Primary Care Commissioning Committee , Part 1 … Care...South East London Primary Care Team Nora...

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Primary Care Commissioning Committee, Part 1 Held in Public

Wednesday 9th October 2019 2-3.30pm Kirkham Room, Bexleyheath Marriot Hotel

AGENDA

Item

Time

Item Description Presented by Enc

Opening Business

36/19 2.00 Welcome and introductions Paul Cutler -

37/19 2.02 Declarations of Interest Paul Cutler A

38/19 2.05 Review of minutes from the Primary Care Commissioning Committee meeting on 19th June 2019

Paul Cutler B

39/19 2.07 Review of action log – no open items to report

Paul Cutler C

Matters Arising

40/19 2.08 1. Update on Bursted Wood Procurement 2. Update on Little Heath Practice 3. Ingleton Avenue Surgery discretionary funding amount

Jill Webb

Jill Webb

Nisha Wheeler

- - -

41/19 2.20 Urgent planned PCCC decisions for reporting: 1. Chairs action 28/06/2019: Update on APL Primary Care Network and Contract Variations 2.Extraordinary meeting 25/07/2019: Review of the need for contractual action following inspection by the Care Quality Commission (CQC) 3. Urgent planned decision 19/09/2019: Special Allocation Scheme contract award decision

Nisha Wheeler

Jill Webb

Jill Webb

D

E -

Items for approval

42/19 2.35 Review of PCCC ToR Nisha Wheeler G

Items for information

43/19 2.40 Primary Care Quality report Sarah Birch H

44/19 2.50 GP patient survey (published July 2019) report Sarah Birch I

36.00 Agenda

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Item

Time

Item Description Presented by Enc

45/19 3.00 Primary Care Network Progress update Nisha Wheeler J

45/19 3.10 Primary Care Finance Report Julie Witherall K

Closing Business

46/19 3.15 Questions from members of the public: Any member of the public who wishes to ask a question at the Primary Care Commissioning Committee should send it in advance to [email protected] Members of the public are reminded that queries relating to individual staff or patients cannot be discussed. The chair reserves the right not to respond to queries relating to issues which are the subject of current confidential discussions or legal action or any other matter at his discretion without giving any reason.

All

Date of next meeting: Wednesday 11th December 2019 2.00- 3.30pm, Bexley Civic Centre, Watling Street DA6 7AT

36.00 Agenda

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mailto:[email protected]

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36.00 Agenda


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Membership: Primary Care Commissioning Committee (part 1) Public

Voting Members

Neil Ross - Chair (NR) Lay member for Legal & and Procurement

Keith Wood (KW) Lay member for Audit and Governance

Paul Cutler – Vice Chair

(PC) Lay member for Patients Participation and Involvement (PPI)

Neil Kennett-Brown (NKB) Bexley and Greenwich CCGs

Managing Director

Michael Boyce (MB) Bexley CCG Deputy Managing Director and Director of Quality

Mary Currie (MC) Bexley CCG Registered Nurse

Nisha Wheeler (NW) Bexley CCG

Director of Primary Care, ICT & IG

Dr Jhumur Moir (JM) Westwood Surgery

GP Locality Lead, Clocktower

Dr Varun Bhalla (VB) Belvedere Medical Centre

GP Locality Lead, North Bexley

Dr Sid Deshmukh (SD) Bexley CCG Chair

Dr Sonia Khanna-Deshmukh

(SKD) Sidcup Medical Centre

GP Locality Lead, Frognal

David Maloney Represented by Julie Witherall

(DM) (JW)

Bexley, Greenwich & Lewisham CCGs Bexley CCG

Director of Finance Deputy Director of Finance

Non-voting members

Dr Anjan Ghosh (AG) London Borough of Bexley

Representative for Health and Wellbeing Board, Director of Public Health and Deputy Director of Health & Wellbeing

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

Station Road Surgery

Jane Garfield-Field (JGJ) Healthwatch Bexley Manager

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

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

Quoracy: 50% of the non-GP voting members

36.00 Agenda


NHS Bexley CCG Primary Care Commissioning Committee members’ declaration of interest 01/10/2019 – Public Meeting

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

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

Dr Sid Deshmukh Bexley CCG Chair

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

Personal Health Budgetsd) Information and service support for people with

physical and sensory impairment.10. GP Lead and Senior Partner, Crook Log Surgery

Dr Varun Bhalla

GB Locality Lead, North Bexley

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

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

Update Signature

Dr Jhumur Moir GB Locality Lead, Clocktower

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

Dr Sonia Khanna-Deshmukh

GB Locality Lead, Frognal

1. GP Partner at Sidcup Medical Centre2. GP Appraiser for South London,3. Blossom Care Homes Ltd:i) 15% Shareholdingii) Father is Director of Blossom Care Homes Ltdiii) Father and Husband are shareholders4. Inspire Community Trust; Father (Vinod Khanna) is the Chief Executive Officer5. Shareholder, Bexley Health Neighbourhood Care; No profit share6. Board Member, Bexley LMC7. Husband, Dr Sid Deshmukh is:i) Senior Partner at Sidcup Medical Centreii) Bexley CCG Chair8. Involved in the developing a pathway for bladder problems in SE London.9. LMC Representative 10. Clinical Lead, Children and Young People

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

involved in decision making where there is a conflict of interest

Keith Wood GB Lay Member for Governance and Audit None

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Update Signature

Paul Cutler GB Lay Member for PPI

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

Does not take on contracts with organisations within Bexley

Neil Ross GB Lay Member for Legal and Procurement None

Mary Currie Governing Body Nurse

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

Michael Boyce Deputy Managing Director and Director of Quality None

Neil Kennett-Brown Managing Director

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

Sept,17Sept.17Jan. 00

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

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Update Signature

David Maloney Director of Finance

Director of Finance;i) Greenwich CCGii) Lewisham CCGiii) Trustee, Greenwich Charitable Trust4. Member, Greenwich Charitable Funds

Nisha Wheeler

Director of Primary Care, ICT & IG

Husband is employed within the ICT department of Kings College NHS Foundation Trust.

Dr Anjan Ghosh

Director of Public Health, LB Bexley Director of Public Health for LB Bexley 2017

Julie Witherall Deputy Director of Finance None

Dr Richard Money

Member, Medicines Management Sub-Committee

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

Jill Webb Primary Care Commissioning Committee

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

Nora Simon Member, Primary Care Commissioning Committee

Assistant Head of Primary Care, SEL Primary Care Team, NHS England

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PRIMARY CARE COMMISSIONING COMMITTEE(Part 1) Public Meeting

Wednesday 19th June 2019 2.00-3.30pm Public Gallery West, Bexley Civic Centre DA6 7AT

Voting MembersNeil Ross (NR) Chair Lay member, legal & procurement Paul Cutler (PC) Lay member, patient and public involvement Dr Varun Bhalla (VB) GP member, North Bexley Locality LeadJill Webb (JW) Head of Primary Care, SEL Primary Care Team Keith Wood (KW) Lay member, governance Mary Currie (MC) Governing Body Nurse Nisha Wheeler (NW) Director of Primary Care, ICT & IGDr Sid Deshmukh (SD) CCG ChairDavid Maloney (DM) Director of Finance, Bexley, Greenwich & Lewisham CCGs

Non-voting members Jayne Garfield-Field (JGJ) Manager, HealthwatchDr Richard Money (RM) Bexley Local Medical Committee (LMC) Chair Jill Webb (JW) Head of Primary Care, SEL Primary Care TeamNora Simon (NS) Assistant Head of Primary Care, SEL PCT

In attendance Lisa Luxford (LL) Primary Care Coordinator(Minutes)

Apologies Julie Witherall (JW) Deputy Director of Finance, Bexley CCG Neil Kennett-Brown (NKB) Managing Director, Bexley and Greenwich CCG’sDr Sonia Khanna-Deshmukh (SKD) GP member, Frognal Locality LeadMichael Boyce (MB) Deputy Managing Director Dr Jhumur Moir (JM) GP member, Clocktower Locality Lead Dr Anjan Ghosh (AnG) LBB Director of Public Health and Deputy Director of Health &

Wellbeing, Health and Wellbeing Board Representative

ENCLOSURE: BAGENDA ITEM:

38.19 Review of minutes 19th June 2019


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Item No1. Standing items

24/1924.19.1

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

25/1925.19.1

Declarations of Conflicts of Interest The declarations of interest register was passed amongst attendees and signed by those present. The following additional declarations were noted:

All GP’s in regard to agenda items 28/19 and 34/19

26/19

26.19.1

26.19.2

26.19.3

Review of minutes from the Primary Care Commissioning Committee meeting (held in public) on 24th April 2019The committee approved the minutes of the Primary Care Commissioning Committee meeting (held in public) on 24th April 2019, as an accurate record, subject to the following amendment

Page 2. Item 16.19.2 last bullet point corrected to: The Local Medical Committee (LMC)

Review of minutes the extraordinary Primary Care Commissioning Committee meeting (Part 1 ) on 21st May 2019The committee approved the minutes of the extraordinary Primary Care Commissioning Committee meeting (part 1) on 21st May 2019, as an accuraterecord of the meeting.

27/1927.19.1

Review of Action Log The action log was reviewed and updated

28/1928.19.1

28.19.2

Matters Arising Primary Care Network (PCN) Update - NW updated the meeting on the current position on the formation of the PCNs in Bexley. Three locality-based networks covering a population of 236, 562 (as at the 1st April) have been approved/endorsed by the Commissioning Strategy Committee (CSC), Local Care Network (LCN) and the Primary Care Commissioning Committee. In addition to the three supported PCNs, there is an unsupported network application, APL. APL consists of three practices spanning vertically across each of the three localities and covering a population of approximately 31,000 patients. In an effort to reach a mutually acceptable position a series of discussions have taken place between local stakeholders, LMC, STP and members of the Primary Care Commissioning Committee. The STP have issued a letter to the APL practices requesting consideration of an alternative compromise proposal with a response date of 20th June 2019. Ongoing discussions with all parties have continued to taken place to determine how a position of support can be achieved.

A further meeting with the APL network, LWLMC representatives and the CCG is scheduled to take place after the PCCC meeting today to discuss what needs to be put in place by the APL network to enable wider partners from the Local Care Partnership Board to support their proposed network.



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28.19.3

28.19.4

28.19.5

28.19.6

28.19.7

28.19.8

28.19.9

Ingleton Avenue Surgery has chosen not to sign the Network contract DES. The practice has a patient list size of 5,150 as at 1st April and lies within the Clocktower locality. Following discussion and negotiation with the Clocktower PCN, an agreement has been reached for the Clocktower PCN to take responsibility for the provision of network services for Ingleton Avenue Surgery patients under a locally commissioned agreement.

Once a final position has been reached in regard to the formation of the all PCNs, the PCCC will be required to approve all PCN arrangements in Bexley and for practice contracts to be varied to include the Network Contract DES. This may need to take place as either an urgent planned meeting of the PCCC or can be done via Chairs action.

Overview of recent Care Quality Commission (CQC) inspection reports - JW provided an overview of the newly published CQC reports for a number of GP practices in Bexley. It was brought to the committee’s attention that due diligence was yet to be undertaken with each of the practices following the publication of the reports which could not be done prior to the meeting due to the reports being published within the last week.

Following a CQC inspection a report is published that provides an overall rating for a service, together with a rating for each of the following questions: Are services safe? Are services caring? Are services responsive? Are services effective? Are services well-led?

Bellegrove Surgery - CQC inspection report published 06/06/2019. Overall rating; requires improvement. In the area of safe the practice was rated as inadequate and requires improvement in the “well-led” domain. The practice was rated as good in all other areas. Themes that were identified by the report included an issue relating to recruitment and training procedures and the prescribing of a high risk medicine. The GP has provided assurance that immediate action was taken following the CQC visit and upon re-auditing the practice was found to be 100% compliant. A meeting with the practice to review the action plan will be arranged. A paper providing further detail on the agreed action plan following the findings of the CQC report will be provided to the committee ahead of the next scheduled PCCC on 24th August 2019.

Lyndhurst Medical Centre - CQC inspection report published 20/05/2019. Overall rating; requires improvement. In the area of “safe” the practice was rated as requires improvement in well-led domain the practice was also rated asrequires improvement. The practice was rated as good in all other areas. Themes that were identified by the report included the process for monitoring high risk medications and issues with infection control. The CCG medicines management team are supporting the practice and the NEL commissioning unit will be undertaking an audit. A meeting with the practice to go through the action plan has been arranged.

Bexley Medical Group - CQC inspection report published 30/05/2019. Overall rating; good. In the area of “safe” the practice was rated as requires improvement. The practice was rated as good in all other areas. An action plan



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28.19.10

28.19.11

28.19.12

28.19.13

28.19.14

28.19.15

will be requested.

Dr Thavapalan Practice - CQC inspection report published 29/03/2019. Overall rating; requires improvement. Further detail in agenda item 30/19

Crook Log Surgery - CQC inspection report published 07/06/2019 following unannounced inspection on 27/03/2019. Overall rating; inadequate. In the areas of “safe” and “well-led” the practice was rated as inadequate. In the areas of “effective” and “responsive” the practice was rated as requires improvement. In the area of “caring”, the practice was rated good. The practice has been placed into special measures and warning notices have been issued. As previously reported to the committee, on-going assurance activities have been carried out by the partners and management team at the practice. Monthly meetings to support and monitor the practice have continued together with quarterly senior management assurance meetings. The contractor has been fully cooperative. Regular review meetings and quarterly assurance milestone meetings will continue until the all the improvement plans actions have been remedied. The practice has agreed to add any required additional actions to the contractualised Improvement Plan. From 01/05/2019 two new contract signatories were added to the contract and a subsequent proposed merger with Sidcup Medical is due to take place on 01/04/2020. Early indications from the patient engagement team are that the practice is beginning to receive positive feedback. The CCG is engaging with the Patient Participation Group (PPG) to keep patients informed.

JW advised that in regard to practices that have received a CQC inspection rating of inadequate or requires improvement a decision by the committee will be required to determine the course of contractual action, if any, to take place. Due to the timings of publication of the CQC reports and the subsequent meetings with the practice it will be necessary for the committee to make these decisions ahead of the next planned meeting on 24/08/2019.

JW noted that Bexley was not alone in the position of having practices previously rated as good by the CQC, receiving a lower rating in their subsequent inspection. The committee should be assured that all practices concerned are offering their complete co-operation and engaging in a very thorough way.

PC expressed an opinion that communications regarding the recently published CQC reports need to be managed carefully to avoid the misconception of a pattern of primary care in Bexley that is not a reality.

VB expressed a view that particularly in the case of high risk drugs and shared care, a whole system approach was needed to overcome logistical issues that may negatively impact on a GP practice when looked at in isolation.

2. Items for decision 29/1929.19.1

Bellegrove Surgery formal list closure application The committee is asked to consider the request by Bellegrove Surgery to formally close its list for a limited period for the following reasons:

∑ The practice has been unable to fill a permanent salaried GP vacancy for 6 months and is running at below the recommended number of whole



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29.19.2

29.19.3

time equivalent (WTE) GPs. ∑ The number of patients on the practice list has been steadily growing.

The practice list size shows an increase in every quarter wit he largest increase in Qtr 2 of 2018/19 and Qtr1 2019/20.

∑ The contractor has seen a significant movement of patients from neighbouring practices, many of which have complex needs or are terminally ill. This has resulted in significant pressures on the clinicians to maintain the high level of care the practice provides to its patients.

∑ The senior partner’s capacity is impacted by his commitment to supportthe GP Federation work at Bursted Wood Surgery, providing supervision to a GP recruited through the International GP Scheme.

∑ The practice is confident it will be able to re-open its list in the near future following recruitment of a GP via the vocational training scheme (VTS).They will be starting part-time in August 2019 with a view to working full-time from September 2019. In addition there is another VTS GP currently in training at a local practice who has expressed an interest in joining the practice once their training is complete.

