year the

PCNs would engage in the conversation as to how that funding

is being used. SH advised that the Clinical Directors are

invited to the Primary Care Transformation and Operational

Management Group, and a discussion will be held regarding

ongoing funding and services. AMc confirmed that a plan for

next year is being developed and is in traction.

• SH commented that there is £64k unallocated in the budget

and it is anticipated that this will be utilised to support PCN

development. SMG asked if the PCCC could be given

assurance at each meeting in terms of the progress going

forward. CE suggested that this should be a standing item at

each meeting to provide assurance that the CCG and the

PCNs are working together collegiately and to hold each

organisation to account.

Recommendation

The Primary Care Committee APPROVED the allocation of

funding for 2019/20 for the Extended Access Services and the

Primary Care at Scale Programme.

6. Primary Care Network Membership

SH presented the Primary Care Network Membership report and

advised that the last Primary Care Commissioning Committee in

Seminar had approved the membership of networks and it was agreed

at that meeting that this decision should be formally ratified in public.

Recommendation

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The Primary Care Committee RATIFIED the approval of network

membership as described and NOTED the progress towards

meeting the key objectives outlined in this paper.

7. Special Allocation Scheme

WCD presented the report to the Primary Care Commissioning

Committee and advised that it provided an update regarding the

commissioning options for providing the Special Allocation Scheme

(SAS) services in SW London, the proposed commissioning

arrangement and the cost of the service.

WCD advised that key points to note include:-

• There are currently two providers of this service in SW London,

the Primary Care Extra Service in Wandsworth and the

Croydon Safe Haven for Croydon patients. The Croydon Safe

Haven service has recently been reprocured as an APMS

contract.

• NHS guidance has changed whereby more support has been

added to the service. This support includes the provision of a

security guard and a separate telephone line in accordance

with a more standardised approach across the country.

• The CCG will be looking to recommission the service as a DES

and all practices will be offered the opportunity to provide the

service.

• The SWL DES model includes a provision for the provider to

carry out regular risk audits and to provide security guards on

site to protect staff.

• The cost per CCG equates to £22,000 per annum which is an

increase to the service of £8,976.

The Primary Care Commissioning Committee discussed the report

and the following comments and questions were raised:-

• SMG asked if there was a threshold level for the services.

WCD advised that a nominal figure has been set of 70 patients

across the four CCGs, individual CCGs would then have to

pay for their individual patients who exceeded this threshold.

• SMG asked what is the historical use of the service across the

CCGs? WCD stated that it has not been possible to predict on

a population usage due to fluctuations in use, however,

historical information is available to determine trends.

• CE asked if patients are being monitored to determine the

usage of the service and that he would want to know that the

capacity is being fully utilised. WCD stated that the new

service will provide much more data rich information than in

the past.

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• PB questioned who will monitor the service and how will it be

evaluated. WCD stated that the monitoring process will be

stipulated in the contract and one CCG will host the contract

for SWL.

Recommendation

The Primary Care Commissioning Committee APPROVED the

commissioning of the Special Allocation Scheme (SAS) as an

Enhanced Service arrangement and NOTED that there would be a

small increase in the cost of the SAS services.

For Discussion

8. Primary Care Transformation and Operational Management

Group Report - 12 March, 23 April and 11 June 2019

SH highlighted a key issue from the last Operational Management

Group meeting which was namely that the meeting had reviewed the

first draft report regarding PMS performance. The report will be

further reviewed when data regarding all indicators is available.

Where practices are not performing to the level of their contract, LN

will be working with them to develop an improvement plan and a

formal feedback report regarding PMS performance will be presented

to the September Committee meeting.

CE stated that one practice has not joined a Primary Care Network.

Arrangements with the Federation have been put in place with regard

to provision of the extended hours service for those patients.

LR asked if the practice that has not joined the Primary Care Network

would have any contractual agreement with the PCN. WCD confirmed

that it is envisaged that a contract variation agreement will be entered

into with this practice.

The Primary Care Commissioning Committee NOTED the Primary

Care Transformation and Operational Management Group Report

Update

9. Primary Care Quality Surveillance Group Report - 6 June 2019

CE advised that discussions at the Primary Care Quality Surveillance Group include how the CCG reviews and assesses the ‘subtle’ quality issues in general practice in Sutton. CE advised that he has a slight concern regarding the arrangements for the quality role with PCNs in the future, specifically how much of

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this role will stay at the practice and how much will transfer to PCN level. SMG asked will there be a change in the strategy and focus of the practice visits. CE confirmed that the strategy will stay the same as they are there to support the practice as much as they are to challenge them. LN advised that she plans to discuss the options around practice visits going forward as the value of these visits has been recognised at the Quality Surveillance Group. It has been acknowledged that the resource required to continue the visits will be difficult to sustain. WCD highlighted the fact that as part of the new arrangements, PCNs

will have ownership of their own dashboards which can then be

reviewed peer to peer within the network. CE stated that local

ownership is important, however expertise which exists within the

CCG is vital to support practices.

SH advised that practices do not see their role as performance

managing each other, however there is merit in reviewing quality data

for areas where they can collectively work together to improve quality.

The Primary Care Commissioning Committee NOTED the Primary

Care Quality Surveillance Group update

10. Sutton Medical Centre Remedial Report

PH presented the Sutton Medical Centre Remedial Report to the

Primary Care Commissioning Committee and advised that it provided

an update relating to the contractual requirements that were breached

by the practice following an inspection by the CQC in October 2018.

PH advised that key points to note include:-

• A second remedial notice was issued to the practice following

a CQC inspection in October 2018. The first remedial notice

was issued in January 2015 following an inadequate rating.

• Following the second remedial notice, the practice was asked

to provide an action plan which would then be reviewed by the

commissioning team. Sufficient evidence of improvement has

been provided and the practice was again inspected in May

2019. The outcome of this inspection is still awaited.

The Primary Care Commissioning Committee is asked to ratify the

Primary Care Transformation and Operational Management Group’s

approval of the recommendation that no further contractual action is

required at this stage but that the remedial notice remains in place and

that the practice is reviewed again in three months’ time. It should be

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noted that this recommendation is subject to change depending on the

outcome of the CQC inspection in May 2019.

Recommendation

The Primary Care Committee ratified the decision agreed by the

PCTOMG as below that:-

• No further action is currently taken and the remedial notice remains in place.

• They are reviewed again in three months’ time, with a caveat that this could be subject to change depending on the outcome of the CQC inspection.

When the practice is reviewed in three months’ time, this should

include a request for evidence of continuous improvement,

particularly relating to:

• Clinical audit;

• Management of complaints, significant events and incident reporting, and;

• Risk management.

11. Primary Care Finance Report GPr summarised the Primary Care Finance Report 2018/19 and 2019/20 budget report to the Primary Care Commissioning Committee. Finance Report 2018/19

For financial year 2018/19, there was satisfactory financial

performance in that primary care budgets were in balance. For the

core contract (delegated budget) there was an underspend of £89k on

total spend of £26.7 million which is a 0.3% variance.

For other CCG primary care budgets there was a net underspend of

£400k for which the main variances were an overspend on GPIT,

offset by underspends on the Out of Hours contract, Locally

Contracted Services (LCS) and staff pay (due to one off recharges).

2019/20

The primary care allocation for the financial year 19/20 has increased

by some 5.84% over 18/19. This quite significant increase is to fund

part of the 18/19 award that was not funded in 18/19, the 19/20 pay

award, list size growth, non-pay inflation and importantly the costs of

PCNs.

The allocation change from 18/19 to 19/20 is summarised below:-:

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Primary care delegated budget allocation

£000s

2018/19 allocation start point 26,294

Growth 1,589

James O'Riordan adjustment 946

GP Indemnity insurance adjustment -801

2019/20 allocation

28,028

The £800k insurance adjustment arises as these costs are now met

centrally. The allocations announced changed the way allocations are

calculated and the Sutton allocation did not include funding for the

James O’Riordan practice. This funding was subsequently transferred

from Merton CCG.

2019/20 core Practice/delegated budget

This shows a projected gap (budgeted costs exceed allocation) of

£247k. This is the result of the cost of PCNs shown as £949k. In fact

the PCN costs in 19/20 is around £1.25 million as there is also a

budget for £1.50 per head (£300k) included in other CCG budgets.

The gap of £247k assumes all PCN staff will in in place in accordance

with the guidance but in reality this is probably unlikely. The position

will be monitored monthly. Note that the £247k for Sutton CCG

contributes to a £1.5 million potential gap across SWL.

All other Primary care budgets funded by the CCG have now been set.

These include the primary care team; GP training; LCS; GP

engagement scheme; Out of Hours and the £1.50 ph (£400k) for

PCNs. The funding for primary care at scale (and extended access)

has recently been set (£1.13m for Sutton CCG) and this budget will be

established for 19/20 once funding is received.

Recommendation

The PCCC noted the Primary Care Finance report

For Note

12. Primary Care Work Plan 2019/20

LN presented the Primary Care Work Plan 2019/20 to the Primary

Care Commissioning Committee for information and advised that it

mapped out the key primary care workstreams to provide clarity

around the work which is currently being undertaken and how it links

in with the delivery of the Primary Care Strategy. The work plan also

outlines where the leadership sits and relevant timescales to enable

monitoring on performance and delivery and to support forward

planning and recognise where key decisions need to be made.

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SMG commented that it is beneficial to know when decisions need to

be brought Primary Care Commissioning Committee and that they

have gone through due process. SMG suggested that feedback on

the primary care strategy could be brought to the Committee on a

thematic basis to provide assurance.

Recommendation

The Primary Care Committee NOTED the Primary Care Work Plan

2019/20

12. Estates Update

LN presented the Estates Update to the Primary Care Commissioning

Committee and advised that it provided information on the progress to

date of two estate projects which are namely:-

• Hackbridge Medical Centre at New Mill Quarter

• Benhill and Belmont GP Centre (Belmont branch) new

development.

LN advised that key issues to note include:-

Hackbridge

• Practical completion is expected between the end of November

and early December which will therefore still conform to the

practice’s exit strategy.

• The shell is complete and fit out works are due to commence in

mid-July.

• LN has asked the practice to inform the CCG if there are any

cost pressures associated with the move.

Benhill and Belmont GP Centre (Belmont Branch)

• Planning permission has been approved to build a new GP

surgery on the former Henderson Hospital site.

• A Section 106 Agreement is currently being worked up by

lawyers.

• Given that the project was approved by the Committee some

time ago, LN has written to the third party developer to

determine if there are any material changes to cost. Any such

changes would need to be reviewed by the CCG prior to the

tender of contracts.

• A 12 month build is expected, therefore practical completion is

anticipated in the autumn of 2020.

Recommendation

The Primary Care Commissioning Committee NOTED the

progress of the two estate projects.

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13. Policy Guidance Manual

WC-D presented the Primary Medical Care Policy Guidance Manual

V2 to the Primary Care Commissioning Committee and advised that a

second revision of the document was published in April 2019. Primary

Care Commissioning Committee members are therefore asked to note

the amendments.

Recommendation

The Primary Care Committee NOTED the changes in the Primary

Medical Care Policy Guidance Manual V2

14. Risk Register

SH presented the Primary Care Risk Register to the Primary Care

Commissioning Committee and advised that a request was made at

the last Quality Surveillance Group for an additional risk to be added

regarding the development of Primary Care Networks. This new risk

will be added to the register for presentation at the next Primary Care

Commissioning Committee.

A new process around the risk register has been put in place, however

it was noted that more clarity is needed as there was insufficient

information provided regarding the narrative and risk description

against each risk.

PB commented that some risks are described better than others and

suggested that the Operational Management Group could be asked to

review the register to ensure that the document is worded effectively

to clearly outline the risk and the action being taken to mitigate that

risk.

Action: It was agreed that the risk register document would be

discussed and reviewed at the PCTOMG prior to presentation at

the next Primary Care Commissioning Committee.

SH

For Information

17. Questions from the public There were no questions from the public.

Any Other Business

18. Any Other Business There was no other business to report.

19. Meeting Close

20. Date of Next Meeting The next meeting of the Primary Care Commissioning Committee in public will take place on Wednesday 18 September 2019.

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Updated: 09 September 2019 Jane Walker, Head of Corporate Governance

Sutton CCG Primary Care Commissioning Committee (PCCC) Part 1 - Matters Arising /Action Points from previous meetings.

Date Item Title Lead Comments and Action Required Status

20 March 2019 6 New GP Contract and Primary Care Network Directed Enhanced Services (DES)

SH To ensure key decision milestones are outline in the work plan and define the role of the PCCC in assuring the GB on its successful implementation

Completed: workplan presented

to June PCCC. Future role of PCCC

being developed by SWL to align

committee roles and workplans

19 June 2019 14 Risk Register SH It was agreed that the risk register document would be discussed and reviewed at the PCTOMG prior to presentation at the next Primary Care Commissioning Committee.

Completed: Risk register is reviewed at PCTOMG and PCQSG prior to PCCC

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Sutton Clinical Commissioning Group Primary Care Commissioning Committee Meeting Part 1 in Public

Date Wednesday, 18 September 2019

Document Title Ear Irrigation and Spirometry Locally Commissioned Services

Lead Director (Name and Role)

Michelle Rahman – Acting Managing Director

Clinical Sponsor (Name and Role)

Dr Chris Elliott - Clinical Associate Director - Primary Care

Author(s) (Name and Role)

Lou Naidu – Head of Primary Care Commissioning

Agenda Item 5 Attachment 4

Purpose (Tick as Required) Approve Discuss Note

Executive Summary Ear irrigation and Spirometry are historically procedures undertaken within Primary Care however there are currently no contractual arrangements in place to recognise the work being undertaken. Recognising the resources required to deliver these services it is proposed that a locally commissioned service (LSC) is put in place to ensure that Sutton GP practices are contracted to continue providing each of these services to patients. Working with clinical leads, service specifications have been developed to outline delivery requirements with a view to offering these LCS’s out to practices from 1st October 2019. These service specifications were approved by the Executive Committee on 22/08/2019. Ear irrigation – given the work being undertaken by the planned care team at a SW London level to consider the need for a community micro-suction service and the aspiration to align ear irrigation services in primary care by way of a common LCS, the primary care team propose an initial 6 month LCS contract for the period 01/10/19 – 31/03/2020. This will allow sufficient time to consider a SWL ear irrigation proposal across all 6 CCGs. Spirometry – The primary care team wish to offer this LCS for the period 01/10/19 – 31/03/2021, noting that this is the date the new ARTP guidelines come into force, and as such it would be a sensible time to review the spirometry service specification. Reason for Committee Review: The Primary Care Commissioning Committee are asked to APPROVE the decision to commission Ear Irrigation and Spirometry from Primary care for the periods outlined above.

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Key Issues:

1. This work is already being undertaken by primary care however these procedures sit outside current GP contracts.

2. There is currently no clear service specification or monitoring in place for these services.

3. Tariffs for these services have been developed taking into account similar services commissioned locally and nationally and have been agreed with the LMC.

4. Primary care continues to be the most appropriate place to deliver these services rather than less convenient and more costly referral to secondary care.

5. Delivery through primary care will ensure access for all registered patients. 6. Quality assurance KPIs are included in the specifications and assurance around

competency to deliver the services will be sought at sign up.

Conflicts of Interest: None noted

Mitigations:

Recommendation: The Committee is asked to: APPROVE the decision to commission the following LCSs from general Practice for the periods outlined below;

• Ear Irrigation - 01/10/19 – 31/03/2020

• Spirometry - 01/10/19 – 31/03/2021

Corporate Objectives This document will impact on the following CCG Objectives:

Objective 1: Ensure patients are at the heart of decision making, working in partnership with individuals, patient representative groups, families and carers to deliver high quality, accessible services that tackle inequalities and respond to personal need. Objective 2: Commission high quality cohesive health services for the population of Sutton through joint working between health and social care organisations ensuring patients’ physical, mental and social wellbeing needs are met. Objective 3: Maintain an efficient and financially stable, local healthcare system by improving primary care and community services and working closely with secondary care to deliver

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integrated services that bring healthcare into the community.

Risks This document links to the following CCG risks:

Should these services not be commissioned from primary Care GP practices may choose to cease to provide these services in which case alternative commissioning arrangements would need to be put in place.

Mitigations Actions taken to reduce any risks identified:

Financial/Resource/ QIPP Implications

A budget has been identified from within the current LCS Budget. Forecast spend for each service (01/10/19-31/03/20) is as follows: Ear irrigation - £20k Spirometry - £37k Should these service not be commissioned from primary care there could be an increase in referrals to both ENT and the respiratory team at secondary care thus placing pressure on acute spend and activity.

Has an Equality Impact Assessment (EIA) been completed?

N/A - not relevant as no change in service therefore not completed.

Are there any known implications for equalities? If so, what are the mitigations?

No

Patient and Public Engagement and Communication

Given the proposal would not directly impact or change services for patients this is not relevant in this case

Previous Committees/ Groups Enter any Committees/ Groups at which this document has been previously considered:

Committee/Group Name: Date Discussed:

Outcome:

Executive Committee Thursday, 22 August 2019

Clinical service specifications approved with amendments

PCTOMG Tuesday, 02 July 2019

Consider commissioning through LCS, take to Exec and PCCC

LMC Liaison meeting (Part 2)

Thursday, 04 July 2019

Feedback provided by LMC on service specs

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and similar specs being delivered elsewhere in the country.

Supporting Documents

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Document Title Robin Hood Lane Health Centre PID


Geoff Price – Chief Finance Officer and Estates Lead, Sutton CCG







Executive Summary Dr Seyan’s Practice is a high-performing teaching & training PMS Practice, with a current patient list totalling over 12,500. Currently, the Practice has 847 sqm NIA (Net Internal Area) under rental reimbursement. The proposed development will provide Dr Seyan’s Practice with 6 new clinical rooms (5 consulting rooms and 1 treatment room suite) to accommodate their service, teaching and staffing needs. It will also facilitate service delivery for Primary Care Networks, where the Practice is working with other local surgeries to focus on increased service provision for the locality in conjunction with Sutton GP Services, the local Federation comprising all 23 Sutton Practices. The proposal provides the required capacity for the Practice to deliver increased and improved primary care services for their rising registered population, driven by significant town centre population growth from new housing developments. Under a separate development project, Dr Grice and Partners will be relinquishing 130sqm NIA space in the Robin Hood Health Centre to consolidate their practice onto the expanded Old Court House Surgery site. Adding this to Dr Seyan’s current allocation, the total space becomes 977 sqm NIA, which is within NHS New Build Guidance for a patient list size of 12,500. The landlord of Robin Hood Lane Health Centre, Primary Health Properties PLC (‘PHP’) will fund the reconfiguration and refurbishment works in return for a longer lease commitment extending the current term to 25 years from completion of the works over the whole building. Purpose: The request is put forward by Dr Seyan’s Medical Practice, Robin Hood Lane Health Centre (‘RHL’), Sutton, SM1 2RJ, for confirmation of rent reimbursement for the extended term of the new lease, under the GMS Premises Directions (Rent & Rates

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Scheme) for an increase in surgery floor space to accommodate local population growth and an expanding range of services. It is proposed a new lease will be entered into, over the whole building, extending the unexpired term to 25 years. Reason for Committee Review: On the 8th August Sutton CCG’s Executive Management Team considered this proposal to ensure the strategic fit of this development with Sutton’s Primary Care Strategy, Estates Strategy and financial viability. The Executive Management Team has recommended the PCCC APPROVE this proposal.

Key Issues: 1. The refurbishment and remodelling of RHL will provide functionally-designed accommodation that is both of the highest quality and fit-for-purpose for primary care service delivery. The reconfiguration will provide 6 additional clinical rooms for Dr Seyan’s Practice. 2. With their enlarged surgery area, taking up the whole of the RHL ground floor, the functioning and operation of the Practice will be more efficient, allowing a growing patient list to be accommodated alongside delivering an increased range of primary care and community services, while helping to deliver the new Primary Care Network models of care. 3. While RHL is in good overall condition and was purpose built for the Practice as a third party development completed in 2007, internally it is now tired and out-dated, requiring refurbishment and remodelling to improve the layout and the efficiency of space use. As landlord, PHP is prepared to fund the capital works for the refurbishment in return for the rental commitment requested for the additional space provided. 4. There are no NHS capital cost or anticipated revenue cost increases, however a longer lease commitment is sought by the developer. 5. The project supports the requirement for increased primary care capacity given the significant town centre population growth forecast at 41.8% by 2038.


Mitigations:

Recommendation: The Committee is asked to: APPROVE the confirmation of rent reimbursement for the extended term of the new lease, under the GMS Premises Directions (Rent & Rates Scheme) for an increase in surgery floor space to accommodate local population growth and an expanding range of services. subject to:

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• Robin Hood Lane Health Centre releasing Old Court House Surgery from the existing sub lease arrangements

• Value For Money recommendation and Valuation by the District Valuer

• Agreement of Heads of Terms between the landlord and the tenant


Objective 1: Ensure patients are at the heart of decision making, working in partnership with individuals, patient representative groups, families and carers to deliver high quality, accessible services that tackle inequalities and respond to personal need. Objective 2: Commission high quality cohesive health services for the population of Sutton through joint working between health and social care organisations ensuring patients’ physical, mental and social wellbeing needs are met. Objective 3: Maintain an efficient and financially stable, local healthcare system by improving primary care and community services and working closely with secondary care to deliver integrated services that bring healthcare into the community.


All risks identified within the PiD are mitigated by the developer as per section 20 of the PiD If agreed the project will only proceed subject to the successful repatriation of Old Court House patients from the RHL space which is currently sub-leased to OCH



The cost of developing the space will be covered by the Landlord. There is no capital funding required of the NHS/Sutton CCG, however the landlord will require a new 25 year lease commitment. The current lease expires November 2027.

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The CMR rental required in order to refurbish RHL is £408,000 + VAT (£489,600 Gross) pa. This is the same as currently paid. The rental reimbursement levels to the GPs will be confirmed in the Value for Money Report prepared by the District Valuer to the CCG’s instruction (and cost), from which the rental figures for the lease will be confirmed. The CCG may be approached by the practice to provide financial support for a monitoring surveyor and legal fees. Such a request will need to be considered in accordance with Premises Cost Directions.


N/A - not relevant therefore not completed.


No


At this stage there has not been any formal patient engagement. However should the project be approved and proceed then a patient engagement plan would be developed to ensure patients, staff and other stakeholders are aware of the project and how business continuity will be maintained throughout the programme of works



Outcome:

Executive Management Team

Thursday, 08 August 2019

Recommended to the PCCC to approve

Click here to enter a date.


Supporting Documents • Dr Seyan RHL PiD Final Copy 1MAY19

• RHL Dr Seyan PiD Appendix 1 Current Proposed Room Utilisation Schedule 30April19

• RHL Dr Seyan PiD Appendix 2 Floor Plans current proposed 30April19

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• Dr Seyan RHL Appendix 3 Services List Staffing Table 30April19

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NHS England PAU. PID Type 1 Clinical Premises VF2 28/06/17 Page 1 of 16

Project Appraisal Unit

Capital Investment, Property, Equipment & Digital Technology proposals

NHS England Project Appraisal Unit

Project Initiation Document - Type 1

Clinical Premises Not to be used for NHS England administrative premises - see PID Type 2

Sponsors and authors of documents seeking appropriate authority to fund or proceed with a

scheme or project must consider whether the content or strategy to which the document applies at this stage is sensitive or may have commercial implications. If it is considered necessary, the

document should be headed and watermarked appropriately.

Unless building and premises based PIDs are informed by sufficient detail and forward planning this can hinder a prompt and informed decision on PID approval. A PID is the first stage in the process, but there are fundamental

issues to be considered before progressing to business case stage. This particular PID type for clinical premises is therefore designed to support authors in considering some of those important issues that need to be covered in the

PID to inform local decision making. It is also acknowledged that at PID stage not all of the information asked for may be available. However, all PIDs for

this type of proposal must be as complete as possible and, where information is not known, a brief explanation should be provided.

Document version control (for use by PID sponsors)

Add rows as required.

Last entry should read: ‘Final for signatures’

Version No. Status Issue date Notes

1. TITLE OF SCHEME Robin Hood Lane Health Centre – Surgery Extended Area and Refurbishment Proposal

Scheme reference number and source of number (organisation).

Please ensure the relevant unique reference (for all Schemes) is used in all correspondence and reporting using an appropriate format: e.g. XXX – YY - XXX (Org Code – 17 – 001)

Reference No.

N/A

Confirm the Organisation issuing the reference number.

N/A

2. DATE OF FORMAL PID SUBMISSION

Date 30 April 2019

3. IS THIS A RESUBMISSION OF AN EARLIER PID?

If so, provide details & reference no.

Reference No. No

IF YES: Will this resubmission result OR potentially result in a

Please provide

details

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duplicate funding application already covered by another PID, etc.?

Is any element of this PID actually, or potentially funded through any other previous (already approved), parallel (current) or planned (future) application for funds?

4. NHS ENGLAND CAPITAL FUNDING STREAM (from any source)

Please confirm the NHS England capital funding stream relevant to this investment e.g. BAU, etc.

Financial tables should clearly show the NHS England commitment.

Where capital funding is from a special initiative e.g. ETTF, please use the first two rows opposite to denote initiative name and scheme reference number

Please use standard NHS finance codes when completing this section

If applicable, funding initiative name

N/A

Scheme reference No.

N/A

Funding stream

N/A

Cost Centre N/A

Subjective Code

N/A

Total value of NHS England funding. £

N/A

5. DETAILS OF ANY ADDITIONAL CAPITAL FUNDING SOURCE (where applicable)

Please confirm and briefly explain ANY additional capital funding stream relevant to this investment e.g. NHSPS Customer Capital.

The additional/alternative funding should be clearly shown in Table 3 below with relevant totals.

The implications of the additional funding must be clearly shown in the Economic and Financial sections of this PID.

Funding source name

N/A

Brief explanation of funding

N/A

Is this funding to be used for a specific purpose?

N/A

Is any element of this funding liable for repayment?

N/A

If yes, please give details including reason, amounts and dates.

N/A

Total value of additional funding. £

N/A

6. NHS ENGLAND REGION/LOCAL DIRECTOR OF COMMISSIONING OPERATIONS (DCO) OFFICE

Region N/A

DCO N/A

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7a. SPONSORING ORGANISATION No. 1 AND LEAD CONTACT

Please include a named lead contact for this application who can answer any queries relating to this PID

Organisation Robin Hood Lane Health Centre

Title/position Senior GP Partner

Name Ravi Seyan

Office tel. 020 3011 1891

Mobile tel. n/a

e-mail [email protected]

7b. SPONSORING ORGANISATION No. 2 (where applicable)


Organisation NHS Sutton Clinical Commissioning Group

Title/position Head of Primary Care Commissioning

Name Lou Naidu

Office tel. 020 3668 3385

Mobile tel. 07920722201


7c. SPONSORING ORGANISATION No. 3 (where applicable)


Organisation Primary Health Properties PLC

Title/position Asset Manager

Name James Wilkinson

Office tel. 02071042069

Mobile tel. 07595192581


8. NHS PROPERTY SERVICES OR COMMUNITY HEALTH PARTNERSHIPS CONTACT (where applicable)

Please include a named contact as appropriate

Organisation N/A

Title/position N/A

Name N/A

Office tel. N/A

Mobile tel. N/A

e-mail N/A

9. OTHER LOCAL STAKEHOLDERS OR TENANTS

Please add further lines where required

CCG Clinical Commissioning Group

Local Authority

N/A

Other (1) N/A

Other (2) N/A

10. SCHEME DESCRIPTION

Include a brief description of the scheme, which should include, but need not be limited to:

• scope and content

• the scheme type - new build, refurbishment or a lease

• objectives and benefits – these may be financial and/or non-financial

• location – address and name of the facility

• NHSPS/CHP premises code where known and available

• wider stakeholders and their interest e.g. potential occupants

• indicative scheme value for approval purposes

The request is put forward by Dr Seyan’s Medical Practice, Robin Hood Lane Health Centre (‘RHL’), Sutton, SM1 2RJ, for confirmation of rent reimbursement for the extended term of the new lease, under the GMS Premises Directions (Rent & Rates Scheme) for an increase in surgery floor space to accommodate local population growth and an expanding range of services. It is proposed a new lease will be entered into, over the whole building, extending the unexpired term to 25 years. This will be made possible by the relocation of another Practice’s branch surgery, currently co-located at RHL, which will provide ground floor space for the Practice to move into. The other Practice, Old Court House, will be relocating to their main surgery site upon completion of a refurbishment project due for completion December 2019.

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• confirm other stakeholders are signed up to the general terms, costs and implications of the proposal.

• confirm that where details are known, any proposed leases, are appropriate and acceptable to all participants.

• if the scheme requires temporary accommodation

• if costs for enabling works are required and, if so, included in the overview costs.

Dr Seyan’s Practice has a current patient list size of 12,500 and increasing by more than 500 patients per annum. This experiential growth does not include new housing in the locality which will further increase the patient list. The relocation of the Old Court House branch surgery will free up sufficient space to provide 5 new clinical rooms and 1 treatment suite for Dr Seyan’s Practice, that will then occupy the whole of the ground floor. The first floor is let to NHS Property Services that will remain unchanged. While RHL is purpose-built, it is now over 12 years old and in need of internal renovation and refurbishment, which will form part of the refurbishment works to be funded by the landlord in return for the rental commitment detailed in this proposal. These works will also include reconfiguration and refurbishment of some of the Practice’s existing clinical rooms. Background: Dr Seyan’s Practice is a high-performing teaching & training PMS Practice, with a current patient list totalling over 12,500. Currently, the Practice has 847 sqm NIA (Net Internal Area) under rental reimbursement while the relocating Practice will be relinquishing 130 sqm NIA. Adding this to Dr Seyan’s allocation, the total becomes 977 sqm NIA which is within NHS New Build Guidance for a patient list size of 12,500. The development will provide Dr Seyan’s Practice with 6 new clinical rooms (5 consulting rooms and 1 treatment room suite) to accommodate their service, teaching and staffing needs. It will also facilitate service delivery under Primary Care Networks, where the Practice is working with other local surgeries to focus on increased service provision for the locality in conjunction with Sutton GP Services, the local Federation comprising all 23 Sutton Practices. The project provides the required capacity for the Practice to deliver increased and improved primary care services, while also catering for local population growth from new housing developments. Development: The landlord of RHL, Primary Health Properties PLC (‘PHP’) will fund the reconfiguration and refurbishment works in return for a longer lease commitment extending the current term to 25 years from completion of the works over the whole building. The proposal meets the commissioning objectives for NHS Sutton CCG as well as delivering the NHS Five Year Forward View and local initiatives around federated joint working of the NHS South West London Alliance (Kingston, Richmond, Merton, Wandsworth and Sutton CCGs and Primary Care Networks being developed with other local surgeries. Appendices attached to this application are as follows: Appendix 1 – Current and Proposed Room Utilisation Schedules for Dr Seyan’s Practice. Appendix 2 – Current & Proposed Floor Plans. Appendix 3: - Current & Proposed Services List.

