Ealing Primary Care Standard

Paper: 4

Date Wednesday, 26 July 2017

Presenter Neha Unadkat, Deputy Managing Director

Tessa Sandall, Managing Director

Author Neha Unadkat

Responsible Director

Tessa Sandall, Managing Director

Clinical Lead Dr Mohini Parmar, Clinical Lead

Confidential Yes ☐ No Items are only confidential if it is in the public interest for them to be so

The Governing Body is asked to:

The Governing Body is being asked to Ratify the decisions made by the Investment Committee (IC) and the Primary Care Committee (PCC).

If the Governing Body does not ratify, then the issues preventing such will be returned to the relevant non-conflicted Committee for (re-)consideration.

• Ratify the outcomes of the Primary Care Commissioning Committee (PCC) on the

19th July • Ratify the outcomes of the Investment Committee (IC) on the 20th July • Note that if the GB believe the decision of the PCC or the recommendation of the IC

require further assurance, the request would be required to go back to the relevant committee for consideration to ensure that conflicts are appropriately managed

• Note the additional supporting slides which demonstrate the decision making process for the Standard

The Investment Committee were asked to:

• Note the outcome of the Primary Care Commissioning Committee’s consideration of the whole case on the 19th July which will be reported to the committee on the 20th July

• Approve on-going/renewal of funding relating OOH, Paediatric Phlebotomy, LIS, Dementia (£7.2M annually 18/19 – 20/21)

Title of paper Ealing Primary Care Standard

Paper: 4

• Approve investment of £923k 18/19-20/21 new funding from core funding is

affordable based on conservative savings case • Confirm the approach taken to manage Conflicts of Interest was proper and robust • Note the view of the non-conflicted F&P members; • Inform the Governing Body of the decisions of the Investment Committee for

ratification by the Governing Body

The Primary Care Commissioning Committee were asked to:

• Consider and Approve the Ealing Standard and the supporting business case. • Approve the use of the headroom in the primary care allocation to fund in 2017/2018

the access specification and from 2018/2019 to support the standards relating to access, screening, prevention and patient experience.

• Note that the standards have been developed by clinical leads with a period of co-production with the broader CCG membership.

• Note that the costing of the standards has been developed in line with the OOH costing model or using the Local Improvement Scheme (LIS) as the benchmark, with clinical leads determining the length of the clinical interventions and the staff groups involved, with the officers using this information to cost the standards.

• Agree to a KPI Moratorium in 17/18 to allow practices to mobilise effectively • Note the report provided by Healthwatch on Access to general practice in Ealing.

Summary of purpose and scope of report

The CCGs ambition in commissioning the Ealing Standard is:

1. To have equity of offer and access to patients registered with an Ealing GP through commissioning the Ealing Standard

2. To reduce the unwarranted variation in general practice and improve outcomes for individuals

3. To address the concerns and feedback received from patients regarding access to general practice and drive ongoing improvement over the term of the Ealing Standard.

4. To address the needs of the population as identified in the Joint Strategic Needs Analysis (JSNA) and ensure the primary care standards deliver a full, holistic offer of care for patients

5. To support and improve resilience and sustainability within general practice whilst meeting the strategic requirements as set out in the NWL STP, 5YFV, and the Strategic Commissioning Framework (SCF). It is very clear that general practice is the golden thread that runs through all five of the delivery areas of the STP supporting and enabling the realisation of the triple aims of the STP of Improving Health & Wellbeing, Improving care & quality, Improving productivity and closing the financial gap.

6. To utilise the opportunity that Primary Care Delegation has provided in enabling the

Paper: 4

CCG to direct the use of the headroom within the primary care allocation for Ealing GPs. The headroom recognises the historical underfunding in general practice from a national level and the increasing allocation addresses this up to and including 2020/2021.

7. That the CCG commissions an equitable offer on an equitable financial basis from practices and therefore the Ealing Standard is the commissioning intention for PMS discussions to support the NHS England required renegotiation of PMS premium funding.

The CCG is requesting approval relating to three funding streams as outlined below:

8. To utilise £2.8m of the headroom during 2017/2018 with a focus on access increasing to £3,474k to support access, prevention, screening and patient experience recurrently.

9. As the allocation increases in future years, following managing any growth pressures or increases in core primary care spend, such as funding implications of national contract negotiations, increases in rents, rates and applying any NHS business rules as directed by NHSE, further headroom funding released is allocated to support primary care in Ealing to further stretch the primary care offer through stretched targets or new standards in line with the needs of the population.

10. To seek agreement that the funding already being utilised from the CCG programme budget, £7.2m, should continue to be used to commission the Out of Hospital (OOH) services as part of the Ealing Standard. That this agreement is made based on the understanding that the care will need to be provided from somewhere within the healthcare system and for a proportion of the services this would be at a higher cost, £2.6m, in the acute service.

11. To seek agreement to additional investment from CCG programme budget of £923k into the Ealing Standard noting that the costs have been derived through either the out of hospital costing model or through the LIS incentive scheme approach. The request for an additional £923k annually is made against the most conservative realisation of savings derived directly from the standard of £1,160k in 2018/2019 with a total incremental saving at the end of the 2020/2021 of £4,124k.

12. That the Ealing Standard enables the implementation of primary care led elements of the STP across the five domain areas and underpins some of the financial benefits to be realised e.g. on going investment into primary care to support mental health care enabling the Like Minded business case (DA4), enabling the use of PAMS (DA1) or the system wide programmes on Diabetes, Hypertension and AF (DA2).

13. To seek approval for a moratorium on the KPIs in 17/18 to start to mobilise and prepare for phase 2 in April 2018. This is in line with the process to mobilise the original OOH services contract with primary care

That the committee note the approach to the costing of the standards and the approach to contracting:

14. That the costing of the standards has been developed in line with the OOH costing

Paper: 4

model or using the Local Improvement Scheme (LIS) as the benchmark, with clinical leads determining the length of the clinical interventions and the staff groups involved, with the officers using this information to cost the standards. This was further reviewed by a finance officer outside of Ealing.

15. That the Ealing standard is commissioned as a single wrap around contract from each provider of medical services.

That there is a need to invest in mobilisation through internal and additional resource:

16. That additional resource is agreed as part of the business case to support mobilisation of the standard throughout the rest of 2017/2018 and this is funded from the primary care allocation and the headroom available. That this mobilisation is overseen by a steering group made up of CCG clinical leads and managers with responsibility for primary care. That this group reports into and includes members from the Primary Care Commissioning Committee, F&P and that Healthwatch are included as members.

That the following assurances have been received through:

a) Independent Review Panel has reviewed all the new standards in line with the

original out of hospital services business case and confirmed their view that General Practice is the ‘most capable provider’

b) Finance & Performance and Primary Care Commissioning Committees have approved the core primary care budget delegated to CCGs, subject to a desktop review by the District Valuer on the rent increases pressure on the budget and a review of the rates implication

Feedback will be provided in the committee meeting from the discussion held at F&P.

Quality & Safety/ Patient Engagement/ Impact on patient services:

The Standards are designed to:

1. Provide an equity of offer and access to patients registered with an Ealing GP through commissioning the Ealing Standard

2. Reduce the unwarranted variation in general practice and improve outcomes for individuals

3. Address the concerns and feedback received from patients regarding access to general practice and drive ongoing improvement over the term of the Ealing Standard.

4. Address the needs of the population as identified in the Joint Strategic Needs Analysis (JSNA) and ensure the primary care standards deliver a full, holistic offer of care for patients

Paper: 4

Finance, resources and QIPP

The Business Case sets out the case for:

1. Agreement to invest the increase in allocation (Headroom) of £2.8M during 2017/2018 with a focus on access increasing to £3,474k to support access, prevention, screening and patient experience recurrently.

2. To continue to invest the funding allocated to the Out of Hospital Contract, Dementia Contract, Local Improvement Scheme Budget and the Paediatric Phlebotomy contract of £7.2M, but into the Primary Care Standard.

3. Agreement for a further £923K to be invested from core CCG funds into these standards.

The Net Savings following the reinvestment of the request for core funding based on the most conservative case is as follows:

Financial Period

2018/2019 2019/2020 - Cumulative

2020/2021 Cumulative

Total Core additional funding £923,258 £1,855,749 £2,797,564

Conservative case benefit realisation £1,159,511 £2,543,214 £4,123,130

Net savings £236,253 £687,465 £1,325,566

% savings on additional funding 26% 37% 47%

Conservative case incremental saving year on year

£1,159,511 £1,383,703 £1,579,916

Equality / Human Rights / Privacy impact analysis

An Equality Impact Assessment has been conducted and is available in the Business Case.

Risk Mitigating actions

The complete risk register is available in the business case

Paper: 4

Supporting documents

Ealing Primary Care Standards Business Case Ealing Primary Care Standards

Governance and reporting

Committee name Date discussed Outcome

Document Name Ealing Standard Decision Making Business Case

Version V.15

Status Final

Author Neha Unadkat – Deputy Managing Director Primary Care & Integration

Tessa Sandall – Managing Director

Date created 30 May 2017

Date last amended 12 July 2017

Ealing Standard Decision Making Business Case

Ealing New Primary Care Offer Business Case

July 2017 i

Contents

1 Introduction ................................................................................................................................ 1

1.1 Purpose of this business case ............................................................................................ 1

1.2 Structure and content of this document ............................................................................... 1

2 Strategic case ............................................................................................................................ 2

2.1 Strategic context ................................................................................................................. 2

2.1.1 National context ........................................................................................................... 3

2.1.2 Regional (London-wide) context .................................................................................. 4

2.1.3 North West London context ......................................................................................... 5

2.2 Case for change ............................................................................................................... 18

2.2.1 Patient Perspective .................................................................................................... 18

2.2.2 Population Perspective .............................................................................................. 19

2.2.3 General Practice perspective ..................................................................................... 19

2.2.4 Economic Case ......................................................................................................... 21

2.2.5 Financial sustainability ............................................................................................... 22

2.2.6 Headroom funding opportunity ................................................................................... 22

2.2.7 High administrative burden ........................................................................................ 23

2.2.8 Case for change summary ......................................................................................... 23

2.3 Investment objectives ....................................................................................................... 24

3 Economic Case........................................................................................................................ 25

3.1 Critical success factors ..................................................................................................... 25

3.2 Long list of options ............................................................................................................ 26

3.2.1 OOHS contract .......................................................................................................... 27

3.2.2 LIS contract ............................................................................................................... 28

3.2.3 Winter resilience funding ........................................................................................... 30

3.2.4 Paediatric phlebotomy and dementia ......................................................................... 31

3.2.5 PMS funding .............................................................................................................. 32

3.2.6 Headroom funding ..................................................................................................... 33

3.2.7 Summary of long list analysis .................................................................................... 35

3.3 Short list appraisal ............................................................................................................ 35

3.3.1 Short listed options .................................................................................................... 35

3.3.2 Short list benefit and dis-benefits analysis ................................................................. 35

3.4 The preferred option ......................................................................................................... 37

4 Commercial case ..................................................................................................................... 38

4.1 The Commissioning Strategy ............................................................................................ 38


July 2017 ii

4.2 Payment Mechanisms ...................................................................................................... 39

4.3 Contractual and Other Issues ........................................................................................... 40

4.3.1 Type of contract ......................................................................................................... 40

4.3.2 Contract management ............................................................................................... 40

5 Financial case .......................................................................................................................... 41

5.1 Available funding .............................................................................................................. 41

5.2 Costing of the specifications ............................................................................................. 41

5.3 Affordability assessment ................................................................................................... 44

5.3.1 The Primary Care headroom investment ........................................................................ 44

5.3.2 The renewal of the funding for the services detailed in the above section ...................... 44

5.3.3. The request for additional investment into the standards .............................................. 44

5.3.4 Savings attributable to the Ealing Standard .................................................................... 44

5.3.1 The Primary Care headroom investment ......................................................................... 44

5.5 Impact on PMS practices .................................................................................................. 56

6 Management case ................................................................................................................... 59

6.1 Governance ...................................................................................................................... 59

6.2 Mobilisation plan ............................................................................................................... 60

6.3 Provider development ....................................................................................................... 62

6.4 Resourcing Requirements in the CCG .............................................................................. 65

7 Conclusion and Recommendation ........................................................................................... 66

Appendix 3 Equality impact statement ............................................................................................ 68

Appendix 4 Risk register ................................................................................................................. 82

Appendix 5 OOHS contracts ........................................................................................................... 85

Appendix 6 Outcome of the Independent Review Panel ................................................................. 86

Appendix 7 Annual Self Declaration .............................................................................................. 109

Appendix 8: Primary Care Offer Steering Group TOR ................................................................... 111


July 2017 1

1 Introduction

1.1 Purpose of this business case

- The purpose of this business case is to seek approval to commission the Ealing Primary

Care standard commencing with access in 2017/2018 with the full standard being

commissioned from 2018 through until 2021. The investment will be used to fund the

Ealing Standard, which aims to improve the resilience of general practice, improve

access for patients, reduce unwarranted variation in health outcomes and ensure long

term sustainability in the local health system. The Ealing Standard is a contract for

primary care providers for the delivery of a set of 23 standards that focuses on the

delivery of high quality care in general practice

1.2 Structure and content of this document

This business case sets out to consider the five cases that align to the HMT Green Book

guidance:

The Strategic Case: setting out the strategic context and the case for change, together

with the supporting investment objectives for the scheme

The Economic Case: setting out the available options to meet the investment objectives

and establishing which is the preferred option

The Commercial Case: outlining the commercial strategy for the preferred option?

The Financial Case: confirming the funding arrangements and affordability for the

preferred option?

The Management Case: demonstrating that the preferred option is achievable and can

be delivered successfully to cost, time and quality.

The following sections provide the evidence for each of these five cases in turn.


July 2017 2

2 Strategic case

This section will set out the current situation for primary care in Ealing and the strategic context

in terms of national, regional and local drivers for change. It will also set out the case for change

and the investment objectives of this project.

2.1 Strategic context

Ealing is the largest borough in North West London and works within the collaboration of eight

CCGs in North West London. The STP has been developed by commissioners, providers and

with local authorities across North West London and has a triple aim of Improving Health &

Wellbeing, Improving care & quality and Improving productivity and closing the financial gap.

The golden thread running across and within the STP is general practice; the five delivery areas

within the STP all require general practice to enable the benefits they describe. However,

primary care cannot deliver this on its own, but as part of a system aligned to deliver to the same

outcomes. Therefore, primary care must be commissioned and supported to become resilient

and transformed, so that it is not working in isolation.

Ealing Clinical Commissioning Group (Ealing CCG) commissions services from 76 GP practices,

meeting the needs of 425,000 registered patients. Practices are arranged into seven locality

networks, as shown in Figure 1. Of the 76 practices, 64 hold GMS contracts, 7 hold PMS

contracts and 5 hold APMS contracts. Ealing GP Federation was formed in October 2014,

representing all 76 practices. The Federation has been commissioned to deliver an Out of

Hospital Services (OOHS) contract through the member practices. In addition to the core and

OOHS contracts, practices in Ealing also deliver an annual Local Improvement Scheme (LIS),

paediatric phlebotomy, winter resilience and dementia contracts and some deliver out of hours

services.


July 2017 3

Figure 1: Practice and locality locations in Ealing

Acute activity is spread across four different NHS Trusts and the principal places of referral are

across seven different sites within Ealing and neighbouring boroughs (Northwick Park Hospital,

Ealing Hospital, Charing Cross, The Hammersmith Hospital, St Marys Hospital, West Middlesex

University Hospital, Chelsea and Westminster Hospital).Mental Health services are provided by

West London Mental Health Trust and community services by London North West Healthcare

Trust.

The following sections will set out relevant national, regional and local strategies and drivers for

change.

2.1.1 National context

The Five Year Forward View (FYFV)1, published in October 2014, sets out recommendations for

sustaining and improving the NHS in the period between 2015 and 2020 to be a universal health

service free at the point of access. Key points in the FYFV included:

A key focus on Primary Care, Mental Health, Urgent & Emergency Care, Cancer,

integrating care locally, funding and efficiency, strengthening our workforce, patient

safety and harnessing technology and innovation.

A radical upgrade in prevention and public health, including national action on obesity,

smoking, alcohol, cancer and other major health risks;

A shift to give patients far greater control of their own care;

1 https://www.england.nhs.uk/publication/nhs-five-year-forward-view/, October 2014

https://www.england.nhs.uk/publication/nhs-five-year-forward-view/


July 2017 4

Decisive steps to break down the barriers in how care is provided between family doctors

and hospitals, between physical and mental health, between health and social care e.g.

through Primary and Acute Care Systems (PACS);

Support from the NHS’ national leadership to develop radical new care delivery options

including permitting groups of GPs to combine with nurses, other community health

services, hospital specialists and perhaps mental health and social care to create

integrated out-of-hospital care e.g. through Multispecialty Community Providers (MCPs);

Urgent and emergency care services redesign to integrate between A&E departments,

GP out-of-hours services, urgent care centres, NHS 111, and ambulance services;

Greater support for frail older people living in care homes;

A ‘new deal’ for GPs, including investing more in primary care, while stabilising core

funding for general practice nationally over the next two years and a shift in investment

from acute to primary and community services.

The GP Forward View (GPFV)2, published in April 2016, reiterated these themes with a ‘triple

reinvention’ for general practice, comprising recommendations for changes to the ‘clinical

model’, ‘career model’ and ‘business model’. The report pledges a 14% real-terms rise in

general practice investment, with an expectation of local CCG investment on top of this rise in

national funding. It sets out recommendations to grow the number of qualified GPs, support

practices to be more resilient and establish new rules to reimburse up to 100% of premises

developments. It also sets out support to establish federations and ‘superpartnerships’, as well

as direct funding for improved in hours and out of hours access, including clinical hubs and

reformed urgent care.

The Primary Care Home (PCH) model3 was launched by the National Association of Primary

Care in October 2015, supported by NHS England and the NCM programme. It expresses ideas

about improving joint working within and beyond general practice, developed over more than a

decade by clinicians around the country. Initially, fifteen rapid test sites were chosen to test the

principles of the primary care home, there are now more than ninety. The model is based on four

defining characteristics:

Provision of care to a defined, registered population of between 30,000 and 50,000;

An integrated workforce, with a strong focus on partnerships spanning primary,

secondary and social care inclusive of patients and the voluntary sector;

A combined focus on personalisation of care with improvements in population health

outcomes; and

Aligned clinical financial drivers through a unified, whole population budget with

appropriate shared risks and rewards.

The PCH embraces some of the characteristics of the MCP model set out in the FYFV.

2.1.2 Regional (London-wide) context

The Strategic Commissioning Framework for Primary Care Transformation in London (SCF)

aims to support primary care transformation across the capital, responding to strategies for

general practice set out in the FYFV and findings of the London Health Commission. The SCF

sets out a new vision for primary care in the capital, and describes what patients should be able

to expect from primary care. There are 17 service specifications in the SCF, grouped into the

2 https://www.england.nhs.uk/gp/gpfv/, April 2016

3 http://www.napc.co.uk/primary-care-home, accessed June 2017

https://www.england.nhs.uk/gp/gpfv/

http://www.napc.co.uk/primary-care-home


July 2017 5

themes of Accessible, Coordinated and Proactive Care as presented in Figure 2. Importantly

the SCF was worked up in collaboration with many patients and carers, the LMC, clinical

representatives, CCGs and NHS England colleagues.

Figure 2: SCF service specifications

The SCF is clear that investment into primary care is required to be able to deliver the

specifications, as well as improvements to the capacity and diversity of the primary care

workforce in London.

2.1.3 North West London context

The eight CCGs in North West London work together as a collaboration underpinned by the

CWHHE CCG collaboration and the Federation of CCGs in Brent, Harrow and Hillingdon. Each

of the CCGs is currently delivering an ambitious Out of Hospital (OOH) programme intended to

ensure that patients are at the centre of care, with the registered GP providing, managing and

coordinating the care received. A key part of each OOH strategy is the intent in each CCG to

support the continued development of high quality primary care at both a practice level and

network of practices level. Most recently NWL CCGs have worked together with providers and

Local Authority colleagues to develop the STP in response to national requirements. The STP

builds on the work delivered to establish a vision for care delivery in North West London in

Shaping a Healthier Future but considers more broadly its response to the FYFV. The vision for

the STP is set out in the table below and what is clear is the critical importance of general

practice throughout the STP with a delivery area focused on the transformation of this part of the

system as well as an enabler throughout all the delivery areas.


July 2017 6

Figure 3: STP vision for care in North West London

Figure 3 illustrates that the golden thread running across and within the STP is general practice; the

five delivery areas within the STP all require general practice to enable the benefits they describe.

However, primary care cannot deliver this on its own, but as part of a system aligned to deliver to

the same outcomes. Therefore, primary care must be commissioned and supported to become

resilient and transformed, so that it is not working in isolation.

As indicated above the STP builds on the work health partners started with the Shaping a

Healthier Future (SaHF) programme. The SaHF programme is led by clinicians and has been

set up to develop proposals that will improve both hospital and out of hospital care. SaHF is a

reconfiguration that requires a fundamental change in the way both acute and community

services are delivered with a focus on delivering care as close to patients’ homes as is possible.

Following a significant programme of consultation with patients, carers, members of the public

and professionals across North West London, the SaHF Decision Making Business Case

(DMBC) was signed off in February 20134. This set out a vision for the future of care delivery in

North West London which would be localised, centralised and integrated.

4 https://www.healthiernorthwestlondon.nhs.uk/documents/joint-committee-primary-care-trusts-nwl/jcpcts-

meeting-papers-19022013/decision-making, accessed June 2017

https://www.healthiernorthwestlondon.nhs.uk/documents/joint-committee-primary-care-trusts-nwl/jcpcts-meeting-papers-19022013/decision-making

https://www.healthiernorthwestlondon.nhs.uk/documents/joint-committee-primary-care-trusts-nwl/jcpcts-meeting-papers-19022013/decision-making


July 2017 7

Figure 4: SaHF DMBC vision for care in North West London

The SaHF case focused on both the acute reconfiguration and out of hospital care with Out of

Hospital strategies underpinning the acute changes. Ealing CCG has been working to deliver

the out of hospital strategy over a number of years which had the transformation of general

practice as a critical enabler. Within the delivery of the acute configuration are the changes

which enable Ealing Hospital to transform into a local hospital and hub for the Borough.

Alongside two further hubs in the Borough the transformation requires comprehensive out of

hospital care underpinned by resilient general practice. The case for the Ealing Standard as set

out in this business case and in the support documents providers general practice with clear

requirements in terms of the standards of care expected to support comprehensive out of

hospital care to the registered population in Ealing with the income that practices can expect to

receive if they deliver the standard.

Central London, West London, Hammersmith & Fulham, Hounslow and Ealing CCGs have

elected to work together as a collaboration of CCGs: CWHHE.

2.1.4 Local Ealing context

The GP Forward set out the transformation objective and expectation of local areas to ensure

primary care is a sustained and resilient component of the overall health system recognising the

critical role it plays to coordinate and proactively support patients.

Ealing’s primary care health economy has been significantly underfunded historically, however, it

has survived and provided the population of Ealing with a primary care service in very difficult

financial circumstances. Ealing general practice has faced many challenges including the

historical under investment, workforce challenges and the lack of capacity and compliance in

estate,.