∑ The practice has engaged with its PPG which is in support of the application

JW advised the committee that regulations state that a practice cannot re-apply to close their list within a twelve month period. To ensure that the practice has sufficient time to re-establish their resilience, it was suggested that approval was given for a formal closure of the list for slightly longer than the requested four months: up to six months.

The committee approved the request by the contractor at Bellegrove Surgery to formally close its list from 1st July 2019, for up to six months subject to the following conditions being met:

∑ The contractor works with the CCG to ensure that its list size is re-opened at the end of October 2019 or December 2019 at the latest.

∑ The contractor provides evidence of the PPG meeting that took place on the 4th June 2019.

∑ The contractor provides evidence of its engagement with local practices about its plans to apply for a formal list closure.

∑ The contractor displays posters of the 4 months closure with the practice, via practice communications and on its website.

.30/19

30.19.1

30.19.2

Dr Thavapalan (Littleheath Surgery) : Review of the need for contractual action following inspection by the Care Quality Commission (CQC)Following an announced comprehensive CQC inspection on 29/03/2019 at Littleheath Surgery the practice received an overall rating of requires improvement. In the domain of “safe” the practice was rated as inadequate. In the domains of “effective” and “well-led” the practice was rated as requires improvement. In the domains of “caring” and “responsive” the practice was rated as good. A warning notice was issued to the practice on 02/04/2019.

The contractor will be subject to another CQC inspection within six months of the inspection report publication on 22/05/2019.Commissioners met with the practice on 29/04/2019 to discuss the warning notice and the contractor’s plans to



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30.19.4

30.19.5

30.19.6

30.19.7

30.19.8

30.19.9

30.19.10

address areas of non-compliance.

The committee was directed to the consider the following points ∑ The Primary Care Joint Committee (PCJC) previously approved the

London Region standard operation procedure for Primary Medical contracts: A consistent approach to responding to CQC requiresimprovement rating.

∑ Should contractual action be considered?∑ Should a breach or remedial notice be issued based on the CQC visit

report evidence?∑ What is the Contractor’s track record?∑ Is it a proportionate response to issue a breach or remedial notice?

It was noted that the practice has a good record with no previous concerns on record and is cooperating fully to resolve the compliance issues. A majority of concerns identified in the report have already been actioned and work is in progress to resolve the remaining issues.

The committee discussed the commissioner’s recommendation to issue a remedial notice in respect of those areas of contractual non-compliance which have not yet been fully resolved.

KW expressed the view that he was unsure what would be gained by the NHS issuing a remedial notice when a majority of issues had already been dealt with.JW reminded the committee that the CQC and NHS had separate statutory responsibilities, and there were some serious statutory and contractual compliance issues identified in the CQC report.

RM confirmed that the LMC is satisfied that procedures have been followed and advised that the practice has not approached the LMC for support.

JW confirmed that a remedial notice could be escalated to a breach notice if the contractor does not undertake the necessary actions.

The committee was of the opinion that the issue of a remedial notice would be appropriate response given the good record of the practice and demonstrated a consistent approach.

The committee approved the issue of a remedial notice to Dr Thavapalan in respect of those areas of non-contractual compliance identified in the CQC report and yet to be resolved

31/1931.19.1

31.19.2

Primary Care Network (PCN) - Ingleton Avenue SurgeryIngleton Avenue Surgery is located in Welling with a list size of approximately 5000 patients (April 2019). The practice lies within the Clocktower locality and was rated good in a CQC inspection report published on 23/03/2019.

The practice has chosen not to sign the Network contract DES despite extensive engagement by the GP Federation to try and facilitate an agreement.



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31.19.3

31.19.4

31.19.5

31.19.6

Clocktower PCN is the most geographically aligned network to the practice and has agreed to provide extended hours services for the registered patients of Ingleton Avenue Surgery. The CCG is required to put in place a locally commissioned scheme to support this arrangement.

Under this arrangement Ingleton Avenue Surgery patients will have equal access to the extended hours service which will become a network service under the Network Contract DES from the 1st July and provided by the Clocktower PCNalong with any future network services as stipulated by the Network Contract DES. Whilst initially, the Network Contract DES will cover only a small part of a practice’s undertaking, the expectation is that within 3 years it will grow to represent in the region of 40% of a practice’s income stream. The practice is able to join a PCN at a later date if it so wished.

The committee noted the actions taken to engage Ingleton Avenue Surgery in joining a PCN.

The committee noted that a locally commissioned scheme will need to be developed for Clocktower PCN to formally take responsibility of the registered list of patients of Ingleton Avenue Surgery and provide extended hours services to them for the amount of £5659.85. (This funding would have been passed to Ingleton Avenue Surgery as part of the Network Contract DES services if the practice had signed up to a PCN. The funding is already within Bexley CCG’s primary care budget, which was based on 100% take up of PCN arrangements).

The committee also endorsed the discretionary Practice network participation, network administration and clinical director payments which will enable Clocktower PCN to provide network services to Ingleton Avenue Surgery patients.

3. Items for Information32/19

32.19.1

32.19.2

Special Allocation Scheme (SAS) update The Special Allocation Scheme (SAS) provides primary care services to patients who have been removed from their practice list because of their abusive, aggressive or violent behavior.

The service is currently in the process of being procured on a SEL wide level. The service specification documentation has been prepared and the procurement will launch later this week (w/e 21/06/2019)

33/1933.19.1

33.19.2

Bursted Wood APMS procurement update The Tranche 7 London business case was presented to the NHSE Commercial Executive Group on 11th June 2019 where approval was given for the contract to be procured on a 5+5+5 year basis

All procurement documentation has been prepared and is being reviewed by the London procurement team. When the invitation to tender is launched bidders will have a four week period to respond



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34/1934.19.1

34.19.2

34.19.3

34.19.3

Delegated Primary Care Finance Report Month 2 2019/20All GPs are potentially conflicted on this agenda item

The 2019/20 delegated budget is £30,605k. This is a reduction of £907K on the initial budget of £31,512K, but represents a 3.5% increase on the 2018/19 allocation. All South East London (SEL) CCGs have a 1% savings target, which equates to £315k for Bexley.

DM advised the committee that at month 2 the delegated primary care budget isreported as showing a small overspend of £23k, which is due to the fact that the QIPP has not been identified in full. However, it is the expectation that the QIPP will be delivered in full.

The committee noted the Delegated Primary Care Finance Report as at month 2 (May 2019)

4. Closing items 35/1935.19.1

Questions from members of the publicSabi Ghosh from Plas Meddyg Surgery PPG drew the committee’s attention to a flyer that the PPG have produced advising of the cost of NHS services. The committee thanked the SG for the work undertaken. SD queried the amount quoted for a GP appointment. It was suggested that if the document is to be formalised the evidence source for the figures quoted should be referenced on the document

5. Date of next meeting: Wednesday 21st August 2019 2.00-3.30pm, Bexley Civic Centre, DA6 7AT



ENCLOSURE: C

AGENDA ITEM:

Action Meeting

Date

Action Agreed Lead Action Taken Date for

completion

Status

14.19.3 24/04/2019 A report on the outcome of the Demand Management meetings

between the CCG and the practices is being drafted and will be

shared with the LMC when complete

Nisha

Wheeler

Report completed, will

be sent to next LMC

meeting

30/07/2019 close

17.19.7 24/04/2019 To request that the leadership team /contractor at Crook Log

Surgery generate a transformation plan and produce a

statement of intent in regard to working with the emerging

Primary Care Networks

Nisha

Wheeler

Discussions completed,

papers due to

forthcoming PCCC

30/05/2019 close

18.19.5 24/04/2019 NW to arrange for checks to be made to ensure that the 20

patients identified in March as children on the child protection

register and not yet registered with a new practice, are now

registered with a new practice

Nisha

Wheeler

19/06/2019 NW liasing

with the practice to make

sure all follow-up actions

are completed regarding

re-registration of these

patients . The relevant

social work teams have

been involved

15/05/2019 close

Primary Care Commissioning Committee (public) Action log updated 19/06/2019

39.19 Review

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DATE: 28th June 2019

TitleUrgent Planned Decision: Update on the APL Primary Care Networkand Contract Variations

This paper is for decision

Recommended action for the primary care commissioning committee

That the primary care commissioning committee approve:

1. All PCN member contracts to be varied to include the Network Contract DES which will enable implementation from 1 July 2019.

That the primary care commissioning committee note:

1. A position of support has now been reached, across all partners, based on the APL network agreeing to include a set of key commitments and assurances within schedule 7 of their network agreement.

Potential areas for conflicts of interest

It is noted that all GP members on the Primary Care Commissioning Committee will be conflicted as each will be a member of a Primary Care Network.

Executive summary

At it’s extraordinary meeting held on the 21st May 2019 on the proposed Primary Care Networks in Bexley, the PCCC endorsed and acknowledged the following:

∑ the 3 locality network applications which are aligned to the national and SEL STP guidance

∑ that Ingleton Avenue Surgery would not be accepting the Network Contract DES and that the CCG would need to develop and commission a local incentive scheme for Ingleton Avenue Surgery patients that will be delivered by the Clocktower PCN as necessary, once guidance has beenreceived from the STP. In respect of the delivery of the extended hours requirement for this practice and its patients, confirmation has now been received that Ingleton Avenue Surgery can provide the extended hours service for their patients via a subcontract agreement with the Clocktower PCN.

∑ the approach set out in respect of the unsupported network, APL, to

ENCLOSURE: D

Primary care commissioning committee (held in public)

41.19 PCCC decsions for reporting


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continue discussions with the practices involved and key stakeholders, including the London wide LMC and partners from the Bexley Local Care Partnership Board, to come to a mutually agreed position that would enable support for the network or for an alternative agreeable solution to be found.

Since the extraordinary meeting on the 21st May 2019, the following actions have been taken:

∑ Significant discussions regarding APL with all key stakeholders as outlined above.

∑ A position of support has now been reached, across all partners, based on the APL network agreeing to include a set of key commitments and assurances within schedule 7 of their network agreement, demonstratingtheir intentions to fully collaborate with both the Frognal PCN and Frognal local care network, in respect of the patients who are registered at the Plas Meddyg Surgery and which is located in the Frognal locality area, as well as working with the Clocktower PCN and Clocktower local care network for the patients registered with both the Albion Surgery and Lyndhurst Medical Centre.

∑ Approval has now been received for all Bexley networks under the governance of the Our Healthier South-East London (OHSEL) Board and the Integrated Care System Development Board for South East London.

∑ In respect of the extended hours requirements due to go live under PCNs from the 1st July, all practices in Bexley will maintain their current extended hours provision, in light of the time constraints to engage with patients, however funding will flow through their respective PCNs.

In light of the subsequent approval of all PCN arrangements in Bexley, virtual approval is being requested, in the form of Chairs action, to APPROVE all PCN member contracts to be varied to include the Network Contract DES which will enable implementation from 1 July 2019.

What are the organisational implications

Key risks

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

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

∑ Challenging timescales in which to implement PCNs

Equality∑ Ensuring that all patients receive equitable access to

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



3

Financial

∑ Funding has been committed nationally, but the size of each network may require more funding to be available, particularly in 19/20 when some funding is based on networks, rather than list size

∑ CCGs need to allocate funding as outlined in this paper, this will be paid to the PCN’s single nominated practice or provider

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

Clinical lead: N/AExecutive sponsor:

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



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PRIMARY CARE COMMISSIONING COMMITTEEExtraordinary Meeting

Thursday 25th July 2019 4.30-5.30pm Clocktower, Bexley Civic Centre DA6 7AT

Voting MembersDr Varun Bhalla (VB) GP member, North Bexley Locality LeadPaul Cutler (PC) Lay member patient and public involvement Nisha Wheeler (NW) Director of Primary Care, ICT & IGDr Sid Deshmukh (SD) (by phone) CCG ChairDr Jhumur Moir (JM) GP member, Clocktower Locality Lead Keith Wood (KW) Lay member, governance Mary Currie (MC) Governing Body Nurse David Maloney (DM) (by phone) Director of Finance, Bexley, Greenwich & Lewisham CCGsDr Sonia Khanna-Deshmukh (SKD) GP member, Frognal Locality Lead

Non-voting members Dr Richard Money (RM) Bexley Local Medical Committee (LMC) Chair Jill Webb (JWebb) Head of Primary Care, SEL Primary Care Team

In attendance Julian May (JMay) (minutes) Administration team manager

Apologies Nora Simon (NS) Assistant Head of Primary Care, SEL PCTNeil Ross (NR) Lay member, legal & procurement Michael Boyce (MB) Deputy Managing Director Julie Witherall (JW) Deputy Director of Finance, Bexley CCG Jayne Garfield-Field (JGF) Manager, HealthwatchNeil Kennett-Brown (NKB) Managing Director, Bexley and Greenwich CCG’sDr Anjan Ghosh (AnG) LBB Director of Public Health and Deputy Director of Health &

Wellbeing, Health and Wellbeing Board Representative

Item NoStanding items

06/19

06.19.1

WELCOME AND INTRODUCTIONS

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

07/19

07.19.1

DECLARATIONS OF CONFLICTS OF INTEREST

The declarations of interest register was passed amongst attendees and signed by those present. The following additional declarations were noted:

∑ SD declared an interest in relation to Crook Log surgery. PC asked SD and SKD to abstain from decision making in relation to item 8.

ENCLOSURE: E1



2

Items for decision 08/19

08.19.1

08.19.2

08.19.3

08.19.4

CROOK LOG: REVIEW OF NEED FOR CONTRACTUAL ACTION FOLLOWING INSPECTION BY THE CARE QUALITY COMMISSION (CQC)

JWebb referred to the previous meeting at which progress had been reported. The recommendation in the case of Crook Log Surgery was to issue a breach notice and a remedial notice around areas of non-compliance which were listed.

∑ An unannounced comprehensive inspection had resulted in two improvement notices and an overall rating of ‘inadequate’. The CCG had met the contractor to discuss progress and CQC visited again on 3 July, but did not change their ratings. The CCG visited the contractor on 16th

July to discuss progress. ∑ It was appropriate to consider a breach notice in accordance with NHSE

policy in responding to CQC inspections. A breach notice should be issued based on the compliance issues evidenced in the report, which had been shared with the contractor for comment.

∑ Crook Log had a significant history of issues resulting in monthly monitoring for a considerable time. However since the improvement plan was put in place the contractor’s performance continued to improve.

∑ It was proportionate to issue a breach notice as the issues were serious and in order to be consistent with other decisions and the standard operating procedures. A remedial notice was also recommended because some areas were not yet fully resolved.

KW commented that an indication of areas which were serious would be useful in future. JW noted that only some examples had been given in the paper but that these gave an indication of the seriousness. For example failure to stock emergency medication could result in a life-threatening situation, and inadequate recruitment checks could result in inappropriate people working in the practice.

RM noted that the LMC had been supporting the practice concerned through the process.

The primary care commissioning committee APPROVED that the contractor be issued with a breach and remedial notices in respect of those areas of contractual non-compliance documented in this paper.

09/19

09.19.1

BELLEGROVE: REVIEW OF NEED FOR CONTRACTUAL ACTION FOLLOWING INSPECTION BY THE CARE QUALITY COMMISSION (CQC)

JWebb noted that in relation to Bellegrove surgery a remedial notice was recommended.

∑ Following a comprehensive inspection on 22nd February 2019, where one area was rated inadequate and an overall rating of ‘requires improvement’ was given. Support had been offered from the LMC, CCG and medicines management team as was standard in all cases.

∑ There was no previous action taken by the CQC and a history of good performance, however a 6 month list closure had been agreed by the previous PCCC meeting to ensure the contractor was able to deliver



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09.19.2

09.19.3

09.19.4

high quality services. There had been no previous concerns and clear co-operation from the contractor.

∑ It was appropriate and proportionate to issue a remedial notice because of the ‘inadequate’ CQC rating as well as the overall ‘requires improvement’. Unlike breach notice the remedial notice would not stay on the register once remedial actions were complete. The contractor would need to complete actions or have a clear action plan for their completion within 28 days.

RM noted that the practice had not contacted the LMC for support.