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Improved primary care facility: The proposal represents the Practice’s preferred development option for solving their capacity and premises issues, as confirmed from an Options Appraisal process undertaken by the GPs. With their enlarged surgery area, taking up the whole of the RHL ground floor, the functioning and operation of the Practice will be more efficient, allowing an growing patient list to be accommodated alongside delivering an increased range of primary care and community services, while helping to deliver the new PCN models of care. Currently, the Practice has 10 GPs, comprising 5 Partner GPs, 3 salaried GPs, 2 GP Registrars, 1 Specialist Advanced Nurse Practitioner, 2 Practice Nurses, 1 HCAs and 1 Midwife and Counsellors. It urgently needs to take on more staff to be able to cater for its increasing list. However, without the space to accommodate new doctors and other clinical staff, as well as teaching and training functions, the Practice is restricted in what it can provide until it has more clinical space. Surgery space allocation: The tables below are extracted from “The Procurement, Development, and Management of Primary Medical Care Premises Infrastructure – Principles of Best Practice”, as issued by NHS England.

Number of patients 2,000 4,000 6,000 8,000 10,000

Type of premises - see notes (i) and (ii)

A A B B B

Gross internal area (GIA) allowance

199 333 500 667 833

Number of patients

12,000 14,000 16,000 18,000 20,000

Type of premises - see notes (i) & (ii)

B B B B B

Gross internal area (GIA) allowance

916 1,000 1,083 1,167 1,250

Dr Seyan’s current surgery area is 847 sqm NIA while the additional area requested is 130 sqm NIA making a total of 977 sqm NIA. According to the above NHS England Guidance, even for its current patient list size of 12,500, the Practice should be operating from some 900-1,000 sqm GIA (Gross Internal Area) when treatment room, teaching and training and clinic requirements are also taken into account, which increase the total floor space requirement. With the Practice’s list rising to some 15,000 (as projected over a 5 year horizon) it should be operating from a GIA of a least 1,000 sqm. This proposal is to provide a facility of 977 sqm which meets the guidance. See Appendix 2 – Current & Proposed Floor Plans. Premises position: While RHL was in good overall condition and was purpose built for the Practice as a 3PD, completed in 2007, internally it is now tired and out-dated, requiring refurbishment and remodelling to improve the layout and

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the efficiency of space use. As landlord, PHP is prepared to fund the capital works for the refurbishment in return for the rental commitment requested for the additional space provided. Current and Proposed CMR Rent

(A) The CMR rental required in order to refurbish RHL is £408,000 +

VAT (£489,600 Gross) pa.

The rental reimbursement levels to the GPs will be confirmed in the Value for Money Report prepared by the District Valuer to the CCG’s instruction, from which the rental figures for the lease will be confirmed. Clinical Accommodation: A table of the current and proposed clinical room accommodation is set out below (while detailed schedules are provided as Appendices 1 & 2).

Room Type Consulting

Rooms

Treatment

Rooms

Meeting,

Health Ed,

Counselling

& Group

Rooms

Totals

Dr Seyan

Current 12 1 1 14

Old Court

House Current 5 1 0 6

Current Total 17 2 1 20

Proposal for

Dr Seyan

surgery

17 2 1 20

Dr Seyan Gain

(reallocation) 5 1 0 6

The refurbishment and remodelling will provide functionally-designed accommodation that is both of the highest quality and fit-for-purpose for primary care service delivery. As detailed in the table above, the reallocation will provide 6 additional clinical rooms for Dr Seyan’s Practice. Project Outputs & Deliverables:

Improved value-for-money will be delivered from the rental reimbursement from the improved surgery facility for the Practice, that will also help meet the four core NHS criteria for premises-evaluation;

(i) Improved access to effective care (ii) Increased capacity for primary care services out of hospital (iii) Commitment to a wider range of services as set out in the CCG’s (iv) Teaching & Training functions.

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• Increased clinical capacity in terms of better quality facilities, allowing the Practice to operate from improved clinical space.

• Offering more core-additional-enhanced primary & community care services to widen the scope and depth of support services for patients, facilitating Primary Care Network development locally.

• Having the capacity to allow patients to be seen by other providers in the building. As part of and alongside PCNs, this may include District Nursing and HV teams, Social Services community and mental health providers, outreach clinics and independent parties.

• Offering further access for external providers, including urgent care and a local youth advisory service.

• The improved facility will also make it easier for the Practice to offer support services to patients ‘offsite’, such as for self-help and domiciliary support that are easier to manage from an effective multi-disciplinary team base.

Lease arrangements: The GPs lease the whole surgery building under a 20 year TIR lease from 2007, expiring 22 November 2027, i.e with less than 9 years remaining. The first floor is sub-let to NHS PS who use it for Community Health Services, while the current OCH ground floor space is sub-let to that practice. Hence, when OCH moves out, their sub-lease will be extinguished, leaving the whole of the ground floor as the Seyan Practice demise, once the requested approvals have been given. With the works to the building, a new lease will be agreed to take into account the additional surgery space allocation. The landlord is Primary Health Properties PLC (‘PHP’) who is working closely with the Practice in formulating the plans and designs for the internal works and refurbishment. Planning consent should not be a requirement, while PHP will ensure compliance with local authority building control and clinical specification requirements.

11. STRATEGIC NEED

• Provide the strategic drivers and justification for the scheme.

• Confirm and outline alignment with other strategies as appropriate

Sutton’s JSNA states that: The ONS 2014 sub-national population projections estimate that between 2014 and 2024 Sutton’s population is projected to increase by 12.7%. This is similar to London (13.7%) and higher than for England (7.5%). Over this time the population of young people aged 0 to 19 is expected to increase by 16.6% in Sutton, higher than for London (14.8%) and England (7.8%). This will have implications for children’s services. For older people aged 65 and over, the population is expected to increase by 19.7% in Sutton, less than for London (23.6%) and England (20.4%). One of the key consequences of longer lives is that people are more likely to develop long-term conditions, particularly if they have less healthy lifestyles. The ethnic profile in Sutton is projected to change with the borough becoming increasingly more diverse. Sutton Council’s website shows the following population projection for the borough: - 2018 total borough population: 207,378 - 2030 projection including new housing developments: 222,186 - growth of nearly 20,000 During 2015-16, Sutton CCG reviewed primary care services and surgery capacity as a distinct piece of work to underpin delivery of its commissioning requirements and the 5 Year Forward View for the five GP Practices occupying seven surgery sites in Sutton town centre and serving a rising local population of 55,000+.

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The work concluded that there is an urgent need for more primary care space in central Sutton, identifying a capacity shortfall of just under 1,500 sqm GIA when measured against NHS primary care design guidance. This was for the Practices as they stood, before taking population growth into account from new housing developments in the locality. The review also found that majority of the sites are older buildings that are no longer fit for purpose, nor meet CQC and infection control requirements. RHL is the largest surgery facility. Since that review was carried out, the Old Court House Practice has undertaken its own main surgery development, so that it will be merging its branch surgery when the works are completed. In moving out of Robin Hood Lane Health Centre, it will free up much needed space for the Dr Seyan Practice as proposed here. Their enlarged surgery capacity will help the Dr Seyan Practice to function more effectively while delivering a broader range of primary and community care services to its growing patient list, as well as taking on PCN functions and opening up more activity to all local people, including patients of other Practices. This will also allow the Practice to offer more support services, including working with Social Services and community providers to engage with patients either at home or at clinics to help prevent falls, repeated A&E attendances, and avoid crisis events, for example with MD and LD client groups. Outpatient and Day-case activity can also be delivered under a primary care pathway, e.g. carpal tunnel, to allow patients to avoid having the travel to hospital to be seen when their procedure can be carried out at RHLHC using the treatment room suite for minor surgery. As well as being more convenient for patients, this will also help save money for the local health economy. Additional services the Practice will seek to support in the extended and improved facility include the following:

• Extended GP services: e.g. Minor surgery, contraceptive services, diabetes & ophthalmology clinics, phlebotomy for all local people.

• Anti-coagulation and diabetic clinics on a larger scale than currently, available also to patients of other practices under PCNs

• Out-reach and allied services from other providers: midwifery, counselling, sexual health clinics, physiotherapy.

• Shared-care services: out-patient facilities for secondary care, joint clinics with specialists, telemedicine clinics as well as extending physiotherapy & MSK clinics.

• Shared clinical space with co-providers: nursing services, closer collaboration with community providers and developing the role of nurse pharmacist.

• Provide “1-stop shop” service with clinician, nurse, dietician, counsellor, podiatry, pharmacist for Diabetic clinics as an example

• Training facilities: Foundation Program, GP Registrars, medical student placements as well as nursing training, carers training/support, work-experience for local students interested in all aspects of health and care careers

• Provide group room and meeting facilities for use also by outside health-care providers, allied services and others, eg yoga groups.

These all fit with the PCN locality models being developed for the Sutton area. The joint commissioning of primary care services, with the ultimate objective of migrating to locally based commissioning for GMS and related activity, are strategic drivers for these areas and for delivering the

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NHS 5 Year Forward View. A Current & Proposed Services List.is provided as Appendix 3 summarising the services delivered by the Practice, those where the GPs are held back by lack of clinical space and those they will be delivering in the future or as part of PCN development with other surgeries . The focus is on (i) improving access and accessibility to effective care (ii) supporting the migration of outpatient and day-case activity into primary care settings from delivering increased capacity (iii) committing to a wider range of services to meet local commissioning needs while helping to reduce unplanned hospital admissions and (iv) increasing teaching and training capacity. This joint commissioning approach enables CCGs to influence the content and management of core and enhanced primary care contracts (within national parameters) and to align the commissioning of primary care with the organisations’ broader commissioning intentions, thereby enabling care to be commissioned across the full extent of the patient pathway, and supporting the move towards place-based budgeting. The strategic drivers for this include:

• Placing a greater emphasis on prevention, as it will facilitate Practice-based multi-disciplinary joint working that brings together health and social care providers for pro-active patient intervention and management.

• Putting patients in control of their own care planning, using MDT joint working to engage with patients whether as part of an active CDM programme or as an early intervention for those considered at risk (such as for CHD, COPD and diabetes). These initiatives require staff resources that can only be employed by the Practice (or associated providers) in a larger, single facility.

• Better use of technology, from the provision of a new minor-procedures facility within the building, the Practice can provide a greater number of surgical procedures using the latest equipment. This will help in taking the strain off the secondary care sector.

• Better integration between health and social services, from joint team working, for which the development will support the delivery of co-ordinated joint working from team bases.

• Commissioning hospital services delivered through new models of care – with a smaller number of centres of excellence, one-stop shops, combining hospital and community services.

• Utilising tariff flexibilities and new models of contracting to deliver these priorities, that may be promoted working with the local PCN and Federation, in response to local commissioning needs for more day-case and outpatient activity to be provided from surgery settings, at lower cost to help release local health funding.

• The Practice is currently developing ever closer working relationships with patient groups, and is involved with an innovative patient champion initiative. A larger space would enable the practice to develop co-produced solutions to social isolation which has been proved to help improve GP resilience.

12. CONSISTENCY WITH SUSTAINABILITY AND TRANSFORMATION PLANS (STP), COMMISSIONING AND ESTATES PLANS

Primary care service delivery needs to respond to each of these themes with services planning and delivery that helps to maintain patient well-being and self-help as well as responding to conditions presented, while both planned and unplanned care need to be taking pressure away from the secondary and tertiary environments with greater activity in the

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• Confirm alignment with the NHS England Five Year Forward View and related implementation plans.

• Confirm that the proposed scheme is consistent with the relevant STP, commissioning, clinical and (where appropriate) estates and or technology strategies.

• Confirm whether formal public consultation is required.

• Confirm whether any planning permission (including change of use) is required and its current status.

• Confirm that any proposed property development brief to designers will require and ensure compliance with appropriate and relevant NHS guidance, such as BREEAM, Health Building Notes, common minimum standards for the procurement of built environments in the public sector, etc.

primary care setting, in particular for children’s and older people’s services. The improved primary care facility at RHL proposed here will support and assist in delivery of these public health requirements as part of a co-ordinated multi-disciplinary approach under PCNs. The case for change includes a number of issues directly relevant to primary case provision, namely.

• By 2020 about one in ten people in Sutton is expected to have diabetes, and one in eight will have heart disease;

• The quality of general practice care in Sutton is generally high, but there is significant variation – for example, with regards to the amount of evening and weekend appointments;

• More than half the patients currently admitted to community hospitals could instead be treated, cared for and supported at home and a further third nursed in their own homes, helping to maintain their independence;

• Access to mental health services is generally good, but in some areas there is not enough support provided to patients outside working hours and in other places there are not enough services for children with mental health conditions;

• A&E attendances have increased significantly over the past few years but over half of these patients have minor conditions that do not require hospital treatment.

• Sutton CCG has developed key strategies which will respond to these drivers, and others, and drive change locally, including Clinical Services Reviews and its Sustainability and Transformation Plan (STP) alongside the Five Year Forward View Delivery Plan and Primary Care Commissioning Strategy.

• Responding to the objectives set out in these documents, the improved surgery premises will support a number of Sutton CCG’s strategic ambitions, including: o Using digital technology to improve access to care, support

collaborative working, drive efficiencies in workload and relieve demand;

o Helping to grow and develop the workforce by driving recruitment and retention through improved working conditions;

o Improving the patient experience, accessibility of services and health outcomes through modern premises, collaborative working and provision of technologies to enable self-care.

In the longer term, the subsequent phases of development will help deliver further CCG ambitions:

• Extended acces

• s across seven days, with advanced practitioners working closer to patients’ homes;

• A range of enhanced primary care services focusing on frailty and long-term care;

• Rehabilitation programmes, patient education sessions, advice and sign-posting to support services offered in the voluntary sector.

The GP Five Year Forward View Delivery Plan for Sutton is particularly relevant within the context of the RHLMC. Key messages within the plan include:

• GPs are facing rising patient demand, particularly from an ageing population with complex health conditions, physical and mental health presentations;

• The Sutton population is set to increase by as much as 20,000

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over the next 10 years, including growth from new housing developments in Sutton town centre;

• Primary care will build on its strengths and past successes by working in larger groups to achieve sustainability, as part of wider primary and community teams across a range of sites – hence the PCN initiative now being moved forward locally.

• By 2020/21 all Sutton practices will be working in collaboration at increased scale with consistent quality and improved outcomes. The ambition for the future GP model is that it will provide integrated care based on population need and will work as part of multi-disciplinary teams (MDTs) across primary and community services, using a network of GP practices and/or primary care and community service hubs.

Sutton town centre Masterplan: The ‘Successful Sutton’ website includes the following summary: ‘Sutton Council has agreed a vision for the future of Sutton Town Centre and a 15-year Masterplan to help make the vision a reality that includes redeveloping the Civic Centre area and transforming the gyratory system around the High Street. The Masterplan will ensure that in these economically uncertain times the Town Centre continues to attract new business to invest in the centre and to provide shopping, services and local employment opportunities. In order to deliver this vision the Masterplan makes a commitment that Sutton Council will:

• Explore the redevelopment of the Civic Centre area to create new spaces for arts, culture and entertainment activities in the town centre as well as providing much-needed new homes.

• Work with the owners of the St Nicholas Shopping Centre to create new activity along St Nicholas Way, with shops, leisure and dining venues near the existing cinema;

• Work to help deliver new employment development at or above Sutton railway station to strengthen the existing focus for employment in Sutton, support existing local employers and boost the number of jobs in the town centre;

• Transform the gyratory road around the town centre on St Nicholas Way and Throwley Way into an urban boulevard lined with street trees and ensure that all new development facing onto it is of exceptionally high quality;

• Work with grant funders to secure a range of High Street projects to strengthen the centre of Sutton and improve the image of the town centre; and

• Work with Historic England and landowners on a plan to enhance the historic core of the Town Centre.

This will all be in conjunction with major housing development schemes that will increase significantly the town’s resident population needing to register with a local surgery, for which the Robin Hood Centre is ideally placed to cater for this growth as discussed above. Stakeholder engagement for this project includes the following: The Practice’s Patient participation group is initially engaged through patient representatives, as the plans are finalised and approved. Then, patient advisory information is displayed at the surgery once the project is proceeding.

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Through local Practice groupings, as part of the new Primary Care Network, the GPs and staff are working in a co-ordinated way to plan for increased local service delivery and the substantial population growth that will be taking place even while the extension is being constructed. For ensuring patient access and service delivery is provided in a coherent way, community services and local authority agencies will be liaising with primary care, while scoping their usage requirements for the enlarged building. The Practice is also engaging with external providers, particularly where it helps deliver more outpatient and day case work in a primary care setting, as well as external professions allied to medicine (e.g. MSK and podiatry services). Working with the Deanery for increasing the number of GP student placements and nurse training that the centre can provide, as the Practice is a well-established teaching and training establishment.

13. ESTIMATED PROJECT DEVELOPMENT COSTS Cost per Stage of Development

Funded by Project Sponsor £

Total incl. VAT £

Incurred Pre PID Capex costs to be funded by Landlord

PID to Option Appraisal

Option Appraisal to OBC

OBC to FBC

Total

14. CAPITAL COST ESTIMATES

(Inc. VAT)

This section is anticipated to be very high level (but based on evidence), prior to any formal options appraisal. Benchmarked construction costs can be accessed through the NHS England PAU team.

Please use table 2 (and, if and where available, append any more detailed ready prepared tables that are considered appropriate), to detail the capital requirements to deliver this scheme in years 1, 2 and year 3 where applicable.

Please use Table 4 to confirm capital funding sources that should sum to the total in Table 2.

Two-site scheme Two-site schemes may potentially occur where, say, there is a move from one site to another and to achieve this there may be some level of expenditure on two sites. The total scheme costs for both related sites are to be provided in the tables. This does not mean that 2

n/a

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unrelated sites or schemes can be approved under a single PID.

Please ensure that all proposed costs set out in these tables are for capitalisable expenditure.

Please insert the relevant dates in the [square brackets]

15. REVENUE AFFORDABILITY / IMPACT • Net Recurrent Revenue Impact:

£’x’k over the following years.

• Outline any additional revenue costs of capital investment beyond current costs, and other additional costs if applicable e.g. additional rates, energy, FM costs and any planned offsetting savings

• Specify funding source for any adverse net revenue impact

• £’x’k Estimated lifecycle costs:

• £’x’k Gross Recurrent Revenue Impact

Current and Proposed CMR Rent

(A) The CMR rental required in order to refurbish RHL is £408,000 +

VAT (£489,600 Gross) pa.

The rental reimbursement levels to the GPs will be confirmed in the Value for Money Report prepared by the District Valuer to the CCG’s instruction, from which the rental figures for the lease will be confirmed.

16. PROPOSED PROCUREMENT STRATEGY

Please describe the procurement strategy, who will be leading, and when it is anticipated to complete and capital spend will be incurred. For new build solutions, please confirm if the proposal is likely to be within a LIFT geographical area.

Where available attach a key milestones plan. As a minimum, this should include, as appropriate:

• Option Appraisal

• Procurement Route Confirmed

• OBC/New Project Proposal

• OBC Approval/Stage 1 Approval

• FBC/Final Project Proposal

• FBC Approval/Stage 2 Approval

• Date of procurement

• Planned start of works

• Estimated completion date

The scheme will be procured as an extension to a standard 3PD (Third Party Development) surgery investment by PHP as landlord of the main surgery. The CCG will employ the services of the District Valuer to agree a level of rent appropriate for the region and facility and to prove value for money for the NHS. This will then set a cost envelope for the scheme which PHP has to deliver within. This type of procurement removes the risk from the tenant and the NHS as all financial risk is taken by the 3rd party developer. Project Timetable:

Estimated Date Key Stage

May / June 2019.

CCG / LMC support from PID submission leads to preparation of any required further business case material for CCG approval, alongside PHP working with architect and project manager on the scheme design and layout.

July / August 2019.

CCG approvals alongside PHP continuing to work up the scheme. Ongoing consultation with patients, staff & local stakeholders. DV instructed for VFM Report.

From February 2020 (when OCH surgery moves out)

After scheme approval, agreement to new lease can be executed with Practice GPs, tying in with obtaining vacant possession of the additional space when the Old Court House branch surgery moves out to their redeveloped main surgery. Internal refurbishment of the space can then take place.

Mid 2020. Practical completion & Practice takes up occupation of the new space. Lease completed..

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17. CONSIDERATION OF OTHER OPTIONS

Describe other options under consideration, including the ‘Do Nothing’ Option.

Briefly consider the advantages and disadvantages of each option under consideration and identify the one used for benchmarking to indicate the scheme value in this PID

A review and appraisal of the premises development options open to Dr Seyan was undertaken by the GPs in conjunction with Primary Health Properties (PHP), the owner of the property, with regard to the following objectives:

▪ Supporting delivery of national and local strategy ▪ Supporting delivery of key performance targets ▪ Minimising revenue costs in support of healthcare ▪ Delivering long term value for money ▪ Providing services that are clinically safe & meet clinical

governance standards ▪ Addressing existing building constraints ▪ Meeting all statutory & infection control regulations ▪ Delivering a better balanced healthcare system locally

Their preferred option for improving and extending their space at RHL will allow patients to receive their primary care services in a properly specified, modern and compliant facility. It will also allow the Practice to grow its provision of healthcare services and give clinicians and staff a suitably specified working environment. The design of the building will also ensure that it is both flexible and sustainable, thus giving the surgery a new life for at least another 25 years and beyond.

18. SITE PLAN

Where available and for larger schemes (>£1m), please provide a simple site plan to demonstrate the proposal.

Please see Appendix 3 for Current and Proposed Floor Plans.

19. OTHER ISSUES

Confirm and provide brief explanation about: a) Is the output from One Public

Estate planning known for the relevant locality ?

b) Have NHS PS / CHP / or other named party provided input into the PID?

c) Is there spare service (or accommodation) capacity in neighbouring, cross boundary areas?

d) Are any service or accommodation closures anticipated as a result of these proposals?

e) Will any land be released? f) Is the proposal dependent on

reinvestment from disposals? g) Where applicable, is the land

clearly identifiable and available.

h) Is the land in the ownership of the NHS?

i) Are there any known constraints that could influence the outcome of this

a No

b No

c No

d No

e No

f No

g Yes

h No

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scheme in construction or use? E.g. in a flood zone, listed building, etc.?

j) Where GP or other organisations will share the facility, are there plans to integrate the common areas, or are the organisations intent on remaining fully separate entities in practical terms? The latter may not be acceptable for this PID to be approved

k) Has any IT infrastructure been factored into the costs for this scheme in the tables 2, 3, 4 and 5? If yes, please quantify.

l) If not, please confirm source and certainty of funding for this item.

m) In schemes involving GP’s, what is the anticipated value of the GPIT requirement?

n) please confirm source and certainty of funding for GPIT.

i Not aware of.

j n/a

k Not into this rental reimbursement proposal where landlord meets capital costs.

l n/a

m n/a

n n/a

20. KEY RISKS

Please provide adequate information to enable reviewers to understand the level and likelihood of risk and how it is to be mitigated.

Please list any risks to delivery, for example if the spend is dependent on a practice merger other estates investment, involvement of a 3rd party, etc.

Risk Mitigation

Funding (once rent & rates reimbursement confirmed from NHS

Developer (PHP as 3PD).

Preparation of planning application and meeting the costs of complying with planning requirements


Overall Capital Expenditure, including contractor and finance risks during works.


Legal costs and monitoring surveyor for the development

Practice will need monitoring surveyor.

Other professional costs for scheme


Equipment/ Fixtures and Fittings Developer (PHP as 3PD).

Revenue funding (Rent & Rates) NHS England / LAT finance & CCG / LMC support.

Other Areas of Building and Site Practice & developer (PHP).

21. SCHEME OR PROJECT ENDORSED BY:

CCG CHIEF FINANCIAL OFFICER

Statement

I hereby confirm that I am satisfied the investment of capital as set out in this PID is necessary expenditure and offers value for money. I also confirm that any commitments made in this PID to the covering of revenue will be honoured by the CCG and/or its relevant stakeholders. I am satisfied that the capital funding requirement set out in this PID is not replicated in any other NHS capital funding request, e.g. under other parallel capital investment initiatives

Organisation

Name

Signature

Date

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NHS ENGLAND DCO DIRECTOR OF COMMISSIONING

Statement I hereby confirm that I am satisfied the investment of capital as set out in this PID is necessary expenditure, offers value for money and conforms with relevant policy.

DCO

Name

Signature

Date

NHS ENGLAND DCO DIRECTOR OF FINANCE

Statement

I hereby confirm that I am satisfied the investment of capital as set out in this PID is necessary expenditure and offers value for money. I also confirm that I am satisfied with the financial commitments made by the CCG in this PID.

DCO

Name

Signature

Date

NHS ENGLAND REGIONAL

DIRECTOR OF FINANCE

Statement

I hereby confirm that I am satisfied the expenditure of capital as set out in this PID is necessary expenditure and offers value for money. I also confirm that I am satisfied with the assurance provided by the relevant local DCO office Director of Finance in this PID in relation to the covering of revenue costs. I confirm that any NHS England capital expenditure assumed in this PID is funded within the Regional capital budget for the relevant year(s). I am assured that there is a credible plan in place to account for any assumed NHS England capital expenditure in the appropriate financial year in accordance with NHS England standard accounting practice.

Region

Name

Signature

Date

PRIORITISATION (For regional use only where applicable)

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Dr Seyan, RHL: surgery reconfiguration & extension of area proposal.

April 2019.

Appendix 3: Current and proposed services position:

Services currently provided, over and above GMS.

With new capacity from extended & improved premises.

DES – Minor Surgery – Practice priority additional service.

Expand range of services (Level 3). Already provide joint injections & coil fitting. One GP is qualified for carpal tunnel procedures.

LES – Anticoagulation Clinics & Med. Monitoring Practice priority additional service

Develop service further .

LES – Phlebotomy Practice priority additional service

Already provide phlebotomy as a locally commissioned service and can expand to cater for patients of other Practices.

LES – Counselling service Practice priority additional service

More clinics.

DES – Diabetic clinics / NDPP Practice priority additional service

Expand range of service & clinics.

LES – Paediatric clinics. Practice priority additional service

Developing more clinics.

LES – Chlamydia Part of sexual health service.

LES – Dementia support services

LES – Care Home (nursing) GP cover for new nursing home development.

LES – End of Life Care Community support.

LES – HPV Develop service.

LES – Infectious Diseases Expand service.

DES – Influenza & Pneumococcal More clinics.

LES – Sexual Device Insertion/ ICD /IUS Service already provided, including coil fitting.

LES – Tissue Viability (Leg Ulcer) More dedicated clinics.

LES – Family Planning Service for whole community.

LES – Hypertension clinics Good service already provided & want to expand.

LE Develop service further

LES – ECG Community Based 24/48 hr & 7 day support Improved service.

LES - Counseling & Dementia advisory clinics & Mental Health Link Worker

Working with local providers. CPN visits surgery (how many times?) per week.

LES – Treatment Room Suite – surgical procedures, including additional activity eg carpal tunnel, skin treatments

While the GPs are qualified to undertake minor procedures, they are unable as take on as many patients as they would like..

LES -- Obesity clinics Improved service.

Choose & Book Improved service.

Smoking Cessation Community clinics.

Childhood Immunisations & Checks Expand service.

Cervical Smears & Contraception Develop service.

NHS Health Checks Available to other patients.

Shared Care – Drug Use Community service.

Asylum Seeker Services / Ethnic Minorities Community service.

Travel Immunisations Available to other patients.

Risk Reduction Clinics – including Obesity Available to other patients.

Teaching & Training – Registrar & FY2 placements Working with the Deanery to take on more Registrars, FYs and medical student placements.

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Services not currently being provided by the Practice & would like to provide

Enhanced Services - Involvement is principally limited by working environment & lack of space at premises

Dermatology (working with local hospital) Practice keen to develop service in-house.

Eye clinics (working with local hospital) Practice keen to develop service in-house.

LES – Physiotherapy (enhanced service) Need specialised equipment & space

Orthopaedic outreach (working with local hospital Practice keen to develop service in-house.

Pain management Practice keen to develop service in-house.

Dietician services Visiting support service can be arranged.

ECG service Practice keen to develop service in-house.

Current and proposed staffing position:

Staff Category Full time

heads

Part time

heads

WTE Proposed

addition

GP Partners 4 2 5 Add 1

Salaried GPs / Locums

§

1 2 1.5 Add 1

GP Registrars 2 2 add 1 +

Specialist Nurse Practitioner 1 1 Add 1

Practice Nurses 2 2 Add 1+

Practice Technicians / HCAs / MW 2 Add 1+

Nurse Pharmacist / Paramedic Add 1+

Practice Manager 1 1

Current annual total number of GP and Nurse appointments p.a. are as follows:

Annual total patient contacts (face to face) 1 Jan – 31 Dec 2018 = 61,336

Comprising:

- GPs/clinicians (working in consulting/exam rooms) = 35,424

- Nurses/HCAs etc (needing to work in a treatment room) = 25,912

Note that clinicians are currently hot desking to such an extent that a non-clinical

space is now being used for anti-coagulation clinics.

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1

Care Quality Commission

Inspection Evidence Table

Dr Hafeez and Partner (1-566469442)

Inspection date: 29 May 2019

Date of data download: 10 May 2019

Overall rating: Good Please note: Any Quality Outcomes Framework (QOF) data relates to 2017/18.

Safe Rating: Good

Following the inspection on 6 December 2018 we rated safety as inadequate because:

• Recruitment systems, designed to ensure that only staff appropriate for their roles were

employed, were not operating effectively to mitigate the risks. We raised concerns about

recruitment systems at previous inspections.

• The practice did not have effective systems to ensure that high risk medicines were always safely

prescribed. There was no effective written policy for the review of uncollected prescriptions to

ensure that vulnerable patients received their medicines.

• The practice was not taking the action required in response to patient safety alerts. We raised

concerns previously about the practice’s systems for responding to patient safety alerts.

• Significant events were not being identified, analysed and recorded to ensure that lessons were

learnt. We raised concerns previously about how the practice managed significant events.

Following the inspection on 29 May 2019 we have changed the rating for safe to good, because we

found that all of the systems and processes to manage risks to patients were operating effectively.

Safety systems and processes

The practice had clear systems, practices and processes to keep people safe and

safeguarded from abuse.

Safeguarding Y/N/Partial

There was a lead member of staff for safeguarding processes and procedures. Y

Safeguarding systems, processes and practices were developed, implemented and communicated to staff.

Y

There were policies covering adult and child safeguarding. Y

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Policies took account of patients accessing any online services. Y

Policies and procedures were monitored, reviewed and updated. Y

Policies were accessible to all staff. Y

Partners and staff were trained to appropriate levels for their role (for example, level three for GPs, including locum GPs).

Y

There was active and appropriate engagement in local safeguarding processes. Y

There were systems to identify vulnerable patients on record. Y

There was a risk register of specific patients. Y

Disclosure and Barring Service (DBS) checks were undertaken where required. Y

Staff who acted as chaperones were trained for their role. Y

There were regular discussions between the practice and other health and social care professionals such as health visitors, school nurses, community midwives and social workers to support and protect adults and children at risk of significant harm.

Y

Explanation of any answers and additional evidence:

Recruitment systems Y/N/Partial

Recruitment checks were carried out in accordance with regulations (including for agency staff and locums).

Y1

Staff vaccination was maintained in line with current Public Health England (PHE) guidance and if relevant to role.

Y2

There were systems to ensure the registration of clinical staff (including nurses and pharmacists) was checked and regularly monitored.

Y

Staff had any necessary medical indemnity insurance. Y


1. At the last inspection we found that the practice had not carried out a sufficient risk assessment on information received on a DBS check, there were incomplete checks on locums and there were no ongoing checks of the registration of clinical staff.

After the inspection, the practice updated the recruitment policy and appointed two recruitment leads (including a partner) with responsibility for ensuring it was adhered to. We looked at records of three staff (one substantive appointment, two locums) and found that checks were carried out in accordance with regulations. We also saw that there had been checks of the registration of clinical staff.