In 2012, a business case was approved for investment in primary care to work in an integrated

care programme (ICP) as networks of practices serving a population of between 40,000 and

70,000 patients, with comprehensive care planning for individuals that need proactive and

Localised

1

Centralised Integrated

3

• Reduced admissions due to

better local management of

care

• Improved support for

patients with LTCs and

mental health problems

• Improved patient experience

and satisfaction

• Improved carer experience

• Better clinical outcomes

including reduced morbidity

and mortality

• Reduced readmission

• Reduced lengths of stay

• Increased staff training,

skills and job satisfaction

• Increased multidisciplinary

working – improved

coordination

• Improved access to

information leading to better

patient care

• Reduction in unnecessary

investigations and duplicate

assessments

• Improved efficiency and

pathways

Qu

alit

y &

exp

erie

nce

im

pro

ve

me

nts

2


July 2017 8

coordinated care, with any complex cases discussed at multi-disciplinary group (MDG) meetings

where social services, generalist consultants, such as care of the elderly consultants and

diabetes consultants, community nursing teams including Diabetes Specialist nurses and

community matrons or district nurses and community pharmacists. These MDG meetings are

still active across the borough, although less frequent. Through the MDG meetings and

significant investment in training and support, practices started to work together as networks of

practices, recognising that the issues each practice faced with complex patients or inefficient

pathways across the rest of the system were shared across all practices. The primary care

networks started to become a source of peer learning, sharing and support.

In 2014, a business case was agreed across CWHHE for significant investment in a range of 19

services specifications – the Out of Hospital Services contract (OOH). The ICP programme was

subsumed within these services, and took the infrastructure and support for practices to a new

level. As a result of the business case a Federation emerged with all practices across Ealing

becoming a member of the Federation. The principle of this investment was to deliver

population based care, so that no matter which practice a patient was registered at they could

get access to all of the 19 service lines. In some cases at the smaller practices, if they were not

able to safely provide a particular service, the patient registered at that practice could access the

service at another local service. The Federation (Ealing GP Ltd) is responsible for ensuring

population coverage and the safety of the service, as well as supporting practices to run the

business management function that sitst behind the services. It is fair to say that the

mobilisation of the OOH contract was very difficult with an overly complex IT system and

payment mechanism. However, in December 2016, following an in depth review of the IT

system templates and payment processes, an improved set of specifications and underpinning

templates were provided.

The OOH contract is now delivering all the services across the borough although take up is

variable and has been achieved at different rates dependent on the service lines.

In August 2016, following the launch of the GPFV, Ealing CCG ran a series of workshops to

understand the risks in primary care, primarily in terms of workforce and estates.

Key Highlights - Estates:

69 Baseline Estates survey conducted

58 of the properties built before 1961 and therefore do not meet the current design

standards for the delivery of primary care

4 properties constructed since 2000

30 of the surveyed premises have 4 clinical rooms or less

5 of the premises have 10 clinical rooms or more

63 of the premises surveyed were found to be fully or over utlilised

45 of the premises had potential to expand clinical service activity

Backlog Maintenance over coming 5 years was estimated to be approximately £1.6M

with £0.4M required immediately Figure 3

Improvement grants (Previously known as Primary Care Infrastructure funds (PCIF) and

Primary Care Transformation Funds (PCTF) supported by CCG for 26 sites, with 7 of the

sites providing additional clinical space. Funding source NHSE and undergoing NHSE

Due diligence.

8 Estates, Technology Transformation Fund (ETTF) bids submitted to NHSE, all on

pipeline with NHSE, but not supported as yet.


July 2017 9

Figure 5: Quality of Estates following baseline estates survey

Figure 6: Improvement Grant across the borough


July 2017 10

Key Highlights – Quality of Service Provision:

18 single-handed practices (figure 5)

At the time of creating this (July 2016), not all practices had been rated by CQC, At the

time in Ealing there were: 1 Outstanding practice, 26 Good, 5 Requires Improvement, 1

Inadequate, 45 not yet published

Data source for performance against General Practice High Level Indicators (GPHLI)

found at www. Priamrycare.nhs.uk:

Indicators include those relating to long term condition management, prescribing, hospital

admissions, public health screening and immunisation targets, and patient experience

Practice data for each indicator is compared nationally and if a data point falls outside 2

standard errors from the national average it is considered an outlier.

A practice is considered an outlier overall of they have 6 or more outlying data points,

and this may warrant further investigation to assess whether the variation is warranted.

Using 2014/15 data:

o 5 practices with 9-10 Outlying Points

o 5 with 6-8 Outlying points,

o All other practices with 0-5 Outlying points

Figure 7: Practice list size and single handed practices

Key Highlights – Workforce:

Data Collated from Workforce Minimum data set via Primary Care Tool and publically

available reported as at 30th September 2015 – 9 practices did not report


July 2017 11

NOTE: This data does not include locum GPs and 9 practices did not report their data

GPs

172.29 Full time equivalent (FTE) GPs in Ealing (excluding Locums) – based on

reporting practices

In Ealing 2,110 Patients per FTE GP, ranging from 1686 (Acton) to 2994 (North Southall)

London Average is 1929 patients per FTE GP, England average is 1826 patients per

FTE GP.

GP Age profile by Network Figure 6

Nurses

69.7 FTE Nurses in Ealing Primary Care

In Ealing 5395 patients per FTE Nurse, ranging from 3669 (Central Ealing) to 6838

(North Southall)

London Average is 5572 patients per FTE Nurse, England average is 3802 patients per

FTE Nurse.

Nurse Age profile by Network Figure 7

Figure 8: GP Age Profile by Locality


July 2017 12

Figure 9: Nurse age profile by network

Delegated commissioning

In February 2017, the CCG membership made a decision to vote in the responsibility for delegated Primary Care Commissioning to move from NHS England to the CCG. All 8 CCGs in NWL submitted an application to NHS England on 05 December 2016, with agreed caveats. The vote took place in February, with a formal announcement on 24 February 2017 regarding the decision taken by our membership.

This move to full delegation of Primary Care (General Practice) commissioning, assuming full responsibility for commissioning General Practice services in response to the needs and circumstance of their registered populations took effect from 1st April 2017 and supports:

o The delivery of the NW London STP, and in particular, the Local Services strategy that it proposed across our sector of London;

o The CCG to drive efficiency, best value, and consistency in our locally-driven commissioning approach and processes, and in the outcomes derived across NW London; and

o Secures the most efficient and effective governance processes for Primary Care commissioning.


July 2017 13

PMS Review

In February 2014 NHS England’s area teams received national guidance setting out a

requirement to review and renegotiate all PMS contracts, originally by the end of March 2016,

then with a 3 month extension and now extended further to be completed by October 2017. The

purpose of the review is to secure best value from future investment of the ‘premium’ element of

Primary Medical Services (PMS) funding. There is a NWL steering group providing a forum to

agree a single NWL approach where desirable. Otherwise under delegated commissioning

arrangements, Ealing CCG is required to take the lead role in arrangements related to PMS

funding. It is intended that as a result of the PMS review, any additional investment in general

practice services that go beyond core national requirements (whether this is deployed through

PMS or through other routes) should:

Reflect joint NHS England and CCG strategic plans for primary care;

Secure services or outcomes that go beyond what is expected of core general practice or

improve primary care premises;

Help reduce health inequalities;

Give equality of opportunity to all GP practices, i.e. PMS, General Medical Services

(GMS) and Alternative Providers Medical Services (AMPS) (provided they are able to

satisfy locally determined requirements); and

Support fairer distribution of funding at a locality level. All funding released by the review

will be reinvested into general practice.

In Ealing there are 7 practices with a PMS contract. The total value of the premium for the PMS

practices is circa £650k.

Guidance from NHS England confirms that all practices where income reduces by 5% or more

should be offered a minimum of 2 years of transition support. However, in NWL the PMS

Steering group agreed phasing of transition support up to 4 years if a practice is due to lose

more than 15%. Any funds released following the any reinvestment of transition support would

be reinvested back into general practices in the local borough. Figure 10 and 11 show the

principles agreed by the PMS steering group which Ealing CCG has agreed to adopt following

consideration at the Primary Care Commissioning Committee.


July 2017 14

Figure 10: Transition phasing based on loss at a practice.

Figure 11: illustrative example of transition support for practices


July 2017 15

Feedback from patients on Access to Primary Care

Although Ealing CCG has been collating a lot of feedback from patients when conducting

various engagement events across the borough, the overriding feedback we receive is about

access to General Practice..

As a result, Ealing CCG asked Healthwatch to conduct a targeted survey across the borough to

establish the feedback more formally in order to understand in more detail what specific aspects

of access to general practice need improving. The actual report from Healthwatch can be found

in Appendix 2.

A total of 2,000 surveys were conducted across the whole borough with surveys undertaken at:

Local community events and festivals

Shopping areas

Buses, tubes and transport hubs

GP surgeries and Health Centres

Ealing Hospital outpatients department

Primary and Secondary schools

The main findings of the surveys conducted were:

1. While respondents’ experiences of obtaining routine GP appointments varied there were

nuances within this position and many respondents did state they faced difficulties in

getting routine appointments.

While some made statements indicating that it was a struggle to get through busy

telephone lines to book their appointments in the mornings, others complained that

receptionists in GP surgeries were rude; that it cost them money to call for appointments

and some said they were frustrated with the process and it felt like a futile struggle. A

notable number of patients indicated they did not book routine appointments at all whilst

others would have to wait a month in order to see their preferred doctor – and many

reported this preference over perceived changing locums.

On the other hand, however, patients praised their GPs for their services and empathy,

understood the pressures and therefore were satisfied with the service despite any

issues in getting a routine appointment – this understanding was borne through in other

areas of the survey also. One patient in particular mentioned that they had been provided

the extraordinary facility of a home visit for a blood test by their GP.

Specifically reviewing routine appointment times the largest number of our respondents

said they got their routine appointment within 1-2 weeks. This was followed by a slightly

smaller number of respondents who said it took 2 weeks or more to be given an

appointment. A significantly smaller number of respondents said they got their

appointment in 4-6 days, followed by those who said they got it in 2-3days, the very

same day or on the next day. Interestingly, the number of those who said they got it the

same day was higher than those who said they got it the next day.

The most conspicuous complaint from patients was regarding the GP phone being

consistently engaged, or the inconvenience of their being kept waiting between


July 2017 16

approximately 20-30 minutes in a queue. Some people also stated that by the time they

got through to the Practice, there were no longer any appointments available for them.

2. Most of our respondents reported that they did not find it difficult to obtain urgent

appointments.

3. Regarding Urgent Appointments, the majority (over 60%) of our respondents said they

got their appointment on the same day. Next, were those who said they got their

appointment the next day (over 20%). About 7% said they were given an appointment in

2-3 days; next were those who said they got it in 2-3 days, 1-2 weeks or in 4-6 days in

that order.

A number of respondents spoken to had gone to the urgent care centre when they

couldn’t get a urgent GP appointment – mostly this did apply to out of hours but there

were occurrences of attendance at UCC when they simply couldn’t get a appointment at

the GP surgery within an acceptable timeframe.

4. When contacting the surgery by phone early indications suggest the majority of our

respondents rated their experience as “Fair”. This was followed by “Good” and “Very

good”. Next were those who described it as “Poor” or “Very Poor”. Patient experiences

regarding their ability to contact local surgeries via telephone seems to be more positive

than negative though there is room for improvement as suggested by those who rated

their experience as “Very Poor” and “Poor”. As indicated in a previous question above, in

this instance there were also a large number of patients who remained satisfied with the

phone system, despite its difficulties, due to their appreciation of the population

pressures facing GP surgeries.

5. Our patient responses to their experience of obtaining advice from GPs via the telephone

reveals that the majority rated it negatively, describing it as “Very Poor” / “Poor”. Among

the problems they mentioned were the huge difficulty to get through to the practice on the

phone or that they were not able to speak to doctors on the phone at all. Instead, they

spoke to nurses or the receptionist, however a number also reported a system whereby

the doctor would phone back later in the day

The next highest total consisted of respondents who said they were not sure about their

experience of getting advice from a GP. The large number of those “Not Sure”, seems to

indicate that many patients were unable to say anything clearly because they did not

expect to be able to speak to a GP for advice. Some patients who clearly said that they

were not aware of this service and so did not have this expectation nor had they tried to

speak to a GP on the phone for medical advice also corroborate this. GP Telephone

consultations could therefore be a possible area of opportunity in terms of easing access

pressures.

This was followed by those who rated it positively as “Good”/ “Very Good”/

“Excellent”/”Very Good”. Among them were some who said the doctor called back quite

soon.

6. Regarding currently booking appointments online, the majority of our respondents said

they were booking online. A large number of patients said they were “Not Sure” about

booking online. A slightly smaller number than those who said they were “Not Sure”,


July 2017 17

responded by reporting that they were not going on line for their bookings. Those who did

not reply formed the smallest group within our sample. The cross section of respondents

in this sample clearly demonstrates a discrepancy between commuters and non-

commuters. Commuters were predominantly on-line and if not would consider registering

to enable online access to their GP. Whereas a significant number of respondents who

were not commuters but locality patients were not online and were either unsure as to

whether they could register online or didn’t want to.

7. Regarding willingness or agreeing to start booking appointments online, the majority of

our respondents said they were agreeable to do so. However there were two further

significant groups consisting of respondents who did not wish to reply to this question

and those who said they would not like to go online to book their appointments. It is our

assertion that the majority numbers are very likely commuters and those respondents

who were less willing to try on-line booking are Ealing based non-commuters. It will be

interesting to identify in the full report the further demographic of these groups.

In general, our survey makes it evident that although there is public awareness about

online services, which many patients use there are also significant numbers who do not

wish to book appointments online. This is assignable to a variety of reasons that include

the following: people not being computer literate (especially older people), illiteracy, not

having a computer, not having internet access, problems with their Password, not liking

the impersonal nature of online services, and inability to book appointments well into the

future (1 or 2 weeks) via using online services.

8. From responses to the choice of extended opening hours for local surgeries, it is evident

that our respondents considered Monday to Friday evenings the most popular. This was

very closely followed by a preference for Saturday extended hours.

Monday to Friday mornings was voted 3rd in order of preference and Sunday received the

least support from our respondents. A small number of patients said they were happy

with the opening times at present and did not want any change. An almost equal number

did not give any response.

9. Responses to our questionnaire revealed that nearly all respondents were aware about

Nurses being present in GP surgeries. There were a small number who said they did not

know about Nurses or were “Not Sure” about them/their services.

A much smaller sample identified an awareness of Healthcare Assistants (HCAs).

However, a significantly high number of respondents in our sample, reported being

unsure about HCAs.

Awareness of Clinical Pharmacists received the highest number of “No” responses from

our respondents. Patients also responded in good numbers saying that they were “Not

Sure” about services offered by Clinical Pharmacists at their GP practice. In this case,

most respondents were aware of and utilised chemists nearby, but not within the surgery.

10. From patient responses it is clear that there is low awareness of the Urgent Care

Centre (UCC) as well as the NHS111 service. A number of those who said they knew of

the UCC were older people or those with young children who knew about it because they

had already used its services. Similarly, it can be said that most of those who said they

knew about NHS 111 were those who had used the service.


July 2017 18

Comparing awareness of both, it is clear that more people mentioned being aware of the

UCC than that of NHS111. Very few respondents were in the Did Not Answer (or DNA)

category as regards both UCC and NHS 111 services.

Some other observations from Healthwatch

1. It appears that those patients who made online appointments also tended to have fewer

problems in booking GP appointments.

2. Those who booked online also tended to be aware of NHS 111 services.

3. Though some older people in their 50s and 60s reported to be online service users, there

were also many among that particular group who said that they were not going online.

They also tended to be prominent among those who clearly said they did not want to go

online for making appointments, were unsure about it or were reluctant to go online

because they preferred phoning their Surgery or had other practical reasons (already

mentioned above) for not making use of Online GP services.

4. Many disabled people seemed to be unaware of various NHS services such as UCC,

NHS 111 or HCA.

2.2 Case for change

From data and conversations with patients, clinicians and other stakeholders, it is recognised

that general practice in Ealing is facing a range of urgent challenges. These are set out in the

sections below.

2.2.1 Patient Perspective

The GP Patient Survey consistently reports a poorer experience of making an appointment and

lower levels of satisfaction with practice opening times among patients in Ealing CCG’s

catchment area than among patients in other CCGs in London. Latest available data from July

2017 indicates that 67% of patients in Ealing report a positive experience of making an

appointment with their practice, compared to 69% average across London and 74% average

nationally. In terms of opening hours, 72% of patients in Ealing reported they were happy with

opening hours, compared to 76% nationally5. This is also in line with feedback from local Ealing

Healthwatch surveys. A patient’s ease of access to their Practice, and preferred GP, can affect

their experience and quality of care and health outcomes.6

The SCF confirms that good access to primary care should consist of rapid access for patients

who want to speak to someone as soon as possible, continuity of care for patients with on-going

health needs or vulnerable groups who need to be understood by everyone they see and

convenient access for patients who work during core hours and who may want to access primary

care through multiple channels.

5 GP Patient Survey results, July 201. Fieldwork January to March 2017: https://gp-

patient.co.uk/SurveysAndReports 6 The King’s Fund, (2012) Exploring the association between quality of care and the experience

of patients London

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

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


July 2017 19

Good access to general practice has an impact on the health system overall. Inadequate

capacity in General Practice can lead to an increase in demand for Accident & Emergency

(A&E), and other hospital services.7 The National Audit Office reported in 2015 that nationally

practices that were open for 45 hours or less per week had, on average, an 8% higher A&E

attendance rate, after adjusting for differences in patients’ age and gender.8

Overall it is important that Ealing CCG focus on improving patient access to primary care, both

to improve patient experience and to reduce potentially increased costs in the acute sector.

2.2.2 Population Perspective

The STP commits to providing care for the population of Ealing. Historically, primary care

provision and a number of services commissioned from primary care were commissioned based

on whether a practice had the expertise or interest in delivering a service. When the OOH

contract was commissioned the clear principle was that all services could be accessed by all

patients, even though their own practice may not deliver all the services. The IT system

(SystmOne) enabled referrals to be sent between practices, so that patients did not have to

travel very far to receive a slightly more enhanced or specialised service. This principle must be

carried forward and all patients no matter which practice they are registered with should be able

to access all services.

The STP also describes clearly the intention to move to a more proactive approach to care,

focussing on not only diagnosis and treatment but prevention and screening. Primary care has a

significant role to play in delivering the much needed proactive and prevention strategy.

However, with the increasing demands on practices, and an elderly population who require more

support and continuity, primary care is in danger of side lining the important prevention

discussions. If primary care are not effectively commissioned and targeted to deliver their part of

the prevention pathway, as has been described in a number of national programmes, the NHS

will soon become unaffordable.

2.2.3 General Practice perspective

Primary care in Ealing is under unprecedented strain, with a rise in the number of appointments and increasing numbers of practices who report that their current workload is unmanageable or unsustainable. This is supported by Figure 12, which shows that the number of registered patients per FTE GP in Ealing is significantly higher than the London and England averages, and the number of registered patients per FTE Nurse in Ealing is comparable to the London average, but significantly higher than the England average.

Figure 12: Number of patients per FTE GP and Nurse in Ealing

7 Rosen R., (2014) Meeting need or fuelling demand? London: Nuffield Trust & NHS England

8 National Audit Office (2015) A Stocktake of Access to General Practice and (2017), improving

access to general practice


July 2017 20

NOTE: This data does not include locum GPs and 9 practices did not report their data

The current GP workforce in Ealing is ageing and facing a ‘retirement bubble’ which has the potential to put the system under greater strain. This is set out in 13, which shows that some localities in Ealing (such as Central Ealing and South Central Ealing) have a much higher proportion of workforce over 55 than the London and England averages. In addition, 21% of practices in Ealing are single handed, which is the third highest proportion of single handed practices in London, after Barking and Dagenham and Havering. If GPs in single handed practices retire or are otherwise unable to work then this can pose significant business continuity issues and impact negatively on patient care.

Figure 13: Percentage of workforce over 55 in Ealing


July 2017 21

Currently there is little support for struggling GP practices, with an increased number of practices

facing closure or serious viability issues. Ealing CCG urgently needs to address these issues to

ensure long term sustainability within the health economy and positive outcomes for patients.

In addition to the workforce concerns, the OOH Contract, Dementia and Paediatric Phlebotomy

contracts issued by Ealing CCG are due to end in April 2018 and agreement needs to be

reached to commit to this funding on going. Having a registered GP providing, managing and

coordinating the care included in the standard will ensure patients can receive appropriate care

closer to home and the cost of delivering care is reduced. To ensure these benefits continue to

accrue, a new contract and business case for the delivery of enhanced primary care in general

practice is required.

The continued investment of the funds for the OOH contracts will ensure the good work that has

been undertaken in primary care to deliver an enhanced range of services across the borough,

as well as supporting practices to develop its core service offering and improving access, will

help practices to plan longer term, and feel confident to commit to recruiting staff, improving

resilience, sustainability and continuity of care for patients.

2.2.4 Economic Case

General practice has a critical role to play in all 5 of the Delivery Areas articulated in the STP

and is the golden thread running through the STP:


July 2017 22

Figure 14: Role of Primary Care in delivering the STP

Without primary care, many of the system benefits would not be realised, This ranges from

complementing and delivering components of the prevention strategy led by Public Health, to

ensuring people with Mental Health needs are identified early and sign posted to the right

support services, and from ensuring the role as the navigator to the rest of the health system is

being delivered optimally, supported by the rest of the system and ensuring individuals with

complex needs have continuity of care and get the right support at the right time to reduce the

risk of deterioration.

It is essential to note that primary care cannot deliver this on its own, but as part of a system

aligned to deliver to the same outcomes.

In order for primary care to deliver its part of the pathway, it is essential to commission and

support primary care to become resilient and transformed in a way that ensures sustainability, so

that it is not working in isolation from each other or from the rest of the system.

2.2.5 Financial sustainability

In Ealing over the next 15 years we expect to see larger rises in the segments of the population

that have increased health needs than in the wider population. This means that activity, and the

cost of delivering services, will increase faster than our overall headline population growth would

imply. NHS budgets, while increasing more than other public sector budgets, are constrained

and significantly below both historical funding growth levels and the expected increase in

demand, while social care budgets face cuts of around 40%. If we do nothing, the NHS in Ealing

will have a significant funding gap by 20/21.

Ealing CCG faces the continued financial challenge to deliver more with constrained resources.

The gap between the expected growth in demand and the expected growth in the financial

allocations (the amount of money available to Ealing CCG) requires the CCG to identify

approximately £67m of savings between 2017/18 and 2020/21. These savings are targeted to be

achieved by reducing spend in the acute setting and shifting it into the out of hospital setting. In

order to implement this strategy, Ealing CCG will need to revise and invest in its primary care

offer to patients and practices as well as considering the investment and offer in the broader out

of hospital landscape.

2.2.6 Headroom funding opportunity

Ealing CCG’s NHS England funding allocation is being increased on a yearly and recurrent basis

up to 2020/21 such that the 2020/21 allocation is 25% greater than the 2016/17 allocation. The

increase in allocation (known as ‘headroom funding’) is in recognition of the comparatively low

levels of primary care funding received by Ealing primary care. Figure 15 shows the average

payment per weighted patient made to practices across London, England and the CWHHE

CCGs for core services, and shows that Ealing practices currently receive significantly less than

the London and England averages and the lowest of the CWHHE CCGs.