SKD expressed confidence that the practice would improve given their good track record.

The primary care commissioning committee APPROVED the recommendation that a remedial notice should be issued to Bellegrove Surgery following the CQCinspection on 22nd February 2019.

10/19

10.19.1

10.19.2

10.19.3

10.19.4

LYNDHURST: REVIEW OF NEED FOR CONTRACTUAL ACTION FOLLOWING INSPECTION BY THE CARE QUALITY COMMISSION (CQC)

JWebb noted an unannounced comprehensive inspection of the Lyndhurst Medical Centre took place on 8th March 2019 gave an overall rating of ‘Requires Improvement’. On 20th May 2019 a report requesting an action plan was received by the CCG on 28th June and a visit to discuss the plan took place on 5th July 2019.

∑ There was a good contractual history, and the action plan had been completed with only one of the actions now outstanding. There had been no previosu inadequate or warning notices and therefore the recommendation was that it was not proportionate to issue a remedial or breach notice.

∑ It was proposed that the CCG write formally to the contractor asking them to complete their action plan and provide assurance to the CCG.

PC asked if the primary care community were likely to view this as a proportionate decision. RM reported that the LMC accepted the decision and the proportionality of the response.

JWebb noted that the primary care track record across London would provide assurance that the decisions were made on a proportionate basis. The standard operating procedure was currently being refreshed, and would be brought back as a separate paper.

The primary care commissioning committee APPROVED the recommendationthat formal contractual action should not be taken against Lyndhurst Medical Centre following the CQC inspection on 8th March 2019. Instead the contractor should be required to formally review and complete its current action plan to evidence what steps have been taken to address the remaining statutory and contractual issues/concerns as identified in this paper.



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Items for Information(none advised)

Closing items 11/19

11.19.1

ANY OTHER BUSINESS

The procurement for Special Allocation Service SAS had closed and there had been bidders. A fuller update would be provided at the next meeting.

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



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

DATE: 25th July 2019

TitleCrook Log Surgery Review of need for contractual action following Inspection by the Care Quality Commission (CQC)



The purpose and content of this report is to seek approval from the Primary Care Commissioning Committee, to the recommendation below with reference to those areas of contractual non-compliance identified in the warning notices and CQC published report of Crook Log Surgery.

The contractor be issued with a breach and remedial notices in respect of those areas of contractual non-compliance documented in this paper

These recommendations are both in line with NHS England’s Framework for responding to CQC inspections of GP practices, the London Standard Operating Procedure (SOP) for practices rated as Requires Improvementand NHS General Medical Services contractual requirements.


Dr Sid Deshmukh is the clinical Chair of Bexley CCG

Executive summary

Introduction:

The CQC carried out an unannounced comprehensive inspection of Crook Log Surgery practice on 27th March 2019. The contractor was rated as ‘Inadequate’ for ‘Are services safe?’ and Are services well-led?’. It was rated as ‘Requires Improvement’ for ‘Are services effective?’ and Are services responsive?’. It was rated as ‘Good’ for ‘Are services caring?’ ‘The contactor received an overall rating of ‘Inadequate’ and was placed under special measures for the quality of care provided. Click here for a copy of the inspection report (published on 7th June 2019): https://www.cqc.org.uk/location/1-560383996

As a result of the inspection, the contractor was served two warning notice under Section 29 of the Health and Social Care Act (HSCA) 2008 on 5th

April 2019. The contractor was required to be compliant with Regulations

ENCLOSURE: E2

Primary care commissioning committee



https://www.cqc.org.uk/location/1-560383996

2

12 and 17 of the HSCA by 30th June 2019.

The contractor will be inspected again by the CQC within six months of the report publication, since it was rated as ‘Inadequate’ for one domain - ‘Are services safe?’ and ‘Are services well-led?’.

Officers held a meeting with the contractor on 11th June to discuss the progress on the concerns outlined in the warning notices. Officers also metwith the contractor on 16th July 2019 to discuss the concerns in the CQCpublished report and the progress the contractor has made to address the areas of non-compliance.

Key issues

Sequence of events

∑ The Care Quality Commission (CQC) carried out an unannounced comprehensive inspection of Crook Log Surgery on 27th March 2019. As a result of the inspection, the CQC issued two warning notices to the contractor on 5th

April 2019 where it had been found that the contractor was failing to comply with Regulation 12 (safe care and treatment)and Regulation 17 (good governance) of the Health and Social Care Act 2008.

∑ Following the CQC issuing the warning notices officers from NHS Bexley CCG and the South East London Primary Care Team, met with the contractor on 11th June 2019 to seek assurances and to discuss the issues outlined in the warning notices and the contractor’s on-going Improvement Plan.

∑ The contractor assured officers that it will be compliant with the CQC and contractual actions outlined in the warning notices, by 30th June 2019.

∑ On 3rd July 2019, the CQC carried out a focused inspection based on the warning notices. The CQC notified that the rating will not change as a result of the inspection.

∑ The unannounced inspection report was published on 7th

June 2019. Officers met with the contractor on 16th July 2019 to discuss the progress that has been made to address the concerns in the report. The contractor assured officers that some actions have been addressed and some are still on-going.

The warning notices and the published report showed that the contractor was non-compliant in the areas listed below:

- Failure to carry out infection control audits - Failure to provide staff with some mandatory training.- Failure to ensure recruitment checks were carried out for



3

some staff members including no record of staff immunisation- Failure to calibrate equipment or received portable appliance

test- Failure to stock some emergency medication- Failure to have a programme of quality improvement.- Failure to have clear and effective processes for managing

risks, issues and performance- Failure to manage complaints in line with the practice's policy- Failure to provide adequate support for staff- Failure to carry out premises/security risk assessment

∑ The contractor will be revisited within 6 months of the date of publication due to receiving one ‘inadequate’ rating for ‘are services safe’ and ‘Are services well-led?’.

Rationale for recommendation

In accordance with NHS England’s Framework for responding to CQC inspections of GP practices, where a contractual failure is not capable of remedy the commissioner may issue a breach notice in accordance with the policy for Managing contract breaches, sanctions and termination for primary medical services contracts.

A breach that is not capable of remedy is where a breach occurs but either does not continue prior to a notice being issued or there is no action that can be taken to remedy the breach. (NHS England Primary Medical Care Policy and Guidance Manual (PGM) 2019.

Where a contractual failure is capable of remedy, the commissioner may issue the contractor with a remedial notice under the terms of their contract/agreement.

The Primary Care Joint Committee (PCJC) previously approved the London region Standard Operating Procedure (SOP) for Primary Medical contracts: A consistent approach to responding to Care Quality Commission ‘Requires Improvement’ ratings. The considerations within that SOP are appropriate to use to determine whether it would be reasonable and proportionate for commissioners to recommend to the Bexley PCCC that formal contractual actions be taken as a result of Crook Log Surgery receiving a CQC ‘Inadequate’ rating.

The considerations have included:

∑ Should contractual action be considered?When a contractor is in receipt of a CQC report indicating that they ‘Require improvement’, they have immediately breached their contract ‘The Contractor shall comply with all relevant legislation and have regard to all relevant guidance issued by the Board or the



4

Secretary of State or Local Authorities in respect of the exercise of their functions under the 2006 Act.’ It is therefore reasonable for commissioners to consider further contractual action.

∑ Should a breach or remedial notice be issued based on CQC visit report evidence?Commissioners conclude that the report findings, on which the contractor has had the opportunity to comment, provide sufficient evidence of the existence of contractual compliance issues, and that it is therefore able to issue a breach or remedial notice based on the evidence contained within the report.

∑ What is the Contractor’s track record/contractual history?Crook Log Surgery has undergone monthly Improvement Plan monitoring since September 2018. The contractor’s performance has improved since the Improvement Plan was put in place. According to the General Practice Indicator Rating, it is considered an ‘Approaching Review’ practice, NHS Choice user’s overall rating is 1.5 stars (9 ratings) and 69% of patients describe their overall experience as good (CCG average 80%). The current FFT rating is63% as at June 2019.

∑ Is it a proportionate response to issue a breach or remedial notice?Commissioners conclude that taking into account the CQC findings and the response of the contractor to those, together with the contractor’s track record/contractual history confirmed above, it is proportionate and reasonable to issue:

1. A breach notice for those areas of contractual non-compliance which have now fully been resolved, for example:

- Failure to ensure recruitment checks were carried out for some staff members

- Failure to stock some emergency medication- Failure to have clear and effective processes for managing risks,

issues and performance

2. A remedial notice for those areas of contractual non-compliance which have not yet fully been resolved, for example:

- Manager complaints in line with the practice's policy- Mandatory training is completed for all staff members



5

- Premises/security risk assessment

Links and Documents:

CQC Report: https://www.cqc.org.uk/location/1-560383996

NHS England Policy Book for Primary Medical Services – Chapter 7 –Contract Breaches and Termination: https://www.england.nhs.uk/medical/

NHS England Framework for responding to CQC inspection of GP practices:

Frmwk-respond-CQC-i-nsp.pdf

Recommendation:

Commissioners recommend that formal contractual action is pursued on this occasion.

Taking into account the guidance set out in the NHS England’s Framework for responding to CQC inspections of GP practices, commissioners recommend that as a proportionate response to the CQC 27th March 2019 inspection report:

∑ The contractor be issued with a breach and remedial noticesin respect of those areas of contractual non-compliance documented in this paper.


Key risks

If the contractor is not able to satisfy the requirements of the follow up inspection by the CQC within 6 months due to the ‘inadequate’ in ‘Safe’ and ‘Well lead’ domains, this could lead to an extended period of monitoring the contractor’s Improvement Plan. Patients will leave the practice, thereby putting pressure on other local practices.

Equality Patients of the practice may perceive they are not getting a high quality of service.

FinancialN/A

Author:Stella Babudoh, Senior Commissioning Manager (South East London Primary Care Team)

Clinical lead:Executive sponsor:





https://www.england.nhs.uk/medical/

6



1



TitleUrgent Planned Decision: Bellegrove Surgery: Review of need for contractual action following Inspection by the Care Quality Commission (CQC)



The purpose and content of this report is to seek approval from the Primary Care Commissioning Committee, to the recommendation that a remedial notice should be issued to Bellegrove Surgery following the CQC inspection on 22nd February 2019.

This recommendation is in line with the London Standard Operating Procedure (SOP) for practices rated as ‘Requires Improvement’ and the NHS Personal Medical Services contractual requirements.


None

Executive summary

Introduction:

The CQC carried out an announced comprehensive inspection of Bellegrove Surgery on 22nd February 2019. The contractor was rated as ‘Inadequate’ for ‘Are services safe?’ and rated as ‘Requires Improvement’ for ‘Are services well-led?’. It was rated as ‘Good’ for ‘Are services effective?’, ‘Are services caring?’ and ‘Are services responsive?’. The contactor received an overall rating of ‘Requires Improvement’ for the quality of care provided. Click here for a copy of the inspection report (published on 06th June 2019): https://www.cqc.org.uk/location/1-562029218

Officers held a meeting with the contractor on 17th July 2019 in order to discuss the contractor’s plan to address the areas of non-compliance.

Key issues

Sequence of events

∑ The Care Quality Commission (CQC) carried out an announced

ENCLOSURE: E3






2

comprehensive inspection of Bellegrove Surgery on 22nd February 2019 and received an overall rating of ‘Requires Improvement’. The formal inspection report was published on 6th June 2019.

∑ Following the published report officers from NHS Bexley CCG and the South East London Primary Care Team (SELPCT), scheduled a meeting and sent an action plan to the contractor to evidence what steps had been taken to address the statutory and contractual issues/concerns identified by the CQC.

∑ The contractor returned the completed action plan to officers on 16th

July 2019.

∑ Officers met with the contractor on 17th July 2019 to seek assurances and to discuss the contractor’s responses to the concerns on the action plan.

∑ Officers were assured that all the necessary CQC and contractual actions highlighted in the report, had either already been completed or were in progress.

∑ The contractor did not send or show documentary evidence relating to the actions at the meeting. Officers advised that these should be sent as soon as possible.

∑ The contractor was advised that they could access support from NHS Bexley CCG, the LMC and Medicines Management Team.

∑ The contractor was advised that they will be revisited within 6 months of the date of publication due to receiving one ‘inadequate’ rating for ‘are services safe’.

∑ The contractor was advised by officers that although it was clear that they are cooperating to resolve compliance issues, they would need to consider the information provided by the contractor and if it was deemed appropriate, it may recommend that the contractor be issued with a breach and/or remedial notice in line with the standard operating procedure for those areas of contractual non-compliance which have not yet been fully resolved.


The Primary Care Joint Committee previously approved the London region Standard Operating Procedure (SOP) for Primary Medical contracts: A consistent approach to responding to Care Quality Commission ‘Requires Improvement’ ratings. The considerations within that SOP have been used to determine what formal contractual actions, if any, commissioners may recommend to the Bexley PCCC, as a result of Bellegrove Surgery



3

receiving a ‘Requires Improvement’ rating.


∑ Should contractual action be considered?

When a contractor is in receipt of a CQC report indicating that they ‘Require improvement’, they have immediately breached their contract ‘The Contractor shall comply with all relevant legislation and have regard to all relevant guidance issued by the Board or the Secretary of State or Local Authorities in respect of the exercise of their functions under the 2006 Act.’ It is therefore reasonable for commissioners to consider further contractual action.

∑ Should a breach or remedial notice be issued based on CQC visit report evidence?

Commissioners conclude that the report findings, on which the contractor has had the opportunity to comment, provide sufficient evidence of the existence of contractual compliance issues, and that it is therefore able to issue a breach or remedial notice based on the evidence contained within the report.

∑ What is the Contractor’s track record/contractual history?

No contractual action has previously been taken against this contractor. The contractor’s performance is good. According to the General Practice Indicator Rating, it is considered an ‘Achieving’ practice, NHS Choice user’s overall rating is 3.5 stars (10 ratings) and 93% of patients describe their overall experience as good (CCG average 80%). FFT rating is consistently high at 98%.It should be noted that the contractor’s list size is formally closed from 1st July 2019 until 31st December 2019. The contractor requested the formal list closure in order to ensure it could continue to offer high quality of services to its patients and to be able to address the recruitment issues.

∑ Is it a proportionate response to issue a breach or remedial notice?Commissioners conclude that taking into account the failings identified by the CQC, including the fact that the CQC rated the contractor ‘Inadequate’ in the ‘Are Services Safe?’ domain, whilst the contractor’s track record/contractual history evidences no previous concerns, and the contractor is clearly cooperating to



4

resolve compliance issues, it is proportionate to issue a remedial notice for those areas of contractual non-compliance which have not yet been fully resolved. The table below shows the completed contractual actions and those that are still in progress:

Issues\Concerns Completed Contractual Actions

Evidence Provided

Policies for safeguarding adults and children were inspection. were last reviewed in September 2015 January 2011 respectively

Completed: the contractor confirmed that both policies have now been updated.

The contractor provided satisfactory evidence on 18/7/19.

One non-clinical staff member actingas chaperone did not have a DBS or risk assessment in place.

Completed: the contractor confirmed that the DBS has been undertaken for

the staff member. All New Staff have DBS

undertaken as part of recruitment process.


Fire drills had not taken place at the practice. This had also been identified at the previous inspection on 25 August 2015.

Completed: the contractor confirmed that the fire evacuation drill was successfully completed on 13th June 2019. The fire drills will be carried outtwice a year as a minimum.


An oxygen cylinder sign was not found on the door to the room where the oxygen cylinder was kept.

Completed: the contractor confirmed that new oxygen and liquid nitrogen signs were bought and displayed as per current fire guidelines on the front porch and on the doors of treatment Room 1 (Liquid Nitrogen) and Room 3 (Oxygen)


Some Admin staff were able to demonstrate an understanding of the signs of sepsis. Sepsis guidance for staff was not available and easily

Completed: the contractor confirmed that sepsis in Primary Care via e-Lfh was completed by all clinical staff between 18/02/2019 and 08/04/2019. A Sepsis Awareness session was given by the nurse




5

accessible. practitioner to all Admin staff on 13/06/2019.Sepsis information isdisplayed in reception areas. Electronic versions can also be accessed by staff on the G Drive.