2. At the last inspection, we found that the practice had taken statements from staff about their immunity to Hepatitis B, measles, mumps and rubella and varicella, but not from tetanus, diptheria or other infectious diseases as described in guidance Immunisation against infectious disease (‘The Green Book’.) At this inspection we found that records were in line with guidance.

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3

Safety systems and records Y/N/Partial

There was a record of portable appliance testing or visual inspection by a competent person.

Date of last inspection/test:

Y January 2019

There was a record of equipment calibration.

Date of last calibration:

Y October 2018

There were risk assessments for any storage of hazardous substances for example, liquid nitrogen, storage of chemicals.

Y

There was a fire procedure. Y

There was a record of fire extinguisher checks.

Date of last check:

Y November 2018

There was a log of fire drills.

Date of last drill:

Y February 2019

There was a record of fire alarm checks.

Date of last check:

Y May 2019

There was a record of fire training for staff.

Date of last training:

Y May 2019

There were fire marshals. Y

A fire risk assessment had been completed.

Date of completion:

Y April 2019

Actions from fire risk assessment were identified and completed. Y


Health and safety Y/N/Partial

Premises/security risk assessment had been carried out.

Date of last assessment: No specific assessment, see dates above Y

Health and safety risk assessments had been carried out and appropriate actions taken.

Date of last assessment:

Y May 2019


Infection prevention and control

Appropriate standards of cleanliness and hygiene were met.

Y/N/Partial

There was an infection risk assessment and policy. Y

Staff had received effective training on infection prevention and control. Y

Date of last infection prevention and control audit: June 2018

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4

The practice had acted on any issues identified in infection prevention and control audits. Y

The arrangements for managing waste and clinical specimens kept people safe. Y


• The infection prevention and control audit in June 2018 identified some minor actions and that some taps did not meet the latest specification. The minor actions were completed and there was a plan to replace the taps.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient

safety.

Y/N/Partial

There was an effective approach to managing staff absences and busy periods. Y

There was an effective induction system for temporary staff tailored to their role. Y

Comprehensive risk assessments were carried out for patients. Y

Risk management plans for patients were developed in line with national guidance. Y

Panic alarms were fitted and administrative staff understood how to respond to the alarm and the location of emergency equipment.

Y

Clinicians knew how to identify and manage patients with severe infections including sepsis.

Y

Receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients.

Y

There was a process in the practice for urgent clinical review of such patients. Y

There was equipment available to enable assessment of patients with presumed sepsis or other clinical emergency.

Y

There were systems to enable the assessment of patients with presumed sepsis in line with National Institute for Health and Care Excellence (NICE) guidance.

Y

When there were changes to services or staff the practice assessed and monitored the impact on safety.

Y


Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment.

Y/N/Partial

Individual care records, including clinical data, were written and managed securely and in line with current guidance and relevant legislation.

Y

There was a system for processing information relating to new patients including the summarising of new patient notes.

Y

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There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.

Y

Referral letters contained specific information to allow appropriate and timely referrals. Y

Referrals to specialist services were documented. Y

There was a system to monitor delays in referrals. Y

There was a documented approach to the management of test results and this was managed in a timely manner.

Y

The practice demonstrated that when patients use multiple services, all the information needed for their ongoing care was shared appropriately and in line with relevant protocols.

Y


Appropriate and safe use of medicines

The practice had systems for the appropriate and safe use of medicines, including

medicines optimisation

Indicator Practice CCG

average

England

average

England

comparison

Number of antibacterial prescription items prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU) (01/01/2018 to 31/12/2018) (NHS Business

Service Authority - NHSBSA)

0.92 0.98 0.91 No statistical variation

The number of prescription items for

co-amoxiclav, cephalosporins and

quinolones as a percentage of the total

number of prescription items for selected

antibacterial drugs (BNF 5.1 sub-set).

(01/01/2018 to 31/12/2018) (NHSBSA)

10.2% 8.9% 8.7% No statistical variation

Average daily quantity per item for

Nitrofurantoin 50 mg tablets and capsules,

Nitrofurantoin 100 mg m/r capsules,

Pivmecillinam 200 mg tablets and

Trimethoprim 200 mg tablets prescribed

for uncomplicated urinary tract infection

(01/07/2018 to 31/12/2018) (NHSBSA)

7.18 5.65 5.60 Tending towards

variation (negative)

Average daily quantity of oral NSAIDs

prescribed per Specific Therapeutic

Group Age-sex Related Prescribing Unit

(STAR-PU) (01/07/2018 to 31/12/2018)

(NHSBSA)



The practice had audited their antibiotic prescribing and found that some GPs were prescribing longer courses of antibiotics for uncomplicated urinary tract infection than recommended by national and local

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6


average

England

average

England

comparison

guidelines. Staff were reminded of the guidance and there were plans for a repeat audit.

Medicines management Y/N/Partial

The practice ensured medicines were stored safely and securely with access restricted to authorised staff.

Y

Blank prescriptions were kept securely and their use monitored in line with national guidance.

Y

Staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions).

Y

The practice could demonstrate the prescribing competence of non-medical prescribers, and there was regular review of their prescribing practice supported by clinical supervision or peer review.

N/A

There was a process for the safe handling of requests for repeat medicines and evidence of structured medicines reviews for patients on repeat medicines.

Y

The practice had a process and clear audit trail for the management of information about changes to a patient’s medicines including changes made by other services.

Y

There was a process for monitoring patients’ health in relation to the use of medicines including high risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing.

Y

The practice monitored the prescribing of controlled drugs. (For example, investigation of unusual prescribing, quantities, dose, formulations and strength).

Y

There were arrangements for raising concerns around controlled drugs with the NHS England Area Team Controlled Drugs Accountable Officer.

Y

If the practice had controlled drugs on the premises there were appropriate systems and written procedures for the safe ordering, receipt, storage, administration, balance checks and disposal of these medicines, which were in line with national guidance.

N/A

The practice had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and reduce the risk of adverse events and antimicrobial resistance.

Y

For remote or online prescribing there were effective protocols for verifying patient identity. Y

The practice held appropriate emergency medicines, risk assessments were in place to determine the range of medicines held, and a system was in place to monitor stock levels and expiry dates.

Y

The practice had arrangements to monitor the stock levels and expiry dates of emergency medicines/medical gases.

Y

There was medical oxygen and a defibrillator on site and systems to ensure these were regularly checked and fit for use.

Y

Vaccines were appropriately stored, monitored and transported in line with PHE guidance to ensure they remained safe and effective.

Y

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Since the last inspection, the practice had revised their high risk medicines protocol and appointed a lead GP for prescribing, who was responsible for ensuring staff were up to date with guidance and policies and overseeing audits. A practice pharmacist had been recruited who carried out audits. The practice now had a clear protocol for clinical staff to follow, including consistently recording blood test results when medicines needed monitoring, and managing patients who did not attend for monitoring (including communication and short prescriptions). We looked at patients prescribed high risk medicines and found that this had been managed safely.

Track record on safety and lessons learned and improvements made

The practice learned and made improvements when things went wrong.

Significant events Y/N/Partial

The practice monitored and reviewed safety using information from a variety of sources. Y

Staff knew how to identify and report concerns, safety incidents and near misses. Y

There was a system for recording and acting on significant events. Y

Staff understood how to raise concerns and report incidents both internally and externally.

Y

There was evidence of learning and dissemination of information. Y

Number of events recorded in last 12 months: 10

Number of events that required action: 8


When we inspected in December 2018 we found that there was a policy that specified how significant events would be analysed and recorded, but this was not being followed.

At this inspection we found that the practice had a new policy, which was being followed.

The new policy had fewer details of the process for investigating, reporting and sharing significant events, and did not give details of the duty of candour (although there was prompt for this on the significant event form).

Example(s) of significant events recorded and actions by the practice.

Event Specific action taken

The practice recorded a urine sample testing result under the wrong patient’s name and prescribed medicine for that patient, rather than the patient with the infection.

The practice investigated the event and found that there had been several points where the mistake could have been prevented, including staff members refusing the unlabelled sample, and better communication between staff. Practice staff apologised to the patient. The sample handling policy was updated to make it clearer and more specific as to the process for staff to follow.

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The practice reported the incident using the National Reporting and Learning System.

Safety alerts Y/N/Partial

There was a system for recording and acting on safety alerts. Y

Staff understood how to deal with alerts. Y


In 2015 we found that the practice did not have a system to distribute and act upon patient safety alerts. A system was put in place. In 2018 we found that the practice was distributing alerts but not taking the action required by alerts to keep patients safe.

At this inspection we found that there was a clear system in place to ensure that all relevant alerts were distributed and acted upon. We saw evidence of action, including on valproate prescribing for women of child bearing age.

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Effective Rating: Good

Following the inspection on 6 December 2018 we rated effective as requires improvement because:

• Data related to people with long term conditions, families, children and young people and working

age people showed the practice performance was below average/national targets, with no

substantive plans to improve. Some exception rates were relatively high compared to other

practices and the practice had not tested their hypotheses as to why this was.

• Where improvement had been made previously, it had not been sustained.

Following the inspection on 29 May 2019 we have changed the rating for the effective key question to

good, because we found that the practice had taken action to improve care where performance was

below average or did not meet national targets. In some areas, e.g. diabetes and hypertension, there

was evidence (although not yet verified) that outcomes for patients had improved. In other areas, such

as cancer screening, the practice had strengthened the processes but it was too early to evidence

improvement. Unverified data showed that care of the patients in the other population groups had also

been maintained or improved.

The practice had taken a systematic approach to evaluating its exception reporting, and unverified date

for 2018/19 showed that rates had reduced, overall and for most indicators.

Effective needs assessment, care and treatment

Patients’ needs were assessed, and care and treatment was delivered in line with

current legislation, standards and evidence-based guidance supported by clear

pathways and tools.

Y/N/Partial

The practice had systems and processes to keep clinicians up to date with current evidence-based practice.

Y

Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.

Y

We saw no evidence of discrimination when staff made care and treatment decisions. Y

Patients’ treatment was regularly reviewed and updated. Y

There were appropriate referral pathways were in place to make sure that patients’ needs were addressed.

Y

Patients were told when they needed to seek further help and what to do if their condition deteriorated.

Y


The practice had improved its process to ensure clinicians were up to date. One GP reviewed all of the guidance as it was released and presented to colleagues in clinical meetings.

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Prescribing Practice

performance

CCG

average

England

average England

comparison

Average daily quantity of Hypnotics prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU) (01/01/2018 to 31/12/2018) (NHSBSA)

1.94 0.94 0.79 Variation (negative)


• We spoke to the practice at the last inspection about hypnotics prescribing. At the time (data

01/07/2017 to 30/06/2018) the practice’s average daily quantity of Hypnotics prescribed per

Specific Therapeutic group Age-sex Related Prescribing Unit was 2.14. Practice staff told us

that they believed that the higher than average prescribing of hypnotics was due to caring for a

number of patients in a nursing home. Staff told us that they had carried out a review of these

patients with the community pharmacy team, identified a number of patients on high doses and

put in place plans to reduce these.

• At the last inspection, we identified that although the practice policy said that no patients would

be prescribed benzodiazepines on repeat prescription, some patients were. After the

inspection, the practice audited and found 56 patients receiving benzodiazepines on repeat

prescription, and most had no clear reason (inconsistent with prescribing policy). The practice

ensured that all doctors were clear on the prescribing policy and arranged for all patients

prescribed benzodiazepines to have a face to face review. In the second audit, only 10 patients

had benzodiazepines on repeat prescription, and all had documented reason. Nine out of 10 of

these patients were resident in a nursing home or housebound, and the notes recorded a clear

discussion with them and/or their carers about usage. The tenth patient had been prescribed

benzodiazepines by a hospital consultant and was being monitored. A third cycle was due to be

repeated shortly, and there were plans in place to follow the same process for the prescribing of

other controlled drugs.

Older people Population group rating: Good

Findings

• The practice used a clinical tool to identify older patients who were living with moderate or

severe frailty. Those identified received a full assessment of their physical, mental and social

needs.

• The practice followed up on older patients discharged from hospital. It ensured that their care

plans and prescriptions were updated to reflect any extra or changed needs.

• Staff had appropriate knowledge of treating older people including their psychological, mental

and communication needs.

• Health checks were offered to patients over 75 years of age.

• In addition to visiting when patients needed medical attention, the practice did twice yearly visits

to a local care home, with a pharmacist and a care co-ordinator.

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People with long-term conditions Population group rating: Good

Findings

• Patients with long-term conditions had a structured annual review to check their health and

medicines needs were being met. For patients with the most complex needs, the GP worked

with other health and care professionals to deliver a coordinated package of care.

• Staff who were responsible for reviews of patients with long-term conditions had received

specific training.

• GPs followed up patients who had received treatment in hospital or through out of hours

services for an acute exacerbation of asthma.

• The practice could demonstrate how they identified patients with commonly undiagnosed

conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial

fibrillation and hypertension. The practice had recently employed a consultancy to help them

identify more patients with commonly undiagnosed conditions from the medical records and

manage exceptions appropriately.

• Adults with newly diagnosed cardio-vascular disease were offered statins.

• Patients with suspected hypertension were offered ambulatory blood pressure monitoring.

• Patients with atrial fibrillation were assessed for stroke risk and treated appropriately.

• At the time of the last inspection we noted that outcomes for patients with diabetes (QOF

indicators) were below average in 2015/16, improved in 2016/17 but fell again in 2017/18 (to

negatively variant or towards negatively variant). Audit of HbA1c in 2017 showed improvement

and then deterioration. The practice had employed a part-time locum GP with a special interest

in diabetes and were encouraging patients with poorly controlled diabetes to see this GP,

although the GP was primarily employed to cover sessions dropped by other GPs. No other

action had been taken, and the audit had not been repeated.

• At this inspection, we noted that the practice had designated the GP with a special interest in

diabetes as the lead for diabetes, to focus on patients with consistently high HbA1c. A weekly

diabetes clinic started in November 2018. The practice had joined the National Diabetes Audit

programme. A retrospective audit compared HbA1c results from January 2018 to results from

December 2018. There was little improvement, although it was noted to be quite early in the

improvement process. In March 2019, a re-audit found improvement from 63% with HbA1C at 59

mmol/mol or less to 67% at 59 mmol/mol or less (six more patients with well-managed blood

sugars). In April 2019 another audit found that 70% of patients had HbA1c of 59 mmol/mol or less

(an additional five patients).

• The practice gave us the data submitted for 2018/19. This was unverified but showed

significant improvement in all indicators of diabetes care, and reductions in the numbers of

patients excepted. Exception reporting is the removal of patients from QOF calculations where,

for example, the patients are unable to attend a review meeting or certain medicines cannot be

prescribed because of side effects.

• We also looked at the unverified 2018/19 data for other long-term condition indicators. These

showed improvement across all indicators, although some exception reporting rates had

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increased. The unverified 2018/19 data has been added to the tables below.

Diabetes Indicators Practice

2017/18

CCG

average

England

average

England

comparison

2017/18

Practice

2018/19

(unverified)

The percentage of patients with diabetes,

on the register, in whom the last

IFCC-HbA1c is 64 mmol/mol or less in

the preceding 12 months (01/04/2017 to

31/03/2018) (QOF)

68.4% 76.4% 78.8% Tending towards


77%

Exception rate (number of exceptions). 7.4% (20)

9.6% 13.2% N/A 3.64%


on the register, in whom the last blood

pressure reading (measured in the

preceding 12 months) is 140/80 mmHg

or less (01/04/2017 to 31/03/2018) (QOF)



82%


8.2% 9.8% N/A 2.19%


on the register, whose last measured

total cholesterol (measured within the

preceding 12 months) is 5 mmol/l or less

(01/04/2017 to 31/03/2018) (QOF)

65.0% 74.5% 80.1% Variation (negative)

77%


10.9% 13.5% N/A 3.28%

Other long-term conditions Practice CCG

average

England

average

England

comparison

2017/18

Practice

2018/19

(unverified)

The percentage of patients with asthma,

on the register, who have had an asthma

review in the preceding 12 months that

includes an assessment of asthma

control using the 3 RCP questions, NICE

2011 menu ID: NM23 (01/04/2017 to

31/03/2018) (QOF)

75.6% 75.0% 76.0% No statistical

variation 83.3%


7.4% 7.7% N/A 0%

The percentage of patients with COPD

who have had a review, undertaken by a

healthcare professional, including an

assessment of breathlessness using the

Medical Research Council dyspnoea

scale in the preceding 12 months


variation 93.2%

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13

(01/04/2017 to 31/03/2018) (QOF)


7.2% 11.5% N/A 8.3%


average

England

average

England

comparison

2017/18

Practice

2018/19

(unverified)

The percentage of patients with

hypertension in whom the last blood

pressure reading measured in the

preceding 12 months is 150/90mmHg or

less (01/04/2017 to 31/03/2018) (QOF)


83.8%


4.8% 4.2% N/A 1.6%

In those patients with atrial fibrillation with

a record of a CHA2DS2-VASc score of 2

or more, the percentage of patients who

are currently treated with anti-coagulation

drug therapy (01/04/2017 to 31/03/2018)

(QOF)


variation 100%


5.7% 6.7% N/A 12.2%

Families, children and young people Population group rating: Good

Findings

• In 2016/17the practice did not achieve the 90% target for any childhood immunisations. When we inspected in 2018, the practice showed us data that showed rates increased for immunisations given at aged 1 (to above 90%) but decreased for immunisations given to older children.

• At this inspection we reviewed the new process in place. The practice now created a schedule of immunisations as soon as a baby was registered as a new patient. Staff called patients to invite them to book appointments. Parents who declined, or who did not bring their child to an appointment, were contacted by a GP. Evidence of immunisation to be sought on registration, and schedules created where not available. Lead staff members had been assigned for different parts of the process, and to audit monthly to check for improvement. We reviewed four months of data (January – April 2019). These showed that, when averaged over that period, uptake of the PCV and booster and Hib/MenC booster immunisations at age two were both above the 90% target. Uptake of the MMR immunisation at age two had also improved over that period, to 85%. Uptake of Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b for children aged one was lower between January – April 2019 (78%) but we noted that the number of children eligible per month was relatively low (e.g. fewer than ten children in February 2019, when 73% were immunised).

• The practice had arrangements to identify and review the treatment of newly pregnant women on long-term medicines. These patients were provided with advice and post-natal support in accordance with best practice guidance.

• The practice had arrangements for following up failed attendance of children’s appointments

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following an appointment in secondary care or for immunisation and would liaise with health visitors when necessary.

• Young people could access services for sexual health and contraception.

Child Immunisation Numerator Denominator Practice

%

Comparison

to WHO

target

The percentage of children aged 1 who

have completed a primary course of

immunisation for Diphtheria, Tetanus,

Polio, Pertussis, Haemophilus influenza

type b (Hib)((i.e. three doses of

DTaP/IPV/Hib) (01/04/2017 to 31/03/2018)

(NHS England)

47 51 92.2% Met 90% minimum

(no variation)


have received their booster immunisation

for Pneumococcal infection (i.e. received

Pneumococcal booster) (PCV booster)

(01/04/2017 to 31/03/2018) (NHS England)

37 43 86.0%

Below 90%

minimum

(variation

negative)


have received their immunisation for

Haemophilus influenza type b (Hib) and

Meningitis C (MenC) (i.e. received

Hib/MenC booster) (01/04/2017 to

31/03/2018) (NHS England)

38 43 88.4%

Below 90%

minimum

(variation

negative)


have received immunisation for measles,

mumps and rubella (one dose of MMR)

(01/04/2017 to 31/03/2018) (NHS England)

36 43 83.7%

Below 90%

minimum

(variation

negative)

Working age people (including those recently retired and students)

Population group rating: Good

Findings

• The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.

• Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40 to 74 (at a locally commissioned hub service). The practice had systems in place to prompt eligible patients to attend, and book appointments for patients who agreed. There was appropriate and timely follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

• Patients could book or cancel appointments online and order repeat medication without the need to attend the surgery.

• 61.2% of eligible patients were screened for breast cancer in 2017/18. The practice did not have data for 2018/19, but had strengthened the systems to prompt patients to attend for screening.

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Eligible patients who had not been screened had alerts added to their record so that GPs and nurses could raise it, and give them a card with the booking telephone number.

• 48.9% of eligible patients were screened for bowel cancer in 2017/18. The practice did not have data for 2018/19, but staff told us that they had found new ways to encourage take up since the last inspection. Staff identified that a high percentage of those eligible were also eligible for flu immunisation, and so information about bowel screening was provided at the flu immunisation clinic. Eligible patients who had not been screened had alerts added to their record so that GPs and nurses could raise it.

• In 2017/18, 62.5% of patients recently diagnosed with cancer received a review. The practice showed us unverified evidence that 92.85% received a review in 2018/19.

• The practice had investigated whether they were referring appropriate patients using the two week wait process. A case where a routine referral identified a cancer which could have been identified earlier with a two week wait referral was investigated as a significant event and led to an action plan, including audit.

Cancer Indicators Practice CCG

average

England

average

England

comparison

The percentage of women eligible for cervical

cancer screening at a given point in time who

were screened adequately within a specified

period (within 3.5 years for women aged 25 to

49, and within 5.5 years for women aged 50 to

64) (01/04/2017 to 31/03/2018) (Public Health England)


variation

Females, 50-70, screened for breast cancer

in last 36 months (3 year coverage, %)

(01/04/2017 to 31/03/2018) (PHE)

61.2% 71.1% 70.0% N/A

Persons, 60-69, screened for bowel cancer in

last 30 months (2.5 year coverage,

%)(01/04/2017 to 31/03/2018) (PHE)

48.9% 54.4% 54.5% N/A

The percentage of patients with cancer,

diagnosed within the preceding 15 months,

who have a patient review recorded as

occurring within 6 months of the date of

diagnosis. (01/04/2017 to 31/03/2018) (PHE)

62.5% 80.8% 70.2% N/A

Number of new cancer cases treated

(Detection rate: % of which resulted from a

two week wait (TWW) referral) (01/04/2017 to

31/03/2018) (PHE)


variation

Any additional evidence or comments

• The most recent published figures for cervical screening are 64% which is below the PHE coverage target for eligible women to have had a cervical screening sample at the appropriate time. The practice were addressing this using different ways to contact patients, and that monitoring had improved.

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• 61.2% of eligible patients were screened for breast cancer in 2017/18. The practice did not have data for 2018/19, but had strengthened the systems to prompt patients to attend for screening. Eligible patients who had not been screened had alerts added to their record so that GPs and nurses could raise it, and give them a card with the booking telephone number.

• 48.9% of eligible patients were screened for bowel cancer in 2017/18. The practice did not have data for 2018/19, but staff told us that they had found new ways to encourage take up since the last inspection. Staff identified that a high percentage of those eligible were also eligible for flu immunisation, and so information about bowel screening was provided at the flu immunisation clinic. Eligible patients who had not been screened had alerts added to their record so that GPs and nurses could raise it.

• In 2017/18, 62.5% of patients recently diagnosed with cancer received a review. The practice showed us unverified evidence that 92.85% received a review in 2018/19.

• The practice had investigated whether they were referring appropriate patients using the two week wait process. A case where a routine referral identified a cancer which could have been identified earlier with a two week wait referral was investigated as a significant event and led to an action plan.

People whose circumstances make them vulnerable


Findings

• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.

• The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

• The practice demonstrated that they had a system to identify people who misused substances.

People experiencing poor mental health (including people with dementia)


Findings

• The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services.

• When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.

• Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.

• Staff had received dementia training.

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Mental Health Indicators Practice CCG

average

England

average

England

comparison

2017/18

Practice

2018/19

(unverified)


schizophrenia, bipolar affective disorder

and other psychoses who have a

comprehensive, agreed care plan

documented in the record, in the

preceding 12 months (01/04/2017 to

31/03/2018) (QOF)


variation 97.3%

Exception rate (number of exceptions). 11.4%

(4) 8.7% 12.7% N/A 2.6%



and other psychoses whose alcohol

consumption has been recorded in the


31/03/2018) (QOF)


variation 97.3%


6.9% 10.5% N/A 2.6%

The percentage of patients diagnosed

with dementia whose care plan has been

reviewed in a face-to-face review in the


31/03/2018) (QOF)


variation 100%


6.1% 6.6% N/A 0%

Monitoring care and treatment

The practice had a programme of quality improvement activity and routinely

reviewed the effectiveness and appropriateness of the care provided.

Indicator Practice

2017/18

CCG

average

England

average

Practice

2018/19

(unverified)

Overall QOF score (out of maximum 559) 521.0 536.9 537.5 551

Overall QOF exception reporting (all domains) 5.0% 5.0% 5.8% 4.5%

Exception indicator data Practice

2017/18

CCG

average

England

average

Practice

2018/19

(unverified)

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18

Atrial fibrillation 6.4% 3.9% 5.9% 11.8%

Coronary heart disease 13.1% 7.8% 8.7% 11.4%

Heart failure 6.7% 8.7% 8.5% 0%

Hypertension 3.3% 4.6% 4.1% 1.6%

Peripheral arterial disease 5.0% 4.7% 5.9% 0%

Stroke and transient ischaemic attack 5.1% 9.2% 10.1% 6.1%

Asthma 4.4% 3.6% 5.9% 0%

Chronic obstructive pulmonary disease 7.8% 10.6% 12.6% 10.2%

Cancer 37.5% 18.6% 25.6% 6.7%

Diabetes mellitus 7.2% 9.7% 11.8% 4.2%

Dementia 10.4% 11.1% 10.0% 0%

Depression 18.4% 18.0% 22.8% 11.1%

Mental health 9.8% 7.5% 11.0% 6.0%

Osteoporosis 20.0% 14.5% 17.5% 0%

Rheumatoid arthritis 0.0% 2.1% 6.9% 4.8%


• The exception rates for some specific indicators or conditions were above average in 2016/17. We discussed these with the practice in August 2018 and saw that the rate of patients excepted was lower in the data submitted for the 2017/18 QOF year (unverified and unpublished at the time of our inspection, now confirmed).

• There were some indicators with relatively high exception reporting in the 2017/18 QOF year. At the inspection in 2018 we looked at these and found that patients had been excepted appropriately, after reasonable attempts to engage them. Unverified data for 2018/19 showed that the overall rate of exception reporting had reduced slightly, and of the 15 indicator level exception rates, all but four had reduced. Some rates were below the national and local averages. We looked at those were rates were still relatively high, and noted that relatively small numbers of patients were eligible for these interventions.

Y/N/Partial

Clinicians took part in national and local quality improvement initiatives. Y

The practice had a comprehensive programme of quality improvement and used

information about care and treatment to make improvements. Y

Examples of improvements demonstrated because of clinical audits or other improvement activity in

past two years

• Audit of newly diagnosed patients with hypertension to ensure that they had a Q Risk 2 score assessment. Cycle one and two were reviewed at last inspection. Third cycle (2019) showed further improvement (92% had an assessment completed).

• Audit on benzodiazepines on repeat prescribing. Two cycle. First cycle: 56 patients receiving these medicines on repeat prescription, and “most” had no clear reason (inconsistent with prescribing policy). Second cycle: 10 patients had benzodiazepines on repeat prescription, and all had

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documented reason. Nine of the ten patients were in residential care or housebound and there was evidence of discussion with them and/or their carers. The tenth patient had been started on the medicines by a hospital consultant and was being monitored.

• Diabetic QOF Audits. 1st cycle 2018: compared retrospective January 2018 results with December 2018. Little impact of actions noted, hypothesised as being too early to detect. 2nd cycle March 2019: improvement from 63% with HBA1C at 59 or under to 67% (6 more patients). 3rd cycle April 2019: improvement to 70% (5 more patients).

• Clinical/Exception Reporting Audit. 1st cycle: found rates for cervical screening, asthma, COPD and dementia were above average and had increased 2017/17 to 2017/18. Exceptions for diabetes, depression and mental health had dropped 2016/17 to 2017/18 but still above average. This was reported to be due to non-engagement by patients and/or patients in nursing homes being unsuitable for the test/indicator. Action plan: including offering consultation with GP after letter and phone invitations, use of domiciliary care team for bloods/assessments, lead for exception reporting, removal of patients for e-prescribing and small dose prescribing. 2nd cycle February 2019: all target indicators saw reduced exception reporting. Further action plan in place.

Effective staffing

The practice was able to demonstrate that staff had the skills, knowledge and

experience to carry out their roles. Y/N/Partial

Staff had the skills, knowledge and experience to deliver effective care, support and treatment. This included specific training for nurses on immunisation and on sample taking for the cervical screening programme.

Y

The learning and development needs of staff were assessed. Y

The practice had a programme of learning and development. Y

Staff had protected time for learning and development. Y

There was an induction programme for new staff. Y

Induction included completion of the Care Certificate for Health Care Assistants employed since April 2015.

Evidence not gathered

Staff had access to regular appraisals, one to ones, coaching and mentoring, clinical supervision and revalidation. They were supported to meet the requirements of professional revalidation.

Y

The practice could demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurses, paramedics, pharmacists and physician associates.

Y

There was a clear and appropriate approach for supporting and managing staff when their performance was poor or variable.

Y


Coordinating care and treatment

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Staff worked together and with other organisations to deliver effective care and

treatment.

Indicator Y/N/Partial

The contractor has regular (at least 3 monthly) multidisciplinary case review meetings

where all patients on the palliative care register are discussed (01/04/2017 to 31/03/2018)

(QOF)

Y

We saw records that showed that all appropriate staff, including those in different teams

and organisations, were involved in assessing, planning and delivering care and treatment. Y

Care was delivered and reviewed in a coordinated way when different teams, services or

organisations were involved. Y

Patients received consistent, coordinated, person-centred care when they moved between

services. Y

For patients who accessed the practice’s digital service there were clear and effective

processes to make referrals to other services. N/A


Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

Y/N/Partial

The practice identified patients who may need extra support and directed them to relevant

services. This included patients in the last 12 months of their lives, patients at risk of

developing a long-term condition and carers.

Y

Staff encouraged and supported patients to be involved in monitoring and managing their

own health. Y

Staff discussed changes to care or treatment with patients and their carers as necessary. Y

The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Y


Smoking Indicator Practice CCG

average

England

average

England

comparison

2017/18

Practice

2018/19

(unverified)

The percentage of patients with any or

any combination of the following

conditions: CHD, PAD, stroke or TIA,

hypertension, diabetes, COPD, CKD,

asthma, schizophrenia, bipolar affective


variation 96.3%

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21

disorder or other psychoses whose

notes record smoking status in the


31/03/2018) (QOF)


0.6% 0.8% N/A 0.6%

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and

guidance. Y/N/Partial

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. We saw that consent was documented.

Y

Clinicians supported patients to make decisions. Where appropriate, they assessed and

recorded a patient’s mental capacity to make a decision. Y

The practice monitored the process for seeking consent appropriately. Y


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Caring Rating: Good

Following the inspection on 6 December 2018 we rated caring as requires improvement because the

practice had failed to take effective action on previous negative feedback about GP consultations.

Following the inspection on 29 May 2019 we have changed the rating for caring to good, because we

found that the practice had sought and were acting on patient feedback.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion. Feedback from

patients was positive about the way staff treated people.

Y/N/Partial

Staff understood and respected the personal, cultural, social and religious needs of patients.

Y

Patients were given appropriate and timely information to cope emotionally with their care,

treatment or condition. Y


CQC comments cards

Total comments cards received. 5

Number of CQC comments received which were positive about the service. 5

Number of comments cards received which were mixed about the service. 0

Number of CQC comments received which were negative about the service. 0

National GP Survey results

Note: The questions in the 2018 GP Survey indicators have changed. Ipsos MORI have advised that the

new survey data must not be directly compared to the past survey data, because the survey

methodology changed in 2018.