July 2017 23

Figure 15: Average pounds per weighted patient payment made to CCGs

Ealing CCG has committed to investing the headroom funding into primary care, and therefore

has the opportunity to improve funding to general practice – positively impacting on practice

resilience, skill mix, long term sustainability and taking the opportunity to reduce unwarranted

variation in outcomes.

2.2.7 High administrative burden

At present primary care deliver a number of isolated contracts, with a high administrative burden

and costs. In developing any future commissioning options an aim must be to reduce the

unnecessary administrative burden and complexity. The OOH contract is a real example in how

not to make the monitoring of any contract so complex that it has unexpected consequences on

practice administrative burden. With Ealing CCG now with delegated responsibility, there is a

real opportunity to reduce the number of contracts, payment mechanisms and reconciliation

processes without reducing the value from rigorously monitoring the mobilisation and delivery of

future contracts.

2.2.8 Case for change summary

It is now clear that the pressures on general practice in Ealing are so significant – and increasing

- that doing nothing is not an option. Taking no action will result in a deterioration of the current

position in terms of:

Increased financial unsustainability;

Poorer access and longer waiting times for patients;

Reduced services available to patients in the primary care setting

A disenfranchised and demoralised workforce which cannot manage demand, or

innovate to improve services.

Ealing CCG now has the opportunity to address these pressures by revising its offer to patients

and practices for the delivery of enhanced primary care.


July 2017 24

2.3 Investment objectives

To address the case for change, Ealing CCG has developed the some investment objectives

which were agreed by the Primary Care Specification Steering Group for the new primary care

offer:

Standardise what patients can expect from primary care in Ealing, reducing unwarranted

variation in access and improving outcomes;

Improve sustainability and resilience of primary care in Ealing;

Achieve value for money and equity of funding across primary care;

Reduce pressure on acute sector; and,

Move towards a goals based commissioning approach.


July 2017 25

3 Economic Case

This section assesses a long list of options for the commissioning of primary care standards in

Ealing against a range of evaluation criteria and then appraises the non-financial benefits and

disbenefits of a short list of options at a high level to establish a preferred way forward. The

preferred way forward is then economically appraised, to establish the return on investment.

3.1 Critical success factors

Eight Critical Success Factors (CSFs), listed below, have been defined for the project. These

were agreed at a workshop held on the 6th June 2017 attended by Ealing CCG’s Deputy

Managing Director, Clinical Lead for Primary Care Co-commissioning and Governing Body Lay

Member (Quality).

Patient outcomes and experience – Impact on patient outcomes and their experience

of and access to primary care in Ealing.

Primary care sustainability – Ability to positively impact on the sustainability and

resilience of primary care in Ealing.

Equity of funding – Ability to standardise funding per head of population across Ealing

Strategic fit – Alignment with local strategies and national policies.

Provider capability and capacity – Attractiveness to the primary care provider market

and capacity to meet requirements.

Deliverability – Ability of both the CCG and potential providers to deliver the offer on

time, to budget and with available resource in terms of both capability and capacity.

Flexibility – Ability to meet any future changes in regulation, demographic, prevalence or

demand.

Population coverage – Ability for all patients across Ealing to be able to access

services, regardless of where they are registered.

Although value for money and affordability are critical success factors, these factors will only be

appraised against the preferred option.

Red, Amber and Green (RAG) descriptors have been defined for each of these CSFs so that the

long-listed options can be assessed against them. The descriptors are shown in Table 1.

Table 1: Critical success factor RAG descriptors

CSF RED AMBER GREEN

PATIENT

OUTCOMES AND

EXPERIENCE

Patients experience poorer

health outcomes and/or have

reduced access to primary care

There is no significant change

to patients’ health outcomes

and access to primary care

Patients experience better

health outcomes and/or have

improved access to primary

care

PRIMARY CARE

SUSTAINABILITY

Practices are likely to be less

resilient and sustainable as a

result of the proposed option

There is likely to be no change

to practice resilience and

sustainability as a result of the

proposed option

Practices are likely to be more

resilient and sustainable as a

result of the proposed option

EQUITY OF

FUNDING

This option will further increase

the variation in £/head primary

care funding in Ealing

This option will not change

variation in primary care

funding in Ealing

This option will decrease the

variation in £/head primary care

funding in Ealing

STRATEGIC FIT

Poor alignment with relevant

national, regional and local

strategies and policies

Moderate alignment with

relevant national, regional and

local strategies and policies

Good alignment with relevant

national, regional and local

strategies and policies


July 2017 26

PROVIDER

CAPABILITY

AND CAPACITY

The provider market is unable

to deliver the required solution

There is limited capacity within

the provider market to deliver

the required solution

There is freely available

capacity within the provider

market to deliver the required

solution

DELIVERABILITY

Not able to be delivered

successfully within required

timeframes with available

resource and has a negative

impact on continuity of service

Project has to be delivered

within constrained timeframes

Able to be delivered

successfully within the required

timeframes, with no impact on

continuity of services

FLEXIBILITY

There is no flexibility in this

option to meet future changes

in regulation, demographic,

prevalence or demand

It will be possible to change the

contract in this option to meet

future changes in regulation,

demographic, prevalence or

demand with relatively large

financial and service

implications

It will be possible to change the

contract in this option to meet

future changes in regulation,

demographic, prevalence or

demand with relatively small

financial and service

implications

POPULATION

COVERAGE

Some patients have no access

to certain services

Patients perceive some

variation in convenience of

accessing services

Patients perceive minimal

variation in convenience of

accessing services

3.2 Long list of options

Within the scope of this project, the following long list of options for commissioning enhanced

primary care services in Ealing were identified at the 6th June 2017 workshop.

Table 2: Long-list options framework classified by seven dimensions of choice

DIMENSION DESCRIPTION OPTIONS WITHIN EACH DIMENSION

1. OOHS CONTRACT

The OOHS contract was a 2+1 year contract, however the contract and associated business case ends in March 2018

a) Renew OOHS contract in current form

b) Renew OOHS contract in changed/consolidated

form

c) Do not renew OOHS contract

2. LIS FUNDING LIS funding is renewed on an annual basis, with new contracts and payment schedules issued annually

a) Renew LIS funding in current form

b) Renew LIS funding in changed/consolidated

form

c) Do not renew LIS funding

3. WINTER RESILIENCE FUNDING

Winter resilience funding is released annually in October on a discretionary basis

a) Renew winter resilience funding in current form

b) Renew winter resilience funding in

changed/consolidated form

c) Do not renew winter resilience funding

4. PAEDIATRIC PHLEBOTOMY AND DEMENTIA FUNDING

These contracts are renewed annually and the associated business case ends in March 2018

a) Re-tender funding in current form

b) Re-tender funding in changed/consolidated form

c) Do not re-tender funding

5. PMS FUNDING PMS premium funding needs to be invested into primary care, in line with the national PMS review programme

a) Allocate released PMS funding equally across

all practices into a specific commissioning

intention

d) Incorporate PMS funding into wider enhanced primary care funding

6. HEADROOM FUNDING

Ealing CCG’s recurrent allocation from NHSE is increasing over four years, with an overall increase in allocation allocation of 25%

a) Fully invest available headroom into primary

care

b) Partially invest available headroom into primary

care

b) Do no invest available headroom into primary

care


July 2017 27

Six dimensions of choice were identified, with options listed out within each dimension. The

following sections score the options available within each dimension against the CSFs and sets

out the preferred option within each dimension. It should be noted that not all CSFs are

applicable to all option categories and so no score is given where this is the case. It was agreed

at the 6th June workshop that any options scoring red against any CSF would not be considered

further, and if one option scored green against many more CSFs than other options within the

dimension then that would be taken forward for further consideration. If multiple options within a

dimension scored well against the CSFs then they would both be taken forward for further

consideration,

3.2.1 OOHS contract

The Out of Hospital Services (OOHS) contract is commissioned across the CWHHE CCGs and

consists of 18 separate services (please see Appendix 5 OOHS contracts for the full list of

specifications). For OOHS, Ealing CCG contracts with the Ealing GP Federation and separately

with the 76 member practices. In addition, there is a separate tripartite agreement setting out the

responsibilities of all three parties to the agreement. The contract was first commissioned in

Ealing in July 2015 for a period of two years, and subsequently extended to March 2018 as per

the contract terms. There is no option to further extend the contract after March 2018 and

agreement is required for the services to be commissioned on-going.

The options considered within this business case that are available to Ealing CCG to continue to

commission and fund the enhanced primary care services currently sitting within the OOHS

contract are:

Renew OOHS contract in the current form: new business case to be written for the

current funding protocol and service specifications so that the current conditions of the

OOHS contract are replicated exactly.

Renew OOHS contract in a changed or consolidated form within the primary care

standard: OOHS services and funding to be incorporated into a single wraparound

contract, together with other enhanced primary care services, to ensure a single

consistent offer across the borough that takes a population based approach and has

equal funding for each practice.

Do not renew OOHS contract: OOHS services and associated funding to terminate at the

end of March 2018 with no replacement in place.

Table 3 summarises how the three options for commissioning services currently within the

OOHS contract score against the CSFs. It demonstrates that renewing the OOHS contract in a

changed form scores highest against the CSFs and therefore is the preferred way forward for

the OOHS contract dimension.


July 2017 28

Table 3: CSF scoring for the OOHS contract options

CSF RENEW IN CURRENT FORM RENEW IN CHANGED

FORM

DO NOT RENEW

PATIENT

OUTCOMES AND

EXPERIENCE

No change is expected in patient experience with this option

Patient experience expected to improve as the service specifications will be improved in response to patient feedback

No OOHS services therefore patient experiences and outcomes will be poorer

PRIMARY CARE

SUSTAINABILITY

No change is expected in primary care sustainability with this option

Primary care sustainability expected to improve as the service specifications will be improved in response to practice feedback

No OOHS funding therefore primary care sustainability will be reduced as there is a lower level of funding

EQUITY OF

FUNDING

No change is expected in equity of funding with this option

Wraparound contract to ensure equity of funding

Equal withdrawal of funding across the 76 practices therefore no impact

STRATEGIC FIT This option does not align with national accountable care organisation themed programmes/strategies

Population based approach aligns with national accountable care organisation themed programmes/strategies

Not offering OOHS is not in line with national primary care policies

PROVIDER

CAPABILITY AND

CAPACITY

The provider market already delivers this option well

It may be difficult to find sufficient capacity and the correct skill mix in the local workforce

n/a if contract not offered

DELIVERABILITY The provider market already delivers this option well

Project has to be delivered within constrained timeframes with several different services incorporated into the wraparound

Not offering the contract will have a negative impact on continuity of service

FLEXIBILITY This contract offers moderate flexibility as it is CWHHE wide

The local nature will enable the contract to be written flexibility

Not offering the contract means there is no flexibility in the future to react to changes in OOHS needs

POPULATION

COVERAGE

This option offers moderate population coverage, however patients have reported limited access to some services

Unclear if population coverage will improve until all 76 providers have signed up

Not offering the contract will mean there is no population coverage

SUMMARY Option not taken forward Option taken forward Option not taken forward

3.2.2 LIS contract

The Ealing CCG Local Improvement Scheme (LIS) is an annually renewed contract with the

following objectives:

Network Development and Unplanned Care

Planned Care

Achievement of Local Priorities

Improve the Quality of Prescribing

The services and actions required of the practices by the scheme are updated on an annual

basis. In 2017/18, the Local Improvement Scheme (LIS) commissioned care planning,

hypertension, atrial fibrillation, Improved Access to Psychological Therapies (IAPT), asthma,

cancer and Chronic Kidney Disease (CKD) services, together with a prescribing incentive

scheme. The LIS also has certain pre-qualifying business management criteria and a quality and

clinical component. The total funding associated with the LIS in 2017/18 was £5/registered

patient.


July 2017 29


commission and fund the enhanced primary care services currently sitting within the LIS contract

are:

Renew the LIS contract in the current form: renew the LIS contract through to 2018/19,

updating or changing any specific services required in the contract as in previous years.

Renew the LIS contract in a changed or consolidated form: LIS services and funding to

be incorporated into a single wraparound contract, together with other enhanced primary

care services, to ensure a single consistent offer across the borough that takes a

population based approach and has equal funding for each practice.

Do not renew the LIS contract: LIS services and associated funding to terminate at the

end of March 2018 with no replacement in place.

Table 4 summarises how the three options for commissioning services currently within the LIS

contract score against the CSFs. It demonstrates that renewing the LIS contract in a changed

form scores highest against the CSFs and therefore is the preferred way forward for the LIS

contract dimension.

Table 4: CSF scoring for the LIS contract options


FORM

DO NOT RENEW

PATIENT

OUTCOMES AND

EXPERIENCE



No LIS contract therefore patient experiences and outcomes will be poorer

PRIMARY CARE

SUSTAINABILITY


Primary care sustainability expected to improve as the service specifications will be improved in response to practice feedback

No LIS contract therefore primary care sustainability will be reduced as there is a lower level of funding

EQUITY OF

FUNDING




STRATEGIC FIT The LIS contract already has moderate alignment with national accountable care organisation themed programmes/strategies


Not offering the funding and requirements of the LIS at all is not in line with national primary care policies

PROVIDER

CAPABILITY AND

CAPACITY

The provider market already delivers this option well



DELIVERABILITY The provider market already delivers this option well



FLEXIBILITY The contract is renewed locally every year and therefore already offers flexibility.


Not offering the contract means there is no flexibility in the future to react to changes in CCG/population needs

POPULATION

COVERAGE

This option offers moderate population coverage, however patients have reported limited access to some services





July 2017 30

3.2.3 Winter resilience funding

Winter resilience funding is paid by Ealing CCG directly to practices and is designed to increase

the capacity within primary care in order to prevent patients from attending UCC and ultimately

A&E over the winter period. It does this by paying £1/registered patient to GP surgeries to

enable them to offer more on the day appointments during busy periods between December and

March. Winter resilience funding has been offered in Ealing for three years, and practices are

invited to submit Expressions of Interest every year to access the funding. The funding is

approved on an annual basis by the Finance and Performance and Investment Committees.


commission and fund the enhanced primary care services currently sitting within the winter

resilience contract are:

Renew the winter resilience funding in the current form: renew the winter resilience

funding for the 2017/18 year as normal.

Renew the winter resilience funding in a changed or consolidated form: winter resilience

services and funding to be incorporated into a single wraparound contract, together with

other enhanced primary care services, to ensure a single consistent offer across the

borough that takes a population based approach and has equal funding for each

practice.

Do not renew the winter resilience contract: winter resilience services and associated

funding to not be issued from the 2017/18 year with no replacement in place.

Table 5 summarises how the three options for commissioning services currently within the winter

resilience funding score against the CSFs. It demonstrates that renewing the winter resilience

funding in a changed form scores highest against the CSFs and therefore is the preferred way

forward for the winter resilience funding dimension.

Table 5: CSF scoring for the winter resilience funding options


FORM

DO NOT RENEW

PATIENT

OUTCOMES AND

EXPERIENCE



No winter funding therefore patient experiences and outcomes will be poorer

PRIMARY CARE

SUSTAINABILITY


Primary care sustainability expected to improve as providers will be given a bigger funding envelope for a longer period of time

No winter funding therefore primary care sustainability will be reduced as there is a lower level of funding

EQUITY OF

FUNDING




STRATEGIC FIT The winter resilience funding already has moderate alignment with national and local programmes/strategies


Not offering the funding at all is not in line with national primary care policies

PROVIDER

CAPABILITY AND

CAPACITY

The last minute nature of issuing winter resilience funding makes it difficult for providers to plan capacity

The longer term nature of this options makes it easier for providers to plan capacity


DELIVERABILITY The last minute nature of issuing winter resilience funding makes it difficult for

The longer term nature of this options makes it easier for providers to plan delivery



July 2017 31

providers to plan delivery

FLEXIBILITY The last minute nature of issuing winter resilience funding makes it difficult for providers to plan

The longer term nature of this options makes it easier for providers to plan around other priorities


POPULATION

COVERAGE

This option offers moderate population coverage




3.2.4 Paediatric phlebotomy and dementia

The standalone paediatric phlebotomy contract has historically been issued to ensure parents

can access phlebotomy services for their children close to home and to avoid unnecessary

activity in the acute sector. The CCG currently holds multiple contracts with multiple GP

providers, each at a different price and age range. In addition the waiting time to access

paediatric phlebotomy service is increasing and there is limited capacity to deliver the service

within the workforce. The current contract for paediatric phlebotomy ends in March 2018,.

The standalone dementia contract is designed to support discharge of patients with dementia

from secondary to primary care. The contract is designed to encourage joined up working

between practices involved and West London Mental Health trust. The contract was first issued

in 2016 and was aligned to end at the same time of OOHS, at which point a more holistic view

could be taken about the future of the service.


commission and fund the enhanced primary care services currently sitting within the paediatric

phlebotomy and dementia contracts are:

Re-tender the paediatric phlebotomy and dementia contracts in the current form: new

business case to be written for the current service specifications so that the current

conditions of the paediatric phlebotomy and dementia contracts are replicated exactly.

Commitment to renewing the paediatric phlebotomy and dementia contracts in a

changed or consolidated form: the relevant services and funding to be incorporated into

a single wraparound contract, together with other enhanced primary care services, to

ensure a single consistent offer across the borough that takes a population based

approach and has equal funding for each practice.

Do not re-tender the paediatric phlebotomy and dementia contracts: relevant services

and associated funding to terminate at the end of March 2018 with no replacement in

place.

Table 6 summarises how the three options for commissioning services currently within the

paediatric phlebotomy and dementia contracts score against the CSFs. It demonstrates that

renewing the paediatric phlebotomy and dementia contracts in a changed form scores highest

against the CSFs and therefore is the preferred way forward for the paediatric phlebotomy and

dementia contracts dimension.


July 2017 32

Table 6: CSF scoring for the paediatric phlebotomy and dementia contract options

CSF RE-TENDER IN CURRENT

FORM

RENEW IN CHANGED

FORM

DO NOT RE-TENDER

PATIENT

OUTCOMES AND

EXPERIENCE



No paediatric phlebotomy and dementia services therefore patient experiences and outcomes will be poorer

PRIMARY CARE

SUSTAINABILITY


Primary care sustainability expected to improve as providers will be given a bigger funding envelope for a longer period of time

No additional funding therefore primary care sustainability will be reduced

EQUITY OF

FUNDING




STRATEGIC FIT This funding already has moderate alignment with national and local programmes/strategies


Not offering the services at all is not in line with national primary care policies

PROVIDER

CAPABILITY AND

CAPACITY

There is limited provider capacity for paediatric phlebotomy and good capacity for dementia



DELIVERABILITY The contract must be retendered at the end of 2017/18



FLEXIBILITY Retendering the contract at the end of this FY offers the opportunity to address and new priorities



POPULATION

COVERAGE

There is moderate population coverage for paediatric phlebotomy and poor coverage for dementia services




3.2.5 PMS funding

Of the 76 practices in Ealing CCG, 7 practices have locally negotiated Personal Medical

Services (PMS) contracts that have a different level of core funding to providers with nationally

negotiated General Medical Services (GMS) contracts. Ealing CCG is required to review and

renegotiate all PMS contracts with the aim of securing best value from future investment of the

‘premium’ element of PMS funding. Under delegated commissioning arrangements, Ealing CCG

is responsible for the commissioning arrangements related to PMS funding.

The level of “PMS premium” funding currently invested in contracts with Ealing CCG practices is

circa £650k based on the NHSE-derived methodology and understanding at this time. This will

need to be confirmed with the PMS practices themselves. A transition period to equalisation of

contracts may apply for some practices depending on the scale of the financial impact.


July 2017 33

It is intended that as a result of the PMS review any additional investment in general practice

services that go beyond core national requirements should reflect CCG strategic plans for

primary care, help reduce health inequalities and give equality of opportunity to all GP practices

(provided they are able to satisfy locally determined requirements) and support fairer distribution

of funding at a locality level.

The options considered within this business case that are available to Ealing CCG to invest PMS

funding are:

Allocate released PMS funding equally across all practices into a specific commissioning

intention i.e equally split funding across all 76 Ealing CCG practices and invest funding

into a specific commissioning intention.

Incorporate PMS funding into wider enhanced primary care funding: incorporate PMS

funding into a single wraparound contract, together with other enhanced primary care

services, to ensure a single consistent offer across the borough that takes a population

based approach and has equal funding for each practice.

Table 7 summarises how the two options for investing PMS funding score against the CSFs. It

demonstrates incorporating PMS funding into wider enhanced primary care funding scores

highest against the CSFs and therefore is the preferred way forward for the PMS funding

dimension.

Table 7: CSF scoring for PMS funding options

CSF ALLOCATE PMS FUNDING INTO A

SPECIFIC COMMISSIONING INTENTION

INCORPORATE PMS FUNDING INTO

WIDER ENHANCED PRIMARY CARE

FUNDING

PATIENT OUTCOMES

AND EXPERIENCE

Relatively small amount of funding there difficult to make a meaningful change to patient experience

Improved patient outcomes as small funding amount gets incorporated into wider wraparound pot giving a multiplier effect

PRIMARY CARE

SUSTAINABILITY

Relatively small amount of funding there difficult to make a meaningful change to sustainability

Improved sustainability as small funding amount gets incorporated into wider wraparound pot giving a multiplier effect

EQUITY OF FUNDING Relatively small amount of funding there difficult to make a meaningful change to equity of funding

Improved equity of funding as small funding amount gets incorporated into wider wraparound pot giving a multiplier effect

STRATEGIC FIT Completing the PMS review is strategically in line with national policy

Completing the PMS review is strategically in line with national policy

PROVIDER CAPABILITY

AND CAPACITY

Provider market likely to have capacity to deliver a relatively small contract


DELIVERABILITY Any standalone PMS review investment contract would be small and independent of other contracts and therefore easy to deliver


FLEXIBILITY The small funding amount would require a very targeted and therefore inflexible contract to invest the funding into

Improved flexibility as small funding amount gets incorporated into wider wraparound pot giving a multiplier effect

POPULATION

COVERAGE


Improved population coverage as small funding amount gets incorporated into wider wraparound pot giving a multiplier effect

SUMMARY Option not taken forward Option taken forward

3.2.6 Headroom funding

Ealing CCG’s NHS England funding allocation is being increased on a yearly and recurrent basis

up to 2020/21 such that the 2020/21 allocation is 25% greater than the 2016/17 allocation. The


July 2017 34

increase in allocation (known as ‘headroom funding’) is in recognition of the comparatively low

levels of primary care funding received by Ealing primary care. A portion of this increase has

been committed to premises rent and rate reviews, funding as per standing financial instructions

and regulations and other specific, pre-committed areas of spend including contingency.

However, the majority of the increase in allocation presents an opportunity to invest in Primary

Care. The options considered within this business case that are available to Ealing CCG to

invest available headroom into primary care are:

Fully invest available headroom into primary care: incorporate headroom funding into a

single wraparound contract, together with other enhanced primary care services, to

ensure a single consistent offer across the borough that takes a population based

approach and has equal funding for each practice.

Do no invest available headroom into primary care: treat the additional funding as a cost

saving against existing targets.