The practice did not have a robust system in place to track and monitor safety alerts. There was not an effective oversight of alerts or any records to demonstrate that they had been reviewed, discussed and actioned

Completed: the contractor confirmed that since February 2019 a quarterly spreadsheet has been set-up with actions taken following safety alerts including details of alert, who has been informed, actions taken, actions confirmed, date filed and finished. Clinical governance review of the above are signed weekly by the led GP.


Issues/concerns Contractual Actions in Progress

Evidence Provided

The provider failed to ensure that staff had completed mandatory training, including formal chaperone training,safeguarding adults or children training, fire training, infection control training.

In Progress: the contractor confirmed that the mandatory training via RELIAS e-learning was set for both clinical and non-clinical staff with 8 modules per staff to be completed. As of 15/07/2019 out of 112 modules for clinical staff 99 have been completed,leaving 13 remaining. For administrative staff 144 modules out of 137 havebeen completed.

The contractor confirmed that the training matrix for mandatory training is available and is updated as the training iscompleted

The contractor provided their training matrix log, which provided satisfactory evidence on 18/7/19of what had been completed to date.

Some staff members did not have proof of ID or references in their

In Progress: the contractor confirmed that all staff HR files are beingfully checked to ensure



6

staff records. compliance and/or risk assessment undertaken to ascertain if documentation is still required especially for staff employed before 2014.

An audit undertaken in April 2018 identified issues with five patients not having three monthly bloods. Immediate actions and secure process checks had not been undertaken to ensure patient safety as a result of the audit findings.

In progress: the contractor confirmed that they have identified and written to all Methotrexate patients advising thatPrescriptions will not be issued for the drug unless regular 3-monthly blood tests have been undertaken. All repeat Methotrexate prescriptions have been re-formatted so they have to be re-authorisedeach time they are issued to remind staff to check for testing. The contractor is in the process of issuing Methotrexate books to all patients on the drug to ensure visibility of levels and have reverted to ‘belt & braces’ approach to ensure maximum visibilityof results.

Recommendation:

Taking into account the guidance set out in the Standard Operating Procedure for Primary Medical contracts: ‘A consistent approach to responding to Care Quality Commission ‘Requires Improvement’ ratings’ and the considerations set out above, commissioners recommend that as a proportionate response to the most recent CQC inspection report, in which the contractor was rated Inadequate in the Safe domain:

∑ The contractor should have formal contractual action taken against them and be issued with a remedial notice for those areas of contractual non-compliance which have not yet been fully resolved.


Key risks If the contractor is not able to satisfy the requirements of the follow up inspection by the CQC within 6 months due to the ‘inadequate’ in ‘Safe’ domain, this



7

could lead to the contractor going into Special Measures.

Equality

Patients of the practice may perceive they are not getting a high quality of service. The practice list is closed to new patient registrations until 31st

December 2019 and people wanting to register with the service may be seen this as reduction in their options to choose to register with a service of their choice.

FinancialN/A

Author:Stella Babudoh, Senior Commissioning Manager (South East London Primary Care Team)

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




1



TitleUrgent Planned Decision: Lyndhurst Medical Centre: Review of need for contractual action following Inspection by the Care Quality Commission (CQC)



The purpose and content of this report is to seek approval from the Primary Care Commissioning Committee, to the recommendation that formal contractual action should not be taken against Lyndhurst Medical Centre following the CQC inspection on 8th March 2019. Instead the contractor should be required to formally review and complete its current action plan to evidence what steps have been taken to address the remaining statutory and contractual issues/concerns as identified in this paper.

This recommendation is in line with the London Standard Operating Procedure (SOP) for practices rated as ‘Requires Improvement’ and the NHS Personal Medical Services contractual requirements.


None

Executive summary

Introduction:

The CQC carried out an announced comprehensive inspection of Lyndhurst Medical Centre on 8th March 2019. The contractor was rated as ‘’Requires Improvement’ for ‘Are services safe?’ and ‘Are services well-led?’. It was rated as ‘Good’ for ‘Are services effective?’ ‘Are services caring?’ and ‘Are services responsive?’. The contactor received an overall rating of ‘Requires Improvement’ for the quality of care provided. Click here for a copy of the inspection report (published on 20th May 2019): https://www.cqc.org.uk/location/1-547765682

Officers held a meeting with the contractor on 5th July 2019 in order to discuss the contractor’s plan to address the areas of non-compliance.

Key issues

ENCLOSURE: E4





2

Sequence of events

∑ The Care Quality Commission (CQC) carried out an announced comprehensive inspection of Lyndhurst Medical Centre on 8th March 2019and received an overall rating of ‘Requires Improvement’. The formal inspection report was published on 20th May 2019 and the South East London Primary Care Team (SEL PCT) requested an action plan from the contractor to evidence what steps had been taken to address the statutory and contractual issues/concerns identified by the CQC.

∑ The contractor submitted the necessary action plan on 28th June 2019 and on 5th July 2019, NHS Bexley CCG and SEL PCT, met with the contractor in order to go through the action plan and to review any accompanying evidence of issues already addressed or in progress. The contractor was advised that they could access support from NHS Bexley CCG, the LMC and Medicines Management Team.

∑ The contractor confirmed that most of the required actions were already complete and some were still in progress. Officers were assured that the contractor was doing all it could to remedy any remaining contractual actionsand the contractor provided the necessary accompanying evidence to support this (as noted in the table below). At the meeting, the contractor was advised by officers that although it was clear that they are cooperating to resolve compliance issues, they would need to consider the information provided by the contractor and if it was deemed appropriate, it may recommend that the contractor be issued with a breach and/or remedial notice in line with the standard operating procedure for those areas of contractual non-compliancewhich have not yet been fully resolved.


The Primary Care Joint Committee previously approved the London region StandardOperating Procedure (SOP) for Primary Medical contracts: A consistent approach to responding to Care Quality Commission ‘Requires Improvement’ ratings. The considerations within that SOP have been used to determine what formal contractual actions, if any, officers may recommend to the Bexley PCCC, as a result of Lyndhurst Medical Centre receiving a ‘Requires Improvement’ rating.


∑ Should contractual action be considered?When a contractor is in receipt of a CQC report indicating that they ‘Require improvement’, they have immediately breached their contract ‘The Contractor shall comply with all relevant legislation and have regard to all relevant guidance issued by the Board or the Secretary of State or Local Authorities in respect of the exercise of their functions under the 2006 Act.’ It is therefore reasonable for officers to consider further contractual action.

∑ Should a breach or remedial notice be issued based on CQC visit report evidence?



3

Officers conclude that the report findings, on which the contractor has had the opportunity to comment, provide sufficient evidence of the existence of contractual compliance issues, and that it is therefore able to issue a breach or remedial notice based on the evidence contained within the report.

∑ What is the Contractor’s track record/contractual history?No contractual action has previously been taken against this contractor. The contractor’s performance is very good. According to the General Practice Indicator Rating, it is considered an ‘Achieving’ practice, NHS Choice user’soverall rating is 4.5 stars (9 ratings) and 94% of patients describe their overall experience of the practice as good (CCG average 80%).

∑ Is it a proportionate response to issue a breach or remedial notice?Officers conclude that taking into account the response of the contractor to the CQC findings, together with the contractor’s track record/contractual history confirmed above, it is not proportionate to issue a breach and/or remedial notice. Instead, it is recommended that the contractor’s current action plan is further reviewed to evidence what steps have been taken to address the remaining statutory and contractual issues/concerns identified. The contractor’s current action plan has not yet fully addressed all of the actions in the CQC report. The table below shows the completed and uncompleted actions along with the evidence seen:

Issues/concerns Completed Contractual Actions Evidence Provided

Printer prescriptions were not tracked.

Complete – The contractor confirmedthat the receipt of blank printer prescription boxes is recorded, and the allocation of these prescriptions is recorded. The contractor has devised a new protocol whereby all prescriptions are removed from printers when not in use, logged and stored securely in a central cupboard. The Business Manager ensures the log is accurate and is reviewed at clinical meetings.

Memorandum issued to all staff on prescription security providedalongside a copy of a log of blank prescriptions and protocol contractor is now following.

Action in relation to safety alerts was not alwaysrecorded. The practice did not maintain a log of alerts with a record of action taken.

Complete – the contractor confirmed that all safety alerts are logged when received and circulated as appropriate. All safety alerts are now being reviewed by a single named GP who determines the action required, circulates the alert and maintains a log with the Business Manager

Procedure for circulation of safety alerts provided together with a log of all safety alerts for May and June 2019.



4

Risk assessments were not consistently carried out andnot all risks were mitigated. The registeredperson had systems or processes in place that wereoperating ineffectively in that they failed to enable theregistered person to assess, monitor and mitigate therisks relating to the health, safety and welfare of serviceusers and others who may be at risk. In particular: Therewas no legionella or liquid nitrogen risk assessments.

Complete – the contractor confirmed:1. a legionella risk assessment was carried out by Bison Ltd on 27th March 2019. The required actions from the assessment have been undertaken. The Business Manager has undertaken legionella awareness training and water temperatures will be tested on a monthly basis. The cleaning contractor has ensured that all water outlets have been descaled and maintained and the Business Manager will monitor this going forward. Water temperatures will continue to be tested once a month as advised.

2. Liquid nitrogen – they no longer offer a cryotherapy service to patients thus mitigating the need to store liquid nitrogen and therefore a liquid nitrogen risk assessment is no longer required. However, prior to the contractor ceasing the cryotherapy service its supplier carried out a risk assessment every time the Dewar was refilled, and a Health & Safety Risk Assessment undertaken on 27th March 2019 deemed that the Dewar was stored satisfactory.

The contractor provided a copy of the Legionella RA dated 27th March 2019 together with a current water sample log sheet.

The contractor provided evidence of its fire risk assessment which confirms that the liquid nitrogen dewar was being stored correctly.

Issues/concerns Contractual Actions in Progress Evidence Provided

Safety netting for the monitoring of high-risk medicineswas not in place. Gaps in oversight of themonitoring of high-risk medicines meant that not allpatients received monitoring in a timely way prior to theprescription being issued. Prescribers did not all have anunderstanding of the practice repeat prescribing policy.

In progress – the contractor confirmed that from now on patients prescribed Disease Modifying Anti-rheumatic Drugs will only receive a one month supply at a time, patients who have not had the relevant blood test in the specified time frame will not be issued with a prescription and it will no longer accept blood test results from hospitals or any other clinics. Although all prescribers adhere to the guidance within the repeat prescribing policy, not all prescribers had read the repeat prescription policy. The policy has now been re-issued to all prescribers. Confirmation of understanding will be sought, and this will be added to new staff joiner

Copy of Repeat Prescribing Policy provided.

MMT are liaising with the contractor with regards to high risk medicines monitoring. They are working with the contractor to ensurepatients prescribed high risk medicines are being monitored in line with national guidanceand that the contractor has a protocol to reflect that.



5

There was a lack of oversight for the management ofinfection control, and infection control audits were notroutinely carried out. There was no assessment of the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated. In particular: there was no clear leadership of infection control and audits had not been carried out.

In progress – the contractor confirmed that it had an infection control audit undertaken by NEL CSU (Commissioned by NHS England (at its request) on 2nd

May 2019 and received the full report on 5th June 2019. The contractor is completing an action plan based on the actions highlighted which needs to be returned to NELCSU by 5th September 2019. The contractor will continue to undertake monthly risk assessments in relation to prevention and control of infection and will also undertake a self-assessment twice yearly using the NHS England infection prevention audit tool. The Infection Control lead for the Practice is the Practice Nurse who is undertakingtraining for this role.

Copy of NEL CSU’s audit provided along with the necessary actions to take.

Contractor to provide a copy of the action plan highlighting actions they are undertaking along with the agreed timeframe and date of expected completion.

Recommendation:

Taking into account the guidance set out in the Standard Operating Procedure for Primary Medical contracts: ‘A consistent approach to responding to Care Quality Commission ‘Requires Improvement’ ratings’ and the considerations set out above, officers recommend that as a proportionate response to the most recent CQC inspection report:

∑ The contractor should not have formal contractual action taken against them. Instead, it is recommended that the contractor’s current action plan is further reviewed by Officers to evidence what steps have been taken to address the remaining statutory and contractual issues/concerns.


Key risks

A contractor with a Requires Improvement rating will be re-inspected after 12 months. The contractor needs to ensure that similar concerns are not repeated at that visit or that could lead to regulatory and/or contractual action being taken.

EqualityPatients of the practice may perceive they are not getting a high quality of service.

Financial N/AAuthor: Sally-Ann Sheppard, Commissioning Manager (SELPCT)





1


DATE: 9th October 2019

TitleReview of terms of reference for the Primary Care Commissioning Committee

This paper is for approval


The committee is asked to approve the proposed the amendments to the terms of reference ahead of ratification by the Governing Body


N/A

Executive summary

The Terms of Reference (ToR) for the Primary Care Commissioning Committee are reviewed each year to ensure they are up to date, fit for purpose and reflect the membership and meeting arrangements of the Committee. The annual review has been undertaken.

There is one proposed amendment to the ToR (highlighted in red) section 32. This is required to reflect the change in organisational structure andthe creation of NHSE and NHSI in place of NHS England from the 1st April 2019. This amendment is in-line with recommendations made by the auditors, RSM Risk Assurance Services LLP, following the SEL Primary Care Delegated Commissioning audit undertaken earlier in the year.


Key risks If the annual review does not take place the ToR may become non-reflective of current arrangements

Equality N/A

Financial N/A.Author: Nisha Wheeler, Director of Primary Care, ICT & Information Governance



Enclosure: G1

Agenda Item: 42/19

42.19 Review of PCCC ToR


Date of issue: September 2019

Date for review: September 2020

NHS Bexley CCGPrimary CareCommissioningCommittee Terms ofReference

Enclosure: G2

Agenda Item: 42/19



Primary Care Commissioning Committee Terms of Reference

2V1.0

Terms of reference – NHS Bexley CCG Primary Care

Commissioning Committee

Introduction

1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014

that NHS England was inviting CCGs to expand their role in primary care

commissioning and to submit expressions of interest setting out the CCG’s

preference for how it would like to exercise expanded primary medical care

commissioning functions. One option available was that NHS England would

delegate the exercise of certain specified primary care commissioning functions

to a CCG.

2. In accordance with its statutory powers under section 13Z of the National Health

Service Act 2006 (as amended), NHS England has delegated the exercise of the

functions specified in Schedule 2 to these Terms of Reference to NHS Bexley

CCG. The delegation is set out in Schedule 1.

3. The CCG has established the NHS Bexley CCG Primary Care Commissioning

Committee (“Committee”). The Committee will function as a corporate decision-

making body for the management of the delegated functions and the exercise of

the delegated powers as set out in NHS Bexley CCG’s Constitution and Scheme

of Delegation.

4. It is a committee comprising representatives of the following organisations:

∑ NHS Bexley CCG;

∑ In attendance:

o Bexley Council representative of the Health and Wellbeing Board;

o Bexley Local Medical Committee;

o Bexley Healthwatch;

o South east London CCGs Primary Care Contracts Team.

Statutory Framework

5. NHS England has delegated to the CCG authority to exercise the primary care

commissioning functions set out in Schedule 2 in accordance with section 13Z of

the NHS Act.

6. Arrangements made under section 13Z may be on such terms and conditions

(including terms as to payment) as may be agreed between the NHS England

Board and the CCG.




3V1.0

7. Arrangements made under section 13Z do not affect the liability of NHS England

for the exercise of any of its functions. However, the CCG acknowledges that in

exercising its functions (including those delegated to it), it must comply with the

statutory duties set out in Chapter A2 of the NHS Act and including:

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

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

c) Duty to exercise its functions effectively, efficiently and economically

(section 14Q);

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

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

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

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

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

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

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

8. The CCG will also need to specifically, in respect of the delegated functions from

NHS England, exercise those in accordance with the relevant provisions of

section 13 of the NHS Act

∑ Duty to have regard to impact on services in certain areas (section 13O);

∑ Duty as respects variation in provision of health services (section 13P).