Practice

population size Surveys sent out Surveys returned

Survey Response

rate%

% of practice

population

4399 419 125 29.8% 2.84%

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23


average England average

England comparison

The percentage of respondents to the GP

patient survey who stated that the last time

they had a general practice appointment, the

healthcare professional was good or very

good at listening to them (01/01/2018 to

31/03/2018)


variation





good at treating them with care and concern

(01/01/2018 to 31/03/2018)


variation


patient survey who stated that during their

last GP appointment they had confidence

and trust in the healthcare professional they

saw or spoke to (01/01/2018 to 31/03/2018)


variation


patient survey who responded positively to

the overall experience of their GP practice

(01/01/2018 to 31/03/2018)


variation

Question Y/N

The practice carries out its own patient survey/patient feedback exercises. Y

Any additional evidence

We noted in previous inspection reports below average patient satisfaction in the national GP patient survey in 2015 and 2016 for how well GPs treat them with care and concern. The practice had not reviewed the 2017 results, and had not undertaken any other alternative monitoring. The 2017 survey did not show improvement. These indicators were not in the 2018 survey and therefore could be used for comparison purposes. At this inspection we found that the practice had carried out their own patient survey. This was related to named clinicians, so that the practice could assess patients’ views on individual GPs and nurses (particularly whether they showed care and concern). Survey forms were distributed until 30 patients had responded for each GP partner and full time nurse, and 15 for other clinical staff. The survey had a nearly 100% response rate, and showed that satisfaction with all clinical staff was high.

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Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

Y/N/Partial

Staff communicated with patients in a way that helped them to understand their care, treatment and condition, and any advice given.

Y

Staff helped patients and their carers find further information and access community and

advocacy services. Y


Source Feedback

Interviews with patients.

Patients told us that they felt well cared for by the practice, and felt that healthcare staff listened to them and involved them in decisions.




England comparison



last GP appointment they were involved as

much as they wanted to be in decisions about

their care and treatment (01/01/2018 to

31/03/2018)


variation

Y/N/Partial

Interpretation services were available for patients who did not have English as a first language.

Y

Patient information leaflets and notices were available in the patient waiting area which told patients how to access support groups and organisations.

Y

Information leaflets were available in other languages and in easy read format. Y

Information about support groups was available on the practice website. Y


Carers Narrative

Percentage and number of carers identified.

128 (3%)

How the practice The practice offered carers flu jabs and was about to start offering carers

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25

supported carers. annual health checks.

How the practice supported recently bereaved patients.

Staff told us that the GP who best known to the family telephoned them, and sent a card. Staff told us that the practice signposted patients to appropriate support services.

Privacy and dignity

The practice respected patients’ privacy and dignity.

Y/N/Partial

Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations, investigations and treatments.

There were privacy screens

Consultation and treatment room doors were closed during consultations. Y

A private room was available if patients were distressed or wanted to discuss sensitive issues.

Y

There were arrangements to ensure confidentiality at the reception desk. Y


The reception area was separate to the waiting room.

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Responsive Rating: Good

Following the inspection on 6 December 2018 we rated responsive as good.

Following the inspection on 29 May 2019 the practice remains rated as good for responsive.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs.

Y/N/Partial

The importance of flexibility, informed choice and continuity of care was reflected in the services provided.

Y

The facilities and premises were appropriate for the services being delivered. Y

The practice made reasonable adjustments when patients found it hard to access services. Y

The practice provided effective care coordination for patients who were more vulnerable or who had complex needs. They supported them to access services both within and outside the practice.

Y

Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Y


Practice Opening Times

Day Time

Opening times:

Monday 8am – 8pm

Tuesday 8am – 8pm

Wednesday 8am – 6.30pm

Thursday 8am – 8pm

Friday 8am – 8pm

Saturday 10am – 12pm

GP appointments were from 9am to 12pm every morning and in the afternoon until 8pm on Monday, Tuesday, Thursday and Friday. On Wednesday, appointments were available until 6.30pm. Nursing appointments were available 4 days a week, and on Thursday until 6.30pm. Saturday appointments were available by appointment only.

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Practice


Survey Response

rate%

% of practice

population

4399 419 125 29.79% 2.84%



England comparison


patient survey who stated that at their last

general practice appointment, their needs

were met (01/01/2018 to 31/03/2018)


variation


Findings

• All patients had a named GP who supported them in whatever setting they lived.

• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs and complex medical issues.

• In recognition of the religious and cultural observances of some patients, the GP would respond quickly, often outside of normal working hours, to provide the necessary death certification to enable prompt burial in line with families’ wishes when bereavement occurred.

People with long-term conditions Population group rating: Good

Findings

• Patients with multiple conditions had their needs reviewed in one appointment.

• The practice liaised regularly with the local district nursing team and community matrons to discuss and manage the needs of patients with complex medical issues.

• Care and treatment for people with long-term conditions approaching the end of life was coordinated with other services.

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Findings

• Additional nurse appointments were available out of school hours at the local GP practice hub for school age children so that they did not need to miss school.

• We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, DNA.

• All parents or guardians calling with concerns about a child were offered a same day appointment when necessary.



Findings

• The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

• The practice was open until 8pm four days a week, and on Saturdays 10am – 12pm (for pre-booked appointments only).

• Pre-bookable appointments were also available to all patients at additional hub locations within the area, as the practice was a member of a GP federation. Appointments were available at the hub practices on Saturday and Sunday.



Findings

• The practice held a register of patients living in vulnerable circumstances and those with a learning disability.

• People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

• The practice adjusted the delivery of its services to meet the needs of patients with a learning disability.

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Findings

• Priority appointments were allocated when necessary to those experiencing poor mental health.

• Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.

• The practice was aware of support groups within the area and signposted their patients to these accordingly.

Timely access to the service

People were able to access care and treatment in a timely way.

Y/N/Partial

Patients with urgent needs had their care prioritised. Y

The practice had a system to assess whether a home visit was clinically necessary and the urgency of the need for medical attention.

Y

Appointments, care and treatment were only cancelled or delayed when absolutely necessary.

Y





England comparison



how easy it was to get through to someone at

their GP practice on the phone (01/01/2018

to 31/03/2018)

93.3% N/A 70.3% Variation (positive)



the overall experience of making an

appointment (01/01/2018 to 31/03/2018)


variation


patient survey who were very satisfied or

fairly satisfied with their GP practice

appointment times (01/01/2018 to


variation

of 192

30



England comparison

31/03/2018)


patient survey who were satisfied with the

type of appointment (or appointments) they

were offered (01/01/2018 to 31/03/2018)


variation

Source Feedback

Practice internal survey

In the report of the inspection in June 2017 we observed that there was one critical comment common across the patients we spoke to and the comment cards, which related to delays being seen after appointment times (with patients reporting delays of 30 – 60 minutes).

In 2018, we noted that there was no monitoring in place for delays to appointments. Staff told us that on ad hoc basis patients would sometimes (with their permission) be swapped to another GP if the GP they were booked to see was running late.

There was one formal complaint that related to waiting 40 minutes and staff told us that this was the most common complaint made informally to practice staff.

The 2018/2019 practice survey asked patients about how long they had to wait after their appointment time.

The results showed that patients reported an average wait after their appointment time of 15 minutes. However, this was very variable between GPs, with higher waiting times reported by patients of particular GPs. Overall satisfaction with those GPs was very high.

In response the practice spoke to GPs. GPs were reluctant to ‘rush’ patients or to be rigid about only dealing with one issue per appointment.

The practice introduced two ‘catch up slots’ for GPs per day, so that time could be found to deal with patients who needed more than their booked appointment without delaying every other patient. Notices were placed in the waiting room and on the website advising patients that it was best to have only one issue per appointment, and that double appointments could be booked if necessary.

The practice planned to repeat the survey.

Listening and learning from concerns and complaints

Complaints were listened and responded to and used to improve the quality of

care.

Complaints

Number of complaints received in the last year. 4

Number of complaints we examined. 2

Number of complaints we examined that were satisfactorily handled in a timely way. 0

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31

Number of complaints referred to the Parliamentary and Health Service Ombudsman. 0

Information about how to complain was readily available. Y

There was evidence that complaints were used to drive continuous improvement. Y


We looked at records related to the two complaints received in the last year. Both complaints had been well documented, with full details of the complaint, the investigation, the outcome, the lessons learned and the actions taken. The records also had full details of communication with the patients who complained. In both cases the complaint was resolved during a telephone call with the patient. The records had full details of the call, including that the patient was offered a written response and was reminded of their rights to contact the Ombudsman if they were unhappy with the practice’s handling of the complaint.

The legislation governing NHS complaints says that practices must respond in writing to the complainant in writing, after investigating complaints.

The practice had followed its complaints policy, which did not state explicitly that complaints subject to the legislation must be closed in writing. Practice staff told us that the complaints policy would be updated,

Example(s) of learning from complaints.

Complaint Specific action taken

A patient complained about how a GP had completed a health declaration form.

The practice took advice from their Medical Defence Union, which confirmed that the GP had acted appropriately. The practice apologised to the patient that the service had not met their expectations and that the patient had been inconvenienced (a doctor at another service completed the form in the way that the patient needed). The practice also changed its policy on completing fitness forms. Partners decided that, in future, if GPs would not be able to provide the response that the patient hoped, patients would be offered the option to not have the form completed (and therefore would not have to pay for a service that does not meet their expectations). The patient was happy with this response.

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Well-led Rating: Good

Following the inspection on 6 December 2018 we rated well led as inadequate because:

• Practice leaders had not established sufficient policies, procedures and activities to sustain good

quality care.

• Some systems that had been established to manage risk were not working effectively as they did

not ensure appropriate action was taken when necessary to mitigate risks identified.

• Some of the issues we identified at this inspection had been raised with the practice previously,

but had not been effectively addressed.

• The leadership structure did not consistently ensure patient safety. Structures and systems to

support an overarching governance framework were not clearly set out or effective.

• Practice leaders had failed to take effective action on patient feedback.

• Practice leaders had failed to take effective action on areas of clinical performance that were

below average/below national targets. There had been some previous improvement that the

practice had failed to sustain.

Following the inspection on 29 May 2019 we have changed the rating for well led to good, because the

practice leaders had taken effective steps to address the issues we identified. Unlike previously, the

practice had looked more widely at communication and governance and made changes to improve the

sustainability of high-quality care.

Leadership capacity and capability

There was compassionate, inclusive and effective leadership at all levels. Y/N/Partial

Leaders demonstrated that they understood the challenges to quality and sustainability. Y

They had identified the actions necessary to address these challenges. Y

Staff reported that leaders were visible and approachable. Y

There was a leadership development programme, including a succession plan. Y


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Vision and strategy

The practice had a clear vision and credible strategy to provide high quality

sustainable care. Y/N/Partial

The practice had a clear vision and set of values that prioritised quality and sustainability. Y

There was a realistic strategy to achieve their priorities. Y

The vision, values and strategy were developed in collaboration with staff, patients and external partners.

Y

Staff knew and understood the vision, values and strategy and their role in achieving them.

Y

Progress against delivery of the strategy was monitored. Y


Culture

The practice had a culture which drove high quality sustainable care. Y/N/Partial

There were arrangements to deal with any behaviour inconsistent with the vision and values.

Y

Staff reported that they felt able to raise concerns without fear of retribution. Y

There was a strong emphasis on the safety and well-being of staff. Y

There were systems to ensure compliance with the requirements of the duty of candour. Partial

The practice’s speaking up policies were in line with the NHS Improvement Raising Concerns (Whistleblowing) Policy.

N


The practice significant event policy did not provide guidance on when the duty of candour applied and the actions required. The significant event form did prompt staff to consider duty of candour. The examples we saw showed that practice staff were open and honest with patients, even though the issues did not meet the criteria for the statutory duty of candour to apply.

The practice whistleblowing policy did not have details of an external person that staff could contact. This was rectified during the inspection.

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34

Examples of feedback from staff or other evidence about working at the practice

Source Feedback

Staff Staff told us that they felt happy and well supported. Team members who had taken new responsibilities as part of the practice’s improvement work told us that they were working as part of a team to give better care, and were keen to show us evidence of improvement.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support

good governance and management. Y/N/Partial

There were governance structures and systems which were regularly reviewed. Y

Staff were clear about their roles and responsibilities. Y

There were appropriate governance arrangements with third parties. Y

Explanation of any answers and additional evidence: Since the last inspection the partners had established regular formal meetings, to discuss the practice’s performance and governance systems.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and

performance.

Y/N/Partial

There were comprehensive assurance systems which were regularly reviewed and improved.

Y

There were processes to manage performance. Y

There was a systematic programme of clinical and internal audit. Y

There were effective arrangements for identifying, managing and mitigating risks. Y

A major incident plan was in place. Y

Staff were trained in preparation for major incidents. Y

When considering service developments or changes, the impact on quality and sustainability was assessed.


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Appropriate and accurate information

There was a demonstrated commitment to using data and information proactively

to drive and support decision making. Y/N/Partial

Staff used data to adjust and improve performance. Y

Performance information was used to hold staff and management to account. Y

Our inspection indicated that information was accurate, valid, reliable and timely. Y

There were effective arrangements for identifying, managing and mitigating risks. Y

Staff whose responsibilities included making statutory notifications understood what this entails.

Y

Explanation of any answers and additional evidence: At the last inspection we noted that practice meeting minutes we reviewed did not have sufficient detail to act as a reference for follow up, or for those who could not attend. There were no actions with details of the person responsible and the deadline. At this inspection we found that all the meeting minutes we reviewed had clear actions and evidence of follow up of actions previously identified. Meeting minutes were emailed to all staff members.

Engagement with patients, the public, staff and external partners

The practice involved the public, staff and external partners to sustain high quality

and sustainable care. Y/N/Partial

Patient views were acted on to improve services and culture. Y

Staff views were reflected in the planning and delivery of services. Y

The practice worked with stakeholders to build a shared view of challenges and of the needs of the population.

Y


Feedback from Patient Participation Group.

Feedback

Members of the patient participation group told us that that they met regularly, with representatives of the practice. We were told that the practice told the group about patient feedback, listened to the group’s feedback and suggestions and discussed and proposed changes.

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Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and

innovation.

Y/N/Partial

There was a strong focus on continuous learning and improvement. Y

Learning was shared effectively and used to make improvements. Y


Examples of continuous learning and improvement

The partners had considered how to make sustainable improvements, to the areas identified at the last inspection, and more broadly to performance and governance. The partners had assigned themselves lead roles for the areas of repeated weakness (e.g. recruitment), to ensure these had adequate leadership. At the time of the last inspection, the two partners only worked four sessions a week, and did not have any allocated time to meet or discuss governance issues. At this inspection, staff told us that the partners now both worked on a Saturday morning – with one partner seeing patients and one carrying out management and leadership tasks. This also provided an opportunity for the partners to meet, when the practice manager would also join them. Communication had improved in the practice overall, and this was documented in clear and detailed meeting minutes, and records of complaints and significant events. To improve the areas of below average performance in managing long term conditions, the practice had employed a practice pharmacist. Evidence (unverified) for 2018/19 showed that performance had improved to in line with average for all of the long term conditions data we review. The practice had improved their systems for other indicators with national targets (e.g. childhood immunisations) and was making progress towards meeting them. The practice had commissioned an external organisation to advise them on how to better identify patients with long term health conditions and best practice on coding exceptions.

Notes: CQC GP Insight

GP Insight assesses a practice's data against all the other practices in England. We assess relative performance for the majority of indicators using a “z-score”

(this tells us the number of standard deviations from the mean the data point is), giving us a statistical measurement of a practice's performance in relation to

the England average. We highlight practices which significantly vary from the England average (in either a positive or negative direction). We consider that

z-scores which are higher than +2 or lower than -2 are at significant levels, warranting further enquiry. Using this technique we can be 95% confident that the

practices performance is genuinely different from the average. It is important to note that a number of factors can affect the Z score for a practice, for example

a small denominator or the distribution of the data. This means that there will be cases where a practice’s data looks quite different to the average, but still

shows as no statistical variation, as we do not have enough confidence that the difference is genuine. There may also be cases where a practice’s data looks

similar across two indicators, but they are in different variation bands.

The percentage of practices which show variation depends on the distribution of the data for each indicator, but is typically around 10-15% of practices. The

practices which are not showing significant statistical variation are labelled as no statistical variation to other practices.

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37

N.B. Not all indicators in the evidence table are part of the GP insight set and those that aren’t will not have a variation band.

The following language is used for showing variation:

Variation Bands Z-score threshold

Significant variation (positive) ≤-3

Variation (positive) >-3 and ≤-2

Tending towards variation (positive) >-2 and ≤-1.5

No statistical variation <1.5 and >-1.5

Tending towards variation (negative) ≥1.5 and <2

Variation (negative) ≥2 and <3

Significant variation (negative) ≥3

Note: for the following indicators the variation bands are different:

• Child Immunisation indicators. These are scored against the World Health Organisation target of 95% rather than the England average. • The percentage of respondents to the GP patient survey who responded positively to how easy it was to get through to someone at their GP practice

on the phone uses a rules based approach for scoring, due to the distribution of the data. This indicator does not have a CCG average.

It is important to note that z-scores are not a judgement in themselves, but will prompt further enquiry, as part of our ongoing monitoring of GP practices.

Guidance and Frequently Asked Questions on GP Insight can be found on the following link:

https://www.cqc.org.uk/guidance-providers/gps/how-we-monitor-gp-practices

Glossary of terms used in the data.

• COPD: Chronic Obstructive Pulmonary Disease • PHE: Public Health England • QOF: Quality and Outcomes Framework • STAR-PU: Specific Therapeutic Group Age-sex weightings Related Prescribing Units. These weighting allow more accurate and meaningful comparisons within a specific

therapeutic group by taking into account the types of people who will be receiving that treatment.

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7da52473-241a-4692-8b2f-1e81ed2b2200

PRACTICE ROOMS

Floo

r PRINCIPAL USE TIMES MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

08:30-12:30 Dr A Saffar Dr S Badshah Dr A Saffar Dr A Saffar Dr A Saffar

12:30-15:00 GP / other admin GP / other admin GP / other admin GP / other admin GP / other admin

15:00-19:00 Dr A Saffar Dr S Badshah Dr A Saffar Dr A Saffar Dr A Saffar

08:30-12:30 Dr M Rodin Dr M Rodin Dr M Amjad Dr M Rodin Locuum GP


15:00-19:00 Dr M Rodin Dr M Rodin Dr M Amjad Dr M Rodin Locuum GP

08:30-12:30 Dr R Seyan Dr R Seyan Dr R Seyan Dr R Seyan Dr R Seyan


15:00-19:00 Dr R Seyan Dr R Seyan Dr R Seyan Dr R Seyan Dr R Seyan

08:30-12:30 Dr A Seyan Dr A Seyan Dr S Badshah Dr A Seyan Dr A Seyan


15:00-19:00 Dr A Seyan Dr A Seyan Dr S Badshah Dr A Seyan Dr A Seyan

08:30-12:30 Dr S Machin Dr S Machin Dr S Machin Dr S Machin Dr C Galundia


15:00-19:00 Dr S Machin Dr S Machin Dr S Machin Teaching & Training Dr C Galundia

08:30-12:30 Dr B Subashini Dr B Subashini Dr B Subashini Dr C Galundia Dr B Subashini


15:00-18:00 Dr B Subashini Dr M Amjad Dr B Subashini Dr C Galundia Dr B Subashini

08:30-12:30 Practice Nurses Midwives clinic Practice Nurses Practice Nurses Practice Nurses

12:30-15:00 Practice Nurses/admin Midwives clinic Practice Nurses/admin Practice Nurses/admin Practice Nurses/admin

15:00-18:00 Practice Nurses Midwives clinic Practice Nurses Warfarin clinci Practice Nurses

08:30-12:30 Practice Nurses Practice Nurses Practice Nurses Practice Nurses Practice Nurses

12:30-15:00 Practice Nurses/admin Practice Nurses/admin Practice Nurses/admin Practice Nurses/admin Practice Nurses/admin

15:00-18:00 Practice Nurses Practice Nurses Practice Nurses Practice Nurses Practice Nurses

08:30-12:30 Specialist Nurse

Practitoner

Specialist Nurse

Practitoner

Specialist Nurse

Practitoner

Specialist Nurse

Practitoner

Practice Nurses


Practitoner

Specialist Nurse

Practitoner

Specialist Nurse

Practitoner

Specialist Nurse

Practitoner

Practice Nurses/admin


Practitoner

Specialist Nurse

Practitoner

Specialist Nurse

Practitoner

Specialist Nurse

Practitoner

Practice Nurses

08:30-12:30 GP Registrar GP Registrar GP Registrar GP Registrar GP Registrar






08:30-12:30 Nurse led treatment Nurse led treatment Nurse led treatment Nurse led treatment Nurse led treatment



08:30-12:30 Admin Anti-coagulation clinic Admin Anti-coagulation clinic NDPP (diabetic clinic)

12:30-15:00 Admin Anti-coagulation clinic Admin Anti-coagulation clinic NDPP (diabetic clinic)

15:00-18:00 Admin Anti-coagulation clinic Foot clinic Anti-coagulation clinic NDPP (diabetic clinic)

08:30-12:30 Counselling (therapist 1) Counselling (therapist

2)

Counselling (therapist

3)

Counselling (therapist 5) Vascectomy clinic

Counselling (therapist 12:30-15:00 Counselling (therapist 1) Counselling (therapist

2)


3)

Counselling (therapist 5) Vascectomy clinic

Counselling (therapist 15:00-18:00 Admin Counselling (therapist

2)


4)

Counselling (therapist 6) Counselling (therapist

6)

08:30-12:30 GP GP GP GP GP


15:00-18:00 GP GP GP GP GP

08:30-12:30 GP GP GP GP GP


15:00-18:00 GP GP GP GP GP

08:30-12:30 Nurse Pharmacist Nurse Pharmacist Nurse Pharmacist Nurse Pharmacist Nurse Pharmacist



08:30-12:30 Social Prescriber Social Prescriber Social Prescriber Social Prescriber Social Prescriber



08:30-12:30 PNs / Visiting

consultants

PNs / Visiting

consultants

PNs / Visiting

consultants

PNs / Visiting consultants PNs / Visiting

consultants12:30-15:00 PNs / Visiting

consultants

PNs / Visiting

consultants

PNs / Visiting

consultants


consultants15:00-18:00 PNs / Visiting

consultants

PNs / Visiting

consultants

PNs / Visiting

consultants


consultants08:30-12:30 GP led treatment GP led treatment GP led treatment GP led treatment GP led treatment

12:30-15:00 GP led treatment GP led treatment GP led treatment GP led treatment GP led treatment

15:00-18:00 GP led treatment GP led treatment GP led treatment GP led treatment GP led treatment

Practice Nurses /

Visiting Consultants /

c;ommunity services

Consulting Room 9 -

Specialist Nurse

Practitioner

FF Specialist Nurse

Practitioner & shared

with others (iNurse

Paramedic)

Consulting Room 8 -

Practice Nurses

FF Practice Nurses / DNs /

HVs

Nurse led treatment

room

New Nurse Pharmacist

GP led treatment room /

including visiting

consulan.

Consulting Room D FF New Social Prescriber

GF

Clinical Room 6 / GP

led Treatment Room

with supporting utility

Consulting Room E

G

Consulting Room A GF

GF

Consulting Room B GF New GP Registrar /

trainee

Consulting Room C

Consulting Room 11 -

GP Registrar

G

Non-clinical side room

(annexe)

G Nurse led treatment

room

Counselling /

Recovery Room (ref

20) in corridor

Clinical Room 12 /

Treatment Room

G Room used mainly for

counselling

Dr Ravi Seyan

(8+ sessions p.w.)

GF Dr Amit Seyan

(8+ sessions p.w.) &

shared with others.

Consulting Room 6 -

GP Partner

GF

GP Registrar

Consulting Room 10 -

GP Registrar

FF

Consulting Room 4 -

GP Partner

FF

New GP Partner /

Salaried GP

Consulting Room 5 -

Salaried GP

GF Dr Stephanie Machin (7

sessions p.w.) & Dr

Chandni Galundia (4

sessions p.w.)Dr Baktavatsalu

Subashini (7 sessions

p.w.) shared with others.

Consulting Room 7 -

Practice Nurses

GP Registrar

Practice Nurses / DNs /

HVs

G

ADDITIONAL RENTALISED AREA REQUESTED - for Dr Seyan

Practice once vacated by Old Court House Practice's branch surgery

(130 sq.m.)

Consulting Room 2 -

GP Partner

GF Dr Marion Rodin (8

sessions p.w.) & Dr M

Amjad (1 session p.w.)

Consulting Room 3 -

GP Partner

GF

CURRENT RENTALISED AREA - Robin Hood Lane HC, Dr Seyan &

Partners (847 sq.m.)

Consulting Room 1 -

GP Partner

GF Dr Ammer Saffar (8

sessions p.w.) & Dr Soha

Badshah (3+ sessions

p.w.)

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Document Title PMS Performance and Assurance Report 2018/19


Michelle Rahman – Acting Managing Director







Executive Summary In April 2018 Sutton GP Practices commenced delivery of a new PMS contract, which includes the delivery of 16 Sutton specific Key Performance Indicators (KPIs) at a value of £3.7million per annum. Practices have been submitting KPI data quarterly to the SWL PC team and this report brings together this information and provides an overview of activity. Where possible data has been presented ‘per 1000 registered patients’ to take into account of practice variation attributed to list size. This report is to inform commissioners and GP contract holders of the practices’ performance and to help identify any issues or areas of concern as well as provide assurance that the PMS Premium KPIs are delivering the benefits that were intended. The process is intended to be supportive and part of the on-going dialogue between practices and commissioners. There are no financial implications for practices not having achieved a given target. However action plans will need to be developed as per the KPI specification if particular targets/improvements have not been made There is considerable variation in activity per practice, even when normalised for list size. Practices have therefore been asked to check that:

• All activity is correctly coded (Read codes for PMS can be found on GP Teamnet)

• They have effective systems in place to report the data at the agreed intervals Practices have also been encouraged to discuss the report as team and:

• Celebrate the good work that has been achieved

• Consider what improvements should be focussed on for 19/20

✓

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✓

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Over the coming weeks Sutton CCG’s Executive Management Team will consider the need to review and refresh Sutton’s current PMS KPIs. If a review is required a working group will be formed (which includes the LMC) to take this work forward. Reason for Committee Review: This report is being brought to the committee to provide assurance that general practices in Sutton are delivering the Key performance indicators on line with the specifications outlined in the Sutton PMS contract. The committee are also asked to note the planned next steps.

Key Issues:

1. 2018/19 was the first year practices delivered the new PMS contract. Overall practices delivered well against the 16 specifications

2. There are some concerns about the accuracy of coding and thus activity volumes presented in this report. The draft report has been shared with practice managers and a request made to review activity and coding to ensure this is accurately represented in 2019/20

3. The Executive committee is to discuss and consider the need to review/refresh any of the existing PMS KPI’s to support delivery of the joint financial recovery plan

4. If a review is to be undertaken a working group will be established to undertake this work with a view to any changes being implemented in April 2020


Mitigations:

Recommendation: The Committee is asked to: The Primary Care Commissioning Committee are asked to DISCUSS the content of this report noting next steps


Objective 1: Ensure patients are at the heart of decision making, working in partnership with individuals, patient representative groups, families and carers to deliver high quality, accessible services that tackle inequalities and respond to personal need.

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Objective 2: Commission high quality cohesive health services for the population of Sutton through joint working between health and social care organisations ensuring patients’ physical, mental and social wellbeing needs are met. Objective 3: Maintain an efficient and financially stable, local healthcare system by improving primary care and community services and working closely with secondary care to deliver integrated services that bring healthcare into the community.


None noted




N/A - not relevant as no change in service therefore not completed.


No


Given the proposal would not directly impact or change services for patients this is not relevant in this case



Outcome:

PCTOMG Tuesday, 11 June 2019

LMC Liaison meeting (Part 2)

Thursday, 04 July 2019

Practice Manager Forum Tuesday, 06 August 2019

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Supporting Documents 2018/19 PMS Performance and Assurance Report

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1

PMS Performance and

Assurance Report

(2018/19)

Lou Naidu - Head of Primary Care, Sutton CCG

SWL Primary Care Team

June 2019

of 192

2

Overview and summary recommendations

In April 2018 Sutton GP Practices commenced delivery of a new PMS contract, which includes the

delivery of 16 Sutton specific Key Performance Indicators (KPIs) [Appendix 1].

This report is to inform commissioners and GP contract holders of the practice’s performance and to

help identify any issues or areas of concern. The process is intended to be supportive and part of the

on-going dialogue between practices and commissioners.

Overall the performance of Sutton practices has been good. Those practices who have fallen short of

specific targets will be asked to develop an action plan for improvement during the year 2019/20.

The matrix below indicates where improvement is required.

PMS KPI Improvement Matrix

A number of practices fell short of the bowel screening 60% target however a significant number of

practices are above 50% and making good progress towards achieving this.

All practices will be asked to review their coding, as the data reported demonstrates considerable

variation when normalised by list size. Sutton CCG cannot at this stage determine if this is genuine

variation in activity or if the data provided is incomplete due to poor coding.

Assessment of PS 2 & 3 (Patient Voice) is reliant on the publication of the GP National Survey, due

July 2019.

PS

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access

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H85018 Mulgrave Road Surgery

H85019 GP Centre (Dr Jolly)

H85021 Chesser Practice

H85022 Park Road Surgery

H85023 Bishopsford Road Practice

H85025 Wrythe Green Surgery

H85030 Old Court House Practice

H85031 Benhill & Belmont GP Centre

H85032 Carshalton Fields Surgery

H85053 Sutton Medical Practice

H85054 Leghari & Muktar Practice

H85063 Dr Scott

H85095 Robin Hood Lane Medical Centre

H85103 Hackbridge Medical Centre

H85105 Cheam Family Practice

H85113 Maldon Road Surgery

H85115 Shotfield Medical Practice

H85116 Manor Road Practice

H85618 James O'Riordan Medical Centre

H85653 Wallington Family Practice

H85662 Beeches Surgery (GMS)

H85665 Wallington Medical Centre

H85683 Faccini House Surgery

H85686 Grove Road Practice

H85693 Green Wrythe Surgery

KPI requirements met

KPI requirements partially met

KPI requirements not met

Sutton CCG Improvement Matrix

PMS KPIs 2018/19

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PS1 – Prevention.

Practices were asked to select 3 from the following 5 immunisation programmes and improve

uptake. Baseline positions were established on 01/04/18 and practices submitted uptake figures at

year-end, 31/03/19.

The following table demonstrates the indicators selected and whether any improvement had been

achieved.