Table 8 summarises how the two options for investing headroom funding score against the

CSFs. It demonstrates that wholly investing the headroom funding into primary care scores

highest against the CSFs and therefore is the preferred way forward for the headroom funding

dimension.

Table 8: CSF scoring for headroom investment options

CSF INVEST WHOLLY IN

PRIMARY CARE

DO NOT INVEST IN

PRIMARY CARE

PATIENT OUTCOMES AND EXPERIENCE Patient experience expected to improve as the service specifications will be improved in response to patient feedback

No improvement to patient outcome will be delivered without any investment

PRIMARY CARE SUSTAINABILITY Primary care sustainability expected to improve as providers will be given a bigger funding envelope for a longer period of time

No improvement to primary care sustainability will be delivered without any investment

EQUITY OF FUNDING Wraparound contract to ensure equity of funding

No impact to funding

STRATEGIC FIT Population based approach aligns with national accountable care organisation themed programmes/strategies

Not investing the headroom at all is not in line with national primary care policies

PROVIDER CAPABILITY AND CAPACITY It may be difficult to find sufficient capacity and the correct skill mix in the local workforce


DELIVERABILITY Project has to be delivered within constrained timeframes with several different services incorporated into the wraparound


FLEXIBILITY The local nature will enable the contract to be written flexibility


POPULATION COVERAGE Improved population coverage as practices take up and deliver on behalf of each other as per current OOH contract



July 2017 35

SUMMARY Option taken forward Option not taken forward

3.2.7 Summary of long list analysis

The assessment of long-listed options against the agreed CSFs has confirmed the following

elements of the preferred way forward:

Renew the OOHS, Paediatric Phlebotomy and Dementia contracts in a changed form –

incorporating them within a single wraparound enhanced primary care contract

Renew the LIS and Winter Resilience contracts in a changed form – incorporating them

within a single wraparound enhanced primary care contract

Incorporate PMS funding and headroom funding into wider enhanced primary care

funding

3.3 Short list appraisal

The long list process reviewed all the options available to ECGG, set out in Table 2, and by the

process of scoring the options against the CSFs arrived at the preferred way forward, set out in

Section 3.2.7. In accordance with HM Treasury Green Book guidance, the preferred option must

also be benchmarked against the do nothing and do minimum (in this case the status-quo)

options. This process is usually undertaken to confirm the Value for Money (VfM) of the

preferred option, however in this case a qualitative appraisal of the benefits and dis-benefits of

the preferred option and two benchmarked options will be undertaken, to confirm the relative

benefit of implementing the preferred option. This is because the qualitative appraisal confirms

that the do nothing and do minimum options are not well aligned with the CCG’s publicly stated

aims and commitments of delivering care close to home and investing headroom into primary

care.

3.3.1 Short listed options

The three shortlisted options are described in Table 9.

Table 9: Short listed options

OPTION TITLE DESCRIPTION

1 Do nothing Allow OOHS, paediatric phlebotomy and dementia contracts to end with no replacement, renew LIS and winter resilience funding, make no change to Out of Hours premium funding, invest PMS funding into a specific commissioning intention and treat headroom funding as a cost saving

2 Do minimum (status quo)

Write a business case for renewing OOHS, paediatric phlebotomy and dementia contracts in their current state, renew LIS and winter resilience funding, invest PMS funding into a specific commissioning intention and treat headroom funding as a cost saving

3 Preferred Option

Incorporate OOHS, LIS, Winter Resilience, Paediatric Phlebotomy, Dementia, PMS Review and Headroom funding into a single wraparound contract delivering enhanced primary care using a population based approach against a set of standards forming an Ealing Standard.

These options were agreed with the Deputy Managing Director at Ealing CCG as the most likely

scenarios in the do nothing and do minimum cases. In particular it was felt that renewing LIS and

winter resilience funding has become a part of business as usual within Ealing CCG and

therefore offering that funding is likely in the do nothing scenario.

3.3.2 Short list benefit and dis-benefits analysis

The benefits and dis-benefits of the three shortlisted options were considered by Ealing CCG’s

Clinical Lead for Primary Care Co-Commissioning. This analysis is set out in


July 2017 36

Table 10.

Table 10: Short list benefit and dis-benefit analysis

BENEFITS DIS-BENEFITS

OPTION 1: DO NOTHING

Increased cost savings achieved through not investing headroom and OOHS monies

Reduced overall demand for service delivery at practices – which may benefit practices that are currently understaffed

Gives the opportunity to wait for a national programme to be implemented, which would reduce the costs of implementing any enhanced primary scheme and give national alignment

Short term cost savings contributed towards

The services available to patients in the community would significantly decrease – reducing patient satisfaction and potentially outcomes

The costs of delivering the services currently under OOH would be significantly more expensive elsewhere in the system

Other providers (such as secondary care and mental health providers) would experience a significant increase in demand – destabilising the rest of the system

Reduced integration between health providers within the system

Potentially be forced to adopt a national programme which would not be tailored to local needs and requirements

OPTION 2: DO MINIMUM

Fewer change processes required to transition to this option as CCG and providers are already familiar with the process

Issuing multiple short term contracts allows for greater flexibility from the CCG’s perspective as changes can easily be made to individual contracts

Short term cost savings contributed towards

Activity based contracts makes it difficult for providers to implement long term strategies

Not changing enhanced primary care contracting would not address ongoing concerns within the local system

Some contracts are currently issued annually which makes long term planning difficult for the both CCG and providers

OPTION 3: PREFERRED OPTION

Reduced costs in the acute sector

A four year wraparound contract provides greater security and assurances to the provider landscape about their future stability

Potentially reduced on-costs for the administration of the contract at both commissioner and provider level resulting in a higher percentage of contract value spent on patient care

Reduced risk of overlapping contracts and duplication across multiple contracts

A wraparound contract would result in a more seamless care delivery to patients, with fewer interface issues or contractual gaps

One quality contract would enable simplified communications between the commissioner, provider and patient

Would support delivery of STP

This approach has been implemented in other areas successfully from where the learning has been taken.

Potentially reduced capacity to respond agilely to external factors due to the large size of the contract

The requirement to take a single contracting approach across all specifications reduces flexibility (i.e some specifications can’t be paid by service with others paid on a capitated basis)

Short term cost savings not contributed towards

Overall it was felt that the benefit and dis-benefit analysis reinforced the suitability of the

preferred option. The do nothing option would entirely remove a large section of service delivery

from the primary care setting, making delivery of those services more likely to take place in the

acute setting which is likely to be more expensive and more inconvenient for the patient. The do

minimum option would continue the status quo but not improve the sustainability and resilience

of primary care or address patient concerns over access. The Preferred Option provides the


July 2017 37

opportunity to invest the PMS review and headroom funding into primary care in the long term in

order to deliver meaningful improvements to patient experience and outcomes and also to

reduce cost in the acute sector. The full Return on Investment (RoI) delivered by the preferred

option is further explored in Section 5.

3.4 The preferred option

As set out above, the preferred option for commissioning enhanced primary care within Ealing

CCG is to:

Renew the OOHS, Paediatric Phlebotomy and Dementia contracts in a changed form –

incorporating them within a single wraparound enhanced primary care contract

Renew the LIS and Winter Resilience contracts in a changed form – incorporating them

within a single wraparound enhanced primary care contract

Incorporate PMS funding and headroom funding into wider enhanced primary care

funding

In order to deliver this option, Ealing CCG collaboratively developed a set of standards for the

single wraparound contract, collectively known as the ‘Ealing Primary Care Standard.’ The

development of the standards was overseen by the Ealing CCG ‘Primary Care Steering Group’ –

a group with clinical representation from the Ealing CCG Clinical Leads and local and London-

wide LMC, an Ealing CCG lay governing body member and Ealing CCG senior management.

The development of the standards was led by Clinical Leads and developed in a series of four

Council of Members meetings with Ealing CCG member practices, and additional drop in

sessions. A key learning from the process of commissioning the out of hospital services was the

need for local clinical leadership and this design process has enabled this.

In total there are 23 service specifications included within the Ealing Primary Care Standard, as

set out in Table 11. All of the standards are included in Appendix 1. It should be noted that these

23 include and build on the 18 Out of Hospital specifications.

Table 11: 23 service specifications in the Ealing Primary Care Standard

HEALTHCARE AND LONG TERM CONDITION MANAGEMENT

HEALTHCARE IMPROVEMENT ACCESS, SAFETY AND EXPERIENCE

Mental Health Cancer screening Access Diabetes Prevention Homelessness

Respiratory Self-care & use of patient Activation Measures

Medicines optimisation and medicines safety

Cardiovascular Learning disability Drug monitoring Musculoskeletal Carers Patient experience Ring Pessary Demand management

Care Planning And Coordination Business management (Pre-Qualifier)

End Of Life Care Wound Care Phlebotomy Dementia


July 2017 38

4 Commercial case

4.1 The Commissioning Strategy

Ealing CCG set out in its Annual Commissioning Intention document for 2014/2015 both the

approach they intended to take to commissioning a range of ‘Out of Hospital’ services and their

view that in the majority of instances GPs were the most capable providers of these services.

The CCGs published the intention to let the OOH contract to primary care in Ealing and received

no challenge to either the approach or the commissioning route.

The process incorporates the Out of Hospital framework that the CCGs across CWHHE

developed to support the procurement of out of hospital services. The framework balances the

requirements of complying with the law and reducing legal challenge with the need to make

effective and integrated commissioning decisions that are right for the local population.

The services that the original process covered when the OOH services contract was let are:

Ambulatory blood pressure monitoring (ABPM)

Anticoagulation

Care planning

Chronic Obstructive Pulmonary Disease (COPD)

Diabetes

Electrocardiogram (ECG)

Homeless care

Management of common mental health issues

Mental health – transfer of care

Near patient testing

Phlebotomy

Ring pessary

Vasectomy

Wound care

The second stage of the process includes:

Additional Respiratory Components

Musculoskeletal Services (MSK)

End of Life

Dementia

Cancer Screening

Self Care and Patient Activation Measures

Learning Disability

Carers

Access

Prevention

Medicines Safety and Optimisation

Demand Management

Ankle-Brachial Pressure Index (ABPI)

The process includes setting up an Independent Review Panel to review the recommended

procurement approach for each of the services.


July 2017 39

The panel was asked to review the recommendations for each service in the context of both

national direction and importantly the STP and the CCGs Out of Hospital Strategies.

The panel was made up of:

Lay Member

Non-Conflicted GP (Out of Area)

Quality Lead for CWHHE

Primary Care Manager from NHSE for NWL (2)

The panel considered each service in turn and the outcome was recorded on each of the sheets

for the services. The outputs of the Independent Review can be found in Appendix 6.

The commissioning of the Standard is therefore proposed at an individual practice level on a

direct award basis.

4.2 Payment Mechanisms

Services are split between

capitation-based services 75% for delivery and 25% based on achievement against KPIs

(KPIs are paid on sliding scale of achievement)

activity-based on achievement of agreed Minimum data-set

prevalence-based services based on current Out of Hospital Services. Diabetes is paid

on 40% against prevalence and 60% against achievement at a CCG level. Mental

Health may be paid on a prevalence based mechanism but if not would revert to the

capitation based approach. As the contract is developed over time, the CCG will assess

which of the activity based work, if any, can move to a capitation based model.

The KPIs for the capitation component are weighted based on a range of factors. These are:

• Effective care

• Difficulty to implement

• Patient experience

• Clinical impact elsewhere

• Financial impact elsewhere

• Collaborative working

Practices will be paid on a sliding scale of achievement.

A further 1 % in 18/19 will be allocated (based on affordability) for delivery based on a Goals

Framework Target. In 18/19, the Goals Framework will be aligned to delivery of a reduction in

unwarranted variation in Non-Elective Admissions and unwarranted variation in planned care.

It is not proposed to use the CQUIN function within the NHS Standard contract for this due to the

approach being taken with the payment related to the Goals Framework.


July 2017 40

It is proposed that the KPIs relating to access in the first six month of the contract (October to

March 2017) are not enforced to support mobilisation. It is proposed KPIs are live and

monitored from April 2018.

4.3 Contractual and Other Issues

4.3.1 Type of contract

Practices will be offered a contract for services with a 3.5 year term with the ability to sub

contract to other primary care list based providers.

The quality standards / key performance indicators and specific reporting requirements for

measuring practice performance are set out in each of the standards.

Variations to contract will be in writing and signed by both parties. Variations involving an

increase in price must only be made within the limit of the financial delegated authority.

Practices will be required to make a self-declaration once a year, similar to the process under

the contract management of the Out of Hospital Services – Appendix 7.

Practices are also expected to fulfil all contractual requirements for their core contract, including

all annual declarations to NHSE and CQC as required.

The contract will be held with each individual practice, however, there will be provision in the

contract to allow sub-contracting to other practices to deliver services on their behalf with the

agreement of the CCG.

4.3.2 Contract management

The responsibility for managing delivery under the contract as well as relationship management

will be with the CCG primary care team on the signing of the contract. The CCG will support and

work with practices to ensure that they provide safe care in line with the standard and that all

patients across the borough have access to all the services.

The critical part of the contract is the mobilisation phase – further information in section 6.2.


July 2017 41

5 Financial case

5.1 Available funding

This business case requires funding from both the primary care allocation and the CCG

programme budget as follows:

1. £3.5m worth of headroom funding from the Primary Care allocation from 2018/2019 with

£2.8m being requested in 2017/2018.

2. £7.2m worth of funding from the CCG core budget broken down as:

Renewal of out of hospital services £5.4mRenewal of Paediatric phlebotomy £0.2m,Dementia £0.1m,

LIS £1.1m Winter Resilience funds £0.4m.

3. Additional core funding to support the additional requirements and new standards £923k

This section will set out the approach to costing the standards and the affordability for the CCG

in commissioning the standards.

5.2 Costing of the specifications

A costing model was developed to support the commissioning of the out of hospital services in

2014 across the five CCGs in CWHHE. The Investment Committee has previously reviewed the

approach to the costing model when considering the OOH contract and had the opportunity to

discuss and agree the model. CCGs in CWHHE agreed that when costing services to be

commissioned from primary care this would be the approach used to enable an equitable

approach to the pricing of services. The approach is shown below:


July 2017 42

Figure 16: CWHHE Out of Hospital Costing Model overview

The updated model works by taking the unit cost and linking to either the population prevalence

for a particular service or the known activity from 2016/17. The activity information has been

taken directly from information provided by practices under the OOH contract or from QOF.

Prevalence information is either taken from the Information Centre, QOF or from NICE

guidelines.

Figure 17 below provides further detail:

A number of the indicators for cancer screening and prevention had previously been agreed in

2015 as part of the London PMS contract negotiations to be offered to all practices in London

5 Confidential |

At the most granular level, each service is divided into input component costs to provide standard unit cost and is linked to prevalence or activity

Inputs

FTE and on - costs

Consumables

Equipment and training

Overheads

Standard unit cost

Outcomes U nit cost

Blended unit cost

Where a service has multiple levels (e.g. diabetes) we have calculated the unit cost for each level and amalgamated this to a give a single blended unit cost which spans across all activity levels

I nputs have been tested with a large range of stakeholders, including: • LMC • CCG Chairs • HoFs • GPs • Lead consultants • Service leads • Practice managers • Practice nurses

For example • P er 1,000 patients

on a list with say 100 patients requiring treatment for a disease

• The cost of treating one patient is £5

• The cost of treating 100 patients is £500

• Per 1,000 patients, the cost of delivering this service is £500

Prevalence

Activity 2016/17

Weighted list

• Single adjustment for prevalence across CWHHE based on QoF / HSCIC data

• A single adjustment is not optimal but it simplifies the unit cost in the service contract

A djustment at practice level for local population demographics

or

For the

capitated costs

– the unit cost

is multiplied by

the number of

patients for the

service across

the borough

and divided by

the weighted

population of

the borough


July 2017 43

following the PMS review. The value of the indicator for achievement has been used as a

benchmark for these services.

Using this methodology, the services have been priced as set out in table 13.

Table 12: Pricing of the services within Ealing standard (full year)


July 2017 44

5.3 Affordability assessment

Affordability needs to be considered in relation to both the primary care allocation and in relation

to the CCG core programme budget. Figure 18 below provides an overview of the budget

steams being utilised and details the new budget streams required: The affordability

assessment has been broken into four parts as detailed below:

5.3.1 The Primary Care headroom investment

5.3.2 The renewal of the funding for the services detailed in the above section

5.3.3. The request for additional investment into the standards

5.3.4 Savings attributable to the Ealing Standard

All three component parts make up the funding streams into the Ealing standard and the final

part of the section sets out the direct savings associated with the Primary Care Standard as well

as those programmes and savings that the Ealing Primary Care Standard enables as part of the

STP.

Figure 18

5.3.1 The Primary Care headroom investment

Ealing CCG has been allocated an increase in primary care allocation from 2017 / 2018 up until

2020/2021. The increased funding allocation is in recognition of the historical underfunding into


July 2017 45

primary care within Ealing based on the national funding steams. Figure 19 below shows the

increases to funding that have been published by NHS England for Ealing CCG:

Figure 19

Table 14 below provides the actual funding increases over the four years:

Year of increase in allocation Sum

2017/2018 £4,825,000

2018/2019 £2,244,000

2019/2020 £1,991,000

2020/2021 £2,706,000

Since becoming delegated on the 1st April 2017 the CCG has been going through the process of

determining the primary care budget that is needed for the 76 practice from within the overall

allocation. The CCG has had to work through a number of risks in order to determine a draft

budget and determine the headroom that is available to invest into practices to address the

historical underfunding to meet the needs of the Ealing population. This draft budget has been

recommended for approval by both the Primary Care Committee and the Finance &

Performance committee subject to the work of district valuer to better understand the risks on

premises.

The summary of the draft primary care budget is shown below in Table 15:


July 2017 46

The draft budget has the following contingency and NHS business rules contained within in:

A contingency of at least 0.5% of Allocation

A 0.5% non-recurrent Resilience Fund reserve, which must not be committed

A further 0.5% of allocation committed only non-recurrently

Premises (Rents and Rates) - £1,124k contingency funding due to the lack of clarity

provided by NHS England on rental reimbursement levels.

Headroom – part year effect as the access element of the Ealing standard funded

through headroom will only be commissioned from October 2017.

Once all the primary care commitments have been allowed for, including the contingency

funding, the headroom available for investment is £3,542k.

It is proposed that the £3,542k funding is invested into general practice recurrently to support the

Ealing standard. During 2017/2018 this would be focused on access only but from 2018/2019

would include the patient experience elements of the Ealing standard.

The rationale for the investment going into access:

Patients have consistently fed back in forums over a number of years that access to

general practice needs to improve. This feedback has been further supported by the

survey undertaken by Healthwatch of 2000 residents across the Borough focused on

access. A summary of the findings is contained in the case for change and the full report

accompanies this paper in appendix 2.

Practices across Ealing are not all open between 08:00 and 18:30 and the alternatives to

patients when practices are closed are either 111, the urgent care centre, out of hours

provision or on call arrangements within practices. The work of the National Audit office

suggested that for practices open less than 45 hours per week there was an increased

use of the urgent care system of 8%.

Improving access is a critical enabler for the delivery of the standard itself. Without

additional capacity provided consistently between Monday to Friday practices won’t be

able to provide the other components of the standard nor will they be able to further

support the integration with acute and intermediate care for those patients who can be

supported to remain outside of hospital where appropriate or to support the length of stay

reductions in hospital by having the ability to more proactively support patients in their

place of residence.

Budget

GMS £'000 PMS £'000

APMS

£'000

All CCG

£'000 Total £'000

Total Core Contract Price Core GMS, PMS, APMS, MPIG, OOH Deductions, growth 28,351£ 4,058£ 2,600£ 332£ 35,341£

Total QOF QOF plus 1% reserve 3,460£ 437£ 282£ 42£ 4,221£

Total Enhanced Services Minor Suregery, extended Hours, LD, Violent Patients 1,120£ 131£ 45£ 1,296£

Premises Rents, Rates, Water, Waste, £1,124k provision for rents and rates 4,267£ 430£ 450£ 1,124£ 6,271£

Personally Administered Drugs Handling charge for drugs administered within practice 195£ 12£ 207£

Total CCG Adminitered Costs Seniority, indemnity, CQC, Sick, maternity etc. 1,083£ 114£ 58£ 1,255£

Occupational Health 14£ 14£

Once for London APMS Procurment team, Clinical Waste Management Team, PCSE ad hoc costs 75£ 75£

Contingency Business Rules 0.5% 265£ 265£

1& NR Reserve Business Rules, 1% NR reserve, half to be uncommitted at beginning of year 530£ 530£

Total 38,490£ 5,170£ 3,447£ 2,368£ 49,475£

Current Allocation 53,017£

Headroom (Based on Current Budgets) 3,542£

Current Draft Budgets


July 2017 47

The historical underfunding in practices in Ealing has made it more difficult to invest in

the staff required to provide access and therefore targeting the funding in this way

enables practices to open between 08:00 and 18:30 and provide further services

throughout this period.

Investing in access has provided the CCG with the opportunity to specify requirements

within the standard that support timely home visiting, different modes of access,

increased opening hours, a minimum of 100 appointments per week per 1000 patients

(105/1000 per week in winter months) requirement ,and the requirement to undertake

demand and capacity audits with an improvement trajectory agreed.

That value for money is being achieved through this approach as the CCG is using the

Out of Hospital services costing model to determine the price which has been agreed as

the approach to take by the Investment Committee.

Figure 20 below shows how the headroom will be invested in from 2017 onwards.

As indicated in table 15 above the allocation increases annually over the next three years. The

CCG will review the budget requirements annually and proposes the following in terms of

balancing further investment into the Ealing with meeting the funding agreements reached

nationally that need to be paid for through the primary care allocation at a CCG level as well as

managing the know risks such as premises:

The funding priorities from the allocation over subsequent years are:

Growth in population

• Increase in national contract negotiations

• Rent increases


July 2017 48

• Rates increases

• Other unknown primary care risks which materialise and require a call on funding

• Increase in access provision (appointments / 000 / week)

• Incentives for achievement against Goals Framework

• More Standards

In summary the business case is setting out the case that the headroom in the primary care

budget should be invested into general practice in Ealing to address the historical underfunding

that is set out in figure 19. Without this investment it becomes very difficult to practices to

sustain current delivery and improve capacity and the breadth of service provision at the levels

that have been articulated within the Ealing Standard.

The CCG will focus this additional investment of £3.5m to support the access specification in

2017/2018 with the addition in 2018/2019 of the patient experience, screening & prevention and

patient experience.

5.3.2 The renewal of the funding for the services detailed in the above sections

In addition to the primary care allocation Ealing CCG received a core programme allocation of

£492m in 2017/18 and of this Ealing CCG spends approximately 3% on services from general

practice. The CCG committed £5.4m into Out of Hospital services, £0.4m to primary care winter

resilience, £1.9m to local incentive schemes and £0.1m to Dementia and £0.2m Paediatric

Phlebotomy in 2017/2018. This section of the business case sets out the case that this funding

should be renewed and committed to the Ealing Primary Care standard between 2018 and 2021.