9. The Committee is established as a committee of the CCG Governing Body in

accordance with Schedule 1A of the “NHS Act”.

10. The members acknowledge that the Committee is subject to any directions made

by NHS England or by the Secretary of State.

Role of the Committee

11. The Committee has been established in accordance with the above statutory

provisions to enable the membership of the committee to make collective




4V1.0

decisions on the review, planning and procurement of primary care services in

Bexley, under delegated authority from NHS England.

12. In performing its role the Committee will exercise its management of the

functions in accordance with the agreement entered into between NHS England

and NHS Bexley CCG, which will sit alongside the delegation and terms of

reference.

13. The functions of the Committee are undertaken in the context of a desire to

promote primary care co-commissioning to increase quality, efficiency,

productivity and value for money and to remove administrative barriers.

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

commissioning of primary medical services under section 83 of the NHS Act.

15. This includes the following:

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

∑ Enhanced Services and newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);

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

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

∑ Approving practice mergers; and

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

16. The CCG will also carry out other activities as detailed in Schedule 1 of the

Delegation Agreement between NHS Bexley CCG and NHS England.

Geographical Coverage

17. The Committee will comprise of decisions in respect of the GP registered

population of NHS Bexley CCG.




5V1.0

Membership

18. The Committee shall consist of:

Members with voting rights

∑ 3 Lay Members

∑ CCG Chair

∑ 2 Governing Body GP Members

∑ Registered Nurse or Secondary Care Specialist (single member)

∑ CCG Managing Director

∑ CCG Finance Director

∑ Director of Primary Care, ICT & IG

∑ Director of Governance, Quality & Performance

Non-Voting Members

∑ Local Medical Committee Representative

∑ Healthwatch Representative

∑ Local Authority Representative of the Health and Wellbeing Board (Elected

Member or Mandated Officer)

∑ Officers as required to undertake business of the committee

19. The Chair of the Committee shall be a Lay Member of NHS Bexley CCG. This

will not be the Lay Member responsible for Audit.

20. The Vice Chair of the Committee shall be a Lay Member of NHS Bexley CCG.

This will not be the Lay Member responsible for Audit.

Meetings and Voting

21. As a committee of the Governing Body, the Committee will operate in

accordance with the CCG’s Standing Orders (in line with NHS England Standard

Operating Procedures). This includes the capacity to manage urgent matters

outside the normal arrangements.

22. The aim of the Committee will be to achieve consensus decision-making

wherever possible. In the event a vote is required, each member of the

Committee shall have one vote. The Committee shall reach decisions by a

simple majority of members present, but with the Chair having a second and

deciding vote, if necessary.




6V1.0

Quorum

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

Frequency of meetings

24. The Committee will meet regularly at least 4 times per year. After 12 months the

frequency will be reviewed.

Procedure

25. Meetings of the Committee shall:

a) be held in public, subject to the application of 25(b);

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

open to the public (whether during the whole or part of the proceedings)

whenever publicity would be prejudicial to the public interest by reason of

the confidential nature of the business to be transacted or for other special

reasons stated in the resolution and arising from the nature of that business

or of the proceedings or for any other reason permitted by the Public

Bodies (Admission to Meetings) Act 1960 as amended or succeeded from

time to time;

c) the closed confidential part of the meeting (as provided for at 25(b) above)

shall be referred to as Part 2 of the meeting and shall have a separate

agenda and minutes;

d) the Committee may invite the representatives of the local authority (Health

and Wellbeing Board), Local Medical Committees and Healthwatch to Part

2 of any meeting where it considers it is appropriate for such

representatives to attend all or part of Part 2 of the meeting.

26. The committee may meet in common with other CCGs in south east London

(NHS Bexley CCG, NHS Bromley CCG, NHS Greenwich CCG, NHS Lewisham

CCG, NHS Lambeth CCG and NHS Southwark CCG – or any combination of

these CCGs) when there is common business to transact.

27. Members of the Committee have a collective responsibility for the operation of

the Committee. They will participate in discussion, review evidence and provide

objective expert input to the best of their knowledge and ability, and endeavour

to reach a collective view.




7V1.0

28. The Committee may delegate tasks to such individuals, sub-committees or

individual members as it shall see fit, provided that any such delegations are

consistent with the parties’ relevant governance arrangements, are recorded in a

scheme of delegation, are governed by terms of reference as appropriate and

reflect appropriate arrangements for the management of conflicts of interest.

29. The Committee may call additional experts to attend meetings on an ad hoc

basis to inform discussions.

30. Members of the Committee shall respect confidentiality in attending and

undertaking the business of the committee.

31. The Committee will present its minutes to the governing body of NHS Bexley

CCG and London region following each meeting for information, including the

minutes of any sub-committees to which responsibilities are delegated under

paragraph 28 above. The Committee will present its minutes to the governing

body of NHS Bexley CCG and London region following each meeting for

information, including the minutes of any sub-committees to which

responsibilities are delegated under paragraph 28 above..

32. The CCG will also comply with any reporting requirements set out in its

Constitution.

Accountability of the Committee

33. The Committee will be accountable for the expenditure of the primary care

budget delegated from NHS England to the CCG. Responsibility for authorising

expenditure against this budget may be further delegated only as set out in the

Operational Scheme of Delegation ratified by the Governing Body.

34. For the avoidance of doubt, in the event of any conflict between the terms of the

CCG’s Operational Scheme of Delegation, the Committee’s Terms of Reference

and the CCG’s Prime Financial Policies, the Operational Scheme of Delegation

will prevail.

Decisions

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




8V1.0

36. The Committee will ensure that any conflicts of interest are dealt with in

accordance with the CCG’s Constitution and Standards of Business Conduct

Policies which for the avoidance of doubt may include members (voting or

otherwise) being excluded from a decision and/or the discussions leading

thereto. The Committee will enact its responsibilities as set out in these Terms of

Reference in accordance with the Nolan Principles for Standards in Public Life.

37. The decisions of the Committee shall be binding on NHS Bexley CCG and NHS

England.

Review

38. Terms of Reference will be reviewed on an annual basis.

Schedule 1 – Delegation



1


Title Primary Care Quality Dashboard

This paper is for information


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

highlight report as well as the GP patient survey results summary.


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

Executive summary

Bexley CCG has developed a dashboard that includes a set of publically available metrics about GP practices and relates to patient experience, patient safety and clinical effectiveness. CQC ratings are also included which span all areas.

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

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

The PCQD has been refreshed with the latest available data and this highlight report discusses primary care quality for each metric included, which are list size changes, CQC reports, patient online and friends & family test results. The report also includes summary and analysis of the latest GP patient survey that was published in July 2019.

All practices have access to a more comprehensive set of performance and activity data that shows how they compare to their peers, the borough average and London average. It aims to be a useful support tool to help raise awareness of quality improvement areas and discussions on the mechanisms and support available for practices in raising quality and

ENCLOSURE: H1

AGENDA ITEM: 43/19


43.19 Primary Care Quality report


2

disseminating best practice.


Key risks None. Data already public.

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

FinancialNone

Author: Marina Moores and Sarah Birch, Bexley CCG

Clinical lead: Dr Sid Deshmukh, CCG ChairExecutive sponsor:

Nisha Wheeler, Director of Primary Care, ICT & IG



1

Primary Care Quality Dashboard Highlight Report

Background and Introduction

Bexley CCG maintains a locally developed dashboard that includes a set of publically available metricsabout GP practice performance relating to patient experience, patient safety and clinical effectiveness. CQC ratings are also included which span all areas.

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

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

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

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

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

The dashboard has been designed in such a way to make comparison and trends easy to identify at a practice level. It is important that the dashboard is reviewed alongside this accompanying report that aids interpretation of the dashboard figures.

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

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

Data Explanation

List sizes This is the registered number of patients at the practice and is collected quarterly

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

Quality & Outcomes Framework

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

Enclosure: H2Agenda Item: 43/19



2

Data Explanation

that incentives are appropriate and beneficial to patients.

Patient Online

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

Friends & Family Test

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

GP Patient Survey

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

Primary Care Quality Dashboard – Key Findings

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

List size changes

Key findings to note include:∑ Cairngall Medical Practice – the dashboard shows that there are still 8381 patients on the

Cairngall list even though this practice closed on 30th March 2019. This has been declining and all clinical correspondence relating to these patients continues to be monitored by Belvedere Medical Centre.

∑ Most significant list size growth can be seen at Belvedere (49%) and Dr Thavapalan (16%), due to the closure of Cairngall and Riverside (37%) which completed a merger with Mill Road surgery earlier in the year

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

∑ The average list size of a practice in Bexley (10,186) exceeds the England average (8,676). There is a general trend for practices with larger lists to benefit from economies of scale.

CQC Reports

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

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

Each area is given a rating of either:

1 Verbal update, 955 still showing on PC dashboard.



3

∑ Outstanding∑ Good∑ Requires Improvement∑ Inadequate

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

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

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

Where a practice is rated as either “good or outstanding” they are rated every 5 years as a maximum interval and carry out an annual regulatory review to establish if there has been any changes since the last inspection. If practices are rated “requires improvement” they will be re-inspected in 12 months or within 6 months for an “inadequate” rating to ensure that appropriate actions have been taken to improve the quality of services received.

In 2019 to date, there have been nine CQC published reports. Since the last quality report that was reported at the April PCCC where details of 3 inspections were provided, an additional 6 reports have been published with details as follows:

1. Lyndhurst Medical Centre: Overall rating Requires Improvement

Report published 20/05/2019

The overall rating for this practice was requires improvement due to concerns in providing safe and well-led services. The practice was rated good for all of the population groups. Patients received effective care and treatment that met their needs. Staff dealt with patients with kindness and respect and involved them in decisions about their care. The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way. The way the practice was led and managed promoted the delivery of high-quality, person-centre care. Services were tailored to meet the needs of individual patients. They were delivered in a flexible way that ensured choice and continuity of care. Staff felt supported by leaders within the practice. Officers met with the practice on 5th



4

July and were assured that all the necessary CQC and contractual actions highlighted in the report, had either already been completed or were in progress.

2. Dr Thavapalan & Partners: Overall rating Requires Improvement


The overall rating for this practice was requires improvement due to concerns with providing safe, effective and well-led services. However, the staff provided positive feedback about working at the practice which indicated a good working culture. In addition, the practice had taken action to ensure the sustainability of the practice and responded well to challenges associated with the dispersal of a nearby practice.

3. Bexley Group Practice: Overall rating Good


4. Bexley Medical Group: Overall rating Good




5

5. Bellegrove Surgery: Overall rating Requires Improvement


The overall rating for this practice was requires improvement due to concerns in providing safe and well-led services. However, the population groups were rated as good because patients were able to access timely and effective care and treatment, staff treated patients with kindness and respect and the practice organised and delivered services to meet patient’s needs. Officers met with the contractor on 17th July 2019 to seek assurances and to discuss the contractor’s responses to the concerns on the action plan. Officers were assured that all the necessary CQC and contractual actions highlighted in the report, had either already been completed or were in progress.

6. Crook Log Surgery: Overall rating Inadequate


The inspection carried out at Crook Log was unannounced following concerns raised with the CQC. The practice was rated as inadequate for the safe and well-led key questions. This led to an overall rating of inadequate. Breaches of legal requirements were found, and requirement notices were issued in relation to patient safety, staffing and governance. Since the report has been published the contractor has asked the CCG to endorse two new partners joining the partnership from 1st May 2019 and a proposed merger of Crook Log Surgery and Sidcup Medical Centre on 1st April 2020. The existing and prospective contract holders have set out the priorities for the practice, these include: the appointment of a new, highly experience practice manager, Dr Deshmukh to take on the leadership role from 1st May 2019, to improve patient satisfaction by offering appointments responsive to the needs of the patient, improve staff morale and training.

Following the CQC reports being published all contractors completed the required follow up actions from the CQC inspector who has signed them off for having assured them that they have actioned recommendations and are compliant. The Primary Care Commissioning Committee (PCCC) have approved that Crook Log Surgery, Bellegrove Surgery, and Dr Thavapalan & Partners are issued with a breach and/or remedial notices in respect of those areas of contractual non-compliance resulting in a “requires improvement” or “inadequate” rating. In regard to Lyndhurst Medical Practice the PCCC have



6

required the contractor to formally review and complete its action plan to evidence that steps have been taken to address any remaining statutory and contractual concerns identified. The CCG routinely monitor the publication of CQC reports and summarise emerging themes of success and areas for improvement. Once a greater number of reports have been published, these themes will be discussed with practices more broadly to help inform areas that would benefit from a borough wide response or support.

Some of the emergent themes from inspections recently completed within Bexley can be found in the table below:

Area highlighted Issues being identifiedHigh risk drugs ∑ Ensuring that patients on high risk drugs are routinely followed up

∑ Lack of process for following up those that do not turn up for medication reviews

∑ Continuing to prescribe high risk drugs without review∑ Lack of appropriate follow up for patients on methotrexate

Risk assessments ∑ Absence, lack of review or lack of mitigating actions identified in risk assessments for legionella, fire, infection control

Prescription safety

∑ Prescription pads not always stored safely, left in printers overnight and insufficient monitoring of script numbers

Safeguarding ∑ Absence of policies∑ Absence of training for some staff

Significant events ∑ Lack of policy Infection control ∑ Absence of audit within the last year

∑ Not all staff trained∑ Cleaning standards insufficient

Quality improvement

∑ Not being able to evidence audits and actions that have led to improvements

Registered manager

∑ Registered manager not up to date and CQC need to be notified of partnership changes

Training ∑ Not all staff had completed mandatory training in required time frame∑ No training matrix∑ Not all staff completing sepsis awareness training (clinical and non-clinical)

HR records ∑ Absence of references in staff files∑ Absence of DBS checks∑ Lack of risk assessments for roles where DBS not necessary∑ Missing staff immunisation information∑ No annual appraisals

Fire safety ∑ No evidence that fire drills had recently/ are routinely undertakenRecruitment ∑ Absence of records showing due recruitment process had been followed

∑ No induction pack/processChaperone ∑ Lack of training and awareness of the process to be followedEquipment ∑ Not calibrated

∑ No PAT testingEmergency medicines

∑ Not a full supply stocked

Defibrillator ∑ Not stocked with necessary pads or pads that were out of dateComplaints ∑ Not being managed in required time frame

Quality Outcomes Framework



7

The results of QOF are not published until the October following the previous financial year, therefore there is no update in relation to the 2018/19 QOF performance. 2017/18 QOF performance was reported in the previous PCCC quality report.

Patient Online

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

∑ The following practices are below the 20% target according to the latest available data (June 2019):- Crook Log 18%- Ingleton Avenue 10%- Westwood Surgery 11%- Welling Medical Practice 11%- Bexley Medical Group 11%

∑ All but one surgery has had a 1%-2% increase over the last 2 months. ∑ The Westwood Surgery, Welling Medical Practice and Bexley Medical Group practices have

switched clinical systems over the last year and the two patient online systems do not have interoperability to enable the transfer of this switch from one system to another. This means patients have to re-register for online services, which explains why they fall short of the target. Previously these practices were exceeding the target and they are actively encouraging their patients to re-register with online services and patients do not need to show ID again.

∑ Crook Log and Ingleton Avenue are continuing to take active steps to sign up more patients for online services.

Friends & Family Test Results

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

∑ Crook Log surgery and Barnard Medical Group have seen improvement of FFT results of 13% and 10% respectively in June 2019.

∑ Welling Medical practice has declined from 63% in April to 57% in June 2019 and officers have met with the practice to discuss performance.

∑ Slade Green Medical Centre FFT results have dropped by 17% to 74% and have had a number of recent staffing changes.

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

Latest GP Patient Survey

The GP patient survey is conducted every year with data collected from January to end of March and the results are not published until the following July/August. The latest survey results were published in July 2019 and it should be noted that the survey shows Bexley as having 24 practices. Cairngall Medical Practice closed on 29th March 2019 and there are now 23 practices in Bexley.