PSA1A PSA1B PSA1C PSA1D PSA1E

Age 1Y Age 5Y Flu 65+ Flu at risk Pneumo

Organisation CDB Change Change Change Change Change

The Wrythe Green Surgery H85025 1% 3% -5%

Wallington Family Practice H85653 -2% -5% -1%

Maldon Road Surgery H85113 3% 2% 1%

The Chesser Surgery H85021 4% 1% 0%

The Grove Road Practice H85686 6% 0% 10%

Park Road Medical Centre H85022 4% 0% -1%

Shotfield Medical Practice H85115 -5% -4% 1%

Robin Hood Lane Health Centre H85095 3% 7% -1%

Manor Practice H85116 1% 2% 4%

Wallington Medical Centre H85665 2% -4% 4%

Cheam family Practice H85105 -3% -1% -2%

Green Wrythe Surgery H85693 -2% -4% 4%

Benhill and Belmont GP Centre H85031 0% -3% 0%

Sutton Medical Centre H85053 15% 6% 2%

Dr Scott and Partners H85063 3% 2% 1%

Bishopsford Road Medical Centre H85023 1% 7% 4%

Mulgrave Road Surgery H85018 -4% 9% 3%

Hackbridge Medical Centre H85103 -1% -1% 0%

James O'Riordan Medical Centre H85618 -3% -8% 4%

Beeches Surgery H85662 7% -43% -7%

Old Court House Surgery H85030 -3% 4%

Dr Muktar and Partners H85054 -2% -9% 1%

Dr Jolley and Partners H85019 17% -8% 1%

Carshalton Fields Surgery H85032 2% 2% 7%

Faccini House Surgery H85683 11% 9%

2%

18%

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PS2 &PS3 – Patient Voice

For the 2 statements below the contractor is required to take reasonable steps to either:

• maintain its performance as measured by this indicator, where performance meets or

exceeds the national average performance level for any given financial year; or

• improve its performance as measured by this indicator, where performance falls below the

national average performance level for any given financial year.

Percentage of patients responding within the ‘good’ range to the question “Overall how would you describe your experience of your GP Surgery?”

Percentage of patients responding within the ‘good’ range to the question “Overall, how would you describe your experience of making an appointment?"

The 2018 National GP Patient Survey was used as a baseline position. Achievement against this indicator will be assessed following the publication of the 2019 National GP Patient Survey in July 2019.

2018 2019 2018 2019

NATIONAL AVERAGE 84 83 Target 75%

H85018 Mulgrave Road Surgery 84 89 73 66

H85019 GP Centre (Dr Jolly) 91 82 59 51

H85021 Chesser Practice 87 91 75 80

H85022 Park Road Surgery 89 89 89 89

H85023 Bishopsford Road Practice 84 78 71 65

H85025 Wrythe Green Surgery 91 97 86 90

H85030 Old Court House Practice 89 87 83 77

H85031 Benhill & Belmont GP Centre 81 83 82 74

H85032 Carshalton Fields Surgery 94 83 85 80

H85053 Sutton Medical Practice 83 83 84 85

H85054 Leghari & Muktar Practice 91 90 78 78

H85063 Dr Scott 82 70 73 61

H85095 Robin Hood Lane Medical Centre 90 89 84 82

H85103 Hackbridge Medical Centre 91 95 78 89

H85105 Cheam Family Practice 90 90 77 84

H85113 Maldon Road Surgery 89 88 81 88

H85115 Shotfield Medical Practice 92 86 82 75

H85116 Manor Road Practice 83 90 72 72

H85618 James O'Riordan Medical Centre 93 81 66 50

H85653 Wallington Family Practice 88 83 59 64

H85662 Beeches Surgery (GMS) 89 80 78 67

H85665 Wallington Medical Centre 88 90 74 79

H85683 Faccini House Surgery 66 81 50 66

H85686 Grove Road Practice 89 93 87 90

H85693 Green Wrythe Surgery 79 80 61 53

ACHIEVED-above national target

NOT ACHIEVED

ACHIEVED - below target but

improvement on previous year

% patients responding within the

‘good’ range to the question

“Overall how would you describe

your experience of your GP

Surgery?"

% patients responding within

the ‘good’ range to the

question “Overall, how would

you describe your experience

of making an appointment?"

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5

August 2018

July 2019

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6

August 2018

July 2019

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PS4 – Improved Access

PS4A - The Practice shall submit the percentage 'Good' score from National GP Patient Survey to the

question: “Overall, how would you describe your experience of making an appointment?”

KPI Target 75% - as per previous section

PS4B - The Practice shall submit the average practice DNA Rate for GPs and Practice Nurses each

quarter

4 practices did not meet the less than or equal to 5% target and will be required to develop an action

plan for improvement.

PS4C - The Practice shall make a formal declaration that it has conducted a review of those

registered patients attending A&E and /or UCC during the practice opening hours during each

quarter

All except one practice (Cheam Family Practice) have declared compliance to this KPI

PS4D - The Practice shall submit an annual report setting out the courses of action that it has

initiated in the previous year to reduce A&E and UCC attendances during core hours

22 Practices submitted an annual report. The following practices did not submit a report OR the report did not meet the requirements of the KPI and will be followed up:

Cheam family Practice

Hackbridge Medical Centre

James O’Riordan Medical Centre

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8

PS5 - Improved Outcomes Through Better Compliance with Prescribed Medication

PS5A - The Practice shall submit the total number of minuted meetings with the local community

pharmacist held each quarter

Requirement - greater than 2 (two) in a year All practices achieved this

PS5B - The Practice shall submit the total number of Medicines Usage Reviews coded each quarter

PS6 - Bowel Screening

PS6A - The Practice shall aim to achieve the 60% bowel screening target

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9

Based on the data submitted, 19 practices failed to achieve the target of 60% and will be required to

develop an action plan to increase uptake.

No of practices >60% No. of practices 50-59%

No. of practices 40 – 49%

No. of practices <40%

6 10 7 2 (possible reporting error)

PS6B - The Practice shall submit the total number of non-responders followed up during the quarter

of 192

10

PS6C - The Practice shall submit the total number of patients followed up who did not complete the

screening kit in each quarter

PS6D - The Practice shall make a formal declaration confirming that it complied with the Bowel

Screening Premium Service Specification over the duration of each quarter

All Practices have declared compliance to this KPI

PS7 - Ambulatory Blood Pressure Monitoring (ABPM)

The Practice shall submit the total number of 24 hour ABPM assessments undertaken in the contract

year (target greater than zero)

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11

PS8 - The Practice shall submit the total number of patient transport bookings made by the practice

in the contract year (target greater than zero)

PS9 – Gonadorelin Implants

The Practice shall submit the total number of gonadorelin analogue implants inserted in the contract

year (target greater than zero)

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12

PS10 – E-Referral Scheme

The Practice shall make a formal declaration confirming that it complied with the E-Referral Service

Specification over the duration of each quarter


PS11 – End of Life Care

PS11A - The Practice shall submit the total number of MDT Meetings held (including meetings

required by QOF) during each quarter

Submission greater than or equal to 3 - All Practices have complied with this KPI

PS11B - The Practice shall make a formal declaration confirming that it complied with the End of Life

Care Service Specification over the duration of each quarter


Coordinate My Care (CMC activity 2018/19)

of 192

13

PS12 - Management of People with Dementia in Primary Care

PS12A - The Practice shall submit the total number of Opportunistic Assessments for Dementia

undertaken during each quarter (submission greater than 0)

PS12B - the Practice shall submit the total number of Opportunistic Assessments for Dementia

declined by patients during each quarter (submission greater than 0)

of 192

14

PS12C - The Practice shall make a formal declaration confirming that it complied with the Dementia

Premium Service Specification over the duration of each quarter


PS13 - Management of Stable Prostate Cancer Patients in Primary Care

PS13A - The Practice shall submit the total number patients discharged from secondary care under

the protocols of the Premium Service, in each quarter

PS13B - The Practice shall submit the total number first appointments delivered under the protocols of

the Premium Service, in each quarter (submission greater than 0)

of 192

15

PS13C - The Practice shall submit the total number follow-up appointments delivered under the

protocols of the Premium Service, in each quarter (submission greater than 0)

PS13D - The Practice shall submit the total number DNAs for appointments scheduled under the

protocols of the Premium Service, in each quarter

of 192

16

PS13E - The Practice shall submit the total number of patients on the practice prostate cancer

register at the end of the contract year

PS14 - Follow up of Referrals for Suspected Cancer (2 week rule)

The Practice shall make a formal declaration confirming that it complied with the Cancer Two Week

Wait Premium Specification over the duration of the relevant Quarter


of 192

17

PS15 - Post-Operative Suture Removal and Wound Care

PS15A - The Practice shall submit the total coded activity relating to Post-Operative Wound Care in

each quarter (submission greater than 0)

PS15B - The Practice shall submit the total coded activity relating to Removal of Wound Closures in

each quarter (submission greater than 0)

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18

PS15C - The Practice shall submit the total coded activity relating to Other Wound Dressings in each

quarter (submission greater than 0)

PS15D - The Practice shall make a formal declaration confirming that it complied with the Post-

Operative Suture Removal & Wound Care Service Specification over the duration of each quarter


PS16 – Safeguarding

PS16A - The Practice shall make a formal declaration that the quarterly internal Safeguarding

Meeting was undertaken for each quarter


PS16B - The Practice shall submit the total number of invitations to Initial & Review Child Protection

Case Conferences in the contract year

PS16C - The Practice shall submit the total number of Initial & Review Child Protection Case

Conferences where the practice attended or submitted a report in the contract year

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PS16D - The Practice shall submit the total percentage of Initial & Review Child Protection Case

Conferences where the practice attended or submitted a report in the contract year (should be

equal to or greater than 75%)

PS16E - The Practice shall submit the Annual Safeguarding Audit and the completed Annual

Safeguarding Assurance Template for the relevant contract year

All practices have submitted the assurance template

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20

PS16F - The Practice shall submit an annual report on training completed as per the Intercollegiate

Document for Safeguarding Children for the relevant contract year

Documents submitted and report should confirm that no less than 90% of relevant staff should have

completed GP level 3 training for Safeguarding Children.

23 Practices achieved 90% at submission

James O’Riordan Medical Centre practice achieved 50% and have been followed up.

Wallington Family Practice – 60% but confirmed all training now booked

PS16G - The Practice shall submit an annual report on training completed for Safeguarding Adults &

MCA for the relevant contract year.

Documents submitted and report should confirm that no less than 90% of relevant staff should have

completed appropriate training for Safeguarding Adults and MCA.

22 Practices achieved 90% at submission

Chesser Practice achieved 84% on submission but have now confirmed 90% achievement

James O’Riordan Medical Centre practice achieved 67% and have been followed up.

Wallington Family Practice – 53% but confirmed all training now booked

Appendix 1

KPIs and service

specs FINAL.pptx

of 192

Sutton Clinical Commissioning Group Primary Care Transformation and Operational Management Group

Date Tuesday, 03 September 2019

Document Title Primary Care Finance Report Month 4, 2019/20


Geoff Price, Finance Director


Not applicable


Geoff Price, Finance Director



Executive Summary Financial position - 4 months to 31 July 2019 and full year forecast Core 2019/20 delegated Practice budgets In summary The CCG has reported a £362k underspend for the 4 months to the end of July but a full year forecast balanced position. The 2019/20 primary care allocation increased by 5.84% over the 2018/19 level. This increase has been used to recurrently fund the 2018/19 and 2019/20 practice pay awards, 2019/20 list size growth, non-pay inflation including rent and rate increases and the costs of the new Primary Care Networks (PCN). The results at month 4 show a £362k underspend on budget in the year to date despite the contract commitments for the year being £237k in excess of the resource, £79k in the year to date. The commitments do include the estimated worst case scenario for PCN costs, however this spend may be reduced when the full impact of the additional workforce elements of the PCN are evaluated and costed. The over-spend due to the allocation shortfall is compensated by a series of under-spends. In month, £47k was invoiced to NHSE to recover rates credits due from the GL Hearn exercise, this has increased the one-off benefit from prior year accruals to £237k, and this year to date saving has been rolled forward to the forecast. Premises costs are reported as £122k below budget, but this underspend was overstated by £53k and should have been an under-spend of £69 in the year to date, in line with the forecast underspend of £206k. It arose as a practice had been funded for full occupancy of a building, but had now started to recharge other building users for their occupancy directly. The budget had been set at full occupancy reimbursement but this change of funding will now reduce costs within the delegated budget. There are further underspends recorded in the year to date results, locum costs are £40k below budget, but this can be eradicated by one or two extra cases being funded, and PADMs costs are £18k below budget but this under-spend will dissipate when the winter flu season kicks in. Enhanced

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XX

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Services are £12k below budget due to practices not signing up for the old Extended Hours DES which was available for Quarter 1 only, and £11k of this saving has been included in the year end forecast outturn. The detailed budget report is given in appendix 1.

Other primary care budgets In summary The CCG has reported a break-even position for the 4 months to the end of July and a full year forecast balanced position. All other Primary care budgets funded by the CCG have now been set. These include the primary care team; GP training; GP IT; Locally Commissioned Schemes; Out of Hours and the £1.50 per head CCG contribution to the new Primary Care Networks. The funding for primary care at scale (and extended access) has recently been set (£ 1.13m for Sutton CCG). The CCG is awaiting a resource transfer to recognise the full PCAS budget. The detailed budget report is given in appendix 2.

Reason for Committee Review: To update Committee on financial position for comment and note.

Key Issues: The forecast position at M04 is reported in balance.

Conflicts of Interest: None

Mitigations: Not applicable

Recommendation: The Committee is asked to note the report.

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Objective 3: Maintain an efficient and financially stable, local healthcare system by improving primary care and community services and working closely with secondary care to deliver integrated services that bring healthcare into the community.


531 If costs for commissioned services exceed the resources available then there is a risk of non-delivery of financial targets and plans


Currently on plan


Primary care commissioned services are on plan


Not applicable



Not applicable



Outcome:



Supporting Documents Appendices 1 and 2

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APPENDIX 1

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APPENDIX 2

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1 High quality care for all, for now and for future generations

TITLE H85053 Sutton Medical Practice

CCG: Sutton CCG

DATE: 3rd September 2019 AUTHOR: SWL Primary Care Team

Purpose

This paper provides the Sutton PCCC with an update relating to the contractual requirements that were breached by the Sutton Medical Practice following an inspection by the Care Quality Commission (CQC) on 2nd October 2018. A second remedial notice was issued on 11th January 2019 and kept in place to monitor sustained improvement. The practice was inspected on 29th May 2019, and the report published on 2nd August 2019. They have achieved overall rating of Good, and were rated Good for all indicators. Although their improvements have been acknowledged, the practice has been rated overall as inadequate twice as they had failed to sustain past improvements. Following the outcome of the recent CQC inspection, it is recommended that the remedial notice is lifted, but with the caveat of a period of monitoring.

Background

Sutton Medical Practice was inspected by the CQC on 2nd October 2018 and the practice was rated overall as inadequate. We note that this is the second time the practice has been rated as inadequate by the CQC and placed under special measures; the practice had made improvements, but was unable to sustain these:

January 2015 Rated overall as inadequate and placed under special measures. A remedial notice was issued to the practice with actions to complete

October 2015 Rated overall as requires improvement

June 2017 Rated overall as good

October 2018 Rated overall as inadequate and placed under special measures. A remedial notice was issued to the practice with actions to complete

May 2019 Rated overall as good

Following the October 2018 CQC inspection, commissioners met with the practice to discuss the outcome of the inspection and provide advice and clinical support. A remedial notice was issued to the practice on 11th January 2019, giving the practice 28 days to respond. During this time, the practice has received further advice and support from commissioners, and clinical support from the CCG. External support was also provided via the GP Resilience Fund. The key themes the practice were asked to submit evidence for in the remedial action plan were:

• Policies and procedures

• Monitoring of high risk medicines

• Significant events and incident reporting

• Management of risks

• Monitoring of emergency medical equipment and the management of oxygen

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• Clinical audit

• Patient consent - evidence this has been formally recorded

• Patient experience The practice submitted all of the required evidence by 8th March 2019, after being granted an extension. Following review of the evidence, the actions were rated as either met or partially met. It was agreed that the practice had provided sufficient assurance that they had addressed the actions set out in the second remedial notice, but this should be reviewed again in three months’ time. This would take account of the outcome of the CQC re-inspection in May 2019 and allow time for assurance that the improvements have been sustained. Following the CQC inspection on 29th May 2019, the practice is rated as good for all key indicators and all population groups and removed from special measures. The CQC report published on 2nd August 2019 states that, whilst no breaches of regulations were found, the practice should:

• Continue to monitor areas where improvements to safety, clinical care and governance have been made, to ensure they continue to be effective.

• Improve policies for handling significant events, whistleblowing and complaints to make sure they contain sufficient detail, and monitor complaints to ensure they are managed in line with legislation.

Details of the findings and the evidence supporting the CQC ratings are set out in the attached evidence tables.

Actions

Following the outcome of the recent CQC inspection, at its meeting on 3rd September 2019, the Sutton Primary Care Transformation and Operational Management Group recommended that the remedial notice is lifted, but with the caveat of a period of monitoring. Although it is recognised that the practice has been rated overall Good in their recent inspection, they had been rated Inadequate twice and Requires Improvement once, due to failure to sustain improvements that had been made. It is recommended that the SWL and Sutton Primary Care Teams visit the practice in October 2019 and again in March 2020, for assurance that the practice has been able to sustain their improvements. When the practice is visited in October 2019, it is recommended that they are asked to provide evidence of continuous improvement, particularly relating to:

• Clinical audit;

• Risk management, and;

• Management of complaints, significant events and incident reporting. The PCCC is asked to NOTE the decision of the PCTOMG that the SWL and Sutton Primary Care Teams continue to review their progress for assurance that they have sustained recent improvements. Sutton PCCC are asked to note the above actions.

Supporting documents

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This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this location Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

DrDr HafHafeezeez andand PPartnerartnerInspection report

Sutton Medical Practice181 Carshalton RoadSuttonSurreySM1 4NGTel: 020 8661 1505www.suttonmedicalcentre.nhs.uk

Date of inspection visit: 29 May 2019Date of publication: 02/08/2019

1 Dr Hafeez and Partner Inspection report 02/08/2019

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We carried out an announced comprehensive inspection atDr Hafeez and Partner on 29 May 2019 to as part of ourinspection programme.

At this inspection we followed up on breaches ofregulations identified at the last inspection.

The practice was inspected on 20 January 2015 and wasfound to be in breach of the Health and Social Care Act2008 (Regulated Activities) Regulations 2014. It was rated asinadequate and placed in special measures.

We inspected on 12 October 2015 and found thatimprovements had been made. The practice was rated asrequires improvement as there were areas that still neededimprovement in the key questions of effective and caring.

We inspected again on 13 June 2017. We found thateffectiveness had improved, but services had not improvedfor the caring key question. Although the practice was ratedgood overall, the caring key question remained requiresimprovement.

At the last inspection on 2 October 2018 we found that theimprovements the practice had made had not beensustained. Practice leaders had not established sufficientpolicies, procedures and activities to ensure safety orassured themselves that they were operating as intended.Some of the issues we identified at that inspection hadbeen raised with the practice previously and had not beeneffectively addressed. We rated the practice as inadequateoverall (because it was rated as inadequate for the keyquestions safe and well-led), requires improvement for thekey questions effective and caring, and good for theresponsive key question.

We based our judgement of the quality of care at thisservice on a combination of:

• what we found when we inspected• information from our ongoing monitoring of data about

services and• information from the provider, patients, the public and

other organisations.

We have rated this practice as good overall and goodfor all population groups.

We found that:

• The practice provided care in a way that kept patientssafe and protected them from avoidable harm. Practicepartners were leading on aspects of safety where issueswere identified previously.

• Patients received effective care and treatment that mettheir needs. The practice had taken effective action toimprove areas of below average or below targetperformance.

• Staff dealt with patients with kindness and respect andinvolved them in decisions about their care.

• The practice organised and delivered services to meetpatients’ needs. Patients could access care andtreatment in a timely way. The practice sought andacted upon patient feedback.

• The way the practice was led and managed promotedthe delivery of high-quality, person-centre care.Governance and communication had beenstrengthened since the last inspection.

Whilst we found no breaches of regulations, the providershould:

• Continue to monitor areas where improvements tosafety, clinical care and governance have been made, toensure they continue to be effective.

• Improve policies for handling significant events,whistleblowing and complaints to made sure theycontain sufficient detail, and monitor complaints toensure they are managed in line with legislation.

Following the inspection on 29 May 2019, the practice israted as good for all key questions and all populationgroups. We have changed the ratings for this practice toreflect the improvements made and the practice will beremoved from special measures.

Details of our findings and the evidence supportingour ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and IntegratedCare

Overall summary


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Population group ratings

Older people Good –––

People with long-term conditions Good –––

Families, children and young people Good –––

Working age people (including those recently retired andstudents)

Good –––

People whose circumstances may make them vulnerable Good –––

People experiencing poor mental health (including peoplewith dementia)

Good –––

Our inspection teamOur inspection team was led by a CQC lead inspector.The team included a GP specialist advisor, and a secondCQC inspector.

Background to Dr Hafeez and PartnerSutton Medical Practice is a medium sized practice basedin Sutton. The practice is registered as a partnership withthe Care Quality Commission (CQC) to provide theregulated activities of: treatment of disease, disorder orinjury; diagnostic and screening procedures and familyplanning services; and maternity and midwifery servicesat one location. The practice has a Personal MedicalServices (PMS) contract and provides a full range ofessential, additional and enhanced services includingmaternity services, child and adult immunisations, familyplanning, sexual health services and minor surgery.

The practice has two principal GP partners (who workfour sessions per week), one GP working four sessions perweek and two regular locum GPs. There is a good mix offemale and male staff. The practice has two practicenurses working 30 – 34 hours per week combined, onereception staff member who works 6 hours per week as ahealthcare assistant, a practice manager, an assistantpractice manager and six other non-clinical staff.

The practice is open between 8am and 8pm Monday toFriday, apart from Wednesday when the practice closes at6.30pm. GP appointments are from 9am to 12pm every

morning and in the afternoon until 8pm on Monday,Tuesday, Thursday and Friday. On Wednesday,appointments are available until 6.30pm. The practicewas also open on a Saturday morning for pre-bookedpatients. When the practice is closed, the telephoneanswering service directs patients to contact the out ofhours provider.

The practice has approximately 4400 patients. Theethnicity of most patients is white British. There areapproximately 11% of Asian patients, 5% black patients,4% mixed race patients and 1% other white patients.Compared to other practices in England, the practice hasslightly more patients aged under 18, and a slightlysmaller proportion of patients aged over 65. Lifeexpectancy of patients is slightly below local and nationalaverages. Most patients are in the age category aged 15 –64. The practice population is on the 8th decile fordeprivation (with 10 being the least deprived), and lowerthan average on measures of income deprivationaffecting older people and children. Compared to otherpractices in England, more patients are unemployed.

Overall summary


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Regional Director’s Office, London region briefing template. Jan 2014

TITLE H85662 Beeches Surgery

CCG: Sutton CCG

DATE: 3rd September 2019 AUTHOR: SWL Primary Care Team

Purpose

This paper provides the Sutton PCCC with a summary of the contractual and regulatory concerns identified by the Care Quality Commission (CQC), following their inspection on 19th June 2019. The CQC report was published on 15 August 2019, and they were rated overall as Requires Improvement.

Overall rating Requires improvement

Are services safe Requires improvement

Are services effective Good

Are services caring Good

Are services responsive Requires improvement

Are services well-led Requires improvement

The Committee is asked to RATIFY the recommendation to issue the practice with a Remedial Breach Notice, requesting that they complete and submit an action plan with supporting evidence to the SWL Primary Care Team for review.

Background

Beeches Surgery hold a GMS contract, with a list size of 5,989 as of 1 July 2019. The practice staff consist of two partners on the contract (one partner has retired, but has remained on the contract), three salaried GPs, two nurses, a practice manager, two administrators and six receptionists. A summary of the practice’s previous inspections are shown below:

• January 2015: rated inadequate and placed in special measures.

• November 2015: improvements were found, but also found two breaches of regulations concerning recruitment checks and managing risks. The practice was rated as requires improvement;

• May 2017: no breaches were identified and the practice was rated as good. At the recent inspection on 19th June 2019, the practice was rated overall as Requires Improvement and requires improvement for all population groups. The following ratings were applied: Requires improvement for providing safe services:

• There were systems in place to ensure safety at the practice, but they were not consistently effective. When things went wrong, action was taken, but the learning and action was poorly recorded.

Requires improvement for effective for the population group - people with long-term conditions:

• Most patients received effective care and treatment that met their needs. However, patient outcomes for asthma and hypertension were significantly

EN

C 0

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below average in 2017/18 and there was evidence that performance deteriorated further in 2018/19 (for asthma, hypertension and other long-term conditions). The practice told us of actions taken to improve, but it was too early to demonstrate that these were effective.

Requires improvement for providing responsive services (for all population groups):

• Complaints were not all being managed in line with legislation, and there was no effective system to monitor compliance;

• Individual complaints were responded to and action taken to resolve individual issues, but learning and action was not effectively documented.

Requires improvement for well-led:

• The practice had not taken effective action to improve areas of below average clinical performance in 2017/18. Performance in these indicators deteriorated further in 2018/19;

• There was no effective monitoring system for complaints to ensure that legislation was being followed. There was no effective monitoring of appointment availability. There was no effective system to document actions and learning from complaints or significant events. Meeting minutes were not effective as a record of the meeting for those who could not attend or as a reference;

• The system to ensure that governance documents were up-to-date was not consistently implemented.

Additional concerns noted were:

• No details were available of the external person for staff to contact, in line with the NHS Improvement Raising Concerns (Whistleblowing) Policy;

• Not all policies had been updated to reflect the changed role of the registered manager;

• There was no effective monitoring of appointment availability;

• Not all medicines the practice had assessed as to be kept in stock were present on the day of the inspection;

• No details of the guidelines discussed at clinical meetings, and what action the staff needed to take. There was also no record of attendance, and meeting minutes were not effective;

• There was a programme of audit, but audit had not be used to drive improvement in the areas of weak performance in 2017/18 and 2018/19. Audits were also narrow in focus;

• Significant events were poorly recorded, with no proper record of the learning or action taken. Themes and repeated events had not been identified and recorded;

• Effective action to ensure the safety of electrical items, or to manage risks of fire and infection had not been taken;

• Portable appliance testing had not been undertaken at the time of the inspection, as staff thought this had been done with the recent equipment calibration;

• The fire risk assessment identifies actions for the practice. Some of these had been addressed. However, there was no robust plan in place for the outstanding actions;

• Legionella risk assessment carried out on 30/7/18 recommended regular flushing of water outlets and temperature checks. Evidence of water checks found but not flushing. In response to draft report the practice advised that the flushing was done as part of the temperature checks, but no recorded evidence of this was available;

EN

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• There were no details of monitoring arrangements in the prescribing policy;

• Practice leaflets were not available in other languages or easy read. A full summary of the concerns identified is attached. The CQC have stated that the provider must:

• Ensure care and treatment is provided in a safe way to patients;

• Establish effective systems and process to ensure good governance in accordance with the fundamental standards of care.

The CQC has also advised that the provider should:

• Monitor appointment availability;

• Improve the identification of carers to enable this group of patients to access the care and support they need.

Contractual clauses

Part 6 Clause 41, Infection Control Part 13 Clause 269, Prescribing and Dispensing Part 15 Clause 438, Practice leaflet Part 19 Clause 488, Clinical Governance Part 22 Clause 499, Compliance with Legislation and Guidance Part 23 Clauses 500-516, Complaints

Regulations

Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment Regulation 17 HSCA (RA) Regulations 2014 Good governance

Actions

Sutton’s Primary Care Transformation and Operational Management Group, at its meeting on 3rd September, agreed to issue a Remedial Breach Notice to the contract holders, requesting that they complete and submit an action plan with supporting evidence to the SWL Primary Care Team for review, within 28 days of the of the issue date. The PCCC is asked to RATIFY this decision Following review of the practice’s response, a further paper will be submitted to the PCTOMG and Committee meetings to agree next steps.

Supporting documents

EN

C 0

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This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this location Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Requires improvement –––

Are services well-led? Requires improvement –––

BeechesBeeches SurSurggereryyInspection report

9 Hill RoadCarshaltonSurreySM5 3RBTel: 020 8647 6608www.beechessurgery.nhs.uk

Date of inspection visit: 19 June 2019Date of publication: 15/08/2019

1 Beeches Surgery Inspection report 15/08/2019

of 192

We carried out an announced comprehensive inspection atBeeches Surgery on 19 June 2019 as part of our inspectionprogramme.

The practice was inspected on 13 January 2015 and wasrated inadequate and placed in special measures.Concerns included not having appropriate arrangements inplace for processing prescriptions, inadequate systems forthe reduction of healthcare associated infection controlprocesses, inadequate systems to safeguard patients fromabuse and poor leadership structures. We inspected on 19November 2015 and found improvements but also foundtwo breaches of regulations concerning recruitment checksand managing risks. The practice was rated as requiresimprovement. When we inspected on 16 May 2017 wefound no breaches and the practice was rated as good.

We decided to undertake an inspection of this service tocheck that the practice had sustained the improvementsthat were made between 2015 and 2017. This inspectionlooked at the following key questions:

• Are services safe?• Are services effective?• Are services caring?• Are services responsive?• Are services well-led?

We based our judgement of the quality of care at thisservice on a combination of:

• what we found when we inspected• information from our ongoing monitoring of data about

services and• information from the provider, patients, the public and

other organisations.

We have rated this practice as requires improvementoverall and requires improvement for all populationgroups.

We rated the practice as requires improvement forproviding safe services because:

• There were systems to ensure the safety in the practice,but they were not consistently effective. When thingswent wrong, action was taken, but the learning andaction was poorly recorded.

We rated the practice as good for effective, and all ofthe population groups as good for effective, apartfrom people with long-term conditions. We rated thepopulation group people with long-term conditions asrequires improvement for effective because:

• Most patients received effective care and treatment thatmet their needs. However, patient outcomes for asthmaand hypertension were significantly below average in2017/18 and there was evidence that performancedeteriorated further in 2018/19 (for asthma,hypertension and other long-term conditions). Thepractice told us of actions taken to improve, but it wastoo early to demonstrate that these were effective.

We rated the practice as requires improvement forproviding responsive services because:

• Complaints were not all being managed in line withlegislation, and there was no effective system to monitorcompliance.

• Individual complaints were responded to and actiontaken to resolve individual issues but learning andaction was not effectively documented.

These impacted all population groups and so we haverated all population groups as requires improvement forbeing responsive.

We rated the practice as requires improvement forproviding well led services because:

• The practice had not taken effective action to improveareas of below average clinical performance in 2017/18.Performance in these indicators deteriorated further in2018/19.

• There was no effective monitoring system forcomplaints to ensure that legislation was beingfollowed. There was no effective monitoring ofappointment availability.

• There was no effective system to document actions andlearning from complaints or significant events. Meetingminutes were not effective as a record of the meeting forthose who could not attend or as a reference.

• The system to ensure that governance documents wereup-to-date was not consistently implemented.

The provider must:

• Ensure care and treatment is provided in a safe way topatients.

Overall summary


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• Establish effective systems and processes to ensuregood governance in accordance with the fundamentalstandards of care.

The provider should:

• Monitor appointment availability.• Improve the identification of carers to enable this group

of patients to access the care and support they need.

Details of our findings and the evidence supportingour ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and IntegratedCare

Overall summary


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Population group ratings

Older people Requires improvement –––

People with long-term conditions Requires improvement –––

Families, children and young people Requires improvement –––

Working age people (including those recently retired andstudents)

Requires improvement –––

People whose circumstances may make them vulnerable Requires improvement –––

People experiencing poor mental health (including peoplewith dementia)

Requires improvement –––

Our inspection teamOur inspection team was led by a CQC lead inspector.The team included a GP specialist advisor, and a GPSpecialist Advisor in training.