Figure 21 below provides a view of the elements of funding that is being requested; the

additional shown in yellow and the renewal request shown in blue:


July 2017 49

The list of services that falls into the category of renewal is:


Anticoagulation

Care planning


Diabetes


Homeless care




Phlebotomy

Ring pessary

Wound care

Paediatric Phlebotomy

LIS

Dementia

Respiratory (diagnostic spirometry)

End of life care

Demand Management

Drug Monitoring

Carers

Learning Disability

Medicine Optimisation and safety

Winter Resilience. The total of the request to renew/ fund these services into the Ealing standard from April 18 to March 2021 is at an annual cost of core funding of £7.2m. As indicated in previous sections the services have been costed using the out of hospital services approach. The Ealing Standard is intended to be commissioned as a single wrap around contract to support general practice meet the needs of the Ealing population as identified within the JSNA. This also supports the move that the CCG wishes to make in terms of paying on a capitated model which the standard sets out to do for the majority of the services. For two of the services the payment will be linked to prevalence and for the remaining services it has not been possible to move them from an activity based payment. Despite the different payment mechanisms the standard is being offered as a single wrap around over a 3.5 year contract term to enable general practice to consider the workforce it needs to deliver the services and then make the appropriate investments. Should the renewal of these services not be agreed it would risk the approach being taken and slow down the transformation journey that the CCG recognises is critical for both general practice but also for the wider healthcare system. An assessment has been undertaken of what the financial impact would be of withdrawing the

funding and therefore service provision from general practice. The service provision is likely to

fall back into the acute sector and where this is quantifiable through the availability of an acute

tariff this has been calculated below as shown in table 16:

Cost of OOH activity Cost of OOH activity if

delivered within a Acute

setting (based on 16/17


July 2017 50

with 1.1% Net Inflation )

Anticoagulation Initiation £ 31,121 £ 30,619

Anticoagulation Monitoring £ 481,676 £ 1,138,922

Wound Care £ 115,213 £ 431,227

ECGs £ 304,092 £ 311,253

ABPMs £ 50,925 £ 98,820

Diagnostic Spirometry £ 120,703 £ 168,013

Phlebotomy £ 400,145 £ 450,056

Total £ 1,503,874 £ 2,628,912

Total Net Saving £ 1,125,038

In addition to this it should be noted that it is difficult to quantify the impact of the loss of some of

the out of hospital services from general practice provision would be but it is likely that:

Increased pressure is seen in the mental health system as recovery teams are unable to

discharge stable patients in clusters appropriate for care within general practice

Winter resilience funding has provided for additional capacity during core hours from

general practice. It is well documented that the NHS system comes under increased

pressure during the winter months and additional funding is directed to support. Ealing

CCG has directed £400k of its winter resilience funding to primary care over a number of

years and has seen increased numbers of appointments provided and taken up.

Although not possible to prove it is probable that this capacity would be required from

elsewhere in the system such as the urgent care centre if not provided through general

practice.

Local Incentive Scheme Funding has been used to target areas of care that need focus

to meet the needs of the population or drive an improvement in care. Examples of the

additional value this funding has given are:

o Increased numbers of people have a learning disability assessment

o Increased practices having been through carer friendly training

o Increased numbers of patients have been diagnosed with hypertension which in

turn will prevent prevent strokes

o case reviews of people accessing the non elective environment with the aim of

non elective reductions.

o Increased dementia diagnosis rates

In summary this section asks for:

Agreement to the on-going spend of £7.2m per annum from 2018 until 2021 into the Ealing

Standard. This is in the context of removing this spend leading to an increase in costs

elsewhere in the system of £2.6m annually in addition to the non-financial impacts. The


July 2017 51

agreement to the renewal of funding also supports the CCGs intention to commission a single

wrap around contract over multiple years enabling practices to consider the workforce

requirements and transformation required to improve resilience.

5.3.3 The request for additional investment into the standards

In developing the Ealing standard the review work highlighted a number of areas where further

commissioning is required to meet the needs of the Ealing population as identified within the

JSNA as well as in some areas set appropriate standards of care for general practice to meet.

Within this there have been some standards developed which are entirely new and some Out of

Hospital services that have been reviewed with additional requirements added to which have

then driven an additional cost. This additional cost needs to be considered in the context of then

need to invest in general practice to improve resilience and to support the transformation

journey. The agreement to make this funding available from the core programme budget will

support the intention to commission a single wrap around contract over multiple years enabling

practices to consider the workforce requirements and make necessary investments to support

the delivery of the standard across Ealing.

The list of these services are:



End of Life

Cancer Screening


Prevention

Learning Disability

Carers

Access

Prevention



As detailed in the earlier part of this section these costs have been derived by using the out of

hospital costing model or using LIS schemes as the benchmark. The costs are set out in detail

in table 13 earlier in this section but the total request for additional funding is £923k.

5.3.4 Savings attributable to the Ealing Standard

Work has been undertaken to determine what financial impact there would be on secondary care

as a consequence of investing in the Ealing Standard.

Within the aim of the Ealing Standard is to set a range of standards and fund a level of care that

enables general practice to move to a more proactive and planned model of care, Clinical leads

modelled the impact that the standards would have on both non elective and planned care

systems. Activity and financial changes are attributed to specific standards where it was

possible to make clear modelling assumptions. As established earlier in the business case, this

methodology supports the STP in moving towards a more proactive and planned care system

that includes preventative services which help reduce unwarranted variation and decreased

unplanned admissions into secondary care.


July 2017 52

Activity assumptions have been shown against the IMBC target which was agreed by the

Governing Body to support the Strategic Outline Case for the capital that supports the delivery of

SaHF. This profile is important as it sets out the expected shape change in the NWL healthcare

system and therefore it is important that Ealing’s planning tracks back to these underlining

business assumptions. The activity profiling has therefore also utilised activity growth

assumptions detailed within the IMBC planning.

Table 17 below shows the estimated Non Elective activity reductions derived from modelling the

Ealing Standards:

Financial Period

QIPP Drivers 2018/19 2019/20 2020/21

ImBC QIPP Target 3021 3594 1801

Diabetes Primary Care QIPP 198 186 177

Asthma Primary Care QIPP 336 315 299

COPD Primary Care QIPP 164 154 146

EOL Primary Care QIPP 197 185 175

Total Primary Care QIPP 895 840 797

QIPP Other 2126 2754 1004

Total QIPP 3021 3594 1801

NEL Admission Rate per 1000 82.77 77.76 77.01

The assumptions that underpin the activity change are set out below in table 18:

The activity profile converted into cost is shown in table 19 below:

QIPP Drivers Financial Period

2018/19 2019/20 2020/21

Diabetes Primary Care QIPP £ 344,759 £ 323,524 £ 309,738

Asthma Primary Care QIPP £ 369,756 £ 346,981 £ 329,233

COPD Primary Care QIPP £ 381,572 £ 358,069 £ 339,754

EOL Primary Care QIPP £ 675,185 £ 633,597 £ 601,188

Total Primary Care QIPP £ 1,771,274 £ 1,662,172 £ 1,579,915

Note: All savings are based on unit costs for the QIPP drivers during 2016/17 adjusted by the

annual inflators/deflators in the Ealing CCG Financial Plan

In summary the total NEL admissions that could be saved over the four years alongside the cost

is shown below in table 20:

DiabetesAssumed improved management of patients will prevent emergency admissions for diabetes as a primary diagnosis and that this will recur as patients

might be frequent users of emergency services and new patients are diagnosed.

Asthma There is evidence that increasing the number of patients on preventative asthma medicine can lead to a 75% reduction in secondary care events.

Assumption that the opportunity will recur as patients would be likely to be admitted annually otherwise and new cases will be diagnosed.

COPD Emergency readmissions within 90 days are avoidable if patients referred to pulmonary rehabilitation and prescribed rescue packs. Assumption that

exacerbations requiring emergency admission are inevitable so the opportunity is recurrent.

EOL

Assumption that 1% of the registered population is at an end of life stage. Deaths in hospital where the reason for admission is cancers and tumours),

problems of circulation or problems of the respiratory system. Recurrent due to the assumption about prevalence. There is a probably a further

opportunity based on all emergency admissions during a reference period prior to death.


July 2017 53

Financial Period

2018/2019 2019/2020 2020/2021

NEL Reduction 895 840 797

Cost Saving £1,771,274 £1,662,172 £1,579,916

In addition to the non-elective savings that are anticipated; the standard will also support

planned care savings.

The planned care savings are set out in table 21 below with the underpinning assumptions set

out underneath this in table 22. It should be noted that the activity changes are only profiled for

two of the years that it is intended to commission the standard as the opportunity available will

be saved in that period.

QIPP Drivers

Financial Period

2018/19 2019/20 2020/21

ECGs 1,613 538 -

MSK 785 262 -

Anticoagulation 3,908 1,303 -

Total Primary Care Planned Care QIPP 6306 2103 0

The assumptions that underpin this change profile are:

Table 22:

The activity change shown in cost terms is detailed in the table 23 below:

QIPP Drivers

Financial Period

2018/19 2019/20 2020/21

ECGs £ 318,243 £ 106,187 -

MSK £ 92,469 £ 30,854 -

Planned Care QIPP

ECGs Assumed shift of 100% of ECGs performed at the first out patient appointment.

MSK Avoidable first out patient appointments due to inappropriate referrals for PPwT and estimated follow up attendances.

Anticoagulation Assumes that initiation and maintenance of anticoagulation should be delivered by Out Of Hospital Services.


July 2017 54

Anticoagulation £ 137,036 £ 45,724 -

Total Primary Care Planned Care QIPP £ 547,748 £ 182,765 0

The total gross savings that can be directly attributed to the Ealing standard are shown below in

table 24:

Financial Period

2018/2019 2019/2020 2020/2021

NEL Gross Cost Saving £1,771,274 £1,662,172 £1,579,916

Planned Care Gross Cost Saving £547,748 £182,765 0

Total Gross saving £2,319,022 £1,844,937 £1,579,916

The activity and cost savings shown in the tables above are the total opportunities identified as

available. Evaluation of mobilisations of other large programmes that have been undertaken

demonstrate that it is unlikely that the maximum savings will be derived in year one. Three

options have been determined based on learning from previous mobilisations and are set out

below in table 25:

The recommended case is the conservative case delivering by 2021 a total incremental gross

saving of £4,123,130.

It should also be noted that this means that we are not

Overall Summary

The section sets out the case that:

1. Investment should be made from the headroom within the primary care allocation of

£2.8m in 2017/2018 and budgeted for £3.5m in 2018/2019 to invest into access,

screening & prevention services and patient experience standards. The funding has

been made available nationally and reflects the historic distance from target levels of

funding for practices within Ealing CCG.

2. That agreement to the renewal/ongoing spend for the out of hospital services, LIS and

winter resilience is made. The annual cost of this is £7.2m. This spend is already

committed within CCG core programme budgets and if the funding is ceased will see an

Gross Savings in Finanical Years

2018/19 2019/20 2020/21 TOTAL

A. Best Case 2,319,022 1,844,938 1,579,916 5,743,875

Service delivery as per initial modelling

assumptions

B. Mid Range 1,855,218 1,844,938 1,579,916 5,280,071

Service delivery ramp up: Year 1 = 80%

and Year 2 & 3 = 100%

C.Conservative Case 1,159,511 1,383,703 1,579,916 4,123,130

Service delivery ramp up: Year 1 = 50%,

Year 2 = 75%, Year 3 = 100%


July 2017 55

estimated cost increase in the acute system of £2.6m in addition to a number of non-

quantifiable impacts.

3. That the additional investment of £923k from the core programme spend is agreed on the

basis of the savings that can be attributed to the standard as a whole and summarised in

table 26 below:

Financial Period

2018/2019 2019/2020 2020/2021

Total Core Additional Funding £923K £923K plus inflation,

growth (demographic

and non demographic)

£923K plus inflation,

growth (demographic

and non demographic)

Conservative benefit realisation £1,159,511 £1,383,703 £1,579,916

Net saving £235,511 £459,703 £655,916

It should be noted that all three funding streams are required to enable the commissioning the

Ealing Standard and without any one of the funding streams it would prevent the CCG from

commissioning a single wrap around contract across the 3.5 year contract term that is proposed.

5.4 Enabling STP Delivery

As indicated in earlier sections the Ealing Standard is a critical driver in enabling the delivery of

the NWL STP for Ealing. In addition to the case that has been set out work has been

undertaken to demonstrate where the Ealing Standard will be supporting the five delivery areas

all of which have been determined to have financial benefits to the NWL system and is set out in

figure 21 below:


July 2017 56

5.5 Impact on PMS practices

The increase in allocation provides the opportunity to approach the sustainability of primary care

in a different way.

In Ealing there are 7 PMS practices and the amount of premium released in Year is minimal as

the overall value of PMS premium in Ealing is approximately £650k. Spread across all practices

in Ealing, the premium would not add much value and therefore the primary care standard would

incorporate the PMS review.

One of the principles for the PMS review is to ensure any premium released from PMS practices

is released into general practice and commissioned for 1st October 2017 in line with our primary

care commissioning approach to the increased allocation.

Ealing is committed to commissioning primary care in a way that ensures any funding:

1. Released from the PMS review is reinvested into General Practice

2. Is equitably invested into General Practice

3. Supporting PMS practices with transition funding to ensure there is no destabilisation of any

practice

The access targets have been developed using information and benchmarking from areas that

have commissioned such targets such as Bolton and Salford. Feedback has also been collated

from the Patient and Public Engagement work that has been conducted over the last year,

where access to GP's has been a raised concern and supported by the Survey carried out by

Healthwatch.


July 2017 57

In order to ensure we meet the timeframes for the PMS Review our Governing Body has

previously agreed to include the review of PMS practices with the overall Primary Care

Standard.

There are only 7 practices with a PMS contract in Ealing and therefore the time required to meet

and negotiate with the practices will be faster than in some of the other CCGs, but will also be

staggered and support the Central teams to stagger their work.

Offer letters will be sent out soon after the GB and in the letters, the PMS practices will be

offered a visit to discuss their practices position and options week commencing 24th July 2017.

This will not be the first time the practice would have seen their information as the letter which

breakdowns how the PMS will be calculated will was sent in April using the 16/17 contract

values. In addition all practices have had the opportunity to be involved in the development of

the Commissioning Intentions during May and June 2017. The final offer will be sent using

17/18 figures with the full impact of the Commissioning Intentions for their practice.

The approach to transition has been considered at the Commissioning Committee on the 10th

May. Ealing has already been clear that any funds released are reinvested back into general

practice, equitably, while supporting PMS practices transition aware from PMS premium. In

2015 and 2016, during the initial approach to the PMS review before the ‘pause’, a mapping

exercise was conducted to understand what the impact of the review would be on the individual

practices. At this time, there was no major change expected as a result of the review, apart from

one practice, where they had employed staff that spoke Tamil.

However, during this review, it is our intention to ask each practice again, how they would

transition, in order to understand what the impact would on services to patients. The Impact

assessment would be undertaken in 2 steps.

1. Financial impact on the practice and staffing implications. These will be explored in

detail at the individual practice meeting. Ealing CCG has commissioned NELCSU to

support the financial modelling for each practice to understand the impact on the

practice while they transition to the new offer. This will be used to talk the practices

through the implications as part of the contract negotiation.

2. Equality Impact on services to patients. Once it is clear what the financial impact and

therefore what the potential staffing impact would be on the practice, working closely

with the practice the Equality Impact Assessment will be refreshed.

Transition funding aims to support PMS practices to remain stable as they move to new income

and service arrangements as part of the PMS Review. It is calculated by considering the

difference between the current 16/17 PMS contract values and the GSE (global sum equivalent),

as well as the income offered through newly commissioning services.

Potential income loss (e.g. the difference between current income and GSE + Commissioning

intentions) for year 1 determines each practice’s ‘transition pathway’, allowing transitional offers

to be calculated for the full PMS review period. There are 3 transition pathways, with each

offering different lengths of funding based on magnitude of income lost.

Final Practice offers will be based on updated 17/18 figures when available, with initial ‘baseline

letters’ using 16/17 figures as an interim measure, however this will not alter the transition

pathway of any Practices within the CCG.


July 2017 58

This recommended transition methodology, calculating transition by taking account of income

from newly commissioned services, was recommended for all CCGs at the 2nd February 2017

NWL PMS Review Steering Group, which has an advisory function to each CCG’s Primary Care

Commissioning Committee. The impact on the 7 PMS practices is considered commercially

sensitive and will therefore be considered in private Primary Care Commissioning Committee if

the Governing Body agrees this Business Case. This will be followed by detailed conversations

with individual practices.


July 2017 59

6 Management case

6.1 Governance

As the development of this Ealing Primary Care Standard is clinically led, it is essential that all

actual or perceived conflicts of interest are managed proactively.

Member Engagement

To ensure we get the right answer for our population, the clinical standards have been initially

developed by the Clinical leads and then tested through a co-production phase with the CCGs

clinical membership.

To manage any perceived conflicts, no clinicians were involved in developing the actual financial

case or costing, which was led by officers of the CCG.

Council of Members Co-production workshops 10th May 2017

24th May 2017

14th June 2017

5th July 2017

Member Drop-in sessions 31st May 2017

7th June 2017

LMC at Primary Care Steering Groups

LMC (Local and Londonwide) 18th July 2017

LMC (Local and Londonwide) 25th July 2017

Primary Care Steering Group

The primary care steering group was established to oversee the development of the Standards.

The Terms of Reference (TOR) for the Primary Care Steering Group can be found in Appendix

8. This Steering group consisted of Lay Partners, LMC (Local and Londonwide), CCG Clinical

Leads, Managing Director, Managerial leads within CCG, Communications team and

Healthwatch in attendance once although invited on going.

Independent Review Panel

In addition, each new standard which was developed was tested at an Independent Review

Panel, made up of a Lay Member, a non-conflicted GP from outside of the borough, 2 members

from the NHSE team based working across North West London and the Acting Director of

Quality for CWHHE. This was held on the 5th July 2017. The independent review panel was put

in place to test the recommendation that general practice was the most capable provider of the

standard. This aligns to the procurement process that the Governing Body currently has in place

and also mirrors the process followed for the commissioning of the initial set of out of hospital

services.


July 2017 60

Sign off process

As the potential for conflicts (both actual and perceived) are great with this programme as CCGs

are membership organisations and the contract would be let to members, the following sign off

process for the offer has been agreed.

Extraordinary F&P – All conflicted members will abstain 12th July 2017

Primary Care Commissioning Committee (Public) - All conflicted members will abstain 19th July 2017

Investment Committee 20th July 2017

Governing Body in Public – All Conflicted members will abstain 26th July 2017

Due to the tight timelines the following process has been agreed with the Local LMC:

Initial comments 14th July 2017

Review meeting 1 18th July 2017

Review meeting 2 25th July 2017

It was agreed that any issues still outstanding after review meeting 2 will be shared with the Governing

Body on the 26th July.

6.2 Mobilisation plan

Figure 22 below provides an overview of the programme of work from commencement through

to full mobilisation on April 2018.

The mobilisation will be overseen by a steering group made up of CCG clinical leads and managers with responsibility for primary care. This group reports into and includes members from the Primary Care Commissioning Committee, F&P and that Healthwatch are included as members.

Figure 22 Summary of activities


July 2017 61

Figure 23 below sets out the provider support that the CCG envisages will be required to

mobilise the Ealing Standard and support practices to consider the optimal delivery response.

Figure 23

Provider development activities

It is envisaged that support will be required in 3 phases.

Phase Type of Support

July to October 2017 Establish Mobilisation Steering Group to focus on:

Recruiting to posts

Establishing requirements for templates and BI reporting

Procuring Demand and Capacity tool for practices

Establishing standardised reporting methodology for

practices on SystmOne

Set up Payment Infrastructure

Develop Contractual documentation

Specific requirements for the 2 EMIS Web Practices

Individual practice discussions with all practices

Individual practice discussions with PMS practices

Offer and run the Provider Maturity Assessment Tool with

Federation and any other group interested

Create Engagement and comms material


July 2017 62

Issue contracts

October 2017- March 2018 Support practices to run the Demand and Capacity tools

Support practices to standardise the recording of appointments on

SystmOne

Develop dashboards with the WSIC team to support the delivery of

the contract

Establish thresholds for services commencing in April, where they

have not already been set e.g. Diabetes and Access

April 2018 onwards Mobilise full contract with dashboards

Ensure population coverage

Provide regular data to practices

Monitor KPIs and provide practices with regular data on

performance against KPIs

Quarterly activity based services reconciliation

Close of OOH services contract and reconciliation of 17/18 data

Close of LIS and reconciliation of 17/18 data

6.3 Provider development

In order to deliver the Ealing Standard to the timeline set out in 6.2 above, the CCG

acknowledges that Providers will need targeted support to develop their capacity and capabilities

individually but in particular, collectively at network level.

It is proposed that following the agreement of this business case, and prior to the

commencement of services, the CCG and providers work together to understand the

development support that might be needed. It is currently envisaged that providers may need

support in the areas:

Information technology to facilitate new care models and ways of working

Clinical skills across the primary care workforce

Business operations and administration at scale

Business intelligence and analytics (including population health analysis)

Demand and capacity management

This support will be underpinned by allowing providers the capacity to implement changes to the

service to ensure that they are set up for success.


July 2017 63

Practice level development

The CCG has already been providing support to practices as described under the GPFV. The

support can be summarised under the 10 High Impact Actions in table 25 below:

10 High

Impact

Actions

Examples of types of

activities

Examples of

Outputs/Outcom

es

Comments / work already in

progress

1. Active Signposting

Online portal;

Reception based

navigators

Release of

clinical capacity

within practice

In collaboration with Ealing

CEPN we have already

commissioned and committed

funding for bespoke training to be

delivered to all practices over the

next 2 years. The aim of this

training is to improve GP

receptionists’ knowledge of the

range of in-practice, social and

voluntary care options available

to patients and helping them to

develop the people/telephone

skills to find the most appropriate

care options for each patient.

We are also investing in Numed

Screens in all practices across

Ealing which provide tailored

support and advice to the

practice population by

signposting patients to the most

appropriate services as well as

offering self-care advice.

2. New consultation types (telephone, on-line, video)

Telephone consultations; E-consultations; Text messages/phone notifications; Group[ consultations

Improvement in appointments per 1000 Improved patient survey outcomes

The ETTF Digital programmes are being implemented and will support practices directly to progress various new consultation types.

3. Reduce DNAs Easy cancellation; reminders; patient recording; read-back; report attendances; recue ‘just in case’

Improved patient survey outcomes

SMS Texting is available through the practice systems.

4. Develop the Team (developing the practice team to support all members of the team to operate at the top of their license)

Advanced nurse practitioner; physician associates; Pharmacists; medical assistant; paramedics; Therapists

Increase in clinical capacity Improved patient survey outcomes

Ealing CEPN has been running a range of training for practice staff over the last 2 years. This training will continue to support individuals (clinical and non-clinical) to continually develop their skills with a range of training programmes offered.

5. Productive Matching capacity and Increase in We are building on our practice


July 2017 64

Work Flows

demand; efficient processes; productive environment

clinical capacity Improved patient survey outcomes

resilience programme by funding generic support to a third of interested Ealing practices through the Productive General Practice Quick Start programme during 17/18.