Key findings worth noting are as follows:



8

∑ Overall experience of GP surgeries has remained static at 80% compared to a national average of 83%.

∑ Ease of getting through to GP surgeries on the telephone has decreased slightly from 63% in 2018 to 61% in 2019, compared to a national average of 68%

∑ Patients’ experience of the helpfulness of receptionists at GP surgeries has increased to 87% in Bexley versus a national figure of 89%

∑ Patients’ awareness of online services including booking appointments, ordering repeat prescriptions and accessing medical records have all increased, year on year since 2016.

∑ Patients’ experience of making an appointment has dropped by 1% compared to last year, remains below the national average and is at the lowest point since 2013. The national average also declined dropping from 69% in 2018 to 67% this year.

∑ Bexley patients are more likely to attend other services including A&E department when the GP practice is closed.

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

Conclusion

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

∑ Nine Bexley practices recently participated in a Productive General Practice Quick Start Programme which was an on-site, hands-on, short term support package for practices that forms part of a local Time for Care programme and aims to help practices release time for care and build improvement capability. BHNC, the GP Federation are now overseeing a second cohort of practices completing this programme. Practices who participated have reported significant time savings for staff allowing this time to be redirected to frontline care

∑ Continued support for practices to enhance their use of digital technologies such as econsult, to improve access to patients and ensure appointments are used to best effect.

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

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

Practices are now members of primary care networks which involves practices working in larger groupings to deliver some services. It is hoped that this provides additional resilience and sustainability for practices in the long term and helps to ensure that all patients receive a high quality and consistent service offering. It will also lead to a greater number of services being provided at a network level rather than individual practice level including a number of new roles such as clinical pharmacists, link workers, physician associates, physiotherapists and paramedics.

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

Appendices

Appendix A – September PC Dashboard



Locality July 2018 July 2019%

change

Last CQC

report

publication

date

CQC

Rating

QoF

Achievement

16/17

(Maximum 559

point)

QoF

Achievement

17/18

(Maximum 559

point)

%

change

April

2019

May

2019

June

2019

April

2019

May

2019

June

2019

Overall, how would

you describe your

experience of your GP

surgery?

Generally, how easy

is it to get through to

someone at GP

surgery on the

phone?

Overall, how would

you describe your

experience of making

an appointment?

England average 8562 8676

Bexley average 9980 10186

Bexley total list size 242086 244460

Clocktower Bellegrove Surgery 11876 12237 3% 22/02/19 Requires Improvement 100% 100% 0% 32% 32% 33% 92% 90% 98% 93% 92% 70%

Clocktower Bexley Group Practice 11767 12438 6% 20/03/19 Good 99% 100% 1% 36% 36% 37% 93% 96% 93% 77% 66% 54%

Clocktower Bursted Wood Surgery 5134 5321 4% 29/09/16 Good 90% 94% 4% 23% 23% 23% 96% 100% 90% 90% 93% 87%

Clocktower Crook Log Surgery 8343 7984 -4% 27/03/19 Inadequate 100% 100% 0% 17% 17% 18% 50% 56% 63% 69% 55% 46%

Clocktower Dr Thavapalan & Partners 4437 5131 16% 29/03/19 Requires Improvement 99% 99% 0% 21% 21% 21% 96% 89% 94% 89% 98% 76%

Clocktower Ingleton Avenue Practice 5126 5161 1% 12/02/19 Good 95% 95% 0% 10% 10% 10% 92% 96% 96% 90% 84% 90%

Clocktower The Albion Surgery 14386 14885 3% 29/04/17 Good 100% 100% 0% 46% 46% 46% 94% 94% 90% 92% 54% 73%

Clocktower The Westwood Surgery 9211 9451 3% 22/09/16 Good 99% 98% -1% 10% 10% 11% 84% 74% 87% 71% 48% 52%

Clocktower Welling Medical Practice 12150 11693 -4% 01/04/16 Good 98% 100% 2% 9% 11% 11% 63% 59% 57% 61% 42% 40%

Frognal Barnard Medical Group 14942 14754 -1% 22/04/16 Good 99% 98% -1% 21% 21% 21% 76% 96% 86% 79% 56% 60%

Frognal Plas Meddyg Surgery 7224 7219 0% 06/04/16 Good 100% 100% 0% 48% 49% 49% 94% 100% 100% 83% 72% 65%

Frognal Sidcup Medical Centre 11773 12127 3% 05/10/17 Good 100% 100% 0% 23% 24% 24% 80% 82% 84% 80% 75% 66%

Frognal Station Road Surgery 10177 10140 0% 03/09/15 Good 98% 100% 2% 45% 45% 46% 88% 86% 88% 81% 39% 61%

Frognal Woodlands Surgery 9971 9986 0% 15/10/15 Good 100% 100% 0% 33% 33% 33% 84% 88% 74% 76% 65% 49%

North Bexley Belvedere Medical Centre 10902 16243 49% 05/11/15 Good 99% 99% 0% 35% 34% 34% 84% 75% 79% 83% 56% 58%

North Bexley Bexley Medical Group 16890 17717 5% 24/04/19 Good 100% 98% -2% 10% 11% 11% 89% 82% 82% 74% 61% 48%

North Bexley Bulbanks Medical Centre 3616 4036 12% 15/10/15 Good 100% 98% -2% 25% 25% 26% 100% 100% 96% 97% 73% 81%

North Bexley Cairngall Medical Practice 8867 955 -89% 16/10/17 Good 96% 53% -43% 11% 0% 0% No data No data No data 71% 43% 47%

North Bexley Crayford Town Surgery 8901 9254 4% 20/05/16 Good 100% 100% 0% 25% 25% 0% 88% No data 83% 63% 49% 40%

North Bexley Riverside Surgery 6492 8901 37% 01/10/15 Good 99% 99% 0% 25% 25% 25% 85% 91% 94% 78% 59% 55%

North Bexley Lakeside Medical Practice 16208 16571 2% 16/01/19 Outstanding 98% 98% 0% 28% 28% 28% 89% 88% 89% 87% 64% 78%

North Bexley Lyndhurst Medical Centre 9028 9469 5% 08/03/19 Requires Improvement 100% 100% 0% 30% 30% 31% 96% 98% 98% 94% 67% 79%

North Bexley Northumberland Heath M.C. 13846 14215 3% 03/01/19 Good 100% 100% 0% 26% 26% 26% 90% 86% 80% 87% 57% 65%

North Bexley Slade Green Medical Centre 8251 8572 4% 16/08/17 Good 85% 86% 1% 28% 28% 29% 91% 91% 74% 77% 51% 59%

N/A*Please note the data for Plas Meddyg Surgery,

Woodlands Surgery, and Crayford Town Surgery are

from NHS Digital, the rest are from iPlato.

CCG Average 80%

National 83%

CCG Average 61%

National 68%

CCG Average 61%

National 67%

Monthly Annual

Benchmarking N/A

England

average

Good

England

average

96%

England

average

97%

Practice

Data frequency Quarterly Rolling programme Annual Monthly

List size overview CQC Reports Quality Outcomes Framework Patient Online% patients enabled for e-Bookings

Friends & Family Test (FFT)% Recommended (Responses)

Latest GP Patient Survey (GPPS)

August 2019

(50) (50) (50)

(156) (156) (169)

(50) (50) (48)

(48) (43) (43)

(48) (47) (48)

(49) (47) (45)

(50) (50) (48)

(49) (47) (46)

(49) (49) (46)

(50) (48) (49)

(53) (28) (21)

(46) (50) (45)

(48) (49) (50)

(98) (56) (43)

(44) (48) (48)

(65) (72) (71)

(49) (34) (26)

(49) (47)

(41) (47) (32)

(91) (97) (108)

(50) (50) (50)

(50) (50) (49)

(46) (45) (39)

43.19 Prim

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Title

GP Patient Survey Results



That the primary care commissioning committee note.

1. The contents of the GP patient survey results.


The GP patient survey includes practice level information which is already publically available.

Executive summary

The GP Patient Survey is an annual survey that is operated by Ipsos Mori on behalf of NHS England and gets sent out to a sample of patients in every practice across the country. It provides a standardised collection method for gathering patient feedback. The GP patient survey is conducted every year with data collected from January until the end of March and the results are not published until the following July/August. For Bexley, 7,651 questionnaires were sent out, and 2,656 were returned completed. This represents a response rate of 35% which was above the national average response rate of 33.1%. The enclosed report provides an overview and analysis of the latest survey results tracking where possible how the findings have changed over the last few years and also providing comparison with the Bexley and national average. Key findings worth noting are as follows:

Overall experience of GP surgeries has remained static at 80% compared to a national average of 83%.

Ease of getting through to GP surgeries on the telephone has decreased slightly from 63% in 2018 to 61% in 2019, compared to a national average of 68%

Patients’ experience of the helpfulness of receptionists at GP surgeries has increased to 87% in Bexley versus a national figure of 89%

Patients’ awareness of online services including booking appointments, ordering repeat prescriptions and accessing medical

ENCLOSURE: I1

AGENDA ITEM: 44/19


44.19 GP Patient survey 2019 report


2

records have all increased, year on year since 2016.

Patients’ experience of making an appointment has dropped by 1% compared to last year, remains below the national average and is at the lowest point since 2013. The national average also declined dropping from 69% in 2018 to 67% this year.

Bexley patients are more likely to attend other services including A&E department when the GP practice is closed.

The enclosed report was discussed with the Primary Care Development Working Group on 3rd October and headline findings were presented at the Patient Council Primary Care deep dive session held on 11th September. It is also worth noting that two questions in the GP patient survey are key performance indicators (KPIs) in the PMS contract that relate to:

Overall experience of the practice

Trust and confidence in GP/healthcare professional This means that there may be financial consequences for practices where they have not reached a specified threshold or shown significant improvement since the previous years’ results. Practices who have not achieved these thresholds are required to submit an improvement plan setting out the actions they intend to take to improve their patient feedback


Key risks

None. Data already public.

Equality

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

Financial

None

Author: Marina Moores and Sarah Birch, Bexley CCG

Clinical lead: Dr Sid Deshmukh, CCG Chair

Executive sponsor:

Nisha Wheeler, Director of Primary Care, ICT & IG



Enclosure: I2 Item 44/19

GP Patient Survey Results Summary July 2019 Background and introduction

The GP patient survey is an England wide survey providing practice level data about patient experience of their GP practice, administered by Ipsos MORI on behalf of NHS England. The latest survey results were published in July 2019 and this report represents a summary of those results. The latest survey consisted of around 2.3 million postal questionnaires sent out to adults registered with GP practices in England from January 2019 to the end of March 2019. Around 770,000 patients completed and returned a questionnaire, resulting in a national response rate of 33.1% For Bexley, 7,651 questionnaires were sent out, and 2,656 were returned completed. This represents a response rate of 35% which is same as 2018 however significantly lower than previous years (2016 - 41% and 2017 – 39%). The survey results include 24 Bexley practices as the survey was undertaken in January 2019 so Cairngall Medical Practice, which closed on 29th March, is included. Where data is missing from previous years, this is because the survey question did not exist. In 2018 the questionnaire was redeveloped in response to significant changes to primary care services as set out in the GP Forward View, and to provide a better understanding of how local care services are supporting patients to live well, particularly those with long-term care needs. The GP Patient Survey measures patients’ experiences across a range of topics, and it provides data at practice level using a consistent methodology, which means it is comparable across organisations and over time. However, the survey does have limitations:

• Sample sizes at practice level are relatively small • The survey does not include qualitative data which limits the detail provided by the

results • The data provides a snapshot of patient experience at a given time, being updated

annually. All comparisons are indicative only. Differences may not be statistically significant – particularly when comparing practices due to low numbers of responses. The survey cannot therefore be used in isolation to judge performance but can be used as one element of evidence. It can be triangulated with other sources of feedback, such as feedback from Patient Participation Groups, local surveys and the Friends and Family Test, to develop a fuller picture of patient experience and in order to identify potential improvements and highlight best practice.



https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf


2

Overall experience and access

Although public satisfaction with general practice remains high, in recent years patients have

increasingly reported, through the GP Patient Survey, more difficulty in accessing services

including a decline in good overall experience of making an appointment in general practice.

As a result, NHS England is conducting a review of access to general practice services in

England which aims to improve patient access both in hours and at evenings and weekends

and reduce unwarranted variation in experience. A key output will be the development of a

coherent access to general practice appointment offer that practices (in hours) and primary

care networks (outside core general practice hours) will make and could sustain, for both

physical and digital services, to 100% of patients.

The graph 1 shows comparison of overall experience between individual GP practices, CCG

and national average, whilst subsequent tables represent an overall experience and

experience in relation to the access to GP practice since 2013. The tables also include a

change indicator from previous year as well as comparison to the national average.

Graph 1: Bexley CCG survey results - overall experience per practice and CCG compared with national average. We can see that there are a few practices in Bexley that scored well below the national target and the primary care development team is working closely with these practices to understand the reasons and work towards improving the patient experience. Some of the actions are as follows:




3

- Practices that have not significantly improved or reached a minimum of 81% satisfaction, are required to submit an improvement plan setting out the actions they intend to take to avoid contractual penalties

- Targeted conversations and meetings with practices to understand the likely reasons for this performance and suggestions on how pressures could be alleviated.

- Contract monitoring where performance issues are a long-running issue




4

June 2013

July 2014

July 2015

July 2016

July 2017

Aug 2018

Jul 2019

Movement since last survey

National results

No of practices on or above national average

Bexley range

Local CCG range

Overall experience of GP surgeries

Overall experience of GP surgeries – Good

82% 80% 78% 80% 79% 80% 80% 83%

11/24 61%-97%

74%-88% Overall experience of GP

surgeries – Poor 6% 7% 9% 7% 9% 8% 7% 6%

Access to GP services

Ease of getting through to GP surgery on the phone – Easy

69% 65% 59% 61% 58% 63% 61% 68%

7/24 39% -98%

52%-83% Ease of getting through to

GP surgery on the phone – Not easy

27% 32% 38% 36% 38% 37% 39% 32%

Helpfulness of receptionists at GP surgery – Helpful

85% 85% 81% 85% 83% 86% 87% 89%

14/24 70%-98%

81%-92%

Helpfulness of receptionists at GP surgery – Not helpful

12% 13% 18% 13% 15% 14% 11% 11%

Percentage aware of online services available – Booking appointments online

32% 37% 48% 54% 44% 26%- 83%

Percentage aware of online services available – Ordering repeat prescriptions online

28% 29% 35% 39% 41% 26%-54%

Percentage aware of online services available – accessing medical records online

4% 5% 9% 11% 15% 1%-26%

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June 2013

July 2014

July 2015

July 2016

July 2017

Aug 2018

Jul 2019


National results


Bexley range

Local CCG range

Online services used in the last 6 months – Booking appointments online

8% 8% 14% 17% 15% 1%-31%

Online services used in the last 6 months – Ordering repeat prescriptions online

9% 9% 10% 12% 16% 1%-18%

Online services used in the last 6 months – accessing medical records online 0% 0% 1% 2% 4% 1%-11%

Use of practice website – easy to use 74% 73% 77% 11/24

41%-96%

66%-79%

Table 1: Bexley CCG survey results in relation to overall GP practice experience and access

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On the whole, this section of the patient survey has shown slight improvement when

compared to last year even though performance is generally below the national average.

Findings to particularly note are:

Overall experience of GP surgeries has remained at 80% however this is slightly lower compared with the national average of 83%. It is good to see that poor experience has reduced. This indicator is a KPI within the PMS contract.

Access to GP surgeries via the telephone has decreased compared to last year and this is still notably lower than the national average of 68%. It is important to note that the national average has decreased by 2% since last year. The practice variation within Bexley remains high.

It is very good to see that helpfulness of receptionists showed another increase and is at the highest level since 2013 and only 1% short of national average.