Background to Beeches SurgeryBeeches Surgery is a based in Sutton, in the Carshaltondistrict of Sutton Clinical Commissioning Group. Thepractice list size is approximately 5900. Whilst the practicepopulation is diverse, patients are mainly from whiteBritish backgrounds.

The practice facilities include three consulting rooms, twotreatment rooms, two patient waiting rooms, threeadministration offices and a staff room. The premiseshave wheelchair access and there are facilities forwheelchair users including an accessible toilet.

The staff team consists of two male GPs partners (one ofwhom is no longer in clinical practice), three salaried GPs(one female and two male), one female specialist nurse,one female practice nurse, a practice manager, sixreceptionists, a secretary and an administration assistant.

The practice is open between 8am and 7pm Monday,7am to 7pm on Tuesday, 8am to 6.30pm on Wednesday,Thursday and Friday. There are different appointment

times on different days of the week, but GPs generallyhave appointments in the morning from 8.30am or8.50am to 12.50pm (apart from Tuesday whenappointments begin at 7.20am and Friday when themorning appointments end at 11am). In the afternoon,GPs generally have appointments from 3.30pm or 4pm to6.15pm or 6.50pm (apart from Tuesday when afternoonappointments begin at 1.30pm and end at 6pm).

When the practice is closed patients are directed (througha recorded message on the practice answerphone) tocontact the local out of hours provider. This informationis also in the practice leaflet and on the website.

The practice is registered as a partnership with the CareQuality Commission (CQC) to provide the regulatedactivities of: treatment of disease, disorder or injury;diagnostic and screening procedures and family planningservices; surgical procedures and maternity andmidwifery services at one location.

Overall summary


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Action we have told the provider to takeThe table below shows the legal requirements that the service provider was not meeting. The provider must send CQC areport that says what action it is going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Tre

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

The registered persons had not done all that wasreasonably practicable to mitigate risks to the health andsafety of service users receiving care and treatment. Inparticular: risks of fire and infection.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

The registered person had systems or processes in placethat operated ineffectively in that they failed to enablethe registered person to assess, monitor and improve thequality and safety of the services being provided. Inparticular: outcomes for patients with long-termconditions. There was no effective monitoring system forcomplaints to ensure that legislation was being followed.

Regulation

Regulation

This section is primarily information for the provider

Requirement notices


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Care Quality Commission

Inspection Evidence Table

Beeches Surgery (1-485285503)

Inspection date: 19 June 2019

Date of data download: 05 June 2019

Overall rating: Requires improvement Please note: Any Quality Outcomes Framework (QOF) data relates to 2017/18.

Safe Rating: Requires improvement

Following the inspection on 19 June 2019 we rated safety as requires improvement because:

• The practice had not taken effective action to ensure the safety of electrical items, or to manage

risks of fire and infection.

• There were emergency medicines missing from the practice supply.

• Significant events were poorly recorded, so there was no proper record of the learning or action

taken.

The practice was first rated after an inspection on 13 January 2015. We rated the safe key question as

inadequate because there was no equipment or medicines for managing emergencies, systems were

not in place to ensure safe processing of prescriptions and storage of blank prescription forms, some

staff had not had sufficient safeguarding training, and not all staff were aware of how to report near

misses. The practice had not carried out Disclosure and Barring Service (DBS) checks for staff who

chaperoned or risk assessed this decision. Systems to prevent and control the spread of infections

were not effective, with inadequate cleaning and no audit. The practice had not carried out a fire risk

assessment and was not conducting fire drills.

We rated the practice as requires improvement following the inspection on 19 November 2015 because

improvements had been made but there had not been an adequate fire risk assessment and, although

improved, processes to prevent and control the spread of infection were not sufficiently robust.

The most recent rating for the safe key question was good (following the inspection on 16 May 2017)

when we found that all of the systems and processes to manage risks to patients were operating

effectively.

Safety systems and processes

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2

The practice had clear systems, practices and processes to keep people safe and

safeguarded from abuse.


There was a lead member of staff for safeguarding processes and procedures. Y

Safeguarding systems, processes and practices were developed, implemented and communicated to staff.

Y1

There were policies covering adult and child safeguarding. Y

Policies took account of patients accessing any online services. Y

Policies and procedures were monitored, reviewed and updated. Y

Policies were accessible to all staff. Y

Partners and staff were trained to appropriate levels for their role (for example, level three for GPs, including locum GPs).

Y

There was active and appropriate engagement in local safeguarding processes. Y

There were systems to identify vulnerable patients on record. Y

There was a risk register of specific patients. Y

Disclosure and Barring Service (DBS) checks were undertaken where required. Y

Staff who acted as chaperones were trained for their role. Y

There were regular discussions between the practice and other health and social care professionals such as health visitors, school nurses, community midwives and social workers to support and protect adults and children at risk of significant harm.

Y


1. There were separate policies covering safeguarding adults and children. The policy regarding children had details of the practice lead and external contact details. The policy related to adults did not.

Recruitment systems Y/N/Partial

Recruitment checks were carried out in accordance with regulations (including for agency staff and locums).

Y

Staff vaccination was maintained in line with current Public Health England (PHE) guidance and if relevant to role.

Y

There were systems to ensure the registration of clinical staff (including nurses and pharmacists) was checked and regularly monitored.

Y

Staff had any necessary medical indemnity insurance. Y


Safety systems and records Y/N/Partial

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3

There was a record of portable appliance testing or visual inspection by a competent person.

Date of last inspection/test: 2017

Partial1

There was a record of equipment calibration.

Date of last calibration: 02/05/2019 Y

There were risk assessments for any storage of hazardous substances for example, liquid nitrogen, storage of chemicals.

Y

There was a fire procedure. Y

There was a record of fire extinguisher checks.

Date of last check: 13/06/2018 Y2

There was a log of fire drills.

Date of last drill: 26/02/2019 Y

There was a record of fire alarm checks.

Date of last check: 03/06/2019 Y

There was a record of fire training for staff.

Date of last training: Dependent on start date, last date seen 05/06/2019 Y

There were fire marshals. Y

A fire risk assessment had been completed.

Date of completion: 30/07/2018 Y

Actions from fire risk assessment were identified and completed. N3


1. The practice had an external fire risk assessment on 30 July 2018. This advised that testing of portable electrical equipment was required. Staff on the day of inspection told us that it had been thought that portable appliance testing was carried out with the equipment calibration, but it had not been. We saw evidence that testing had been booked for 24 June 2019.

2. A fire extinguisher check had been booked (on 18 June) for 20 June 2019.

3. The fire assessment assessed the likelihood of fire as medium and consequences as moderate and said that it was essential that efforts were made to reduce the risk. There were a number of actions rated as medium priority (with a recommended timescale of 1 – 3 months), including amending doors and the alarm system, completion of a fixed wiring assessment and improvements to emergency lighting. We saw evidence that some actions had been completed. We asked for the action plan for the other recommendations. The action plan received was a copy of the report, with handwritten notes. Some actions were noted as complete. Some were noted as “In progress” with no details. Some moderate risk recommendations had notes saying the required action was not necessary, and other moderate risk actions had notes suggesting that suitable measures were already in place at the time of the fire risk assessment.

We asked the practice (after the inspection) what additional advice was sought or risk assessment completed to determine that actions recommended by the external fire risk assessor were not required. We also asked why, if suitable measures were already in place, this evidence was not available to the assessor to examine. In response, we received evidence of measures in place (e.g. photos of signage, but not answers to the questions we asked).

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Health and safety Y/N/Partial

Premises/security risk assessment had been carried out.

Date of last assessment: Undated, but reported as 2019 Y Internal

Health and safety risk assessments had been carried out and appropriate actions taken.

Date of last assessment: See below


The practice had a number of risk assessments in place, e.g. for the handling of cleaning chemicals.

The practice had booked an external contractor to carry out a fire risk assessment, health & safety audit, disability access audit and legionella risk assessment on 2 August 2019.

Infection prevention and control

Appropriate standards of cleanliness and hygiene were met.

Y/N/Partial

There was an infection risk assessment and policy. Y

Staff had received effective training on infection prevention and control. Y

Date of last infection prevention and control audit: Internal:

External:

1 May 2019 7 August 2018

The practice had acted on any issues identified in infection prevention and control audits. Y

The arrangements for managing waste and clinical specimens kept people safe. Y


The infection control audit by NHS England on 7 August 2018 found issues that should have been identified and addressed by the practice’s own procedures, i.e. a vaccine fridge that had not been calibrated, no log of vaccine expiry dates and an examination couch had been mended with tape. Action had been taken to rectify the issues identified.

A legionella risk assessment carried out on 30 July 2018 recommended regular flushing of water outlets and temperature checks. We saw evidence of temperature checks, but not of flushing. In response to the draft report, the practice told us that water outlets were flushed as part of temperature checks, but no evidence of this particular task was recorded.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient

safety.

Y/N/Partial

There was an effective approach to managing staff absences and busy periods. Y

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There was an effective induction system for temporary staff tailored to their role. Y

Comprehensive risk assessments were carried out for patients. Y

Risk management plans for patients were developed in line with national guidance. Y

Panic alarms were fitted and administrative staff understood how to respond to the alarm and the location of emergency equipment.

Y

Clinicians knew how to identify and manage patients with severe infections including sepsis.

Y

Receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients.

Y

There was a process in the practice for urgent clinical review of such patients. Y

There was equipment available to enable assessment of patients with presumed sepsis or other clinical emergency.

Y

There were systems to enable the assessment of patients with presumed sepsis in line with National Institute for Health and Care Excellence (NICE) guidance.

Y

When there were changes to services or staff the practice assessed and monitored the impact on safety.

Y


Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment.

Y/N/Partial

Individual care records, including clinical data, were written and managed securely and in line with current guidance and relevant legislation.

Y

There was a system for processing information relating to new patients including the summarising of new patient notes.

Y

There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.

Y

Referral letters contained specific information to allow appropriate and timely referrals. Y

Referrals to specialist services were documented. Y

There was a system to monitor delays in referrals. Y

There was a documented approach to the management of test results and this was managed in a timely manner.

Y

The practice demonstrated that when patients use multiple services, all the information needed for their ongoing care was shared appropriately and in line with relevant protocols.

Y


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Appropriate and safe use of medicines

The practice had systems for the appropriate and safe use of medicines, including

medicines optimisation, but they were not all effective.


average

England

average

England

comparison

Number of antibacterial prescription items prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU) (01/04/2018 to 31/03/2019) (NHS Business

Service Authority - NHSBSA)


The number of prescription items for

co-amoxiclav, cephalosporins and

quinolones as a percentage of the total

number of prescription items for selected

antibacterial drugs (BNF 5.1 sub-set).

(01/04/2018 to 31/03/2019) (NHSBSA)

9.5% 8.7% 8.7% No statistical variation

Average daily quantity per item for

Nitrofurantoin 50 mg tablets and capsules,

Nitrofurantoin 100 mg m/r capsules,

Pivmecillinam 200 mg tablets and

Trimethoprim 200 mg tablets prescribed

for uncomplicated urinary tract infection

(01/10/2018 to 31/03/2019) (NHSBSA)


Average daily quantity of oral NSAIDs

prescribed per Specific Therapeutic

Group Age-sex Related Prescribing Unit

(STAR-PU) (01/10/2018 to 31/03/2019)

(NHSBSA)

0.76 1.27 2.07 Variation (positive)


The practice ensured medicines were stored safely and securely with access restricted to authorised staff.

Y

Blank prescriptions were kept securely and their use monitored in line with national guidance.

Y

Staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions).

Y

The practice could demonstrate the prescribing competence of non-medical prescribers, and there was regular review of their prescribing practice supported by clinical supervision or peer review.

Y

There was a process for the safe handling of requests for repeat medicines and evidence of structured medicines reviews for patients on repeat medicines.

Y

The practice had a process and clear audit trail for the management of information about changes to a patient’s medicines including changes made by other services.

Y

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There was a process for monitoring patients’ health in relation to the use of medicines including high risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing.

Y

The practice monitored the prescribing of controlled drugs. (For example, investigation of unusual prescribing, quantities, dose, formulations and strength).

Y1

There were arrangements for raising concerns around controlled drugs with the NHS England Area Team Controlled Drugs Accountable Officer.

Y

If the practice had controlled drugs on the premises there were appropriate systems and written procedures for the safe ordering, receipt, storage, administration, balance checks and disposal of these medicines, which were in line with national guidance.

N/A

The practice had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and reduce the risk of adverse events and antimicrobial resistance.

Y

For remote or online prescribing there were effective protocols for verifying patient identity. N/A

The practice held appropriate emergency medicines, risk assessments were in place to determine the range of medicines held, and a system was in place to monitor stock levels and expiry dates.

Partial2

The practice had arrangements to monitor the stock levels and expiry dates of emergency medicines/medical gases.

Partial3

There was medical oxygen and a defibrillator on site and systems to ensure these were regularly checked and fit for use.

Y

Vaccines were appropriately stored, monitored and transported in line with PHE guidance to ensure they remained safe and effective.

Y


1. There were relatively few patients with controlled drugs on repeat prescription. Monitoring was informal and carried out by GPs when authorising prescriptions. There were no details of monitoring arrangements in the prescribing policy.

2. The practice had assessed the medicines required, however not all the medicines the practice had assessed as to be kept in stock were present on the day of inspection. There was no GTN spray, hydrocortisone or cefotaxamine.

3. The practice log book showed a note on 28 May that the GTN spray and hyocortisone were “to order” and a note on 6 June 2019 that the medicines (including cefotaxamine) had been ordered. We saw that the missing medicines were in place by the end of the inspection.

Shortly after the inspection the practice told us that the medicines were awaiting collection at the pharmacy. The practice told us of other ways that they could have treated patients without the missing medicines by using other medicines which were in stock and by calling the emergency services. However, doctors we asked were unaware that the medicines were not in stock, which would have delayed treatment.

After the inspection we were sent evidence of a new system for recording the checks made on emergency medicines.

Track record on safety and lessons learned and improvements made

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8

The practice learned and made improvements when things went wrong, but did

not keep good records of the learning and improvements.

Significant events Y/N/Partial

The practice monitored and reviewed safety using information from a variety of sources. Y

Staff knew how to identify and report concerns, safety incidents and near misses. Y

There was a system for recording and acting on significant events. Y

Staff understood how to raise concerns and report incidents both internally and externally.

Y

There was evidence of learning and dissemination of information. Partial

Number of events recorded in last 12 months: 34

Number of events that required action: 23


Significant events were not completely recorded. The practice policy said that events should be recorded on a significant event form, but some events had been recorded on a different form. The significant event forms had fields to record the learning and action taken, but four forms we reviewed had no details of learning or action recorded. The forms referred to a meeting date. We reviewed the minutes of the meetings. These had no details of the discussion or action that had been taken. Actions that were noted were in the future tense, e.g. "reception need training". There was no evidence of follow up to ensure that the agreed actions had been completed.

There were repeated significant events related to staff selecting the wrong patient to receive appointments, be called, booked in or receive documents. There was no evidence that this had been identified as a theme and the issue been considered more fully, and the action noted was similar in each case (staff to check using date of birth).

Shortly after the inspection the practice told us that significant events were discussed in great detail at clinical meetings and that staff were going to monitor the quality of the minutes/written forms, and consider changing the format of the forms.

Example(s) of significant events recorded and actions by the practice.

Event Specific action taken

A patient contacted the practice to complain that they had not received results of testing on a sample they had provided.

Staff told us that the event was investigated and concluded to be an issue with sample handing by non-clinical staff. The significant event form was incomplete. There was no description of the event (a confusing chain of messages had been pasted into the field) and the only action noted was that an alert had been raised, resulting in the lab saying there was no record of the sample. The form stated that the event was

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discussed at a clinical meeting. The meeting minutes have no details of any discussion and the action was recorded as “Reception to be trained”.

A patient received a letter about an upsetting diagnosis, when they did not have that disease

The significant event form said that the letter had been sent in error. The action taken was noted as “dealt with by [GP’s initials]”. There was nothing documented in the lessons learned or changes made fields. Staff told us that the learning was for staff to check with GPs before sending letters.

Safety alerts Y/N/Partial

There was a system for recording and acting on safety alerts. Y

Staff understood how to deal with alerts. Y


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Effective Rating: Good

Following the inspection on 19 June 2019 we rated effective as good.

However, the population group people with long term conditions was rated requires improvement

because patient outcomes for asthma and hypertension were significantly below average in 2017/18

and there was evidence that performance deteriorated further in 2018/19 (for asthma, hypertension and

other long-term conditions). The practice told us of actions taken to improve, but it was too early to

demonstrate that these were effective.

When we inspected the practice on 13 January 2015 we rated the effective key question as inadequate

because there was limited evidence that audits were being undertaken and were driving improvement

in patient outcomes and limited evidence of multidisciplinary work with other health and social care

professionals. There were not effective systems to ensure that people with long term health conditions

and poor mental health received regular and effective reviews.

We rated effective as good following the inspection on 19 November 2015 because improvements had

been made. We also rated effective as good for effective following the inspection on 16 May 2017.

Effective needs assessment, care and treatment

Patients’ needs were assessed, and care and treatment was delivered in line with

current legislation, standards and evidence-based guidance supported by clear

pathways and tools.

Y/N/Partial

The practice had systems and processes to keep clinicians up to date with current evidence-based practice.

Y

Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.

Y

We saw no evidence of discrimination when staff made care and treatment decisions. Y

Patients’ treatment was regularly reviewed and updated. Y

There were appropriate referral pathways were in place to make sure that patients’ needs were addressed.

Y

Patients were told when they needed to seek further help and what to do if their condition deteriorated.

Y


There was evidence that new guidance was discussed at clinical meetings, but there were no details of what guidelines were discussed and what action staff needed to take, so there was no record for anyone unable to attend the meeting.

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11

Prescribing Practice

performance

CCG

average

England

average England

comparison

Average daily quantity of Hypnotics prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU) (01/04/2018 to 31/03/2019) (NHSBSA)

1.01 0.91 0.77 No statistical

variation


Findings

• The practice used a clinical tool to identify older patients who were living with moderate or severe frailty. Those identified received a full assessment of their physical, mental and social needs.

• The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.

• Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions Population group rating: Requires improvement

Findings

• In 2017/18, some patient outcomes for asthma and hypertension were significantly below average.

Evidence (unverified) from the practice showed that performance deteriorated further in 2018/19

(for asthma, hypertension and other long-term conditions). The practice told us of actions taken to

improve, including additional staffing, but it was too early to demonstrate that these were effective.

• Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.

• Staff who were responsible for reviews of patients with long-term conditions had received specific training.

• GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.

• The practice could demonstrate how they identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension.

• Adults with newly diagnosed cardio-vascular disease were offered statins.

• Patients with suspected hypertension were offered ambulatory blood pressure monitoring.

• Patients with atrial fibrillation were assessed for stroke risk and treated appropriately.

• 91.9% of patients with diabetes attended for eye screening.

Diabetes Indicators Practice CCG England England Practice

of 192

12

2017/18 average average comparison 2018/19

(unverified)


on the register, in whom the last

IFCC-HbA1c is 64 mmol/mol or less in

the preceding 12 months (01/04/2017 to

31/03/2018) (QOF)


variation 79.25%


9.6% 13.2% N/A


on the register, in whom the last blood

pressure reading (measured in the

preceding 12 months) is 140/80 mmHg

or less (01/04/2017 to 31/03/2018) (QOF)


variation 63.71%


8.2% 9.8% N/A 3.27%


on the register, whose last measured

total cholesterol (measured within the

preceding 12 months) is 5 mmol/l or less

(01/04/2017 to 31/03/2018) (QOF)


variation 82.70%


10.9% 13.5% N/A 2.04%

Other long-term conditions Practice

2017/18

CCG

average

England

average

England

comparison

2017/18

Practice

2018/19

(unverified)

The percentage of patients with asthma,

on the register, who have had an asthma

review in the preceding 12 months that

includes an assessment of asthma

control using the 3 RCP questions, NICE

2011 menu ID: NM23 (01/04/2017 to

31/03/2018) (QOF)



61.03%


7.4% 7.7% N/A

The percentage of patients with COPD

who have had a review, undertaken by a

healthcare professional, including an

assessment of breathlessness using the

Medical Research Council dyspnoea

scale in the preceding 12 months

(01/04/2017 to 31/03/2018) (QOF)


variation 72.34%


(5) 7.2% 11.5% N/A 27.66%

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13


average

England

average

England

comparison


hypertension in whom the last blood

pressure reading measured in the

preceding 12 months is 150/90mmHg or

less (01/04/2017 to 31/03/2018) (QOF)


66.73%


4.8% 4.2% N/A

In those patients with atrial fibrillation

with a record of a CHA2DS2-VASc

score of 2 or more, the percentage of

patients who are currently treated with

anti-coagulation drug therapy

(01/04/2017 to 31/03/2018) (QOF)


variation 93.75%


5.7% 6.7% N/A


Findings

• Childhood immunisation uptake rates were in line with the World Health Organisation (WHO) targets.

• The practice had arrangements to identify and review the treatment of newly pregnant women on long-term medicines. These patients were provided with advice and post-natal support in accordance with best practice guidance.

• The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation and would liaise with health visitors when necessary.

• Young people could access services for sexual health and contraception. Chlamydia screening was offered, and advertised through posters in the practice.

Child Immunisation Numerator Denominator Practice

%

Comparison

to WHO

target


have completed a primary course of

immunisation for Diphtheria, Tetanus,

Polio, Pertussis, Haemophilus influenza

type b (Hib)((i.e. three doses of

DTaP/IPV/Hib) (01/04/2017 to 31/03/2018)

(NHS England)

57 59 96.6%

Met 95% WHO

based target

(significant

variation positive)


have received their booster immunisation

for Pneumococcal infection (i.e. received 75 78 96.2%

Met 95% WHO

based target

(significant

variation positive)

of 192

14

Pneumococcal booster) (PCV booster)

(01/04/2017 to 31/03/2018) (NHS England)


have received their immunisation for

Haemophilus influenza type b (Hib) and

Meningitis C (MenC) (i.e. received

Hib/MenC booster) (01/04/2017 to

31/03/2018) (NHS England)

74 78 94.9% Met 90% minimum

(no variation)


have received immunisation for measles,

mumps and rubella (one dose of MMR)

(01/04/2017 to 31/03/2018) (NHS England)

72 78 92.3% Met 90% minimum

(no variation)




Findings

• The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.

• Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40 to 74. There was appropriate and timely follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified. The practice had a different computer system to other practices locally, so could not book NHS checks for patients, but would gain this capability after the computer system was changed. Ad hoc checks were performed in the practice.

• Patients could book or cancel appointments online and order repeat medication without the need to attend the surgery.

Cancer Indicators Practice CCG

average

England

average

England

comparison

The percentage of women eligible for cervical

cancer screening at a given point in time who

were screened adequately within a specified

period (within 3.5 years for women aged 25 to

49, and within 5.5 years for women aged 50 to

64) (01/04/2017 to 31/03/2018) (Public Health England)


variation

Females, 50-70, screened for breast cancer

in last 36 months (3 year coverage, %)

(01/04/2017 to 31/03/2018) (PHE)

74.2% 71.1% 70.0% N/A

Persons, 60-69, screened for bowel cancer in

last 30 months (2.5 year coverage,

%)(01/04/2017 to 31/03/2018) (PHE)

66.8% 54.4% 54.5% N/A

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The percentage of patients with cancer,

diagnosed within the preceding 15 months,

who have a patient review recorded as

occurring within 6 months of the date of

diagnosis. (01/04/2017 to 31/03/2018) (PHE)

62.5% 80.8% 70.2% N/A

Number of new cancer cases treated

(Detection rate: % of which resulted from a

two week wait (TWW) referral) (01/04/2017 to

31/03/2018) (PHE)


variation



Findings

• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability. There was a system to register travellers and homeless patients. 75% (15 of 20) patients with a learning disability had received an annual review of their health (three patients were excepted and two did not attend for their booked appointment).

• The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

• The practice demonstrated that they had a system to identify people who misused substances.



Findings

• The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services.

• There was a system for following up patients who failed to attend for administration of long-term medication.

• When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.

• Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.

Mental Health Indicators Practice CCG

average

England

average

England

comparison

Practice

2018/19

(unverified)

The percentage of patients with 91.7% 92.1% 89.5% No statistical

variation 91.18%

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16


and other psychoses who have a

comprehensive, agreed care plan

documented in the record, in the


31/03/2018) (QOF)

Exception rate (number of exceptions). 0

(0) 8.7% 12.7% N/A 10.71%



and other psychoses whose alcohol

consumption has been recorded in the


31/03/2018) (QOF)


variation 88.57%

Exception rate (number of exceptions). 0

(0) 6.9% 10.5% N/A

The percentage of patients diagnosed

with dementia whose care plan has

been reviewed in a face-to-face review

in the preceding 12 months (01/04/2017

to 31/03/2018) (QOF)


variation 92.00%


(3) 6.1% 6.6% N/A

14.29% (4)

Monitoring care and treatment

The practice outcomes (as measured by the Quality and Outcomes Framework)

was below average for some indicators in 2017/18 and (based on unverified data

from the practice) performance fell further in 2018/19.

The practice had decided to change their clinical information system. Staff hoped this would make it easier

for them to identify patients who needed reviews and ensure more accurate data was extracted for the

Quality and Outcomes Framework. The transition was due to take place soon after the inspection.

Since April 2019 the practice increased the hours of an administrator to support patient recalls and

appointment booking and assigned clinical leads. The practice was using a structured template to monitor

performance each quarter.

It was too early to verify that the changes made so far had improved performance.

Exception reporting is intended to allow practices to “achieve” quality improvement indicators without

being penalised for patient specific clinical circumstances or other reasons beyond the contractor’s

control. For example, where a medication cannot be prescribed due to a contra-indication or side-effect,

where patients do not attend for review. We noted that the practice had relatively high levels of exception

reporting at previous inspections. Exception rates were also relatively high in 2017/18. We asked the

practice for exception rates 2018/19. The data was unverified, but showed that most indicators had lower

rates of exceptions. We noted that patient numbers for the individual indicators were relatively small,

which can affect the relative rate.

Indicator Practice CCG England Practice

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17

2017/18 average average 2018/19

(unverified)

Overall QOF score (out of maximum 559) 525.5 536.9 537.5 508.55

Overall QOF exception reporting (all domains) 2.2% 5.0% 5.8%

QOF Exceptions by Domain (2017/18) Practice rate

CCG

average

England

average

Practice

2018/19

(unverified)

Atrial fibrillation 2.4% 3.9% 5.9%

Coronary heart disease 1.5% 7.8% 8.7%

Heart failure 10.3% 8.7% 8.5% 0%

Hypertension 0.9% 4.6% 4.1%

Peripheral arterial disease 0.0% 4.7% 5.8%

Stroke and transient ischaemic attack 6.7% 9.2% 10.1%

Asthma 2.7% 3.6% 5.9%

Chronic obstructive pulmonary disease 14.2% 10.6% 12.6% 6.38%

Cancer 31.3% 18.6% 25.6% 0%

Diabetes mellitus 3.5% 9.7% 11.8%

Dementia 13.2% 11.1% 10.0% 0%

Depression 16.7% 18.0% 22.8% 0%

Mental health 2.9% 7.5% 11.0%

Osteoporosis 0.0% 14.5% 17.5%

Rheumatoid arthritis 0.0% 2.1% 6.9%

Blood pressure 0.1% 1.4% 0.6%

Cardiovascular disease - primary prevention 50.0% 16.9% 24.8% 0%

Smoking 2.1% 0.6% 0.9%

Y/N/Partial

Clinicians took part in national and local quality improvement initiatives. Y

The practice had a comprehensive programme of quality improvement and used

information about care and treatment to make improvements. Partial

Any additional evidence or comments:

The practice had a programme of quality improvement, but this had not resulted in improvements in performance as measured by the Quality Outcomes Framework.

Examples of improvements demonstrated because of clinical audits or other improvement activity in

past two years

• Clopidogrel and proton pump inhibitors: Audit in January 2019 of previous six months found that 50 patients had been prescribed clopidogrel and seven patients had been prescribed both clopidogrel and either omeprazole or esomeprazole. This is not in line with recommendations, because of a risk that the clopidogrel does not work as effectively. Three patients had either received only one

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18

prescription of the two medicines, or had their medicines changed (to clopidogrel and lansoprazole) during the six month audit period. Four patients still had the two medicines on repeat prescription. They had their prescription changed to lansoprazole and were notified of the rationale. In June 2019, 50 patients had been prescribed clopidogrel. No patients had also received omeprazole or esomeprazole on repeat prescription.

• Metformin and renal function: In 2017 an audit was carried out to check that no patients were prescribed metformin with an eGFR less than 30. There were 187 patients prescribed metformin in the previous six months, and 88% of these had eGFR recorded in the previous six months. None of these were over 30. The practice concluded that the guidelines were being adhered to and there were no recommendations for improvement, and there was no discussion of the 22% of patients had not had an eGFR in the last 6 months. A repeat audit in June 2019 said that no patients on metformin had an eGFR under 30. There was no information on the percentage of patients who had not had a recent eGFR. In response to the draft report, the practice told us that all patients on metformin were closely monitored as part of the diabetes recall/review system. The practice told us that 191 patients were prescribed metformin between 1 April 2018 and 31 March 2019, and eight patients did not have an eGFR test to check their kidney function in that year.

• Patients with pre-diabetes: January 2017 – January 2018 11 patients were identified with pre-diabetes. Of these 4 had this coded on the medical system, but 7 did not. All received lifestyle advice. January 2018 – January 2019 23 patients were identified with pre-diabetes. Of these 13 had this coded on the medical system, but 10 did not. All received lifestyle advice.

Effective staffing

The practice was able to demonstrate that staff had the skills, knowledge and

experience to carry out their roles. Y/N/Partial

Staff had the skills, knowledge and experience to deliver effective care, support and treatment. This included specific training for nurses on immunisation and on sample taking for the cervical screening programme.

Y

The learning and development needs of staff were assessed. Y

The practice had a programme of learning and development. Y

Staff had protected time for learning and development. Y

There was an induction programme for new staff.

Induction included completion of the Care Certificate for Health Care Assistants employed since April 2015.

N/A

Staff had access to regular appraisals, one to ones, coaching and mentoring, clinical supervision and revalidation. They were supported to meet the requirements of professional revalidation.

Y

The practice could demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurses, paramedics, pharmacists and physician associates.

Y

There was a clear and appropriate approach for supporting and managing staff when their performance was poor or variable.

Y


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19

Coordinating care and treatment

Staff worked together and with other organisations to deliver effective care and

treatment.

Indicator Y/N/Partial

The contractor has regular (at least 3 monthly) multidisciplinary case review meetings

where all patients on the palliative care register are discussed (01/04/2017 to 31/03/2018)

(QOF)

Y

We saw records that showed that all appropriate staff, including those in different teams

and organisations, were involved in assessing, planning and delivering care and treatment. Y

Care was delivered and reviewed in a coordinated way when different teams, services or

organisations were involved. Y

Patients received consistent, coordinated, person-centred care when they moved between

services. Y

For patients who accessed the practice’s digital service there were clear and effective

processes to make referrals to other services. N/A


Helping patients to live healthier lives

Staff were helped patients to live healthier lives, but was not consistently effective

in doing so.

Y/N/Partial

The practice identified patients who may need extra support and directed them to relevant

services. This included patients in the last 12 months of their lives, patients at risk of

developing a long-term condition and carers.