6. Personal Productivity

Personal resilience; computer confidence; speed reading; touch typing

Increase in clinical capacity Improved patient survey outcomes

7. Partnership Working

Productive federation; community pharmacy; specialists; community services

Improvements in clinical outcomes (QOF, GPOS, GPHLI)

There are groups of practices across the borough who are exploring how partnership working can be taken forwards. The CCG has been providing support and advice where appropriate. Ealing GP Federation has been established to work across the borough and may also explore how they can streamline practice processes and share learning/system and processes across.

8. Social Prescribing

Practice based navigators; external service


There is a great deal of evidence about Social prescribing. The CCG is exploring how they can commission support for social prescribing with partners from the Voluntary Sector.

9. Support Self Care

Prevention; LTC; acute episodes


A Self Care strategy has been developed, however, there is much more work that can be done in primary care. One practice in Ealing is testing how Patient Activation Measures (PAMs) can be used to tailor self-care messages and interventions for individuals. Making Every Contact Count (MECC) training is being offered to all practices.

10. Development of QI expertise

Leadership of change;

process improvement;

rapid cycle change;

measurement

Improvements in

clinical outcomes

(QOF, GPOS,

GPHLI)

Improved patient

survey outcomes

The CCG would encourage

practices to utilise a number of

tools available to them to support

quality improvement: for example

The RCGP QI tool for General

Practice

http://www.rcgp.org.uk/clinical-

and-research/our-

programmes/quality-

improvement.aspx

In addition, the CCG has committed to fund practices £1 per head in 17/18 and £2 per head in

18/19 to directly support practices to develop and implement their own plans on becoming

resilient and sustainable. The CCG believe that without practices ownership on implementing

http://www.rcgp.org.uk/clinical-and-research/our-programmes/quality-improvement.aspx





July 2017 65

changes on the ground, any transformation support the CCG provides will not have the desired

impact, hence the investment.

Providers at Scale development

Through the development of the OOH services contract, Ealing GP Ltd (Federation of all

practices in Ealing) emerged. It is unclear what the ambition of the Federation is as of April

2018 when the OOH services come to an end. The Federation may envisage itself as a

management function on behalf of the practices, but may have wider ambitions in delivering

services itself as an entity in itself practices which practices could sub-contract to as allowed in

the contract. Ultimately the role of the Federation will need to be agreed between itself and its

shareholders; however the CCG recognises there it has a role in enabling the dialogue and

facilitating it.

In order to understand the ambition and ability of the Federation to take this role in Ealing, the

CCG will facilitate a Maturity Assessment with the Federation in a number of stages. This

approach requires further discussion with the Federation Board and there is an initial discussion

set up to do so and therefore it may be that this process is iterated through discussions.

Stage 1: Maturity Assessment of Federation carried out with independent Facilitation team

during September

Stage2: Practices/ groups of practces invited to participate in their own maturity assessment if

interested in a workshop setting during September

Stage 3: Workshop with practices and Federation presented with results of the Maturity

Assessment by the Facilitation team followed by Network based discussions on options for

providers at scale during October

6.4 Resourcing Requirements in the CCG For the mobilisation phase to be effective, significant resource will be required at the CCG to

support practices totalling £510,000 in the context of investing just under £12m through the

standard. The following resources have been identified as being required:

£50k for the Demand and Capacity Analysis Tool for practices to use

£12k to run the series of Provider Development workshops

£279k for 7 additional mobilisation team members (Band 7) to directly support each

Network to mobilise the contract for a period of 12 months between October 2017 –

September 2018

£75k for 1 Band 8d to oversee the mobilisation of the contract for a period of 9 months

between October 2017- June 2018

£31k for 1 Band 8a for System One specialist support to develop the templates on

System One and enable the BI team to extract the data required to monitor the

contract for 6 months between October 2017 – March 2018

£63k (recurrently) for 1 band 8a for BI support to establish the dashboards on a

regular basis for the contract, working closely with the WSIC dashboard team and

supporting reconciliation


July 2017 66

The CCG is supporting and resourcing the CEPN which will support education and

training across the standard

The CCG will through the mobilisation steering group consider the clinical resourcing

requirements to support a QI methodology to support delivering the standard

7 Conclusion and Recommendation

The CCGs ambition in commissioning the Ealing Standard is:

1. To have equity of offer and access to patients registered with an Ealing GP through commissioning the Ealing Standard

2. To reduce the unwarranted variation in general practice and improve outcomes for individuals

3. To address the concerns and feedback received from patients regarding access to general practice and drive ongoing improvement over the term of the Ealing Standard.

4. To address the needs of the population as identified in the Joint Strategic Needs Analysis (JSNA) and ensure the primary care standards deliver a full, holistic offer of care for patients

5. To support and improve resilience and sustainability within general practice whilst meeting the strategic requirements as set out in the NWL STP, 5YFV, and the Strategic Commissioning Framework (SCF). It is very clear that general practice is the golden thread that runs through all the delivery areas of the STP supporting and enabling the realisation of the triple aims of the STP of Improving Health & Wellbeing, Improving care & quality, Improving productivity and closing the financial gap.

6. To utilise the opportunity that Primary Care Delegation has provided in enabling the CCG to direct the use of the headroom within the primary care allocation for Ealing GPs. The headroom recognises the historical underfunding in general practice from a national level and the increasing allocation addresses this up to and including 2020/2021.

7. That the CCG commissions an equitable offer on an equitable financial basis from practices and therefore the Ealing Standard is the commissioning intention for PMS discussions to support the NHS England required renegotiation of PMS premium funding.

The CCG is requesting approval relating to three funding streams as outlined below:

8. To utilise £2.8m of the headroom during 2017/2018 with a focus on access increasing to £3,474k to support access, prevention, screening and patient experience recurrently.

9. As the allocation increases in future years, following managing any growth pressures or increases in core primary care spend, such as funding implications of national contract negotiations, increases in rents, rates and applying any NHS business rules as directed by NHSE, further headroom funding released is allocated to support primary care in Ealing to further stretch the primary care offer through stretched targets or new standards in line with the needs of the population.

10. To seek agreement that the funding already being utilised from the CCG programme budget, £7.2m, should continue to be used to commission the Out of Hospital (OOH) services as part of the Ealing Standard. That this agreement is made based on the understanding that the care will need to be provided from somewhere within the healthcare system and for a proportion of the services this would be at a higher cost, £2.6m, in the acute service.


July 2017 67

11. To seek agreement to additional investment from CCG programme budget of £923k into the Ealing Standard noting that the costs have been derived through either the out of hospital costing model or through the LIS incentive scheme approach. The request for an additional £923k annually is made against the most conservative realisation of savings derived directly from the standard of £1,160k in 2018/2019 with a total incremental saving at the end of the 2020/2021 of £4,124k.

12. That the Ealing Standard enables the implementation of primary care led elements of the STP across the five domain areas and underpins some of the financial benefits to be realised e.g ongoing investment into primary care to support mental health care enabling the Like Minded business case (DA4), enabling the use of PAMS (DA1) or the system wide programmes on Diabetes, Hypertension and AF (DA2).

13. To seek approval for a moratorium on the KPIs in 17/18 to start to mobilise and prepare for phase 2 in April 2018. This is in line with the process to mobilise the original OOH services contract with primary care

That the committee note the approach to the costing of the standards and the approach to

contracting:

14. That the costing of the standards has been developed in line with the OOH costing model or using the Local Improvement Scheme (LIS) as the benchmark, with clinical leads determining the length of the clinical interventions and the staff groups involved, with the officers using this information to cost the standards. This was further reviewed by a finance officer outside of Ealing.

15. That the Ealing standard is commissioned as a single wrap around contract from each provider of medical services.

That there is a need to invest in mobilisation through internal and additional resource:

16. That additional resource is agreed as part of the business case to support mobilisation of the standard throughout the rest of 2017/2018 and this is funded from the primary care allocation and the headroom available. That this mobilisation is overseen by a steering group made up of CCG clinical leads and managers with responsibility for primary care. That this group reports into and includes members from the Primary Care Commissioning Committee, F&P and that Healthwatch are included as members.


July 2017 68

Appendix 3 Equality impact statement

Equality and Health Inequalities Analysis

1 Title: The Ealing Standard – Quality Framework for Primary Care 2017/18 – 2020/21

Ealing CCG - July 2017

What are the intended outcomes of this work? Include outline of objectives and function aims Ealing CCG serves a GP registered population of more than 430,000 patients, with 76 GMS/PMS/APMS Contracts. NHS England is increasing the funding allocation on a yearly basis from 2017/18 up to 2020/21, which will allow the CCG to substantially increase the total investment in primary care across Ealing between 2017 and 2021. Ealing CCG intend to use this investment to change from commissioning multiple services from practices to taking a single commissioning approach, with a single wraparound contract for all non-core CCG commissioned services. The ‘Ealing Standard’ will be holistic, improve outcomes and provide better value for money, providing vital investment to ensure primary care in Ealing is both sustained and transformed. It will also help to address equity of funding across practices and public and patient concerns regarding equality of access across the patch. The new Ealing Standard will incorporate:

Available NHS England investment that has not been otherwise allocated to fund

changes in the core contract, changes in rents and rates reimbursements and

demographic changes.

All existing discretionary CCG funding for services, including winter resilience, LIS

schemes and the Out of Hospital services

Reinvestment of the PMS premium

The contract will be offered across general practice in Ealing, with phase one due to commence from 1 October 2017, and full implementation from 1 April 2018. It contains 23 standards covering healthcare and long term condition management, health improvement and access, safety and experience. The majority of standards described are not new and an Equality Assessment has been conducted previously; rather they are being brought together in a single document for the first time. While the impact of the Ealing Standard as a whole will be considered, standards that are new, and therefore the focus of this Equality Analysis are:

Access

Musculoskeletal health

Prevention

Respiratory disease

Carers

Self-care and use of Patient Activation Measures

End of Life care


July 2017 69

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

Goal Number Description of outcome

Better health outcomes

1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities

1.2 Individual people’s health needs are assessed and met in appropriate and effective ways

1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed

1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse

1.5 Screening, vaccination and other health promotion services reach and benefit all local communities

Improved patient access and experience

2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds

2.2 People are informed and supported to be as involved as they wish to be in decisions about their care

2.3 People report positive experiences of the NHS

2.4 People’s complaints about services are handled respectfully and efficiently

Who will be affected by this work? e.g. staff, patients, service users, partner organisations etc.

Registered Patients of Ealing GPs

Families and carers of patients

Staff working in General Practice

Evidence

What evidence have you considered? List the main sources of data, research and other sources of evidence (including full references) reviewed to determine impact on each equality group (protected characteristic). This can include national research, surveys, reports, research interviews, focus groups, pilot activity evaluations or other Equality Analyses. If there are gaps in evidence, state what you will do to mitigate them in the Evidence based decision making section on page 9 of this template. While the impact of the whole Ealing Standard has been considered, the new elements have been considered in more detail, with references listed below.

General:

Ealing JSNA

Public Health England Health Profiles for London –


July 2017 70

Ealing CCG PPE reports to Governing Body

Standard Alternative Provider Medical Services Contract 2016/17 available at https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/

http://www.kingsfund.org.uk/press/press-releases/our-response-don-berwicks-report-patient-safety

Francis, R. (QC) (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry London:TSO Available at: www.midstaffspublicinquiry.com/report

HM Government, (2014) The Care Act 2014 Available at:www.legislation.gov.uk/ukpga/2014/23/contents/enacted

National Association for Patient Participation (NAPP), (2014) Available at: www.napp.org.uk/overview.html

NHS England (NHSE), (2014) National GP Survey Results Available at: www.england.nhs.uk/statistics/category/statistics/gp-patient-survey/

Access

GP Patient Survey, Ipsos MORI

UCC Data

The King’s Fund, (2012) exploring the association between quality of care and the experience of patients London.

Kontopantelis, E., Roland, M., Reeves, D., (2010 Patient experience of access to Primary Care: identification of predictors in a national patient survey BMC Family Practice Vol: 11 p.61

Bottle, A; Tsang, C; Parsons, C; Majeed, A; Soljak, M; Aylin, P (2012), Association between patient and general practice characteristics and unplanned first time admissions for cancer, observational study. British Journal of cancer, 107 (8),

Rosen R., (2014) Meeting need or fuelling demand? London: Nuffield Trust & NHS England The King’s Fund, (2011) Improving the quality of care in general practice London.

National Audit Office (2015) A Stocktake of Access to General Practice and (2017), improving access to general practice

Imison C, Curry N, Holder H, Castle-Clarke S, Nimmons D, Appleby J, Thorlby R, Lombardo S (2017) Shifting the balance of care, Great expectations, Nuffield Trust

NHSE (2014) Emergency Admissions Technical Paper Carers

Carers UK, (2014) The State of Caring 2014 Available at www.carersuk.org/for-professionals/policy/policy-library/state-of-caring-2014

Ealing JSNA 2016 Carers https://www.ealing.gov.uk/download/downloads/id/11340/carers_chapter_2016.pdf

Ealing Council and Ealing Clinical Commissioning Group (CCG) Joint Carers' Strategy 2012-18

Schonegevel, L. (2013) Macmillan briefing on carers issues Available at: www.macmillan.org.uk/Documents/GetInvolved/Campaigns/MPsCommons2ndReadingBriefing.pdf

NHS England (NHSE), (2014) Commitment to Carers Available at: www.england.nhs.uk/wp-content/uploads/2014/05/commitment-to-carers-may14.pdf

Self-care

Supporting people to manage their health, Kings Fund, 2014, available at: https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/supporting-people-manage-health-patient-activation-may14.pdf

NHS England PAMs guidance, available at: https://www.england.nhs.uk/ourwork/patient-participation/self-care/patient-activation/pa-faqs/

Prevention

British Society of Gastroenterology (BSG), (2010) Alcohol related disease: Meeting the challenge of improved quality of care and better use of resources London.

Connor, JP, Haber, PS, Hall, WD: Alcohol use disorders. The Lancet, Vol.386, No. 9997, Sep 5, 2015.

Department of Health DH, (2013) CVD Outcomes Strategy: Improving outcomes for people with

or at risk of cardiovascular disease London.

Murray C.J. et al., (2013) UK Health Performance: findings of the Global Burden of Disease Study 2010 The Lancet Vol: 381 pp. 997-1020.

NICE (2006) PH Intervention Guidance 1: Brief interventions and referral for smoking cessation



http://www.midstaffspublicinquiry.com/report

http://www.napp.org.uk/overview.html

http://www.england.nhs.uk/statistics/category/statistics/gp-patient-survey/

http://www.carersuk.org/for-professionals/policy/policy-library/state-of-caring-2014

http://www.carersuk.org/for-professionals/policy/policy-library/state-of-caring-2014

https://www.ealing.gov.uk/download/downloads/id/11340/carers_chapter_2016.pdf

http://www.macmillan.org.uk/Documents/GetInvolved/Campaigns/MPsCommons2ndReadingBriefing.pdf

http://www.macmillan.org.uk/Documents/GetInvolved/Campaigns/MPsCommons2ndReadingBriefing.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/05/commitment-to-carers-may14.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/05/commitment-to-carers-may14.pdf

https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/supporting-people-manage-health-patient-activation-may14.pdf

https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/supporting-people-manage-health-patient-activation-may14.pdf

https://www.england.nhs.uk/ourwork/patient-participation/self-care/patient-activation/pa-faqs/

https://www.england.nhs.uk/ourwork/patient-participation/self-care/patient-activation/pa-faqs/


July 2017 71

in primary care and other settings.

Public Health England (PHE), (2013) NHS Health Check implementation review and action plan

London.

Public Health England (PHE), (2015a) Local Alcohol Profiles Available at: www.lape.org.uk/

Public Health England (PHE), (2015b) Local Tobacco Control Profiles

Available at: www.tobaccoprofiles.info

Public Health England (PHE), (2015c) Tackling high blood pressure From evidence into action. Available at: www.gov.uk/government/publications/high-blood-pressure-action-plan

Stroke Association, (2014) About Stroke Available at: www.stroke.org.uk/about-stroke

Department of Health (DH), (2014) [Online] Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/316007/FluImmunisationLetter2014_accessible.pdf

Public Health England (PHE), (2014) Public Health Outcomes Framework for England 2013-2016 Available at: www.phoutcomes.info/

Ealing Health and Wellbeing Strategy 2016-2021 available at https://www.ealing.gov.uk/downloads/download/3755/health_and_wellbeing_strategy

Respiratory

Ealing JSNA

BTS / SIGN Asthma guidelines 2016

Improving the quality of diagnostic spirometry in adults: the National Register of certified professionals and operators

Salford quality standards for primary care

NICE COPD Quality Standards

London Asthma Standards for Children and Young People End of Life

NICE Quality Standard 13 – End of Life care for adults

www.nice.org.uk/guidance/qs13

www.dyingmatters.org

www.goldstandardsframework.org.uk

Ealing JSNA

NWL STP MSK

Preventing musculoskeletal disorders, Fenton, Public Health England 2016.

https://publichealthmatters.blog.gov.uk/2016/01/11/preventing-musculoskeletal-disorders-has-wider-impacts-for-public-health/

Public Health Outcomes Framework

Health and Work: Spotlight on musculoskeletal conditions (MSK), Public Health England and The Work Foundation 2016 https://app.box.com/s/1qm34sx148rx6nyywnjow131xaplp3zl

Arthritis Research UK. Musculoskeletal Health. A Public Approach. Chesterfield: ARUK; 2014. http://www.arthritisresearchuk.org/~/media/Files/Policy%20files/2014/public-health-guide.ashx

National Clinical Guideline Centre. Osteoarthritis Care and management in adults. London: Royal College of Physicians, 2014. https://www.nice.org.uk/Guidance/cg177

National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NICE guideline NG59). 2016. www.nice.org.uk/guidance/ng59

Musculoskeletal Health in Ealing. Chapter for Ealing Joint Strategic Needs Assessment 2014, Bernstein, NHS Ealing CCG and London Borough Ealing, 2014

http://www.ealingccg.nhs.uk/media/1859/Ealing_JSNA_MSk_Health_pre-pub_2014-09-06.pdf

Age Consider and detail age related evidence. This can include safeguarding, consent and welfare issues. The Ealing Standard will improve care for people of all ages, but particularly: Children: through the provision of delivery standards for childhood asthma, immunisations and

http://www.lape.org.uk/

http://www.tobaccoprofiles.info/

http://www.gov.uk/government/publications/high-blood-pressure-action-plan

http://www.stroke.org.uk/about-stroke

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/316007/FluImmunisationLetter2014_accessible.pdf

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/316007/FluImmunisationLetter2014_accessible.pdf

http://www.phoutcomes.info/

https://www.ealing.gov.uk/downloads/download/3755/health_and_wellbeing_strategy

http://www.ealingccg.nhs.uk/media/1859/Ealing_JSNA_MSk_Health_pre-pub_2014-09-06.pdf


July 2017 72

proactive health improvement work on childhood tooth decay and obesity. In Ealing, 23.9% of year 6 children are classified as obese, worse than the average for England, so the standard will help protect the health of children. Older adults: through the provision of delivery standards for a wide range of health conditions which particularly impact upon older adults, including cardiovascular, musculoskeletal, dementia, end of life, proactive health checks and cancer screening. In 2013, the top three underlying causes of death people aged 65+ in Ealing were circulatory disorders, cancer and respiratory disorders. (JSNA, 2014) so the new standards will help protect the health of older people. The MSK standard, with provisions for falls assessments, will also support the wellbeing of older adults. Pulse Checks, one of the provisions of the new prevention standard, could help identify AF earlier and could prevent 4,500 strokes and 3,000 deaths per year in the UK (Stroke Association, 2014). Most people affected by strokes are over 65. Safeguarding of both children and vulnerable adults is included in the Ealing Standard to ensure the protection of these groups from harm and abuse. Access will be improved for all age groups, with various forms of access being supported such as online booking of appointments, e-prescribing, online-consultations and generally more appointments offered.

Disability Consider and detail disability related evidence. This can include attitudinal, physical and social barriers as well as mental health/ learning disabilities. The Ealing Standard contains specific measures on both mental health and learning disabilities, which already form part of existing services. In the recent ‘Big Health Check’ engagement event for people with learning disabilities, for the first time LD patients reported positive experiences while attending their GP appointments, with some excellent examples of good practice. These examples have been built upon in the new standards. The KPIs help protect disabled people’s wellbeing by ensuring care is proactive, coordinated and looks after not just their mental health or learning disability, but also their physical health (with a requirement to provide an annual health assessment a KPI for both the mental health and learning disability standards) and vice versa. There are clear requirements for adherence to Accessible Information Standards, including communication support. Disabled people will also benefit from improved access to their GP surgery, including online methods, which for some people may be very helpful. The carers standard will help improve the wellbeing of those who support disabled people (some of whom may also be disabled themselves) with proactive health assessments, flu jabs, and referral to support services.

Gender reassignment (including transgender) Consider and detail evidence on transgender people. This can include issues such as privacy of data and harassment. There is limited specific reference to gender reassignment in the Ealing Standard, however, as many of the measures are about empowering proactive and personalised contact by GP practices, this will benefit all patients, and even more so for patients who are perhaps less likely to attend their GP surgery due to fear of discrimination.


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Marriage and civil partnership Consider and detail evidence on marriage and civil partnership. This can include working arrangements, part-time working, caring responsibilities. There is limited specific reference to marriage and civil partnership in the Ealing Standard; however the Carers Standard may provide some protection for married people and people in a civil partnership, who care for their loved ones. This ensures carers are identified – even those who do not identify as such and feel they are doing what any husband / wife / civil partner would do. It will help protect their health and wellbeing with annual health checks, flu jabs and referral to support services, including talking therapies.

Pregnancy and maternity Consider and detail evidence on pregnancy and maternity. This can include working arrangements, part-time working, caring responsibilities. The Ealing Standard will help improve the health of pregnant patients by improving access to appointments, and through health improvement measures such as providing all pregnant patients with a flu jab. When they have the baby, the access standard will ensure practices will provide a same day assessment for all children under 12 with urgent needs. If the pregnant patient is also a carer, the carer standard will help support them. The Ealing JSNA (2016) identified a higher proportion of females providing unpaid care compared with males.

Race Consider and detail race related evidence. This can include information on difference ethnic groups, Roma gypsies, Irish travellers, nationalities, cultures, and language barriers. The Ealing JSNA (2014) highlights that race is one of the risk factors for Type 2 diabetes – people of Black African, Caribbean or South Asian origin are more at risk. According to the last Census (2011), there were 41% Ealing residents of Asian or Black ethnic origin, so the Ealing Standard may help protect their health by improving diabetes care in general practice, as well as implementing preventative measures through NHS Health Checks. The Health Checks will also identify risk factors for cardiovascular disease, which is also known to have a higher incidence in the BME population. Evidence suggests that people from certain ethnic groups are less likely to participate in bowel and breast cancer screening. However positive endorsement from a healthcare professional can increase screening uptake. The cancer screening standard will ensure that patients receive personal contact from their practice if they do not respond to invitations for bowel and breast screening. This may help ensure that additional people from black and minority ethnic groups are screened and do not develop cancer. There are a wide range of languages spoken in Ealing and there is a clear expectation in the Ealing Standard that patients should have access to accessible information and communication support.