There continues to be an increase in awareness of and use of online services for booking appointments, ordering repeat prescriptions and accessing medical records. Although Bexley patients reported to be aware of online appointment booking, well above the national average, use of online booking is slightly lower than national average.

In relation to the practice website, we can see that there has been a decline by 1%, which is again slightly lower than national average. The CCG is continuing to work with GP practices on improvement of their online presence.

Making an appointment

The section on patient choice of appointments was introduced in 2018. The table below

summarises overall satisfaction levels with how choice was offered and overall experience of

making an appointment.




7

Aug 2018

Aug 2019 Movement since last survey

National results


Bexley range

Local CCG range

Offered a choice of appointment - Yes 60% 60% 62%

13/24

36%-81%

57%-74% Offered a choice of appointment - No

40% 40% 38%

Satisfaction with appointment offered – Yes took appointment

69% 68% 74% 9/24

51%-88%

62%-77% Satisfaction with appointment offered - No,

but took appointment 22% 23% 20%

Satisfaction with appointment offered - No, did not take appointment

9% 9% 6%

Table 2: Bexley CCG survey results details in relation to choice of appointment

June 2013

July 2014

July 2015

July 2016

July 2017

Aug 2018

July 2019

Movement since

last survey

National results


Bexley range

Local CCG range

Overall experience of making an appointment - Good

72% 66% 64% 65% 64% 62% 61% 67% 8/24

40%-90%

57%-75% Overall experience of

making an appointment - Poor

12% 15% 18% 17% 18% 19% 19% 16%

Table 3: Bexley CCG survey results details in relation to making an appointment with GP practice

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Although 60% of Bexley patients were offered a choice of appointment, 68% were satisfied with the appointment offered which is 1% lower compared with last year. This is still lower than the national average, however it is important to note that there is a large variation between the practices. Work is ongoing to raise awareness of the GP 8-8 service to increase utilisation of this extended primary care offer.

Majority of patients, who were not satisfied, ended up taking the appointment offered.

Patients’ experience of making an appointment has dropped by 2% compared to last year, remains below the national average and is at the lowest point since 2013. This finding is worthy of further feedback and insights from practices and PPG members to assess what else could be done in this area to improve the experience. It is worth noting that changes to the surrounding questions may have inadvertently led to patients responding more negatively than in previous years to this question. The national average of 69% was 4% lower than the average in 2017.

The graph below demonstrates what action patients have taken when they did not take

appointment offered.

Graph 2: Bexley CCG survey results in relation to action if patient didn’t make an appointment with the GP practice. We can see that there has been some changes compared with last year, with the most

significant change in relation to patients attending A&E which increased by 8% compared

with last year which is 11% above national average. It is important to note, however that the

patients may not make a distinction between an A&E and co-located UCC. Bexley patients

are also more likely to make contact with another service (12% above the national average)

and this will likely include services such as the 8-8 extended access hubs.

0%

5%

10%

15%

20%

25%

30%

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What did you do when you did not take the appointment offered?

Aug-18

Aug-19

Nationalaverage




9

Perceptions of care at patients’ last appointment

This section of the patient survey relates to the patient’s last appointment and was

introduced in 2018. The tables below represent yearly comparison of various elements as

well as how this compares with the national average of “poor” responses to the following

questions:

- Last time you had a general practice appointment, how good was the healthcare professional at each of the following*:

*Giving you enough time

*Listening to you *Treating you with care and concern

2018 (%)

2019 (%)

2018 (%)

2019 (%)

2018 (%)

2019 (%)

Very Good 43% 43% 46% 46% 47% 46%

Good 41% 42% 40% 42% 38% 40%

Neither good nor poor 11% 12% 10% 9% 11% 10%

Poor (total) 5% 4% 4% 4% 4% 4%

National results % poor (total) 4% 4% 3% 4% 4% 4%

Table 4: Bexley CCG survey results detail in relation to latest appointment

- During your last general practice appointment…*

*Felt involved in decision

*Had confidence and trust in healthcare professional

*Felt your needs were met

2018 (%)

2019 (%)

2018 (%)

2019 (%)

2018 (%)

2019 (%)

Very Good 56% 56% 64% 64% 59% 61%

Good 36% 36% 30% 31% 35% 34%

Poor (total) 8% 8% 6% 4% 6% 6%

National results % poor (total) 7% 4% 4% 4% 5% 4%

Table 5: Bexley CCG survey results detail in relation to latest appointment

The above tables show that on the whole Bexley patient’s perception of care is generally 1-

2% below the national average but overall patients are very positive about the quality of care

that they are receiving from healthcare professionals working in practices. There is little

change from last year’s results.

Trust and confidence in the GP/healthcare professional is one of the PMS contract KPIs.

The graph below and table show the findings from this specific question.




10

Graph 3: Bexley CCG survey results in relation to the trust in GP

The results for this question have been shown in comparison to the prior years’ question

about the trust and confidence in the GP so caution is needed with interpretation as

“healthcare professional” is the terminology now used. The results show that confidence and

trust has consistently been in the range of 93-95% since 2013, however there has been a

small increase (1%) since 2018. The results exclude ambiguous answers such as “don’t

know”, “does not apply” and “can’t say”.

Satisfaction with general practice appointment times

This question replaced the previous year’s survey question which asked about practice

opening times rather than appointment times.

Aug

2018

Jul

2019

National results



Range – by Practice

Range – by CCG

Satisfaction with appointment times- satisfied

60% 60% 65% 8/24

38%-82%

58%-72% Satisfaction with

appointment times- dissatisfied

22% 21% 18%

Table 6: Bexley CCG survey results detail in relation to appointment times

We can see that 60% of patients advised that they were satisfied with the appointment times

available in both 2018 and 2019, however there is a large variance by practice, where lowest

score was 38%. As the appointment satisfaction rate is 5% below national average it is not

surprising that the dissatisfaction rate is slightly above average. In addition, 19% of patients

reported to be “neither satisfied nor dissatisfied”.

94% 93% 93% 95% 95% 93% 94%

6% 7% 7% 5% 5% 6% 4%

5% 0%

10%20%30%40%50%60%70%80%90%

100%

Jun-13 Jul-14 Jul-15 Jul-16 Jul-17 Aug2018*

Jul-19 Nationalresults2019

Did you have confidence and trust in the GP you saw or spoke to?

No

Yes




11

Use of services when GP practice is closed

The graph below demonstrates what services patients contacted when their GP practice was

closed.

Graph 4: Bexley CCG survey results in relation to the contact when GP practice is closed

We can see that Bexley patients are consistently more likely to make use of other services

compared to the national average for 2019 especially in relation to the face to face contact.

Most concerning is the consistent increase in use of A&E services and below average of

telephoning alternative service. This is especially interesting as there is an expectation that

patients will be making use of NHS 111 service before they attend services such as UCC

and A&E. As noted previously, it is important to note that patients may not make a

distinction between an A&E and co-located UCC.

The data shown in graph 5 suggests a steady raise in number of A&E attendances for

Bexley registered patients by approx. 100 patient per month.

0%

10%

20%

30%

40%

50%

60%

70%

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Services contacted when GP practice was closed

Jul-16

Jul-17

Aug-18

Jul-19

Nationalresults




12

Graph 5: A&E attendance trend, average monthly attendance per year.

The table below demonstrates answers to additional questions from the survey.

Jul-16

Jul-17

Aug-18

Jul-19

National results

How do you feel about how quickly you received care or advice on that occasion – About right

58% 59% 59% 62% 66%

All the people you saw or spoke to on that occasion, did you have confidence and trust- yes

91% 92% 91%

Overall experience of services when GP practice is closed - good

68% 70% 69%

Conclusions and Implications

The July 2019 results illustrate that Bexley remains below the national average in the majority of areas, but there has been a fairly consistent level of performance compared to last year. Some indicators have shown an increase this year albeit most are relatively small. The most positive changes compared to last year relate to the area of access to general practice that related to:

helpfulness of receptionists

awareness and usage of online services for appointment booking.

Some improvement is also seen in relation to the perception of the latest appointment.

The key area that needs further discussion with practices and patients relate to the experience of making an appointment. This area has seen no improvement in patient satisfaction since last survey. This is a challenging area for practices due to the growing demands for GP services and increasing expectations of the population. In addition there is a growing trend of patients attending other NHS services and A&E department when they are either unable to get suitable appointment with the practice or when GP practice is

4,877 4,990 5,031 5,115

2016/2017 2017/2018 2018/2019 2019/2020

Average Monthly A&E




13

closed. This is significantly higher than national average where we are seeing patients calling services before attending. A number of practices are making quite radical changes to how patients can access on the day GP appointments including channelling all demand through the e-consult, an online consultation system. Some patients embrace this change whereas others are less positive and it is a constant balancing act for practices between the demands of patients, managing their own workload and operating within a healthcare system that is financially strained. Currently work is underway with the GP Federation in determining the appetite of practices to change how they may better meet on the day demand through enhancing use of the e-consult system and how they can best be supported to do this. There is also the opportunity to reconsider how to increase the utilisation of the 8-8 GP service (located at Queen Mary’s and Erith Hospital) so that capacity better aligns with the times when there is more demand, aka weekday evenings rather than Sundays. One of the main changes in the primary care delivery in recent months has been the establishment of the Primary Care Networks (PCNs) who are now the vehicle that will seek to address a lot of the challenges and pressures on practices making primary care more resilient in the long term. There are 4 PCNs in Bexley who all went live on 1st July 2019 and they are responsible for providing the extended hours services to their population. Practices continue to be responsible for core primary care services and maintain separate contracts, their own PPGs and autonomy of their leadership, but the PCNs is a facilitator for working together towards common goals. The first priority for the PCNs is establishing the additional roles which, such as clinical pharmacists, primary care physiotherapists, physician associates and community paramedic and these additional roles will be a big support to practices to alleviate pressures and improve the quality of care. PCN’s will also be expected to engage, liaise and communicate with their collective registered populations, informing and/or involving them in developing new services and changes related to service delivery. A time limited strategy and coordination group focussing specifically on PCNs is being established and will comprise members of the Bexley patient council, PCN clinical directors, GP federation leads and primary care leads from the CCG to support initial development of a communications plan and materials which may be helpful to PCNs and their populations. It will also be interesting to see how the GP patient survey continues to change over forthcoming years as an increasing range of services operate at scale rather than at a practice level and will be harder to disaggregate between individual practice level performance. Members are asked to DISCUSS and NOTE the patient survey results. Next Steps It is important that practices take a considered review of their patient survey findings alongside other patient feedback sources to see what they can learn and hence adapt in the areas where they need to focus on improving. The Primary Care Quality Dashboard (PCQD) within the Primary Care Activity Reporting Tool (PCART) will be updated with the patient survey findings from 2019 so serves as a single location where practices can easily access their performance and triangulate this feedback alongside FFT responses.




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The findings are set to be discussed at the October 2019 Primary Care Development Working Group and the primary care team will also raise awareness of the patient survey findings through:

Discussing at practice visits where they are outliers and making suggestions on what they could do to improve

Gather best practice examples where practices have had very positive feedback and hence can be shared more broadly

Taking the enclosed report to the patient council for their consideration and suggestions

Include in this month’s primary care development update.

Analysing and reporting on the findings to the Primary Care Commissioning Committee (PCCC) and using this intelligence alongside other metrics to inform where resilience support may be most beneficial.

The full survey is available at https://gp-patient.co.uk/Slidepacks2019#B



https://gp-patient.co.uk/Slidepacks2019#B

1


Title

Primary Care Network (PCN) update



That the primary care commissioning committee note

1. PCN workforce update 2. Extended hours access provided by each network 3. PCN development support progress 4. Future service requirements for PCNs 5. Patient engagement


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

Executive summary

This paper provides an update on progress made to date with PCN’s in Bexley


Key risks

Challenging timescales in which to implement PCNs and ability to ensure adequate engagement

Equality

Ensuring that all patients receive equitable access to primary care services across Bexley and ensuring that variations to services are minimised or eradicated altogether

Financial

The ability and capacity of PCN’s:

to access funding for additional roles which may be hampered by recruitment delays

to develop the PCN maturity matrix which will draw down funds to access PCN development support.

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

Clinical lead: Dr Sid Deshmukh, Chair Bexley CCG

Executive sponsor:

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

ENCLOSURE: J1

AGENDA ITEM: 45/19


45.19 PCN update


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Primary Care Network Update

Introduction

The NHS Long Term Plan and GP contract were published in January 2019. The plan endorsed the broad approach set out in the Bexley CCG primary care strategy and aligns with the established Local Care Networks (LCNs) within Bexley. The NHS Long Term Plan nationally committed £4.5 billion more for primary medical and community health services by 2023/24.

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

The contractual delivery mechanism for primary care networks comes from the Network Contract DES Directions which commenced on the 1st April 2019. Following sign-up to the Network Contract DES, the requirements on GP practices apply from the 1st July 2019.

The Network Contract DES is intended to remain in place for 5 years until the 31st March 2024, with the Network Contract DES specification evolving over time, subject to annual review and development.

The focus of the Network Contract DES in 2019/20 is to support the establishment of primary care networks (PCNs), the recruitment of new workforce and the delivery of extended hour’s access across the network population, with the bulk of further service requirements coming in from April 2020 onwards.

This paper provides an update on PCNs in Bexley to date.

Primary Care Networks in Bexley

The CCG has four Primary Care Networks as follows:

∑ North Bexley Primary Care Network – (Population 94,359)o Chair – Dr Prem Anando Clinical Director – Dr Sush Bhadrao Clinical Director – Dr Surjit Kailey

Enclosure: J2 Agenda Item: 45/19

45.19 PCN update


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∑ Clocktower Primary Care Network – (Population 63,949)o Chair – Dr Bill Cottero Clinical Director – Dr Lakhbir Kaileyo Clinical Director – Dr Nisha Nair

∑ Frognal Primary Care Network – (Population 46,919)o Chair – Dr Sid Deshmukho Clinical Director – Dr Pandu Balajio Clinical Director – Dr Sonia Khanna-Deshmukh

∑ APL Network – (Population 31,335)o Chair – Dr James Stokeso Clinical Director – Dr Mehal Patelo Clinical Director – Dr Miran Patel

Ingleton Avenue Surgery is geographically aligned to the Clocktower PCN and has chosen not to sign up to the Network Contract DES. Consequently, it is not a member of any primary care network and will not be in receipt of any Network Contract DES subscriptions. The Clocktower PCN has agreed to provide PCN services for registered patients of Ingleton Avenue Surgery, to ensure they are not disadvantaged by the decision of the practice not to sign up to the Network DES contract. Following national guidance, the CCG has put in place a Local Enhanced Service (LES) to formalise this arrangementwith the Clocktower PCN to enable it to formally take on the responsibility of the Network Contract DES for these patients.

Ingleton Avenue Surgery remains responsible for delivering core primary medical services to its registered list.

Primary Care Network workforce update

In 2019/20, every network of at least 30,000 population are able to claim 70% funding for one additional whole-time equivalent (WTE) clinical pharmacist (up to a maximum of £37,810) and 100% funding for one additional WTE social prescribing link worker (up to a maximum of £34,113). These new additional roles being introduced to the primary care workforce will support practices to deliver more integrated health services across the PCNs.

Over the course of the five year period of the contract, PCNs will have the opportunity to introduce five new roles into the primary care workforce with support of the national funding specifically set aside for this purpose.

The additional new roles include: clinical pharmacists, social prescribing link workers, first contact physiotherapists, physician associates and paramedics.

45.19 PCN update


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Where PCNs have:

∑ made efforts to recruit to the clinical pharmacist and social prescribing link worker roles but have been unable to recruit; or

∑ can demonstrate it already has access to a full complement of clinical pharmacists or social prescribing link workers

With agreement of the commissioner, PCNs can substitute between numbers of clinical pharmacists and social prescribing link workers or vice versa.