Y

Staff encouraged and supported patients to be involved in monitoring and managing their

own health. Y

Staff discussed changes to care or treatment with patients and their carers as necessary. Y

The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Y


Smoking Indicator Practice CCG

average

England

average

England

comparison

Practice

2018/19

(unverified)

The percentage of patients with any 90.8% 94.6% 95.1% Tending towards 89.57%

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20

or any combination of the following

conditions: CHD, PAD, stroke or TIA,

hypertension, diabetes, COPD, CKD,

asthma, schizophrenia, bipolar

affective disorder or other psychoses

whose notes record smoking status in

the preceding 12 months (01/04/2017

to 31/03/2018) (QOF)


Exception rate (number of exceptions).

3.2% (33)

0.6% 0.8% N/A


The practice had decided to change their clinical information system. Staff hoped this would make it easier for them to identify patients who needed reviews and ensure more accurate data was extracted for the Quality and Outcomes Framework. The transition was due to take place soon after the inspection. Since April 2019 the practice increased the hours of an administrator to support patient recalls and appointment booking and assigned clinical leads. The practice was using a structured template to monitor performance each quarter. It was too early to verify that the changes made so far had improved performance.

Consent to care and treatment

The practice had systems to obtain consent, and was able to demonstrate consent

was taken. However, the systems did not ensure that consent was obtained and

recorded in line with the latest guidance. Y/N/Partial

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. We saw that consent was documented.

Y

Clinicians supported patients to make decisions. Where appropriate, they assessed and

recorded a patient’s mental capacity to make a decision. Y

The practice monitored the process for seeking consent appropriately. Partial


The practice monitored consent taking for minor surgery, but there was no systemic monitoring of consent taking for family planning.

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21

Caring Rating: Good

We rated the practice as good for being caring, based on feedback from patients, including the

national survey. However, the practice should take action to identify more carers.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion. Feedback from

patients was positive about the way staff treated people.

Y/N/Partial

Staff understood and respected the personal, cultural, social and religious needs of patients.

Y

Patients were given appropriate and timely information to cope emotionally with their care,

treatment or condition. Y


CQC comments cards

Total comments cards received. 8

Number of CQC comments received which were positive about the service. 7

Number of comments cards received which were mixed about the service. 0

Number of CQC comments received which were negative about the service. 1

Source Feedback

Patients Patients said that they felt that staff were caring and supported them in their treatment. We saw examples of caring personalised care.


Note: The questions in the 2018 GP Survey indicators have changed. Ipsos MORI have advised that the

new survey data must not be directly compared to the past survey data, because the survey

methodology changed in 2018.

Practice


Survey Response

rate%

% of practice

population

5970 252 103 40.9% 1.73%

of 192

22



England comparison





good at listening to them (01/01/2018 to

31/03/2018)


variation





good at treating them with care and concern

(01/01/2018 to 31/03/2018)


variation



last GP appointment they had confidence

and trust in the healthcare professional they

saw or spoke to (01/01/2018 to 31/03/2018)


variation



the overall experience of their GP practice

(01/01/2018 to 31/03/2018)


variation

Question Y/N

The practice carries out its own patient survey/patient feedback exercises. Y

Any additional evidence

The practice used the Friends and Family test.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

Y/N/Partial

Staff communicated with patients in a way that helped them to understand their care, treatment and condition, and any advice given.

Y

Staff helped patients and their carers find further information and access community and

advocacy services. Y


of 192

23




England comparison



last GP appointment they were involved as

much as they wanted to be in decisions about

their care and treatment (01/01/2018 to

31/03/2018)


variation

Y/N/Partial

Interpretation services were available for patients who did not have English as a first language.

Y

Patient information leaflets and notices were available in the patient waiting area which told patients how to access support groups and organisations.

Y

Information leaflets were available in other languages and in easy read format. N

Information about support groups was available on the practice website. Y


There were no leaflets in other languages or easy read. Shortly after the inspection we were sent a notice that the practice told us had been placed in the waiting room, inviting patients to let staff know if they needed information in other languages or formats, including easy read.

Carers Narrative

Percentage and number of carers identified.

0.4%, 24 patients. When we inspected in 2017 the practice had 32 patients identified as carers. In 2015, 4 patients were coded as carers.

How the practice supported carers.

Written information was available to direct carers to the various avenues of support available to them. Carers were offered the flu immunisation.

How the practice supported recently bereaved patients.

Staff told us that if families had suffered bereavement, their usual GP contacted them or sent them a sympathy card. This call was either followed by a patient consultation at a flexible time and location to meet the family’s needs and/or by giving them advice on how to find a support service.

Privacy and dignity

The practice respected patients’ privacy and dignity.

Y/N/Partial

Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations, investigations and treatments.

Y

Consultation and treatment room doors were closed during consultations. Y

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24

A private room was available if patients were distressed or wanted to discuss sensitive issues.

Y

There were arrangements to ensure confidentiality at the reception desk.

Y There was a separate waiting room


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25

Responsive Rating: Requires improvement

Following the inspection on 19 June we have rated the practice as requires improvement for being

responsive because:

• Complaints were not all being managed in line with legislation, and there was no effective system

to monitor compliance.

• Individual complaints were responded to and action taken to resolve individual issues, but

learning and action was not effectively documented.

These impacted all population groups and so we have rated all population groups as requires

improvement.

Although national survey data was in line with average, the practice survey showed a lot of variation,

and staff attributed periods of low satisfaction to periods when there was less appointment availability.

Some patients told us that they felt they had to wait too long for a non-urgent appointment. The practice

hoped that the upcoming change of computer system would increase patient satisfaction, as it would

allow staff to book appointments for patients at a local hub practice.

When we inspected the practice on 13 January 2015 we rated the responsive key question as requires

improvement because the practice did not have processes in place to gather patients’ feedback and

review it. There was no patient participation group in operation.

We rated responsive as requires improvement following the inspection on 19 November 2015 because

there were difficulties for patients in getting through by telephone and getting into the practice if they

used mobility aids.

We rated responsive as good following the inspection on 16 May 2017 because improvements had

been made, including a new phone system. People told us on the day of the inspection that they were

able to get urgent appointments when they needed them, but told us of waits of 2 – 3 weeks for routine

appointments (longer for particular GPs). The practice told us that they were keeping the situation under

review and had various plans underway to improve appointment access.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs.

Y/N/Partial

The importance of flexibility, informed choice and continuity of care was reflected in the services provided.

Y

The facilities and premises were appropriate for the services being delivered. Y

The practice made reasonable adjustments when patients found it hard to access services. Y

The practice provided effective care coordination for patients who were more vulnerable or who had complex needs. They supported them to access services both within and outside the practice.

Y

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26

Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Y


Practice Opening Times

Day Time

Opening times:

Monday 8am – 7pm

Tuesday 7am – 7pm


Thursday 8am – 6.30pm

Friday 8am – 6.30pm

Appointment times:

Monday 8am – 7pm

Tuesday 7am – 7pm


Thursday 8am – 6.30pm

Friday 8am – 6.30pm


Practice


Survey Response

rate%

% of practice

population

5970 252 103 40.9% 1.73%



England comparison


patient survey who stated that at their last

general practice appointment, their needs

were met (01/01/2018 to 31/03/2018)


variation

Older people Population group rating: Requires improvement

Findings

• All patients had a named GP who supported them in whatever setting they lived.

• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs and complex medical issues.

• In recognition of the religious and cultural observances of some patients, the GP would respond quickly, often outside of normal working hours, to provide the necessary death certification to enable prompt burial in line with families’ wishes when bereavement occurred.

• Longer appointments were available for older patients with long term conditions. Staff were prompted to offer this by alerts on the computer system.

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27

People with long-term conditions Population group rating: Requires improvement

Findings

• Patients with multiple conditions had their needs reviewed in one appointment.

• The practice liaised regularly with the local district nursing team and community matrons to discuss and manage the needs of patients with complex medical issues.

• Care and treatment for people with long-term conditions approaching the end of life was coordinated with other services.

Families, children and young people Population group rating: Requires improvement

Findings

• We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances. Records we looked at confirmed this.

• All parents or guardians calling with concerns about a child were offered a same day appointment when necessary.


Population group rating: Requires improvement

Findings

• The needs of this population group had been identified and the practice had adjusted the services it offered, with appointments from 7am available on Tuesdays and until 7pm on Mondays and Tuesdays

• The practice was not able to book extended access appointments for patients at local hub practices, but would be able to after the computer system had been changed.



Findings

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.

• People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

• The practice adjusted the delivery of its services to meet the needs of patients with a learning disability.

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28



Findings

• Priority appointments were allocated when necessary to those experiencing poor mental health nd double appointments.

• Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.

• The practice was aware of support groups within the area and signposted their patients to these accordingly.

Timely access to the service

National GP Survey results were in line with average for access care and

treatment in a timely way. Other feedback showed that patients sometimes found

it more difficult than at other times to book a suitable appointment.


Y/N/Partial

Patients with urgent needs had their care prioritised. Y

The practice had a system to assess whether a home visit was clinically necessary and the urgency of the need for medical attention.

Y

Appointments, care and treatment were only cancelled or delayed when absolutely necessary.

Y




England comparison



how easy it was to get through to someone at

their GP practice on the phone (01/01/2018

to 31/03/2018)

84.5% N/A 70.3% No statistical

variation



the overall experience of making an

appointment (01/01/2018 to 31/03/2018)


variation


patient survey who were very satisfied or 68.1% 69.9% 65.9%

No statistical variation

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England comparison

fairly satisfied with their GP practice

appointment times (01/01/2018 to

31/03/2018)


patient survey who were satisfied with the

type of appointment (or appointments) they

were offered (01/01/2018 to 31/03/2018)


variation

Source Feedback

NHS Choices The practice had a rating of 4 stars. Most of the written reviews were positive. There were 5 negative reviews, which were mostly about appointment access and staff attitudes. There were 12 five star reviews.

Friends and Family Test

The practice used the Friends and Family Test. We looked at 12 months data (April 2018 – March 2019).

• In 5 of the months, 100% of patients said they would be likely to recommend the practice.

• In 3 of the months, 80 – 100% of patients said they would be likely to recommend the practice.

• In 3 of the months fewer than 80% of patients said they would be likely to recommend the practice. In September 2018, it was 50%, in February 2019 it was 78.6% and in March 2019 it was 66.7%. Two of the lowest months corresponded to highest numbers of responses (42 and 21 respectively).

We asked the practice what analysis had been carried out into the variation between months. Staff told us that they believed that the periods of low satisfaction corresponded to periods when there was lower appointment availability. The practice could not currently provide patients with appointments at the local extended access hub practice, but would be able to once the change of computer system was complete.

Patients We received two negative comments (one face to face, one on a comment card) that appointment access was sometimes difficult. Staff told us the wait for a non-urgent appointment could be up to 3 weeks, if doctors are away and the practice unable to get locum cover.

Listening and learning from concerns and complaints

Complaints were listened and responded to, but there was limited evidence that

they were used effectively to improve the quality of care.

Complaints

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Number of complaints received in the last year. 9

Number of complaints we examined. 7

Number of complaints we examined that were satisfactorily handled in a timely way. 5

Number of complaints referred to the Parliamentary and Health Service Ombudsman. 0


• Of the seven complaints we examined, two were not handled in line with legislation.

• One complaint was not acknowledged within 3 working days (as it was sent to practice manager's email address when she was on leave). There was no evidence of any acknowledgement for a second complaint, although staff believed it had been acknowledged. In response to the draft report, the practice told us that all nine complaints had received a acknowledgment, and that although the email complaint sent to the practice manager’s own email address when on leave did not receive a formal acknowledgement within three days, the complainant did receive an automatic out-of-office message.

• Most of the complaints letters we saw had evidence that a complaints leaflet had been enclosed. This had details of the Parliamentary and Health Service Ombudsman. Two complaints did not have this reference, so there was no evidence that complainants had been given the details, although staff told us that it was standard practice.

Y/N/Partial

Information about how to complain was readily available. Y

There was evidence that complaints were used to drive continuous improvement. Partial


• Individual complaints were responded to and action taken to resolve individual issues, but learning and action was not effectively documented.

• There was a summary of complaints, but there was insufficient detail of the action and learning. For example, one complaint was described as “Patient complaint regarding care and treatment”, the action taken was noted as “Full response letter to patient answering queries” and the share/implement learning column read “Discussed amongst clinicians.” Meeting minutes had only dates and patient initials for complaints, and a note of the status, e.g. ongoing. After the inspection, the practice told us that meeting minutes would be reviewed and monitored.

• Staff described actions that had been taken as a result of some complaints, for example, tightening of the procedures for handling repeat prescriptions.

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Well-led Rating: Requires improvement

Following the inspection on 19 June 2019 we rated well-led as requires improvement because:

• The practice had not taken effective action to improve areas of below average clinical

performance in 2017/18. Performance in these indicators deteriorated further in 2018/19.

• There was no effective monitoring system for complaints to ensure that legislation was being

followed. There was no effective monitoring of appointment availability.

• There was no effective system to document actions and learning from complaints or

significant events. Meeting minutes were not effective as a record of the meeting for those

who could not attend or as a reference.

• The system to ensure that governance documents were up-to-date was not consistently

implemented.

When we inspected the practice on 13 January 2015 we rated the well-led key question as inadequate

because staff did not always feel supported, and opportunities for development, especially for

non-clinical staff, were limited. We found a lack of effective clinical leadership and absence of a clear

vision and strategic direction. There was lack of arrangements for identifying, managing and mitigating

risks. Non-clinical staff had clinical level access to the system and there was no risk assessment in

place to assess the risks to patients. There were not effective arrangements to seek structured

feedback from patients.

We rated well-led as good following the inspection on 19 November 2015 because improvements had

been made. We also rated well-led as good following the inspection on 16 May 2017.

Leadership capacity and capability

Leaders aspired to deliver high quality care, but did not demonstrate that they had

the capacity and skills to deliver it consistently and sustainably. Y/N/Partial

Leaders demonstrated that they understood the challenges to quality and sustainability. Partial

They had identified the actions necessary to address these challenges. Partial

Staff reported that leaders were visible and approachable. Y

There was a leadership development programme, including a succession plan. Y


The practice was rated as inadequate in January 2015 for being well led as the leaders had failed to establish systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided, and ensure that they were operating effectively. Leaders made improvements by November 2015. At this inspection we found that some of the systems and processes that were established were not operating effectively.

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Vision and strategy

The practice had clear values, but did not have a well-defined vision or strategy to

provide high quality sustainable care. Y/N/Partial

The practice had a clear vision and set of values that prioritised quality and sustainability. Partial

There was a realistic strategy to achieve their priorities. Partial

The vision, values and strategy were developed in collaboration with staff, patients and external partners.

Y

Staff knew and understood the vision, values and strategy and their role in achieving them.

Y

Progress against delivery of the strategy was monitored. Partial


The partners had failed to establish and monitor an effective strategy to deliver good quality clinical care for patients with some conditions in 2017/18 and 2018/19. There was a focus on achieving this in 2019/20, but it was too early to demonstrate that the strategy in place was effective.

The partnership at the time of the inspection was of two GPs. One partner had stepped down from clinical work, but remained as a partner and as the registered manager. There were plans to change the partnership, but these were still being developed. The strategy was focused on the short-medium term, including changes to the partnership and transition to a new clinical information system.

The practice had received a visit from a team of consultants in January 2019, who produced a report with recommendations to improve the practice’s efficiency and resilience. Topics included: appointment system, efficiency of appointment use, management of repeat prescriptions and administration of referrals. The report was given to us with other documents for review during the inspection.

We asked staff about an action plan for the recommendations, which was sent to us shortly after the inspection. For some recommendations, the action plan had details of concrete actions taken and how the improvements were being monitored. For example, the report said that the ‘daybook’ (the module of the computer system to create, track and complete clinical and administrative tasks within the practice) usually ran two months behind. The daybook task list being too long was identified as the cause of a significant event in March 2019. Staff told us that tasks were generally being completed, but not marked as complete, and that a new protocol was now in place to ensure that completed tasks were removed from the active list. The action plan states the action that was taken and the arrangements for daily monitoring that the new process was effective.

From the information in the action plan we could not assess how effectively had responded to many of the other recommendations, as it was not clear whether there had been a change and, if so, what monitoring was in place to ensure it was effective. Some of these areas identified for improvement and for which there was no clear action/monitoring were related to significant events that had occurred, for example, errors with processing repeat prescriptions.

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Culture

Staff told us that the practice culture prioritised the needs of patients. Y/N/Partial

There were arrangements to deal with any behaviour inconsistent with the vision and values.

Y

Staff reported that they felt able to raise concerns without fear of retribution. Y

There was a strong emphasis on the safety and well-being of staff. Y

There were systems to ensure compliance with the requirements of the duty of candour. Y

The practice’s speaking up policies were in line with the NHS Improvement Raising Concerns (Whistleblowing) Policy.

N


The whistleblowing policy said that staff could contact “an external body” but did not have details of an external person that staff could contact, in line with the NHS Improvement Raising Concerns (Whistleblowing) Policy.

Examples of feedback from staff or other evidence about working at the practice

Source Feedback

Staff Staff told us that they felt well supported and encouraged to develop.

Governance arrangements

The overall governance arrangements were not consistently effective. Y/N/Partial

There were governance structures and systems which were regularly reviewed. Partial

Staff were clear about their roles and responsibilities. Y

There were appropriate governance arrangements with third parties. Y


Meeting minutes were not effective as a record of the meeting for those who could not attend or as a reference. Most policies showed evidence of review, but the business continuity plan had not been updated to reflect the changed role of the registered manager. Shortly after the inspection, the practice told us that the plan had been updated.

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Managing risks, issues and performance

There were processes for managing risks, issues and performance, but these

were not consistently effective.

Y/N/Partial

There were comprehensive assurance systems which were regularly reviewed and improved.

Partial1

There were processes to manage performance. Y

There was a systematic programme of clinical and internal audit. Partial2

There were effective arrangements for identifying, managing and mitigating risks. Partial3

A major incident plan was in place. Y4

Staff were trained in preparation for major incidents. Y

When considering service developments or changes, the impact on quality and sustainability was assessed.

Y


1. There was no effective monitoring system for complaints to ensure that legislation was being followed. There was no effective monitoring of appointment availability. There was no effective system to document actions and learning from complaints or significant events.

2. There was a programme of audit, but audit had not be used to drive improvement in the areas of

weak performance in 2017/18 and 2018/19. Audits were narrow in focus, for example assessing

the percentage of patients on metformin with a recorded eGFR (estimated glomerular filtration

rate, a measurement of kidney function) under 30, with no discussion of whether patients without a

recent eGFR result were at risk.

3. There were arrangements for managing risks, but these were not consistently effective. 4. There was a business continuity plan, but it was not up-to-date. Shortly after the inspection, the

practice told us that the plan had been updated.

Appropriate and accurate information

The practice did not always use data and information proactively to drive and

support decision making. Y/N/Partial

Staff used data to adjust and improve performance. Partial

Performance information was used to hold staff and management to account. Partial

Our inspection indicated that information was accurate, valid, reliable and timely. Y

Staff whose responsibilities included making statutory notifications understood what this entails.

Y

Explanation of any answers and additional evidence: The practice did not act effectively to improve patient care after data from the Quality and Outcomes Framework in 2017/18 showed that patients with some conditions had poorly outcomes than those at other practices.

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Engagement with patients, the public, staff and external partners

The practice involved the public, staff and external partners to sustain high quality

and sustainable care. Y/N/Partial

Patient views were acted on to improve services and culture. Y

Staff views were reflected in the planning and delivery of services. Y

The practice worked with stakeholders to build a shared view of challenges and of the needs of the population.

Y


Feedback from Patient Participation Group.

Feedback

Representatives of the Patient Participation Group told us that the practice listened to their feedback and discussed potential changes with them.

Continuous improvement and innovation

There were systems and processes for learning, and improvement, but there was

limited evidence that they had resulted in significant improvements in care.

Y/N/Partial

There was a strong focus on continuous learning and improvement. Partial

Learning was shared effectively and used to make improvements. Partial

Explanation of any answers and additional evidence: The practice was about to change clinical information system, which it was hoped would result in improvements in data, processes and access to appointments for patients. We heard examples of improvements made in response to complaints and significant events, but documentation was poor.

Notes: CQC GP Insight

GP Insight assesses a practice's data against all the other practices in England. We assess relative performance for the majority of indicators using a “z-score”

(this tells us the number of standard deviations from the mean the data point is), giving us a statistical measurement of a practice's performance in relation to

the England average. We highlight practices which significantly vary from the England average (in either a positive or negative direction). We consider that

z-scores which are higher than +2 or lower than -2 are at significant levels, warranting further enquiry. Using this technique we can be 95% confident that the

practices performance is genuinely different from the average. It is important to note that a number of factors can affect the Z score for a practice, for example

a small denominator or the distribution of the data. This means that there will be cases where a practice’s data looks quite different to the average, but still

shows as no statistical variation, as we do not have enough confidence that the difference is genuine. There may also be cases where a practice’s data looks

similar across two indicators, but they are in different variation bands.

The percentage of practices which show variation depends on the distribution of the data for each indicator, but is typically around 10-15% of practices. The

practices which are not showing significant statistical variation are labelled as no statistical variation to other practices.

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N.B. Not all indicators in the evidence table are part of the GP insight set and those that aren’t will not have a variation band.

The following language is used for showing variation:

Variation Bands Z-score threshold

Significant variation (positive) ≤-3

Variation (positive) >-3 and ≤-2

Tending towards variation (positive) >-2 and ≤-1.5

No statistical variation <1.5 and >-1.5

Tending towards variation (negative) ≥1.5 and <2

Variation (negative) ≥2 and <3

Significant variation (negative) ≥3

Note: for the following indicators the variation bands are different:

• Child Immunisation indicators. These are scored against the World Health Organisation target of 95% rather than the England average. • The percentage of respondents to the GP patient survey who responded positively to how easy it was to get through to someone at their GP practice

on the phone uses a rules based approach for scoring, due to the distribution of the data. This indicator does not have a CCG average.

It is important to note that z-scores are not a judgement in themselves, but will prompt further enquiry, as part of our ongoing monitoring of GP practices.

Guidance and Frequently Asked Questions on GP Insight can be found on the following link:

https://www.cqc.org.uk/guidance-providers/gps/how-we-monitor-gp-practices

Glossary of terms used in the data.

• COPD: Chronic Obstructive Pulmonary Disease • PHE: Public Health England • QOF: Quality and Outcomes Framework • STAR-PU: Specific Therapeutic Group Age-sex weightings Related Prescribing Units. These weighting allow more accurate and meaningful comparisons within a specific

therapeutic group by taking into account the types of people who will be receiving that treatment.

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SWL Primary Care Team September 2019

1

Audit of Subcontracting Arrangements of GP Practices declaring a

Half Day Closure during 2018/19

Contents

1. Introduction ............................................................................................................................. 2

2. Context and background...................................................................................................... 2

2.1 Assurance guidance and Key Lines of Enquiries (KLOEs) ..................................... 3

2.2 Identifying GP Practices .................................................................................................... 3

3. South West London overview ............................................................................................. 4

3.1 Croydon CCG position ....................................................................................................... 4

3.2 Kingston CCG position ...................................................................................................... 5

3.3 Merton CCG position .......................................................................................................... 5

3.4 Richmond CCG position .................................................................................................... 5

3.5 Sutton CCG position ........................................................................................................... 6

3.6 Wandsworth CCG position ............................................................................................... 6

4. What powers do Commissioners have? .......................................................................... 7

5. Recommendations and Next Steps ................................................................................... 7

Appendix 1: Key Lines of Enquiries (KLOEs) ........................................................................ 9

Appendix 2: SWL 2018/19 Triangulation Report .................................................................. 12

Appendix 3: GMS & PMS Subcontracting contract clauses ............................................. 13

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1. Introduction

On 11 April 2018 guidance was sent to Commissioners by NHS England outlining the

expectations for the review of GP practice access arrangements, for assurance they meet

the reasonable needs of their patients during core hours.

The previous year’s focus had been on the practices who had declared regular periods of

half day closing on the annual electronic GP Practice self-declaration (eDec). Following this

a significant number of practices nationally had chosen to stop closing for half day. However,

since the 2017/18 eDec was collected a number of practices had also declared that they

were also closed regularly more than 7.5 hours per week during core hours. The guidance

provided in April 2018 requests that a review of the access arrangements for this cohort of

practices is also undertaken.

This paper provides a report on those practices in South West London (SWL) who through

their 2018/19 e-Dec submission declared half day closing, and those practices who are

closed 7.5 hours or more per week during core hours. The report will detail:

The follow up that has been made to confirm the stated position of the practices,

including any discrepancies identified in relation to the opening hours published on

NHS services and practice websites.

The actions taken to fulfil the national requirement to substantiate what

subcontracting arrangements are in place during the closure period to ensure the

reasonable needs of the patients are being met.

2. Context and background

The General Medical Services (GMS) and Personal Medical Services (PMS) Regulations

require general practice contractors to provide essential and additional services at such

times within core hours, ‘as are appropriate to meet the reasonable needs of patients’, and

require the contractor to have in place arrangements for its patients to access those services

throughout core hours in case of emergency. Core hours for GMS practices are defined as

8am-6.30pm, Monday – Friday, excluding weekends and bank holidays. Core hours for PMS

and APMS practices are set out in their contract but largely mirror GMS core hours or longer.

The Public Accounts Committee (PAC) report into GP access held in March 2017 set out a

number of recommendations. One was to ensure that no GP practice that was closed weekly

for half a day should be in receipt of additional funds to provide ‘extended hours’ i.e. outside

‘core hours’ and secondly that patients should know what they can ‘reasonably’ expect of

their GP practice during core hours.

In December 2017 the national team issued guidance to commissioners to assist in reaching

an agreement whether practices access arrangements meet the reasonable needs of

patients.

In April 2018 the NHS England National Team wrote to commissioners requiring them to

give assurance that the reasonable needs of patients is being met when a practice is

regularly closed for half a day, over four hours on any one day, or open for only 45 hours or

less a week. In addition to this, commissioners were directed to assess subcontracted

services.

The first audit was undertaken in September 2018 using the practices 2017/18 e-Dec

submissions in relation to regular and intermittent periods of closure during their core hours.

Each practice that had declared a half day closure was sent a letter detailing the change in

requirements to enable participation in the extended hours DES as of 1st October 2017.

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A second audit was undertaken in 2019 (Appendix 2). Any practice that had declared a half

day closing on their 2018/19 eDec was contacted by telephone to confirm the accuracy of

their submission and what arrangements were in place for the half day closing. The

information has been compared against the responses to the first audit, and any

agreements/ recommendations made by commissioners at the time.

2.1 Assurance guidance and Key Lines of Enquiries (KLOEs)

In order to seek assurance from practices that their access arrangements meet the

reasonable needs of the patients, the practices were asked to respond to a list of questions

(KLOEs – Appendix 1) to assist commissioners in determining if the practice meets the

requirements and to clarify their sub-contracting arrangements (Appendix 4 - GMS & PMS

subcontracting clauses). Each of the access queries varied, so when contacting the

practices, the questions were tailored for each practice, as it was not always necessary/

applicable to ask for all of the KLOE questions to be responded to.

When reviewing half-day closures, practice responses were reviewed. The practices were

asked to state if there were any changes to the information provided. In addition to this, all

practices who declared they were open for 45 hours or less a week were contacted asking

that they confirm their access and sub-contracting arrangements.

Commissioners are also required to review practice responses alongside other data streams

such as those held by CCGs relating to A&E, admissions, hub data and patient survey and

complaints. This will enable an informed decision on determining if the reasonable needs of

the patients are being met or not. The Triangulation Report (Appendix 3) lists these practices

with most recent data relating to:

Sub-contract information

Raw list size @1/4/19

Friends and Family Test data (if available)

GP Patient Survey results (2018/19)

NHS Choices ratings

A&E attendance rates

Total number of Hub appointments

This data has been provided alongside the summary of the practice responses (Appendix 2)

to help inform the Commissioning teams in recommending next steps.

The opening hours declared by the practices have been compared against practice website

data and the NHS Services data to identify any discrepancies. Practices were also asked to

amend these if they did not reflect the opening hours of the services.

2.2 Identifying GP Practices

The Annual GP Practice self-declaration includes a specific question around ‘half day’

closing and required practices to report their hours of availability. This required each GP

practice to complete and submit a template to confirm what arrangements were in place. A

series of questions were raised in order to assess if these arrangements aligned to patient

expectations in terms of meeting their reasonable needs. Key areas covered included:

Ability to attend a pre-bookable appointment (face to face) Ability to book / cancel appointments Ability to collect / order a prescription Access urgent appointments / advice as clinically necessary

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Home visit (where clinically necessary) Ring for telephone advice Ability to be referred to other services where clinically urgent Ability to access urgent diagnostics and take action in relation to urgent results

The services listed above have been refined following NHS England’s engagement with

patient groups and patient representatives at a national level.

3. South West London overview

The SWL Primary Care Team has contacted all practices who have declared half day

closures and / or are open for 45 hours or less a week. Declarations of half day closures

were also compared against the previous year’s responses. Some practices have since

confirmed they are open for the full core hours.

A total of 20 practices have declared half day and/ or opening hours of 45 hours or less a

week. The Triangulation Report (Appendix 3) has been provided alongside the summary of

the practice responses (Appendix 2) to help inform Commissioners.

The sections below provide a breakdown for each SWL CCG area.

3.1 Croydon CCG position

There are six practices in Croydon that have declared regular periods of closure during core hours in the 2018/19 eDec. Two of these have half-day closures:

One practice has a branch surgery. Although the main surgery is closed on Monday afternoons from 2pm-6.30pm, their branch site remains open during the full core hours. The branch site is approximately 30 minutes’ walk or 10 minutes’ drive from the main site. It’s also about a 30 minutes’ bus journey. However, as one of the sites remains open during the full core hours, no further action is required as there is no contractual breach.

The other practice forms part of a group of three practices, and has arrangements in place for their patients to be managed from one of the other sites during the period of the half-day closure. The other site is approximately 10 minutes by car, 20 minutes bus journey, or 17 minutes walking.

Four have declared regular periods of closing 7.5 hours or more per week:

The first practice has advised that the premises remain open during core hours, but their main phone lines are closed between 1pm-3pm. However, urgent calls are diverted to another number within the practice. A separate number is also available for patients to call regarding their prescriptions. The practice has advised that this process has been in place for 20 years. It has been discussed with the PPG and no concerns were noted.

The second practice has confirmed that they are open during their full core hours. However, their phone lines are switched off daily 12.30pm–2pm, with an emergency number for patients to call and speak with the on-call GP.

The third practice is closed daily 1pm-4pm, with access only for patients with pre-booked appointments during this time. The phone lines remain open. A prescription and post box is provided at the entrance door. The practice have noted that this is a historical arrangement which their patients are familiar with. They have recently discussed with their PPG and no concerns were raised.

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The fourth practice is closed daily 1pm-3pm. They advised that they have an answerphone message that directs patients to another practice who they have made arrangements with to triage calls, and where appropriate contact the GPs to arrange a home visit and/ or prescribe medication. Patients are made aware of this during the registration process. It should also be noted that the practice advised that they do not currently have their own website or PPG established. It is a contractual breach for a practice not to have a PPG in place. (See recommendation in section 5).

3.2 Kingston CCG position

There are two practices in Kingston that have declared regular periods of closure of more than 7.5 hours per week during core hours. There are no half-day closures.

One practice confirmed that although they close their doors between 1pm-2.30pm each day, there is an emergency number for patients to call during this time. Details are also provided on their website. Patients are able to leave a message, and prescription box is provided at the front porch. Further information is available on their website.