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Religion or belief Consider and detail evidence on people with different religions, beliefs or no belief. This can include consent and end of life issues. According to the 2011 Census 44% of the residents of Ealing regard themselves as Christian, down from 51% in 2001. The proportion of Muslims has increased from 10% to 16%, with the proportions of other major religions remaining more or less the same as during the last census. The new standards mean patients will benefit from improved access to appointments within general practice. If there are cultural or religious regions why people don’t access health care – for example cancer screening – the new standard will ensure practices make personal contact with the individual and so may be able to arrange for special provisions to be made. The self-care standard will enable patients to self-define what is important to them in improving their health, which will enable them to take account of their religion and belief. People at the end of life sometimes experience spiritual difficulties, in addition to a range of physical health issues. The new KPIs ensuring regular reviews with the patient, and an after death analysis at network level to consider lessons learnt.

Sex Consider and detail evidence on men and women. This could include access to services and employment. The Ealing Standard will improve the health of both men and women who in some cases have similar needs – for example, the MSK standard. Low back and neck pain is now the leading cause of disability in England for both men and women combined. Women are more likely to be unpaid carers, with a higher proportion of females than males in Ealing taking on this role (9.5% females v 7.6% males) so they will benefit from the carers specification. Women who may be less likely to attend for breast screening (such as those from BME groups and Muslim women) may be more likely to attend following personal following up healthcare professional. Some standards, such as ring pessary, are targeted at females specifically and will provide additional services closer to home, making them easier to access. Both men and women will benefit from the self-care standard as they will be able to self-define what is important to them in improving their health, which will enable them to take account of their gendered needs.

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

There is limited specific reference to sexual orientation in the Ealing Standard; however, as many of the measures are about improving access, proactive care and empowering self-care, this will benefit all patients.


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Carers Consider and detail evidence on part-time working, shift-patterns, general caring responsibilities. Carers will benefit from their loved ones being able to access primary care more easily, with a case management approach when appropriate, and regular reviews for those at the end of life. Their loved ones will be proactively identified if they are at risk of a wide range of health conditions. Carers themselves will be more readily identified – even those who do not identify as such and feel they are doing what any family member would do. It will help protect their health and wellbeing with annual health checks, flu jabs and referral to support services, including talking therapies.

Other identified groups Consider and detail evidence on groups experiencing disadvantage and barriers to access and outcomes. This can include different socio-economic groups, geographical area inequality, income, resident status (migrants, asylum seekers). The Ealing Standard includes measures to improve the health and wellbeing of other identified groups with vulnerabilities, included people who are homeless. People who are homeless may experience difficulties in accessing primary care, due to inappropriate registration policies, perceived discrimination and staff attitudes, lack of flexibility in services provided and communication barriers. They may have a number of complex health problems, and may also require proactive support to manage their health needs, for example, targeted support, regular and/or longer appointments. The Ealing Standard sets clear delivery standards designed to address this and improve their experience and health outcomes.


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Engagement and involvement

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

See below.

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

A Steering Group was set up to oversee the creation of the Ealing Standard, which includes lay members, Clinical Leads and the LMC. This met fortnightly throughout the development of the proposal. At various stages of development, right from the beginning, the Council of Members were engaged in shaping the work. The majority of services described in the Ealing Standard are not new, so have been widely engaged on previously, and feedback gathered during the duration of the contracts, which have informed this analysis. In particular, lay members have been active members of the Contract Management Group, which has overseen the management of the existing out of hospital services contract, along with the provider’s patient reference group. A wide variety of feedback has been gathered from specific groups (some listed below) and patient feedback on primary care compiled by Ealing Healthwatch. Access has been identified as patient’s biggest concern, which has been addressed in the new standard. The Ealing Standard supports the local delivery of the pan-London Strategic Commissioning Framework for Primary Care, which was contributed to by over 1,500 key stakeholders, including large numbers of patients.

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

This includes:

Council of Members meetings on 10 May, 24 May, 14 June & 5th July 2017 to discuss the rationale, delivery and metrics of each specification taking detailed feedback;

Additional ‘drop in’ sessions for GPs to attend and give their views;

The collection of patient feedback on general practice, over the course of a year;

The implementation of a specific patient survey on primary care access, led by Ealing Healthwatch;

Patient engagement events held in 2016 to explore appropriate KPIs for patient experience measures;

Annual ‘Healthcheck’ event with people with learning disabilities – taking the opportunity in these Standards to build upon what people with learning disabilities have told us improved their care

Engagement with Practice PPG and Network PPG members on specific clinical services on 10 May 2017


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Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impacts, if so state whether adverse or positive and for which groups and/or individuals. How you will mitigate any negative impacts? How you will include certain protected groups in services or expand their participation in public life? Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. As the aim of the Ealing Standard is to be a ‘wraparound’ contract, ensuring that patients across Ealing have access to the same level of high quality of care wherever they access primary care, which should have a positive impact on people with protected characteristics. In addition to commitment to improving access and standardising high quality clinical care, the Ealing Standard has a definite focus on proactive screening and identification of health needs, of care planning and management for those who would benefit from it, and of addressing the wider determinants of wellbeing and self-care. These should have a positive impact on people with protected characteristics. In addition to this, the Ealing Standard makes explicit the need to make reasonable adjustments for people with protected characteristics.

Eliminate discrimination, harassment and victimisation

Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation). Much of the Ealing Standard supports people with multiple needs and vulnerabilities, who may experience discrimination, harassment and victimisation. This investment in primary care will ensure there is additional access in primary care where these individuals can experience ongoing support. Where certain populations may experience real or perceived discrimination in their access to primary care, measures to address this are outlined in the standard. For example, ensuring that homeless people do not experience discrimination in their ability to register with a GP practice.

Advance equality of opportunity

Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation). The Ealing Standard may help advance equality of opportunity between people who share a protected characteristic and those who do not by ensuring that all patients in Ealing have access to a consistent set of high quality primary care services, closer to home, regardless


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of who they are or where they live. In particular, the self-care standard will advance equality of opportunity by helping patients move away from being passive recipients of care to being active partners in their own health. The use of Patient Activation Measures will help them develop their knowledge, skills and confidence to make informed decisions and adapt their health related behaviours.


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Promote good relations between groups

Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation). The Ealing Standard may help promote good relations between groups by ensuring that all patients in Ealing have access to a consistent set of high quality primary care services, closer to home, regardless of who they are or where they live.

Evidence based decision-making

Please give an outline of what you are going to do, based on the gaps, challenges and opportunities you have identified in the summary of analysis section. This might include action(s) to eliminate discrimination issues, partnership working with stakeholders and data gaps that need to be addressed through further consultation or research.

Ensure that the Steering Group takes account of the feedback in the Healthwatch report when it is published;

Ensure that the need to pay due regard to the specific needs of people with protected characteristics is highlighted in communication about the contract and that practices include this in their mobilisation plan;

Amend the Patient Experience standard to make explicit the need to consider how to improve the experiences of people of different race/religion/sexual orientation/gender identity and how they can feel comfortable and welcome in primary care settings;

Ensure that practice Patient Participation Groups are actively involved in overseeing the mobilisation of the Ealing Standard and helping their practices as a ‘critical friend’, with particular regard for the patients in the practice with protected characteristics. This should also be the case for the local Healthwatch and the lay members on the CCG Steering Group.

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

The Equality analysis will accompany the business case and draft Ealing Standard document when it is reviewed by the Governing Body for decision.


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Health Inequalities Analysis

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

Impact 2. What is the potential impact of your work on health inequalities? Can you demonstrate through evidenced based consideration how the health outcomes, experience and access to health care services differ across the population group and in different geographical locations that your work applies to? Results from the GP Patient Survey consistently report a poorer experience of making an appointment and lower levels of satisfaction with practice opening time than other CCGs in London. This is also in line with feedback from Healthwatch surveys. A patient’s ease of access to their Practice, and preferred GP, can affect their quality of care and health outcomes (The King’s Fund, 2012).

Looking at the evidence, there is great variability across Ealing practices both in the number of appointments they offer (from less than 70 per 1000 patients to more than 100 per 1000 patients) and their opening times (some closing for lunch and/or half days). This would inevitably lead to inequality of access for patients across Ealing. The aim of the Access standard is to provide very clear expectations for improved access, in every practice, for the benefit of every patient. It provides costed evidence and appropriate investment so that this is achievable by 2020. While the aim of the Ealing Standard is to provide consistent, high quality primary care to all registered patients, the standards identify when population groups should be targeted to ensure this succeeds. Many of the standards integrate across healthcare needs, to ensure health inequalities are targeted and mitigated – for example, referring people with severe and enduring mental health needs to physical health checks, and referring people with long term conditions, and those who are carers, to talking therapies and other forms of support. Groups that have previously experienced health inequalities will benefit from additional focus on screening for a range of health issues, and personal follow up if they do not attend. This will particularly benefit BME groups who experience a higher risk factor in some of these conditions (e.g. diabetes or CVD) but may be less likely to attend screening. Groups that may experience disadvantage due to their circumstances, such as carers or those who are homeless, will be targeted for additional support. Emphasis on self-care and the use of patient activation measures will help clinicians and


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patients have conversations that take in to account the unique needs of individuals.

3. How can you make sure that your work has the best chance of reducing health inequalities? The KPIs in the Ealing Standard all have metrics which can be tracked through the duration of the contract. It will be possible to review the impact of different metrics and make changes if required to better improve the health of disadvantaged groups and tackle health inequalities. There will be substantial ongoing patient engagement on the Ealing Standard, and lay members in the Steering Group will oversee this and pay particular attention to the impact on health inequalities. The impact might take some time to be clearly demonstrated – for some practices this will be a journey of improvement throughout the duration of the contract, to 2020. However, practices will receive support from the CCG to ensure they are on an improvement trajectory and that health inequalities will be addressed. Over the years, the proportion of the contract paid on the basis of population health will be increased, which will increase the emphasis practices’ place on addressing health

inequalities locally.

Monitor and Evaluation 4. How will you monitor and evaluate the effect of your work on health inequalities? See above.

For your records

Name of person(s) who carried out these analyses:

Claire Wilson

Name of Sponsor Director:

Neha Unadkat, Deputy Managing Director – Primary and Integrated Care

Date analyses were completed:

10th July 2017

Review date: 10th July 2018


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Appendix 4 Risk register

ID Type Risk

Pre mitigation rating

Mitigation

Post mitigation rating

Likelihood (1-5)

Impact (1-5)

Score (RAG)

Likelihood (1-5)

Impact (1-5)

score / RAG

1 Operations

There is a risk that transferring services from several existing contracts to a new single wraparound contract may impact on the continuity of service offered to Ealing patients

4 4 16

Go-live of the new access component of the contract will be in September 2017, with a six month lead time until full contract go-live, giving sufficient time to engage with all the practices so that they understand any changes in service requirements and are ready for the go-live date

3 3 9

2 Finance

There is a risk that the cost to deliver the service specification for the wraparound contract is greater or significantly lower than the existing service financial envelope

4 4 16

Engagement with providers through Council of Members meetings, feasibility discussions with clinical leads and developing a robust costing approach

2 3 6

3 PMO

There is a risk of that external expertise required to support the development of the business case will not be secured in time which may impact on the ability to meet the July deadline

4 4 16

Experience suggests the market responds quickly and positively to working in NWL. Employ approach similar to successfully tendered projects of similar type

2 2 4

4 Finance

There is the risk that negotiations with 76 practices, the Local Medical Committee and the local Federation may be protracted, causing delays in implementation

4 4 16 Engage with the LMC, Federation and practices early in the process and test the Contract Specification with the CoM

3 4 12

5 Procurement

There is a risk that the market for extended primary care services in Ealing will not be willing or able to deliver outcomes based care

3 5 15

Engage with providers cross Ealing and invest the provisional provider development fund in readying providers to deliver outcomes based care

2 5 10


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ID Type Risk Pre mitigation rating Mitigation Post mitigation rating

6 Procurement

There is a risk that other providers may challenge the most capable provider procurement route, requiring a full market testing and consequential delays in implementation

3 5 15

Seek legal and procurement advice at an early stage and seek Governing Body approval of the procurement process (within the business case )with the legal and procurement advice in hand

3 2 6

7 Procurement

There may be an actual or perceived conflict of interest for primary care staff in CCG roles working to develop this contract

3 5 15

Robust management of the contract development and approval process, making decisions at CCG committees and involving lay members in decision making

3 4 12

8 Clinical

The intended benefits of outcomes based care may be difficult to realise if they are deprioritised by providers facing significant demand pressures coupled with workforce gaps

3 4 12 Invest the provisional provider development fund in readying providers to deliver outcomes based care

2 5 10

9 Comms

There is a risk that purdah may limit engagement with the public, resulting in a less than optimal engaged public audience prior to business case decision making in July

3 3 9 Draw on existing engagement already undertaken on Access. Plan engagement event post-election (and pre GB meeting).

2 2 4

10 Clinical

There is the risk that the workforce is unavailable locally to deliver the services in the way specified within any future contract

4 4 16

Invest the provisional provider development fund in readying existing workforce to deliver outcomes based care and encourage providers to begin developing workforce plans well before contract go-live

3 4 12


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ID Type Risk Pre mitigation rating Mitigation Post mitigation rating

11 Finance

There is a risk that in order to balance the CCG position, funds that are not committed (including the headroom monies) are held to ensure that the control total is met

3 5 15

The headroom within the allocation has been provided centrally as it is recognised that Ealing practices are further from the target level of funding and therefore can only be invested into general practice. The request to invest the headroom monies will be supported by a business case that demonstrates a return on invest for committing these funds (and any others that would be within the offer).

2 5 10

12 Finance

There is a risk that the precise value of the available headroom funding cannot be determined until premises reviews and other contingencies are accounted for.

3 4 12

A desktop review of premise rent evaluations will be conducted during June to provide better certainty of the value of the available headroom funding.

2 4 8

13 Contractual/Clinical

There is a risk that the national GP contract will change in the future due to wider political changes or that clinical practice will change in the future causing portions of the Ealing Standard to become incorrect or duplicate what is in other contracts.

2 4 8 Include variation or termination clauses in the contract allowing the CCG to flexibly respond to changes in the environment.

2 2 4

14 Finance/Contractual

There is a risk that the PMS contract negotiations are delayed resulting from the wider primary care offer negotiations.

3 3 9

Conduct separate meetings with the PMS practices to keep them informed of timelines and engage with them individually to understand specific issues.

1 3 3


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Appendix 5 OOHS contracts

The 18 OOHS service specifications are:

1. Ambulatory Blood Pressure Monitoring (ABPM) 2. Warfarin Monitoring 3. Warfarin Advanced Monitoring 4. Case Finding, Care Planning, Care Management 5. Wound Care 6. Coordinate My Care 7. Diabetes Level 1 8. Diabetes Level 2 9. ECG 10. High Risk Diabetes 11. Homeless 12. Serious & Long Term Mental Health Needs (Enhanced Case Management) 13. Complex Common Mental Health Needs (Enhanced Case Management) 14. Near Patient Monitoring 15. Phlebotomy 16. Ring Pessary 17. Spirometry 18. Extended Hours


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Appendix 6 Outcome of the Independent Review Panel

Outcome of Independent

Review Panel Ealing Primary Care Standards

5th July 2017

Version 1, 24th

March

2014


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A. Overview

Ealing CCG has developed a Primary Care Offer which incorporates 23 Service Standards that they

intend to commission to support the implementation of the OOH Strategies.

The services that Ealing is looking to re-commission were previously commissioned from General

Practices (GPs) on Out of Hospital Service contracts, under the Local Improvement Scheme. This

standard offer for practices combines all the various contracts let to primary care into a single offer.

The OOH service contract also comes to an end at the end of March 2018. The current OOH service

contract would continue until the end of March 2018. The new offer with the corresponding clinical

services would then take their place.

However, during October 2017 – March 2018, practices would be required to start to implement the

Access Standard.

The pricing structure is consistent with how the OOH services contract was established or in line with

the Local Improvement Schemes approved by the Investment Committee. The model to establish the

prices has been updated to reflect the staffing cost increases in 17/18. Any new components of the

services have been costed using the OOH Costing model.

Background

Ealing CCG serves a GP registered population of more than 430,000 patients, with 76

GMS/PMS/APMS Contracts. Practices receive the majority of core contractual funding from NHS

England.

NHS England is increasing the funding allocation on a yearly basis from 2017/18 up to 2020/21 after a

decade of underfunding. This additional investment provides some headroom to increase the total

investment in primary care across Ealing from £11.8m from March 2017 to 2021 (Figure 1).

Figure 1: Cumulative recurrent increase in primary medical care allocation for Ealing

There is also some inequity between PMS and GMS contracts. NHS England has asked CCGs to


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review all contracts to give equality of opportunity to all GP practices to support fairer distribution of

funding at a locality level and provide equality of opportunity to all practices to provide the same range

of services. The level of “PMS premium” funding currently invested in contracts with Ealing practices is

£640,000 which will be invested fairly across all practices over a 4 year timeframe.

The CCG also commissions a number of services from practices directly for services outside the core

contract that are best delivered from primary care for a registered population. With effect from the 1st

April 2017, Ealing CCG took on responsibility for the commissioning of general practice contracts and

the overall management of the primary care allocation. This enables us to accelerate and localize

primary care transformation, with increased autonomy to shape future primary care services and a

stronger voice for General Practice to influence decision making.

Ealing CCG intend to use this investment to change from commissioning multiple services from

practices to taking a single commissioning approach, with a single wraparound contract for all non-

core CCG commissioned services. The ‘Ealing Standard’ will be holistic, improve outcomes and kpi

provide better value for money, providing vital investment to ensure primary care in Ealing is both

sustained and transformed. It will also help to address equity of funding across practices and public

and patient concerns regarding equality of access across the patch.

The new Ealing Standard will incorporate:

Available NHS England investment that has not been otherwise allocated to fund changes in

the core contract, changes in rents and rates reimbursements and demographic changes.

All existing discretionary CCG funding for services, including winter resilience, LIS schemes

and the Out of Hospital services

Reinvestment of the PMS premium

Funding made available from practices opting out of out of hours services, which will be

separately procured for all patients.

NHS England funding for essential and additional services, estates, Directed Enhanced Services

(DES) and Quality and Outcomes Framework (QOF) will remain outside the Ealing Standard.

The majority of services transferring to the Ealing standard will be paid on a capitation basis; some will

continue to be paid on an activity or prevalence basis. This may change over time (Figure 2).

Capitation-based Activity-based

Respiratory (except diagnostic spirometry)

Cardiovascular (AF, HTN/ABPM, HF)

Musculoskeletal health

Care Planning and co-ordination

End of Life care

Wound Care

Dementia

Cancer screening

Prevention

Self care

Learning Disabilities

Carers

Cardiovascular (Warfarin Monitoring,

Warfarin Initiation, ECG)*

Diabetes (initiation)*

Respiratory (Diagnostic Spirometry)*

Phlebotomy*

Ring Pessary*

Homeless*

ABPI*


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Access

Medicines optimisation and medicines safety

Drug Monitoring (NPT)

Patient Experience

Business Management (Pre-Qualifier)

Demand Management

Prevalence-based

Diabetes (High Risk and care for patients with

diabetes)

Mental Health

Figure 2: Summary of payment mechanism for each standard of contract

Independent Review Panel Process

Ealing CCG set out in its Annual Commissioning Intention document for 2014/2015 both the approach

they intended to take to commissioning a range of ‘Out of Hospital’ services and their view that in the

majority of instances GPs were the most capable providers of these services. The CCGs published

the intention to let the OOH contract to primary care in Ealing and received no challenge to either the

approach or the commissioning route.

The same process will be applied for this contract.

The process incorporates the Out of Hospital framework that the CCGs across North West London

developed to support the procurement of out of hospital services. The framework balances the

requirements of complying with the law and reducing legal challenge with the need to make effective

and integrated commissioning decisions that are right for the local population.

The services that the original process covered when the OOH services contract was let are:


Anticoagulation

Care planning


Diabetes


Homeless care




Phlebotomy

Ring pessary

Vasectomy

Wound care

The second stage of the process includes:



End of Life

Dementia

Cancer Screening


Learning Disability

Carers


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Access

Prevention


Demand Management


The process includes setting up an Independent Review Panel to review the recommended

procurement approach for each of the services.

The panel wass asked to review the recommendations for each service in the context of both national

direction and importantly the CCGs Out of Hospital Strategies.

The panel was made up of:

Lay Member

Non-Conflicted GP (Out of Area)

Quality Lead for CWHHE

Primary Care Manager from NHSE for NWL (2)

The panel will considered each service in turn and the outcome was recorded on each of the sheets

for the services.

A costing model has been developed to support the commissioning of the services. The Investment

Committee has previously reviewed the approach to the costing model when considering the OOH

contract and had the opportunity to discuss and review the draft model. The approach is shown below

(Figure 3):

The updated model works by taking the unit cost and linking to either prevalence or known activity

from 2016/17. The activity information has been taken directly from information provided by practices

under the OOH contract or from QOF. Prevalence information is either taken from the JSNA, QOF or

from NICE guidelines.


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The diagram below provides further detail (Figure 4):

B. Financial Summary

This paper is followed by a series of summary sheets for each service. The financial section shows

the total expected cost at Ealing CCG level.

Overall Recommendations:

The Independent Review panel was asked to review the proposed procurement approach for each service and make a recommendation to the governing body.

5 Confidential |

At the most granular level, each service is divided into input component costs to provide standard unit cost and is linked to prevalence or activity

Inputs

FTE and on - costs

Consumables

Equipment and training

Overheads

Standard unit cost

Outcomes U nit cost

Blended unit cost

Where a service has multiple levels (e.g. diabetes) we have calculated the unit cost for each level and amalgamated this to a give a single blended unit cost which spans across all activity levels

I nputs have been tested with a large range of stakeholders, including: • LMC • CCG Chairs • HoFs • GPs • Lead consultants • Service leads • Practice managers • Practice nurses

For example • P er 1,000 patients

on a list with say 100 patients requiring treatment for a disease

• The cost of treating one patient is £5

• The cost of treating 100 patients is £500

• Per 1,000 patients, the cost of delivering this service is £500

Prevalence

Activity 2016/17

Weighted list

• Single adjustment for prevalence across CWHHE based on QoF / HSCIC data

• A single adjustment is not optimal but it simplifies the unit cost in the service contract

A djustment at practice level for local population demographics

or

For the

capitated costs

– the unit cost

is multiplied by

the number of

patients for the

service across

the borough

and divided by

the weighted

population of

the borough


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Overall Recommendation Table:

Service Line Recommendation from

IRP

Cost

1 Respiratory (new components) Most capable provider £214,329

2 Musculoskeletal Services (MSK) Most capable provider £316,369

3 End of Life (new components) Most capable provider £270,052

4 Dementia Most capable provider £66,245

5 Cancer Screening Most capable provider £195,108

6 Self Care and Patient Activation

Measures

Most capable provider £25,396

7 Learning Disability Most capable provider £117,065

8 Carers Most capable provider £180,927

9 Access Only capable provider £2,838,824

10 Prevention Most capable provider £147,393

11 Medicines Safety and Optimisation Most capable provider £390,217

12 Demand Management Most capable provider £18,532

13 Wound Care (ABPI) Most capable provider £24,230

Total £4,804,777


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C. Details on each service

1. Additional Respiratory Components over OOH services (Spirometry)

A. Service components and pricing

Activity Time Prevalence

assumption

Source of

Funding

Calculation

Value

Risk assessment of COPD for

patients who smoke / have smoked

in past five years

15 mins HCA

To increase

recorded COPD

prevalence from

0.9% to 1.5%

OOH Costing

Model

£14,674

Diagnosis and review of adults and

children and young people; review of

patients who have had asthma

attack within 4 days of UCC / A&E

attendance (2 days for children)

5%

LIS (17/18) £195,109

Training for HCAs 3 hours

training 76 Practices

OOH Costing

Model £4,546

B. Proposed procurement route The service detailed within the specification should be commissioned from providers of GMS/PMS/APMS

services as the most capable providers because: The provider group has access to the registered list of patients and can risk stratify from the patient

population to ensure the agreed cohort of patients as targeted for the support The provider group is the only provider that holds a registered list and has access to the entire patient

medical record. Practices are already delivering spirometry to patients as part of out of hospital services which will

continue under this contract. The service would be provided at a location closer to patients home

It is therefore recommended that the additional respiratory components are commissioned from

GMS/PMS/APMS providers as the most capable providers using a single tender process

C. Independent Review Panel Outcome

Agree with the rationale

Practices as the most capable provider as they hold the smoking data as per QOF

To split the service between providers would be detrimental from a patient and pathway perspective, as Spirometry is undertaken by practices at present as is QOF activity

Noted that this is part of the service

D. Recommendation

Recommendation to the Governing Body that the most capable providers of this service would be the GMS/PMS/APMS providers


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2. Musculoskeletal services



assumption

Source of

Funding

Calculation

Value

Refer to weight loss and healthy

lifestyle programmes for people at risk

of lower limb osteoarthritis and back

pain. 5 mins nurse 6.10%

OOH Costing

Model £63,459

Refer patients with a history of falls, or

at medium and high risk of falls, for a

falls assessment, according to local

referral pathway (under development). 5 mins nurse 3.50%

OOH Costing

Model £36,411

Refer people off work for a

musculoskeletal condition for more than

four weeks, when clinically appropriate,

to the ‘Fit for Work’ scheme or an

equivalent occupation health review.