The following table outlines each PCN’s recruitment plans for the additional roles in 2019/20:

PCN Additional RolesAdditional role WTE expecting to claim

APL Clinical Pharmacist 2.00

Clocktower Clinical Pharmacist 2.00

Frognal Clinical Pharmacist 2.00

North Bexley Clinical Pharmacist 1.00

North Bexley Social Prescriber 1.00

PCN’s are experiencing challenges in recruiting, namely in:

∑ Interpreting and staying within guidance. This is partially due to a delay in the guidance document for additional role reimbursement only being released on 16th

August 2019.∑ Ensuring that employees and PCN’s are not placed at risk.∑ A shortage of available staff, because PCN’s nationally are looking to recruit clinical

pharmacists

To address this, the GP federation (Bexley Health Neighbourhood Care CIC) are working with PCN’s to ensure that recruitment decisions made do not disadvantage neighbouring networks (including consideration on salary). This involved a full discussion following release of the national guidance at September PCN network meetings.

PCN’s are also considering what other additional roles they would like to employ in order to utilise reimbursement funds, which will likely be for additional social prescribing link workers. The GP federation are working closely with Bexley Voluntary Service Council

45.19 PCN update


https://www.england.nhs.uk/wp-content/uploads/2019/08/network-contract-des-additional-roles-reimbursement-scheme-guidance-updated.pdf

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(BVSC) and commissioners to ensure the recruitment of social prescribing link workers align with the existing social prescribing service model.

Extended Hours Access

Provision of extended hour’s access appointments is a requirement of the Network Contract DES from 1 July 2019.

All Bexley GP practices have historically provided their own extended hours, this is now included within the PCN DES. This is separate from the CCG commissioned extended access services.

An additional period of routine appointments that equate to a minimum of 30 minutes per 1,000 registered patients per week will be required for each PCN.

PCNThe number of Extended Hours required to be

delivered based on the PCN's registered population as of 1st April 2019

Number of Extended Hours Provided by week by each

PCN

APL 16 16

Clocktower 35 40.7

Frognal 23.5 23.4

North Bexley 47 53.8

All practices across all four PCNs have agreed to continue to provide their current provision of extended hour’s service in this first year; however in the future, it is likely that PCN’s will consider the model of service delivery for extended hours access across the wider network and deploy different solutions that best suit their populations. PCN member practices will be required to engage and inform patients of any changes to the pattern of extended hours access appointments, providing reasonable notice to patients.

PCN Maturity Matrix

The PCN maturity matrix has been developed to help primary care networks and otherlocal organisations involved in the development of PCNs to self-assess the current maturity of a network and to help understand the development trajectory of the network.

Components of the matrix

The matrix is divided into five development themes:1. Leadership, planning and partnerships

45.19 PCN update


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2. Use of data and population health management3. Integrating care4. Managing resources5. Working with people and communities

South East London STP agreed that the PCN development and support tool should be used to support a consistent understanding of PCN and system development support needs.

Whilst there was limited time to undertake the self-assessment, Bexley have completed this with the involvement of wider system stakeholders and discussed and agreed an overall development support position with the local care partnership board prior to submission on 30th September 2019.

PCN development support

Additional funding has been allocated to ICS/STPs for in year delivery of PCN development support. The funding for PCN development support is over and above that set out in the GP contract agreement and should only be used for development support for PCNs and broader professional teams, including staff from wider organisations and independent contractors who provide care in a community setting.

The funding is intended to be recurrent for five years dependent on need and effective use, with funding confirmed on an annual basis. STPs have workedwith CCGs to release an initial contribution to PCNs and wider systems to complete a self-assessment tool that will help to identify the development needs of each PCN in the borough and the wider system.

Supporting the development of PCN Clinical Directors (CDs)

Supporting the development of PCN Clinical Directors so that they can create thriving PCNs is a significant priority. Given the importance of these new roles a PCN Development Support prospectus has been released and sets out the key components of a leadership and development support programme for this professional group. Development needs of this group are also expected to be mapped out by PCNs as part of the self-assessment toolkit which will determine the level of support each area needs.

PCNs collaborating with non-GP Providers

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PCNs will increasingly need to work with other non-GP providers, as part of collaborative primary care networks, in order to offer their local populations more personalised, coordinated health and social care.

To support this, the Network Contract DES will be amended from 2020/21 to include collaboration with non-GP providers as a requirement. The Network Agreement will be the formal basis for working with other non-GP providers and community based organisations.

During 2019 and 2020, NHS England and GPC England will develop seven service specifications, working with a range of relevant stakeholders, and prior to agreeing them with GPC England as part of the annual contract changes. The service specifications will set out standard processes, metrics and intended quantified benefits for patients and will become key requirements of the Network Contract DES.

Patient engagement

GP member practices within a PCN will have requirements relating to patient engagement under their primary medical services contracts. The PCN will therefore be expected to reflect those requirements by engaging, liaising and communicating with their collective registered population in the most appropriate way, informing and/or involving them in developing new services and changes related to service delivery. This includes engaging with a range of communities, including ‘seldom heard’ groups.

45.19 PCN update


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As part of the contractual requirements, PCN’s will be required to provide reasonable support and assistance to the commissioner in the performance of its duties to engage patients in the provision of and/or reconfiguration of services where applicable to the registered population.

To support this, the CCG has already presented a high level overview of PCN’s to the Bexley patient council and delivered a primary care deep dive session in September for the patient council which encompassed PCN’s.

The CCG along with a representation of Bexley PCN clinical directors presented at an all member briefing to Bexley councillors in September 2019.

A focussed PCN engagement group is also being established with representation from Practice patient participation groups (PPGs), PCN clinical directors, Federation and CCG primary care and engagement leads to develop a comprehensive communication and engagement plan.

Going forwards, there is an expectation that much wider collaborative PCN engagement will take place with system stakeholders to support the delivery of the key messages and benefits that a patient / resident can expect to see as PCNs become fully embedded into the Bexley health and care landscape.

Monitoring of Progress and Delivery – PCN Dashboard

CCGs are responsible for overseeing the Network Contract DES registration process and assuring that PCNs deliver against the requirements of the DES. A Primary Care Network Dashboard is being developed by NHS England to support CCG’s in this role and is expected to be introduced from April 2020. The service specifications will set minimum requirements within the DES. The dashboard will include measures of success to allow PCNs to benchmark their performance and monitor their delivery of the five service specifications.

This monitoring should set a baseline for delivery against contractual requirements, and should provide some accountability and transparency on what the new investment has produced in terms of services delivered and, ideally, outcomes.

The CCG will continue to work closely with PCN clinical directors, Federation leads and STP PCN colleagues to ensure that support mechanisms are in place for PCNs to grow and thrive through investment made into the development needs of the PCNs and their wider communities that support and provide services within their PCNS but also to ensure that the PCN clinical directors have access to on-going leadership and development opportunities to assist them to ensure their PCNs are fully integrated and focussed in the delivery of the service specifications that are due to arrive from April 2020 onwards.

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Summary and conclusions

It is recognised that this first year of the Network Contract DES, lasting until 31 March 2020, is a development year for networks.

The key aims in this first year are as follows:

∑ For practices to align themselves into primary care networks (PCN) that are geographically aligned

∑ To nominate Clinical Directors for each PCN ∑ To provide extended hours services to the PCN population∑ To recruit into the additional roles that funding has been made available for in this

first year – that is a social prescriber and clinical pharmacist

The majority of other service requirements will be introduced from April 2020 onwards.

45.19 PCN update


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Title

Delegated Primary Care Finance Report on Month 05 2019-20



That the primary care commissioning committee;

1. NOTE the update on the Month 05 2019-20 position including the year to date small overspend position of £23k and the FOT of breakeven which assumes that the QIPP value of £315k is delivered.


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

Executive summary

As the committee has previously been advised the final 2019/20 delegated primary care budget is £30,605k. The initial budget was £31,512k but on 31 January the NHSE published a new primary care vision and funding details for the next five years. The impact of the above was to reduce the 2019/20 allocation for primary care by £907k to £30,605k. This represents an increase in budget of £1,039k compared to 2018/19 and is a 3.5% increase. At budget setting it was agreed that all CCGs in South East London would have a 1% savings target on this budget which equates to £315k for Bexley. The QIPP is to be delivered at a South East London level and plans are being developed to deliver this value including looking at any slippage on PCN recruitment. Appendix 1 shows that at month 2, the delegated primary care budget is showing a small overspend of £23k on the year to date position which is due to the fact that the QIPP has not been identified in full. However, the FOT position is showing breakeven as it is assumed that the QIPP will be delivered in full. The key financial changes in 19/20 are as follows; Global Sum The global sum value has been increased from £88.96 per weighted patient (pwp) to £89.88pwp to reflect agreed new investment, inflationary uplift, adjustments arising from the phasing out of the Minimum Practice Income Guarantee (MPIG) and of seniority payment and adjustment for the new Clinical

Enclosure: K 1 Agenda Item: 46/19

46.19 PC Finance report


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Negligence Scheme for General Practice (CNSGP). b. Introduction of primary care networks, new payments from primary care delegated allocations include: i. At practice level, the new Practice Network Participation Payment is being paid at £1.761pwp and from July the Extended Hours Des payments to practices will cease. ii. New payments at Network level in 19/20 include Extended Hours access £1.099 per registered patient (prp), Clinical Director contribution £0.514prp and staff reimbursements for Clinical Pharmacists and Social Prescribing Link workers. The first payments to the new primary care networks were made in July 19. The key risk areas identified are as follows; a. Population/List Growth Table 3 below shows changes in list size from April 19 to June 19, compared with the % change in financial year 2018/19 (April 18 to April 19). The impact of July list increases and forecast quarterly increase for October 2019 and from January 2020 have been factored into the position.

b. QOF Final QOF expenditure is not known until after the end of the financial year when the data uploaded from practice systems to the CQRS system. For reporting purposes, 19/20 aspiration payments, which reflect 18/19 achievement, adjusted for assumed improved achievement and list growth are used to estimate current year achievement. c. Premises Rent reviews continue to present a financial risk, to reflect this risk accruals have been made against the “in-year revaluation” budget. d. Prior year accrual benefit Prior year expenditure items are identified each month and remaining balances will be reviewed quarterly. Significant premises reimbursements remain unpaid because of the time taken by some practices to submit claims, specifically those in NHS PS and CHP properties. At this point in the year it is assumed that all accrual credits from 18/19 will be utilised in year.



3

There are a number of local additional risks which need to be considered although at this stage any impact is not being factored into the financial position. These risks are;

any further previously unidentified costs from the closure of Cairngall practice;

any costs incurred from the re-procurement of Bursted Wood. All of these potential risks will be assessed on a monthly basis to establish if they need to be reflected in the financial position. Potential mitigations against these particular items may include;

benefit of any unused 2018/19 accruals;

benefit of any underperformance on the PMS premium for 2018/19;

benefit of any underspend in 2019/20 on areas such as locums.


Key risks

There is a risk that the requirement to identify and deliver 1% QIPP which equates to £315k will not be achieved in year which would result in the CCG potentially not meeting its control total unless savings are found in other areas. The QIPP challenge is being taken forward at a SE London level and whilst some slippage on PCN recruitment has been identified there is still a gap to be bridged. Assurances have been given from the primary care team that this value can be delivered. Other potential risks include any further previously unidentified costs from the closure of Cairngall practice, any costs incurred from the re-procurement of Bursted Woods and any significant increases in list size across the borough.

Equality

N/a

Financial

Given the potential risks identified above, there is a risk that the CCG may not meet its control total which has the knock on effect that the CCG would not be eligible for the Commissioner Sustainability Funding of £7.5m. A further review of the primary care budgets will be undertaken to try to identify any potential savings locally in addition to the SE London work which the CCG is party to.

Author: Julie Witherall, Deputy Director of Finance

Clinical lead: Dr V Bhalla

Executive sponsor:

David Maloney, Director of Finance



Enclosure: K2

Agenda Item: 46/19

Primary Care Medical Services Bexley 135178

Financial Summary - 19/20 Aug-19

Description Annual Budget YTD BudgetYTD Actual

Expenditure

In Month

Accruals

YTD Reported

SpendYTD Variance

Forecast

Out-turn

Forecast

variance

£000 £000 £000 £000 £000 £000 £000 £000

PMS Essential and Additional Services 17,803 7,418 7,449 0 7,449 31 17,803 0

PMS Premium Services 2,043 851 733 118 851 0 2,043 0

GMS Global Sum & MPIG 1,719 716 716 0 716 0 1,719 0

GMS Premium Services 111 46 35 11 46 0 111 0

APMS Essential and Additional Services 466 194 195 0 195 0 466 0

APMS Premium Services 29 12 9 3 12 0 29 0

Caretaking - Management Fee 0 0 0 0 0 0 0 0

Subtotal Core contract 22,170 9,238 9,137 133 9,269 32 22,170 0

Population/List Growth ear-marked fund 232 97 0 65 65 (32) 232 0

Total Core contract 22,402 9,334 9,137 198 9,334 0 22,402 0

QOF aspiration 1,874 781 780 0 780 (0) 1,874 0

QOF achievement 857 357 0 357 357 0 857 0

Total QOF 2,731 1,138 780 357 1,137 (0) 2,731 0

Minor Surgery DES 176 73 51 23 73 (0) 176 0

Extended Hours DES 383 159 170 (10) 159 0 383 0

Learn Dsblty Hlth Chk DES 40 17 6 11 17 0 40 0

SAS/Violent patients scheme 25 10 13 (3) 10 0 25 0

Out of area registration DES 0 0 0 0 0 0 0 0

PCN Practice participation DES 400 167 167 0 167 0 400 0

PCN DES 563 235 28 144 172 (63) Expenditure recalculated based on confirmed number of PCNs563 0

Total enhanced services 1,587 661 433 165 598 (63) 1,587 0

Rent 1,633 680 681 0 681 1 1,633 0

Rent - CHP/NHS PS 480 200 0 200 200 (0) 480 0

In-year revaluation budget 60 25 0 25 25 0 60 0

Business Rates 512 213 145 67 212 (1) 512 0

Business Rates - CHP/NHS PS 49 21 0 20 20 (0) 49 0

CHP Primary Care Void Charges 254 106 0 106 106 0 254 0

Other Premises 65 27 68 (27) 40 13 65 0

Total Premises Reimbursements 3,055 1,273 894 391 1,285 12 3,055 0

Seniority 138 58 29 29 58 (0) 138 0

Locum reimbursements 140 58 14 46 60 2 140 0

Retainer Scheme 4 2 0 0 0 (2) 4 0

PADM Prescribing Fees Admin 173 72 17 55 72 (0) 173 0

CQC Fees reimbursement 147 61 56 5 62 0 147 0

Total PCO administered 603 251 117 135 251 0 603 0

Other 20 8 17 8 25 17 20 0

0 0 0 0 0 0 0 0

Clinical waste 29 12 0 12 12 0 29 0

MOU costs 0 0 0 0 0 0 0 0

Prior Year 315 131 (1,279) 1,411 131 (0) 179 (136)

Prior Year - rechargeable to NHS E 0 0 0 0 0 0 0 0

Savings Target/Contingency (136) (57) 0 0 0 57 arising from 62k allocation surplus, £315k QIP budget on prior year line and £114k budget for lists on closed practices0 136

0 0 0 0 0 0 0 0

Total Other Medical Services 227 95 (1,262) 1,431 168 74 228 0

Total Primary Care Medical Services 30,605 12,751 10,099 2,676 12,775 23 30,605 0

Summary £000 £000 £000 £000 £000 £000 £000 £000

Core contract 19,988 8,328 8,360 0 8,360 32 19,988 0

Population/List Growth ear-marked fund 232 97 0 65 65 (32) 232 0

Caretaking Management 0 0 0 0 0 0 0 0

Premium Services 2,183 909 777 133 909 0 2,183 0

QOF 2,731 1,138 780 357 1,137 (0) 2,731 0

Enhanced Services 1,587 661 433 165 598 (63) 1,587 0

Premises and other reimbursements 3,055 1,273 894 391 1,285 12 3,055 0

PCO administered 603 251 117 135 251 0 603 0

Other 227 95 (1,262) 1,431 168 74 228 0

0

0

Ledger Total 30,605 12,751 10,099 2,676 12,775 23 30,605 0



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