The second practice’s phone lines are closed between 12pm-1.30pm, and patients can leave a message during this time. An emergency number is available for patients and this is also shown on their website, with a GP on-call to deal with any urgent issues. They have also advised that no concerns have been raised by their PPG concerning the arrangements. At the time the practice was contacted they informed that they were circulating a questionnaire to their patients and will review the feedback concerning the opening hours.

3.3 Merton CCG position

There are no practices in Merton that have declared regular periods or half-day closures during core hours for the 2018/19 e-Dec. However there are two practices with intermittent periods of closure every month.

One of the practices is closed to patients between the hours of 1.30pm-2.30pm every two months for a practice meeting during this time, advising that they have a mobile number which is on the door and on a recorded message for emergencies. The SWL Primary Care Team have followed up with this practice, who confirmed that they close on Tuesdays every 2 months for one hour between 1.30pm-2.30pm for a practice meeting.

The second practice declared that they close on a Wednesday afternoon quarterly for a Merton CCG arranged PLT. All Merton practices are invited to attend the PLT event in which the CCG has arranged SELDOC to provide cover. However, the expectation going forward is that all practices remain open during the full core hours, including periods of CCG and practice arranged training events. Practices must ensure they have a minimum level of staff available to maintain patient access to primary care services, or have approved subcontracting arrangements in place. (See recommendations in section 5).

3.4 Richmond CCG position

There are seven practices in Richmond that have declared regular periods of closure during core hours in the 2018/19 eDec. Two of these have half-day closures:

One practice closed at the end of July 2019;

The other practice confirmed they are open full core hours, effective immediately.

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Five have declared regular periods of closing 7.5 hours or more per week:

The first practice has confirmed they are now open their full core hours;

The second practice has advised that patients are able to contact the on call GP for urgent appointments when the reception phones are closed between 8am-8.15am and 1pm-3pm. A box for prescriptions is available at the entrance and another at the reception desk. However, their website and NHS Choices have not been updated to reflect the correct opening hours. SWL primary care team to follow up with the practice regarding this;

The third practice has stated that their phone lines are closed between 8am-8.30am and 6pm-6.30pm, with calls redirected to East Berkshire OOH service. Urgent calls are passed to the on-call GP during these times. Prescription/ repeat prescription requests are not dealt with during this time;

The fourth practice is closed daily 8am-8.30am and 1pm-3pm. They have a contract with East Berkshire OOH services, who direct any urgent calls to the on-call GP. Prescriptions can be sent online or by email, with collections arranged with the pharmacy. They advised that the PPG are aware and supportive of these arrangements;

The fifth practice’s phone line is closed daily between 8am-8.30am and 1.30pm-2.30pm, and 5.30pm-6.30pm on Fridays. Patients are able to leave a message and an on-call GP is available to deal with any urgent issues. The GP OOH team will contact the lead GP with prescription queries. The practice has discussed opening hours with their PPG and no concerns have been noted.

3.5 Sutton CCG position

There was one practice in Sutton that declared regular periods of closure during core hours of more than 7.5 hours per week. When this was queried, the practice advised that this is no longer correct and that they are open for the full core hours.

3.6 Wandsworth CCG position

There are practices in Wandsworth who have declared regular periods of closure during core

hours in 2018/19. Three of these practices have declared regular closing of 7.5 hours or

more per week, and the SWL Primary Care Team have followed up with the practices

concerned.

The first practice corrected the opening hours however they still remain closed

between 1.30pm-3.30pm four days of the week. They advised that the practice and

clinical staff are available during this time;

The second practice closes between 1pm-2pm five days per week. On following up

with the practice they have confirmed that:

o There are reception staff on duty

o Patients can still gain physical access to the practice and by phone, and

o A GP is available for urgent appointments

o Their PPG and the CCG have been informed of these arrangements

The third practice has declared they close Monday, Tuesday, Thursday and Friday

1.30pm-2.30pm. During this time cover is provided by Care UK and they have the

contact details for the GP on call who provides triage and deals with any urgent

appointments. There are no reception staff and there is poster in the entrance. An

automated telephone message provides patients with the contact number for Care

UK. The practice advised that this arrangement has been in place for many years

and that the arrangements have been discussed/agreed with CCG;

A fourth practice closes between 1pm-2pm Monday to Friday. On following up with

the practice they confirmed that they have emergency mobile access number only,

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which is used by patients to access the on-call clinician. They have advised that they

have consulted their PPG and that the CCG are aware of this arrangement;

A fifth practice confirmed they close intermittently each month on a Monday for a

practice meeting, on a Tuesday for staff training, on a Wednesday for a reception

staff meeting, and on a Thursday for a practice staff and clinical meeting;

A sixth practice declared half day closing in 2017/18 which was queried by the

commissioning team, and has since confirmed the practice no longer closes half day.

However their website still needs updating, so requires further follow up by the SWL

Primary Care Team. The practice has also declared that they close between 1pm-

4pm Monday to Friday, and cover is provided by Care UK who provide a telephone

answering service, and a receptionist is available for face to face contact. This is

currently being reviewed by the CCG.

4. What powers do Commissioners have?

Commissioners need to consider if the reasonable needs of the patient are being met by the practice, by looking at all sources of data and feedback available. This may include the GP patient survey results, patient complaints, impact on A&E and admissions along with evidence supplied by the practice including PPG engagement and feedback. Depending on the evidence received CCG Commissioners will need to be assured that practices are complying with the contract by either opening, remaining open during full core hours or ensuring adequate sub-contracting arrangements are in place. Once arrangements are confirmed if there is a dispute between the commissioner and the practice either on the services available or the subcontracted arrangements in place / it is proposed then commissioners may need to consider contractual action. For practices found to be in breach of contract, remedial notices will be required to agree a reasonable and proportionate pace of change and to set out the ongoing dialogue between the commissioner and the practice on progress made.

5. Recommendations and Next Steps

CCGs with a practice declaring a half day closure are asked to consider the response from the practice to decide on any actions that are required or if the CCG are assured that present arrangements for ensuring the reasonable needs of the patient are being met. Following this review and assessment to decide if any contractual breach action needs to take place. The national team are due to publish another directive regarding assurance relating to practices who close periodically during core hours. Details are to follow when this is made available. If a practice proposes to sub-contract, the Contract Regulations require the practice to notify

their commissioner. Where this is a case, the commissioner will need to be assured that a

proposed arrangement will deliver essential medical services during core hours. This

notification should be made at least 28 days prior to the proposed commencement of the

sub-contract.

In regard to practice or CCG (PLT) arranged training events, to date there has been some flexibility for practices to close and direct their patients to out of hours service providers during the periods of training. However, going forward any practice wishing to apply for

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planned closure during core hours will need to provide a written confirmation of what arrangements will be in place to deliver its contractual obligations. This includes practice and CCG arranged training events. At a minimum a system needs to be put in place so that the patients can access the services listed below to meet the reasonable needs of the patients;

Ability to attend a pre-bookable appointment (face to face) – taking into the lone-worker policy, practices may wish to have more than one receptionist or member staff on duty

Ability to book / cancel appointments

Ability to collect/order a prescription

Access urgent appointments / advice as clinically necessary

Home visit (where clinically necessary)

Ring for telephone advice

Ability to be referred to other services where clinically urgent (including for example, suspected cancer)

Ability to access urgent diagnostics and take action in relation to urgent results The SWL Primary Care team will be writing to all practices to clarify the process and

expectations when requesting approval for planned periods of closure during core hours.

CCGs should review the current arrangements with their practices who are closed half-day

or more than 7.5 hours per week, and:

Confirm approval of any arrangements in place (including subcontracting) for their

practices whose plans meet the above the requirements;

Where there are practices who have failed to meet the requirements, approve the

issuing of a remedial notice and agreed action plan and timescales for the practices

to ensure that they remain open during core hours, and for any requests for planned

closure, that they have adequate arrangements in place.

CCGs should also reiterate the process and expectations for planned closure requests i.e. at locality meetings and practice manager forums. Addressing with practices that historical arrangements which span from PCT time no longer stand. Primary Care Access has moved on somewhat and the expectations on access are quite clear that they should not be closing the practice doors. In relation to the practice who advised that they do not have a PPG and website established, it is recommended that the CCG work with the practice and agree an appropriate timescale for both of these to be established. The practice may wish to consider establishing a virtual PPG if they are experiencing difficulties in setting up regular group meetings. If after an agreed period of time the practice has not established a PPG, then a remedial notice should be issued.

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Appendix 1: Key Lines of Enquiries (KLOEs)

KLOEs

1. Was the eDec submission made by the practice in respect of its opening hours

correct / accurate?

YES / NO

If no, provide further details

2. Is a reception accessible to patients either physically or by phone during any period

of closure? i.e. own or subcontracted surgery?

YES / NO

If no, provide further details

3. What arrangement are in place for patients to access services (i.e. meet the

reasonable needs of patients in accordance with the contract) during periods of

closure within contracted hours?

Free text response

4. Name and address of any subcontractor providing services

Free text response

5. Address of Premises used for Service Provision

Free text response

6. Distance of premises from main surgery

Miles

7. What services are provided under the Sub-Contracting arrangements

Free text response

8. Duration of Sub-Contract

Years and Months

9. As part of the subcontracting arrangements, are Patients able to:

a. visit the reception of the subcontracting provider

b. Attend a pre-bookable appointment (face to face)? YES / NO

c. Book / cancel appointments? YES / NO

d. Collect / order a prescription? YES / NO

e. Access urgent appointments / advice as clinically necessary? YES / NO

f. Request a Home visit (where clinically necessary)? YES / NO

g. Receive telephone advice? YES / NO

h. Access the alternative service locally by public transport? YES / NO

i. Be referred to other services where clinically urgent? YES / NO

j. Access urgent diagnostics and take action in relation to urgent results? YES /

NO

10. When the alternative service is operating, what are the arrangements when a patient

needs to speak to either a receptionist or clinician?

Free text response

11. Can the sub-contractor have access to the patient’s clinical record (not just the

summary care record)? Please provide details.

YES / NO – provide details

12. What is the current average waiting time at the practice for a non-urgent

appointment?

Number of working days (including weekends)

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13. Has the practice consulted the PPG to determine whether its current opening hours

and subcontracting arrangements meet the reasonable need of the patients?

YES/NO

Yes – go to question 13

No – go to question 14

14. How has the practice consulted with the PPG to determine whether its current

opening hours and subcontracting arrangements meet the reasonable need of the

patients?

Free text response

15. The contract states that “the Contractor must provide the services described in Part 8

(namely essential services) at such times, within core hours, as are appropriate to

meet the reasonable needs of its patients, and to have in place arrangements for its

patients to access such services throughout the core hours in case of emergency”

The contractor should therefore provide justification for not having consulted with its

PPG and advise when they intend to seek their feedback

Free text response

16. When did the practice last make this assessment and engage with the PPG?

Month / Year

17. Do patients understand the approved / proposed arrangements?

If yes – provide details. Practice responses should include how they have explained

to patients how their arrangements differ from other practices providing services

throughout core hours (e.g. not subcontracted)

18. Do patients have any concerns with service provision during core hours when the

alternative service is operating? If yes, please provide details.

YES / NO

If yes – provide details

19. How are patients informed of opening hours?

Free text response

20. Please describe the demographics of the PPG and how it reflects the whole practice

patient demographics and what measures has the practice taken to establish the

views of particular patients groups:

Free text response covering each group

Patient Group Number of patient reps

Measures Taken

(a) Working age adults

(b) Working age women

(c) Children

(d) Patients with learning difficulties / dementia

(e) Patients with long term conditions

(f) Patients with severe and enduring mental health problems

(g) Patients that are housebound, dependant on home visits

21. How has the practice reflected on any trends in its GP Patient Survey results

Free text response and evidence should be provided (if available)

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22. What analysis has the practice (or the Commissioner for its constituent practices)

done to assess patient behaviour when the practice is closed / subcontracts?

Free text response and evidence should be provided

23. What analysis (if any) has the practice / CCG done in relation to patient flows to A&E

or urgent care services when the practice is closed / subcontracts?

Free text response and evidence should be provided (if available)

24. How many complaints has the practice received regarding access in 17/18 – have

these been upheld / partially upheld / not upheld

Provide number and breakdown

25. Has the practice had any significant events arising that could be attributed to its

current pattern of opening and / or it subcontracting arrangements? If yes, what has

the learning been from the SEA.

Provide number and breakdown

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Appendix 2: SWL 2018/19 Triangulation Report

See attached spreadsheet

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Appendix 3: GMS & PMS Subcontracting contract clauses

GMS (Schedule 3, Part 5, Sub contracting)

44. (1) Subject to sub-paragraph (2), the contractor must not sub-contract any of its

rights or duties under the contract in relation to clinical matters to any person unless-

(a) In all cases, including those duties relating to out of hours services to which paragraph 45 applies, it has taken reasonable steps to satisfy itself that-

(i) It is reasonable in all the circumstances to do so, and (ii) The person to whom any of those rights or duties is sub-contracted is

qualified and competent to provide the service; and (b) Except in cases to which paragraph 45 applies, the contractor has

given notice in writing to the board of its intention to sub contract as soon as reasonably practicable before the date on which the proposed sub-contract is intended to come into effect

(2) Sub-paragraph (1)(b) does not apply to a contract for services with a health

care professional for the provision by that professional personally of clinical services

(3) A notice given under sub-paragraph (1)(b) must include-

(a) the name and address of the proposed sub-contractor; (b) the duration of the proposed sub-contract (c) the services to be covered by the proposed sub-contract; and (d) the address of any premises to be used for the provision of services

under the proposed sub-contract Furthermore

(5) The contractor must not proceed with a sub-contract or, if the sub-contract

has already taken effect, the contractor must take steps to terminate it,

where—

(a) (a) the Board gives notice in writing of its objection to the sub-contract on the grounds that the sub-contract would—

(i) put the safety of the contractor’s patients at serious risk, or (ii) put the Board at risk of material financial loss, and notice is

given by the Board before the end of the period of 28 days beginning with the date on which the Board received a notice from the contractor under sub-paragraph (1)(b); or

(b) the sub-contractor would be unable to meet the contractor’s obligations under the contract.

Paragraph 45 relates to sub-contracting of out of hours services.

PMS (Schedule 27 Sub-contracting of clinical matters)

27.1 The Contractor shall not sub-contract any of its rights or duties under this Agreement in relation to clinical matters unless it has taken reasonable steps to satisfy itself that: Classification: Official

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27.1.1 it is reasonable in all the circumstances; 27.1.2 the person is qualified and competent to provide the service; and 27.1.3 it is satisfied that the sub-Contractor holds adequate insurance pursuant to clause

27.2 Where the Contractor sub-contracts any of its rights or duties under the Agreement in relation to clinical matters, it shall:

27.2.1 inform the Board of the proposed sub-contract as soon as is reasonably practicable; 27.2.2 provide the Board with such information in relation to the sub-contract as it reasonably requests; 27.2.3 comply with all directions from the Board regarding its relationship with such sub-Contractor including (without limitation) termination of such sub-contract.

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Sutton Clinical Commissioning Group Primary Care Commissioning Committee


Document Title Report from the Primary Care Transformation and Operational Management Group (PCTOMG) on 2nd July and 6th August 2019


Michelle Rahman, Acting Managing Director


Dr Chris Elliott, Clinical Associate Director of Primary Care


Sian Hopkinson, Associate Director of Primary Care



Executive Summary Background: Sutton’s Operational Management Group (OMG) and Primary Care at Scale Programme Board merged from April 2019 to form the Primary Care Transformation and Operational Management Group (PCTOMG). This group meets each month to support the Primary Care Commissioning Committee in the execution of its functions. Purpose: The PCTOMG is not a formal committee or sub-committee of the Governing Body, but is a ‘Steering Group’ to advise and operationalise primary care strategy in Sutton. Reason for Committee Review: The Transformation and Operational Management Group is accountable to the Primary Care Commissioning Committee and this report is to ensure the Committee is sighted on key items of discussion.

Key Issues: PCTOMG 02/07/19 1. Primary Care Network Development – all practices had completed and signed their

network agreements. Regular meetings were being planned to develop PCNs in Sutton. Three practices (Bishopsford Road, Carshalton Fields and Cheam GP Centre) will not be providing Extended hours in house but this will be provided by the GP Federation on behalf of PCNs

2. PCAS Programme a. Proactive MDT - the GP Federation report that FR will be presenting this

work at SH&C Alliance Board. A summary of activity was reported – discussions centred on how future reports could demonstrate the impact of the project. A service specification will be developed by the CCG. A darzi fellow will be undertaking a review of the impact of MDTs to date and will

XX

✓

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work with system partners to reshape the model as required, and devlop clear outcomes.

b. Acute Home Visiting – An activity report was presented and planning was underway regarding staff training on GP TeamNet. A service specification will be developed by the CCG. An outcomes based service specification will be co-produced with PCN clinical directors.

3. GP IT Dashboards – An overview was given on a new dashboard designed to show practices’ progress on IT projects such as patient online access and completion of the Data Security & Protection Toolkit.

4. Risk Register was reviewed with a new risk logged regarding network development.

5. A CEPN/Training Hub proposal was presented which outlined options to relocate this service with a primary care organisation. Further meetings are planned to explore the options.

6. Ear Irrigation & Spirometry – there are no contractual agreements for these services currently. It was decided having such services as a Locally Commissioned Service (LCS) would be the most appropriate contracting solution. Service specifications will be shared with the LMC for comment and agreement.

PCTOMG 06/08/19 7. GP Resilience Funding Applications – details of the applications were provided

and the report was approved by PCTOMG members for submission to the South West London team for review.

8. Primary Care Network Development – Networks are required to complete a self-assessment (maturity matrix) to chart progress and highlight development needs. The publishing of a national prospectus was imminent and a meeting between Clinical Directors and the Primary Care Team was agreed to complete this task and access funding.

9. PCAS Programme a. Proactive MDT - A draft service specification was circulated and the group

provided feedback. It was agreed the GP Federation needed to discuss with Sutton Health & Care Alliance as they are both responsible for the delivery of MDTs.

b. Acute Home Visiting - A draft service specification was circulated and the group provided feedback.

10. The Primary Care Team workplan was reviewed. 11. The risk register was reviewed; risk 179 and 181 for update. 12. Public Health presented a Diabetes Dashboard which was developed in

conjunction with PRIMIS. This was a proof of concept approach and if helpful could be adapted to other specialities. The group asked if learning from other areas who have implemented the approach could be brought to a future meeting.

13. An overview of budget was provided to note: a. Core budget - there was a £250k cost pressure due to new commitments for

the Primary Care Network DES. b. Underspend at month 3, however some of the estimates were higher than

the cost. 14. GP Patient Survey – results showed Sutton Practices were above the national

average. Some practices had areas that required improvement and LN was

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working on a revised service specification for Sutton Healthwatch to support practice teams

15. LN provided an overview of the contract summary report for quarter 1 of 2019/20 and noted that Beeches Surgery and Cheam GP Centre have both been inspected by CQC, however we are awaiting publication of their reports.

Conflicts of Interest: Any conflicts of interest are managed in line with CCG policy.

Mitigations: N/A

Recommendation: The Committee is asked to: NOTE the contents of this report and the work of the Transformation and Operational Management Group


Objective 2: Commission high quality cohesive health services for the population of Sutton through joint working between health and social care organisations ensuring patients’ physical, mental and social wellbeing needs are met. Objective 3: Maintain an efficient and financially stable, local healthcare system by improving primary care and community services and working closely with secondary care to deliver integrated services that bring healthcare into the community.


1006 – Potential failure to implement the primary care strategy


The work of the PCTOMG supports delivery of primary care strategy


N/A

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N/A


N/A


This report is in the public domain.



Outcome:



Supporting Documents

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Sutton CCG Clinical Commissioning Group Primary Care Committee


Document Title Primary Care Commissioning


Michelle Rahman


Dr Chris Elliot


Claudine Bond Risk Lead



Executive Summary The Primary Care risk register has been updated since the last meeting to ensure the Directorate sufficiently acknowledges the level of risk facing Sutton CCG. The new risk reporting system makes it easier to review and actively manage risks.

Top Risks: Any risk scoring 15 or above will automatically be escalated to the BAF and shared at the Governing Body. For Primary Care risks these are currently:

• None

Closed Risk:

• None New Primary Care Risk There are no new risks identified within this reporting period. Changes to risk scores detailed below:

Risk

Number

Description Risk Score Movement

June

2019

Report

Sept

2019

Report

174 Primary Care Strategy 8 (4x2) 8 (4x2)

175 GP IT Service Failure

12 (4X3) 12 (4X3)

✓ ✓

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Risk

Number

Risk Score Movement

June

2019

Report

Sept

2019

Report

176 Primary Care Estates Investment 12 (3x4) 12 (3x4)

178 Primary care Workforce Shortage

8 (4X2) 8 (4X2)

179 Vulnerable GP Practices

12 (4x3) 8 (4X2)

181 Disconnection Between Stakeholder Group

12 (4X3) 12 (4X3)

227 Primary Care Network Development

9 (3X3) 6 (3X2)

Key progress/ Issues: There are currently 7 risks on the Primary Care risk register and good progress is being made. Four of these risks are owned by the CCG Deputy Managing Director and one by the Director of Performance & Delivery and the other by the Director of Finance. All risks have a named delegated owner, and most risk have been reviewed during this reporting period, but there are a few still overdue. Delegated risk owners are requested to review their risks when prompted to do so by the system, and to ensure they risk assess the scores, especially when the actions have completed. Risk owners should consider if there is any known emerging risks that could impact the CCG, within the next 6 months, and plan prevention controls in advance of the risk materialising, via the 4Risk system.

The Primary Care risk register update describes the risks, mitigating actions to date and action plans for implementation. The register also sets out ownership of these risks, mitigation plans, inherent, residual, target risk ratings and review dates.

Conflicts of Interest: No key decisions are expected form this paper that would have an impact on conflicts of interest.

Mitigations: Please refer to attached risk register.

Recommendation: The Committee is asked to: Consider the detailed risks presented and discussed and agree they are sufficiently assured over the management and ongoing mitigation of key risks.

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The committee is requested to focus on the following queries to achieve assurance:

• Do we feel the risks documented reflect the current key risks to the Primary Care function?

• Is adequate management action and control being exerted to mitigate and manage the risks?

• Do the risks as documented adequately account for any implications to any of the other elements of the business (finance, performance, quality, governance)?

• Raise any omission of emerging risks that are not included to consider adding to the primary care risk register.


Objective 1: Ensure patients are at the heart of decision making, working in partnership with individuals, patient representative groups, families and carers to deliver high quality, accessible services that tackle inequalities and respond to personal need. Objective 2: Commission high quality cohesive health services for the population of Sutton through joint working between health and social care organisations ensuring patients’ physical, mental and social wellbeing needs are met. Objective 3: Maintain an efficient and financially stable, local healthcare system by improving primary care and community services and working closely with secondary care to deliver integrated services that bring healthcare into the community. Objective 4: Work with the local authority to develop an integrated commissioning framework that supports single, pooled budget for health and social care services with planned and agreed delivery across a range of areas.


Sutton Primary Care risk register.


Please refer to the Primary Care risk register.

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Management of risks is incorporated in the role of substantive employees, there are no identified implications.


An EIA has been considered but is not required


There are no implications for equalities.


None is required.



Outcome:




Supporting Documents Primary Care Risk Register

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Report Date 29 Aug 2019

Risk Status Open

Control Status Existing

Action Status Outstanding

Standard Risk Register

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SCCG Primary Care

Risk Ref

Risk Title Inherent Risk

Priority

Cause & Effect Risk Control Action Required Residual Risk Priority

Target Risk Priority

174 Primary Care StrategyRisk Owner: MichelleRahmanDelegated Risk Owner: SianHopkinsonLast Updated: 28 Aug 2019

I = 4 L = 312

Failure to implement the primary care strategyCause:GP Practices may fail to engage with national and/or local workstreams designed to improve the resilience of general practice and integration of health and care services locally.Effects:GP Practices may not achieve resilience, risking closure, which will impact our ability to deliver high quality care. Patients may not receive integrated health and care services, resulting in poorer health outcomes and unnecessary costs to the system.

Contractual levers in PMS Contracts.

New 5 year GP contract in place which will directly support delivery and mitigate risk.

Ongoing engagement with GP Practice teams through locality meetings, Practice Manager and Practice Nurse Forums and dedicated workshop events

Significant engagement by locality leads in place

Significant engagement with GP practice through locality meetings

On-going development and implementation of the Sutton Health and Care Proactive Model.Person Responsible: SianHopkinsonTo be implemented by: 31 Mar 2020

I = 4 L = 28

I = 4 L = 14


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SCCG Primary Care

Risk Ref


Priority



175 GP IT Service FailureRisk Owner: Sean MorganDelegated Risk Owner:Last Updated: 27 Jun 2019

I = 4 L = 312

Potential failure of IT services may impact on the delivery of GP ServicesCause:Recurrent IT system failureEffect:Clinicians unable to carry out patient consultation with no access to primary medical services.

Practice Manager Forum

Regular performance contract meetings with the provider. Practice Manager Forum

Engagement with provider to address and resolve failures. CCG IT director lead to escalate on-going IT issues through new IT govrnance structure. Rollout of HSCN connections to all sites.

Person Responsible: Sean MorganTo be implemented by: 31 Oct 2019

SWL-wide IT review implementation.Person Responsible: Sean MorganTo be implemented by: 31 Dec 2019

2018/19 GP IT Refresh to provide new equipment for practices with the greatest need.NEL CSU to produce a plan.

Person Responsible: Sean MorganTo be implemented by: 31 Mar 2020

I = 4 L = 312

I = 3 L = 26

176 Primary Care Estates InvestmentRisk Owner: Geoffrey PriceDelegated Risk Owner: SianHopkinsonLast Updated: 27 Aug 2019

I = 4 L = 416

Primary Care Estates are not fit purposeCause:lack of investment in primary care premisesEffective:Financial implications of getting estates to the standard where they are fit for purpose.

CCG estates strategy agreed and in place.

Regular NHSE contract performance monitoring .

Progressing Schemes for South Sutton, Hackbridge Old Court House and Cheam.

Person Responsible: SianHopkinsonTo be implemented by: 31 Dec 2019

Sutton estates strategy to be reviewed.Person Responsible: SianHopkinsonTo be implemented by: 30 Sep 2020

I = 3 L = 412

I = 3 L = 39


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SCCG Primary Care

Risk Ref


Priority



178 Primary Care Workforce shortageRisk Owner: MichelleRahmanDelegated Risk Owner:Sarah KavanaghLast Updated: 21 May 2019

I = 4 L = 312

Significant number of GPs and nurses are at or approaching retirement age, Cause:Retirement, nautral wastageEffect:Staff shortage, impacting the ability to provide services at sufficient capacity

Extensive programme of training and retention of Nurses by CEPN and HEEL

Facilitating and supporting student placement opportunities (All roles) to promote careers in general practice and develop relationships with graduating potential employees

Member of SWL wide workforce initiative - looking at apprenticeships, retention and induction programmes.

Monitored and reviewed at Primary Care Operational Group

Primary care strategy includes workforce as a priority - new roles such as Pharmacists, PAs and Paramedics being promoted and employed.

Upskilling existing staff to develop roles and to assist succession planning

Workforce Plan now in force as part of the Primary Care Strategy

Ongoing collaborative working across SWL to promote GPN and SWL Preceptorship programmes.

Person Responsible: SarahKavanaghTo be implemented by: 31 Dec 2019

Clear plan to promote Sutton as an attractive place to work - attending careers fairs and working closely with HEIs to promote vacancies to undergraduate and return to practice students.

Person Responsible: SarahKavanaghTo be implemented by: 31 Dec 2019

I = 4 L = 28

I = 3 L = 26

179 Vulnerable GP PracticesRisk Owner: MichelleRahmanDelegated Risk Owner: LouNaiduLast Updated: 28 Aug 2019

I = 4 L = 416

There is a risk that vulnerable GP Practice may close.

Cause:CQC removal of registrationPractice finances unsustainableStaff leaving the profession

Effect:GP surgery closure

Regular visits to the Practices by NHSE and the CCG.

Ongoing support to Practices by Primary Care Team Person Responsible: Lou NaiduTo be implemented by: 31 Mar 2020

I = 4 L = 28

I = 1 L = 22


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SCCG Primary Care

Risk Ref


Priority



181 Disconnection Between Stakeholder GroupRisk Owner: MichelleRahmanDelegated Risk Owner:Last Updated: 01 Aug 2019

I = 4 L = 312

Engagement with CCG practices inadequateCause:Different perspectives on service transformation, capacity, Primary Care Collaborative Commissioning and resultant conflicts of interest.EffectsMembership not feeling communicated with and part of decision-making - Membership become disengaged or demotivated - Loss of freedom to lead clinical redesign - Effect on change delivery - Loss of clinical engagement in NHS GovernanceDiscussion on what further actions can be taken

Communication with CCG practices .

Localities regularly report to executives.

Membership views sought for any constitutional change regarding SWL CCGs.

Positively target areas where there is disengagement

Person Responsible: MichelleRahmanTo be implemented by: 31 Jul 2019

Locality and Practice visits as part of FRP Plan.Person Responsible: Sean MorganTo be implemented by: 31 Jul 2019

I = 4 L = 312

I = 2 L = 36


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SCCG Primary Care

Risk Ref


Priority



227 Primary Care Network DevelopmentRisk Owner: MichelleRahmanDelegated Risk Owner: SianHopkinsonLast Updated: 26 Jun 2019

I = 4 L = 416

Failure to engage in development of primary care networks by general practices or other stakeholders in Sutton would reduce the expected benefits of collaborative, integrated delivery of care.Cause:Non-engagement of practices or other organisations in development of primary care networksNon membership of practice(s) with PCNs may cause a delay or gap in service provisionChange in delivery model for extended hours services.Effect:Failure to realise the benefits of networks such as resilient general practice, integrated delivery of healthcarePatients from practice(s) not members of a PCN may benefit from all services that should be provided under the Network DESPrimary Care Networks may fail to deliver to all services to their whole populationNew delivery model for extended hours may fail to deliver equitable provision across the whole population

GP Federation commissioned to support network development

Monthly meetings with Primary Care Network Clinical Directors

PCNs have Memorandum of Understanding with GP Federation to deliver extended hours service for those practices not providing the service directly

Regular Locality Meetings for all practices including non-member

Primary care commissioners to monitor delivery of new Network Directed Enhanced Service (DES)Person Responsible: SianHopkinsonTo be implemented by: 31 Dec 2019

I = 3 L = 26

I = 1 L = 22


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Primary Care Commissioning Committee Forward Plan – September 2019

Updated 02/09/19

September 2019 October 2019 December 2019 March 2020

Seminar

• Digital Programme review

• Workforce review

• Moving Forward Together – impact on primary care

Standing agenda items:

• Minutes plus actions

• Declaration of interest

• Contractual changes

• Finance report

• Quality Report

• PCTOMG Report

• Risk register

• PCCC Forward Plan For Approval: For Discussion

For Note:

Standing agenda items:

• Minutes plus actions

• Declaration of interest

• Contractual changes

• Finance report

• Quality Report

• PCTOMG Report

• Risk register

• PCCC Forward Plan For Approval: For Discussion

For Note:

Part 2 Part 2

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AGENDA - NHS Sutton CCG · AGENDA Chair: Susan Gibbin Report Author Presented by ENC WELCOME &...

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Transcript of AGENDA - NHS Sutton CCG · AGENDA Chair: Susan Gibbin Report Author Presented by ENC WELCOME &...