30 mins GP 0.30%

OOH Costing

Model £79,602

Manage patients with chronic

musculoskeletal pain in primary care if

a treatable musculoskeletal condition

has been excluded, particularly those

previously assessed by

musculoskeletal, orthopaedic or pain

services.

5 mins GP 3.70%

OOH Costing

Model

£129,253

Training for clinical and non-clinical

staff.

Drs: 60

minutes/yr

Nurses, HCA:

30 minutes/yr

Reception: 20

minutes/yr

76 Practices

OOH Costing

Model £7,644

B. Proposed procurement route Musculoskeletal services detailed within the specification should be commissioned from providers of

GMS/PMS/APMS services as the most capable providers because: The provider group has access to the registered list of patients and can proactively case find from the

patient population, refer patients and prescribe. The provider group is the only provider that holds a registered list and has access to the entire patient

medical record. The provider group would be able to manage this vulnerable and complex cohort of patients care in the

context of their complete medical record The service would be provided at a location convenient to the patients’ home.

It is therefore recommended that the musculoskeletal service is commissioned from GMS/PMS/APMS

providers as the most capable providers using a single tender process.

C. Independent Review Panel – outcome

Primary care is the Coordinator/Navigator to the rest of the system and this service would ensure the rest of the pathway is successful


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This is clarifying the pathway with primary care in the role of the Coorinator/Navigator for the patient and the rest of the system

Additional time reflects the work being asked for by the offer D. Recommendation

Recommendation to the Governing Body that the most capable providers of this service would be the GMS/PMS/APMS providers


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3. End of life care (additional components above inclusion of patients on CMC register)



assumption

Source of

Funding

Calculation

Value

Regular update of palliative care

register, and regular reviews of

patients on the register including

symptom review, medication review

and care needs

15 minutes

per quarter

plus one

hour per

annum of GP

time

0.3%

OOH Costing

Model £251,520

Training 3 hours GP

per annum 76 practices

OOH Costing

Model

£18,532

B. Proposed procurement route The additional end of life care service components detailed within the specification should be

commissioned from providers of GMS/PMS/APMS services as the most capable providers because: The provider group has access to the registered list of patients and can provide an integrated on-going

case management approach, including proactive follow-up as well as prescribing, monitoring and administration of medication

The provider group is the only provider that holds a registered list and has access to the entire patient medical record.

Practices are already asked to include patients on the palliative care register to ensure that all agencies have information about their preferred place of death and other information.

The provider group would be able to manage this vulnerable and complex cohort of patients care in the context of their complete medical record

Practitioner can provide care in a location convenient to the patient

It is therefore recommended that the additional end of life care service components are commissioned from GMS/PMS/APMS providers as the most capable providers using a single tender process


Most Capable provider

Reviewed Palliative and Cancer QOF requirements to ensure there is not duplication

Agreed that the specification is above QOF requirements as focussed on individual patient

This is about raising standards across all practices

Recognises the time for practices to do this work

D. Recommendation

Recommendation to the GB that the additional end of life care service components are commissioned from GMS/PMS/APMS providers as the most capable providers using a single tender process


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4. Dementia

A. Service component and pricing


assumption

Source of

Funding

Calculation

Value

Maintain >80% in diagnosis

rates

Review of patients with

dementia, including medication

and care plans

Accept referrals form the

Cognitive Impairment and

Dementia Service with support

of link workers and monitor

progression of dementia

>80% for all

patients

diagnosed

OOH Costing

Model

£66,245

B. Proposed procurement route The service for dementia patients detailed within the specification should be commissioned from providers

of GMS/PMS/APMS services as the most capable providers because: The provider group has access to the registered list of patients and can provide an integrated on-going

case management approach, including proactive follow-up as well as prescribing, monitoring and administration of medication

The provider group is the only provider that holds a registered list and has access to the entire patient medical record.

The provider group would be able to manage this vulnerable and complex cohort of patients care in the context of their complete medical record

The service would be provided at a location convenient to the patient

It is therefore recommended that dementia is commissioned from GMS/PMS/APMS providers as the most capable providers using a single tender process


Delivery is explicit

KPI is higher than QOF requirement

Money needs to follow the patient as they are transferred from a secondary care setting to primary care and recompense to maintain high level of support for this patient group

Standard recognises that by increasing diagnoses rates, means managing patients to ensure no deterioration and provide proactive support takes more time

D. Recommendation

Recommendation that dementia is commissioned from GMS/PMS/APMS providers as the most capable

providers using a single tender process


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5. Cancer screening



assumption

Source of

Funding

Calculation

Value

Letter / phone call to patients from the practice GP who have not responded to the bowel cancer screening invitation

Increase from 44%

LIS (17/18)

£78,043

Letter / phone call to patients from the practice GP who have not responded or declined to attend a breast cancer screening invitation.

Increase from 67%

PMS London Offer baseline

£117,065

B. Proposed procurement route The cancer screening service detailed within the specification should be commissioned from providers of

GMS/PMS/APMS services as the most capable providers because: The provider group has access to the registered list of patients and is therefore best placed to provide

proactive follow-up The CCGs believe that the costs of competitively procuring the service are high for a service that has a

low value per item and low clinical risk. Enabling providers of GMS/PMS/APMS services to deliver a phlebotomy service supports convenient and

accessible care for patients.

It is therefore recommended that cancer screening is commissioned from GMS/PMS/APMS providers as the most capable providers using a single tender process


- The Good Practice Guide for Cancer Screening in London recommends interventions to increase screening uptake through endorsement by a patient’s own GP.

D. Recommendation

Recommendation to GB that cancer screening standard is commissioned from GMS/PMS/APMS providers as the most capable providers using a single tender process


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6. Self care and patient activation measures



assumption

Source of

Funding

Calculation

Value

Review Patient Activation Status when reviewing patients care plan and input PAM data. Training on how to use the Patient Activation Status to support self-management of long term conditions.

5 mins

2% of practice population

OOH Costing Model

£16,304

Training for HCAs/Administrative team

3 hours 76 practices OOH Costing Model

£9,092

A. Proposed procurement route The self-care service detailed within the specification should be commissioned from providers of

GMS/PMS/APMS services as the most capable providers because: The provider group has access to the registered list of patients and can provide this service as part of

their an integrated on-going case management approach The service would be provided at a location closer to patients home

It is therefore recommended that self-care and patient activation is commissioned from GMS/PMS/APMS

providers as the most capable providers using a single tender process

B. Independent Review Panel Outcome Supporting patients to take more proactive role in self-care is a key national strategy as well as STP strategy

D. Recommendation

Recommendation to the GB that self-care and patient activation is commissioned from GMS/PMS/APMS

providers as the most capable providers using a single tender process


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7. Learning disabilities



assumption

Source of

Funding

Calculation

Value

Review registered list to ensure concordance of diagnosis of patients with LD and ensure that those >14 years have an annual health check

70% of patients with LD

LIS (16/17)

£117,065

C. Proposed procurement route The learning disabilities service detailed within the specification should be commissioned from providers of

GMS/PMS/APMS services as the most capable providers because The provider group has access to the registered list of patients and can case find patients who require this

service The provider group would be able to manage this vulnerable and complex cohort of patients care in the

context of their complete medical record The service would be provided at a location closer to patients home

It is therefore recommended that learning disabilities is commissioned from GMS/PMS/APMS providers as

the most capable providers using a single tender process. D. Independent Review Panel Outcome

Noted that at the Annual Health Check event, patients were clearly advocating the need for this support for practices and how much of a difference it makes to them.

Clarification – this is from age 14, under 14 delivered by community Paediatric support services D. Recommendation

Recommendation to the GB that learning disabilities is commissioned from GMS/PMS/APMS providers as the most capable providers using a single tender process.


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8. Carers



assumption

Source of

Funding

Calculations

Value

Offer annual health assessment and flu vaccination Refer to appropriate support services

30 mins HCA time; 10 mins nursing time


OOH Costing Model £59,316

Carers training and systems: Identify carers lead, ensure all staff are carer aware, record carer status in patient notes


LIS (15/16)

£117,065

Training for HCAs and/or administrative staff

3 hours 76 practices OOH Costing Model

£4,546

E. Proposed procurement route The carers service detailed within the specification should be commissioned from providers of

GMS/PMS/APMS services as the most capable providers because: The provider group has access to the registered list of patients and can proactively identify patients The provider group is the only provider that holds a registered list and has access to the entire patient

medical record The provider group would be able to manage this vulnerable and complex cohort of patients care in the

context of their complete medical record The service would be provided at a location closer to patients home

It is therefore recommended that carers is commissioned from GMS/PMS/APMS providers as the most

capable providers using a single tender process F. Independent Review Panel Outcome

- Assume training is for HCAs and Administrative staff

- This provider group is required to record carer status on their systems

D. Recommendation

Recommended to the GB that carers is commissioned from GMS/PMS/APMS providers as the most capable providers using a single tender process


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9. Access

G. Service component and pricing


assumption

Source of

Funding

Calculations

Value

By 2020, patient access to primary medical care from 8-6.30 Monday to Friday as set out in the strategic commissioning framework; At least 100 appointments per 000 population, 105 during winter period During Opening hours: Staffed reception Under 12 or for any patient with urgent needs seen same day Flexible appointment System Telephone consultations and online booking (4 weeks in advance) Ability to book appointment with clinician of patients choosing through any route Home visits triaged within 1 hour and visit time agreed Accept UCC re-directions

1 GP, 2 x band 4 (HCA / admin) per hour per 1,100 registered list size

100% patient population

OOH Costing Model

£2,838,824

H. Proposed procurement route The access service detailed within the specification should be commissioned from providers of

GMS/PMS/APMS services as the only capable providers because: The terms of the strategic commissioning framework can only be met by general practice. The provider group is the only provider that holds a registered list and has access to the entire patient

medical record. The service would be provided at a location closer to patients home

It is therefore recommended that access is commissioned from GMS/PMS/APMS providers as the only

capable providers using a single tender process

I. Independent Review Panel Outcome

Provided context of development of this standard

And feedback from Patients and Public over the last few years on access to primary care

Explained that Healthwatch is running a survey across the borough – early feedback from the survey has fed into the development of the standard – Report to be added to the Business Case

Primary care funding in Ealing is significantly distant from target funding levels

Add Healthwatch report to Business Case

Clear that these areas of access are not defined in the core contract for PMS/GMS, and 1 APMS contract, however, 4 APMS contracts are aligned to this specification and therefore would not be eligible for this component of the offer.

D. Recommendation


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Recommendation that access is commissioned from GMS/PMS/APMS providers as the only capable

providers using a single tender process


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10. Prevention



assumption

Source of

Funding

Calculations

Value

Imms call and recall 240 mins admin OOH Costing Model

£82,993

Training 8 hours admin OOH Costing Model

£12,123

Proactive identification of patients with CKD

10 min nurse patient population 4,679


Blood pressure monitoring

10 min HCA patient population 4,300

OOH Costing Model

£16,304

Management of GFR

10 min HCA patient population 430

OOH Costing Model

£1,630

Pulse Checks 1 min nurse patient population 24,186


B. Proposed procurement route The prevention service detailed within the specification should be commissioned from providers of

GMS/PMS/APMS services as the most capable providers because: The provider group has access to the registered list of patients and is therefore best placed to risk stratify,

screen and provide proactive follow-up The service would be provided at a location closer to patients home

It is therefore recommended that the prevention service is commissioned from GMS/PMS/APMS providers

as the most capable providers using a single tender process.


Explained that the call/recall for Childhood Imms is not done by the CHIS is Ealing which led to a Serious Incident in 2015/16

D. Recommendation

Recommendation to GB that the prevention service is commissioned from GMS/PMS/APMS providers as the most capable providers using a single tender process.


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11. Medicines safety and optimisation



assumption

Source of

Funding

Calculations

Value

Patient safety audit as part of the Medicines Optimisation and Safety Scheme

Identify and review patients with unsafe prescriptions in line with MHRA alerts

Abide by the North West London Integrated Formulary, NICE guidance and other nationally agreed guidance.

n/a

LIS (17/18)

£390,217

B. Proposed procurement route The medicines safety service detailed within the specification should be commissioned from providers of

GMS/PMS/APMS services as the most capable providers because: This service is about managing prescribing for patients from a practices own list safely and to national and

local guidelines

It is therefore recommended that the medicines safety and optimisation service is commissioned from GMS/PMS/APMS providers as the most capable providers using a single tender process.


No additional comments, but clarified that areas for focus for audits, will be agreed annually

D. Recommendation

Recommendation to the GB that the medicines safety and optimisation service is commissioned from



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12. Demand management



assumption

Source of

Funding

Calculations

Value

Refer all referrals through RFS unless the referral is on the specific RFS exclusion list.

Comply with the PPwT Policies; review referral data and engage in practice referral discussions for a range of specialties

Conduct internal practice peer reviews and/or establish processes to review referrals and participate in peer reviews in network based sessions as arranged by the CCG (1 per annum)

3 hours GP time

n/a

Out of Hospital Costing Model

£18,532

B. Proposed procurement route The demand management service detailed within the specification should be commissioned from providers

of GMS/PMS/APMS services as the most capable providers because: This standard requires practices to reflect and peer review their referring practices

It is therefore recommended that demand management is commissioned from GMS/PMS/APMS providers

as the most capable providers using a single tender process. C. Independent Review Panel Outcome Clarification that there would be 1 peer review per annum

D. Recommendation

Recommendation to the GB that the medicines safety and optimisation service is commissioned from



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13. Wound Care (ABPI)



assumption

Source of

Funding

Calculation

Value

Carry out ABPI 30 minutes

of a nurse

time 1000 patients

OOH Costing

Model

£17,230

Equipment and Training

OOH Costing

Model

£7,000

B. Proposed procurement route The ABPI service detailed within the specification should be commissioned from providers of

GMS/PMS/APMS services as the most capable providers because: – The provider group has skilled staff capable of delivering the service – The provider group would be able to manage this cohort of patients in the context of their

complete medical record – The service would be provided at a location closer to patients home

It is therefore recommended that ABPI is commissioned from GMS/PMS/APMS providers as the most

capable providers using a single tender process


Recognised that the overall standards brings the role of primary care together in supporting the system D. Recommendation

Recommendation that ABPI is commissioned from GMS/PMS/APMS providers as the most capable providers

using a single tender process


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Notes from IRP 05.07.17:

Introduction and Context provided by Tessa Sandall

Purpose of the meeting is to review specifications to determine whether GMS/PMS/APMS contract holders

were the most capable provider and the services should be commissioned using a single tender waiver

process.

Governing Body signed off the procurement approach which remains in place which sets out the decision

making tree, described in the paper.

The Independent Review Panel (IRP) is a part of that process.

The Panel fed back on each specification as described on the cover sheets.

Overall feedback from IRP

The offer is patient orientated and link to the ‘I’ Statements developed when Whole Systems Integrated Care

was being developed. This will go quite some way to implementing this.

Supports the GPFV on providing resilience and sustainability in general practice, providing continuity and

coordination of care for individuals

This offer will support the agenda of raising standards and reducing variation across primary care thereby

delivering Quality Improvements. It recognizes the need to pay for the work that primary care is having to do

as the population changes and not doing more for the same.

Primary Care is the most capable provider of the overall standards as they are the registered holders of the

list, can provide continuity of care, working with a multi-disciplinary team and provide a

coordination/navigation function for the rest of the system


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Appendix 7 Annual Self Declaration

Issue Please

Tick

Maintaining and achieving all regulatory requirements including CQC, HTA, HFEA, MHRA, and

medicines regulation

Ensuring delivery of primary medical services contractual and statutory requirements. No unlifted,

uncontested, related breaches in the last 12 months.

Confirming that the practice is registered with the CQC with no conditions, except in circumstances

beyond the control of practices, such as the void position resulting from GP retirements

Having due regard to NHS policy, clinical guidelines, best practice and local CWHHE policies and

procedures

Ensuring that all staff are appropriately credentialed, including:

DBS check

Work permits

Maintenance of professional accreditation and statutory registration

Revalidation for doctors

Confirming that all doctors meet all requirements to practice, do not have any restrictions on their

registration, and are also not under investigation for any clinical matters

Ensuring that appropriate insurance arrangements are in place:

Employers liability

Public liability

Medical negligence cover (doctors only)

Professional liability insurance (nurses and therapists not employed within the NHS)

Ensuring that staff receive regular mandatory training:

General health & safety

Fire

Manual handling

Basic life support

Safeguarding

Infection prevention and control – hand hygiene (basic)


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Ensuring that appropriate clinical governance arrangements are in place, including but not limited to:

Evidence of having undertaken appropriate checks of staff employed(as above)

Policies and procedures to ensure a safe working environment and safe care for patients

Signed Information Sharing Agreement as part of the Federation or Cluster

Information governance and security – Completion of Information Governance Toolkit

Continuing professional education and other training

Clinical audit and other quality review mechanisms

Review of patient feedback and complaints, action taken and any trends identified

Incident reporting mechanism

Review of incidents with corrective action taken

Maintenance of a clinical risk log

Checking staff vaccinations and incidence of communicable diseases(e.g.Hep B)

Notifying Ealing GPF of any material incident or issue and providing evidence of root cause analysis and corrective action taken

Process for logging and taking action against Clinical Alerts

Evidence of collection of Equality and Diversity data to support delivery of appropriate services for the population served

Ensuring the practice participates in clinical audit cycles and peer review external to their practice

Ensuring the practice has an open list

Ensuring same day appointments are available for patients clinically assessed as requiring them

Ensuring individuals have access to relevant and comprehensive information, in the right formats, to

inform choice and decision-making about their care

Ensuring information and services are available for individuals who are able to self-manage their

conditions or who need care plan support


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Appendix 8: Primary Care Offer Steering Group TOR

__________________________________________________________________________

Ealing Primary Care Offer steering group Terms of Reference

___________________________________________________________________

1. Purpose

Ealing CCG are developing a primary care offer within the borough, to be commissioned from April

2018. This new offer is distinct from the core GMS and PMS contracts. The aim is also for the

Access component to go live from October 2017. The ‘Ealing Primary Care Offer steering group’ will

oversee and drive this process. It will:

• Oversee the development of a business case for decision making by the Ealing CCG Governing

Body;

• Drive the development of the new contract specification;

• Ensure an appropriate procurement approach is employed, compliant with procurement rules

and providing assurance to the CCG;

• Ensure clinical safety and quality is maintained during and post-contract transition, and risks and

issues managed; and

• Oversee the mobilisation of the new primary care offer.

This is a discussion-only body to oversee the development of the specification. All

recommendations will be made by committees and decisions made by the Governing Body.

2. Responsibilities

To identify and agree services to be commissioning within the new primary care offer, ensuring

all contract interdependencies (GMS, PMS etc.) are realised and managed;

To identify the high level priority outcomes, ensuring service users have been engaged and their

views are reflected in the approach;

To design an outcomes-based framework with linked financial incentives for in scope services;

To identify contract budget, commercial risk and reward arrangements;

To identify KPIs linked to the desired outcomes against which the contract will be monitored;

To oversee the development of the contract service specification and overarching business case

for Ealing CCG Governing Body decision making;

To oversee the development of appropriate procurement documentation ensuring alignment with

procurement legislation;

To manage the commissioning and mobilisation process;

To develop a detailed programme plan (incorporating phases: Plan, Engage, monitoring

progress against plan and escalating any major risks and issues to Ealing CCG Governing

Body for resolution;

To ensure appropriate engagement with protected and disadvantaged groups, and that an

equalities impact assessment has been undertaken;

To ensure all stakeholder groups are identified and appropriately engaged, and the impact on

their services realised;


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To ensure patient safety and service quality is maintained throughout the process;

To identify and address any risks and issues that may be realised throughout the procurement

process; and

Report progress to the Ealing CCG Governing Body in line with reporting requirements.

3. Reporting and accountability

The Ealing Primary Care offer steering group will be accountable to the Ealing CCG Governing Body and will report to this Body as required.

4. Membership

Dr Mohini Parmar – Chair, Ealing CCG Tessa Sandall – MD, Ealing CCG Dr Vijay Tailor – Governing body member, Ealing CCG Dr Raj Chandok – Governing body member, Ealing CCG Dr Shanker Vijayadeva – Governing body member, Ealing CCG Dr Maria Waters – Governing body member, Ealing CCG Fionnuala O’Donnell - Governing body member, Ealing CCG Sally Armstrong - Governing body member, Ealing CCG Carmel Cahill – Lay governing body member, Ealing CCG Adam Jenkins – Chair of Ealing, Hammersmith and Hounslow LMC Jane Betts – London Wide LMC representative Neha Unadkat – Deputy MD, Ealing CCG Catherine Williams – Interim Head of Primary Care, Ealing CCG Andrew Pike – Assistant Director of Comms & Engagement, Ealing CCG

Additional commissioning, local authority colleagues and service users may be co-opted as necessary to support the Steering Group in specific task and finish groups to complete individual outcomes. The Ealing PMS practices have been offered a position on this steering group but a representative has not yet been nominated. The wider Council of Members will also be offered a position on this steering group.

5. Meetings

The group will meet on a fortnightly basis. Frequency of these meetings may be varied on the direction of the chair.

Papers will be circulated one working day in advance of, and updated action logs one working days after, the meeting.

A meeting quorum is achieved with 50% of members in attendance.

Management and administrative support for the group will be provided by the Primary Care Project Manager.

Ealing Primary Care Standard

Documents

Transcript of Ealing Primary Care Standard