Primary Care Commissioning Committee (PCCC) · Primary Care Commissioning Committee (PCCC) Meeting...

Primary Care Commissioning Committee (PCCC)

Meeting to be held at 10.30am on Thursday, 25th May 2017 in the Board Room, Sanger House, Brockworth, Gloucester GL3 4FE

No. Item Lead Recommendation

1. Apologies for Absence

Chair

2. Declarations of Interest

Chair

3. Minutes of the Meeting held on 30th March 2017

Chair Approval

4. Matters Arising

Chair

5. Draft SOP for applications for contractual mergers

Jeanette Giles Approval

6. General Practice Forward View – NHSE feedback from March 2017 Submission & Updated GCCG Plan

Helen Goodey Information & Approval

7. Delegated Primary Care Commissioning Financial Report

Cath Leech Information

8. Primary Care Quality Report Marion Andrews-Evans

Information

9. Any Other Business (AOB)

Chair

Date and time of next meeting: Thursday 27th July 2017 at 10.30 am in the Board Room at Sanger House.

Agenda Item 3

Primary Care Commissioning Committee (PCCC)

Minutes of the Meeting held on Thursday 30 March 2017 in the Board Room, Sanger House, Gloucester GL3 4FE

Present:

Alan Elkin (Chair) AE Lay Member – Patient and Public Engagement

Cath Leech CL Chief Finance Officer

Julie Clatworthy JC Registered Nurse

Joanna Davies JD Lay Member – Patient and Public Engagement

Colin Greaves CG Lay Member - Governance

Mary Hutton MH Accountable Officer

Dr Andy Seymour (Non-Voting)

AS Clinical Chair

In attendance:

Helen Goodey HG Director of Primary Care and Locality Development

Andrew Hughes (Item 5) AH Locality Implementation Manager

Declan McLaughlin DM Primary Care Project Manager

Becky Parish BP Associate Director, Engagement and Experience

Helen Edwards HE Associate Director of Locality Development and Primary Care

Chris Graves CsG Healthwatch Representative

Bronwyn Barnes BB Programme Manager

Jane Haros (Item 6) JH Lead Clinical Commissioner

Jeanette Giles JG Head of Primary Care Contracting

Stephen Rudd SR Head of Locality and Primary Care Development

Mark Gregory (Item 6) MG Medicines Optimisation Lead

Chris Roche (Item 6) CR Information Manager

Zoe Barnes ZB Corporate Governance Officer

Ryan Brunsdon RB Board Administrator

There were no members of the public present.

1 Apologies for Absence

1.1 Apologies were received from Marion Andrews-Evans (MAE) and Cllr Dorcas Binns (DBi).

2 Declarations of Interest

2.1 AS declared a general interest as a GP but more specifically in respect of agenda item 6 The Primary Care Offer, as his Practice (Heathville Medical Practice) may submit bids as part of the offer.

2.2 AE declared that the meeting was quorate and that he felt that AS should not be excluded from any discussions as he was a non-voting member.

3 Minutes of the Meeting held on Thursday 19 January 2017

3.1 The minutes were approved as an accurate record.

4 Matters Arising

4.1 28.01.2016 Item 9.1 Any Other Business – AE advised that the Primary Care Commissioning Committee self-assessment was on the agenda (item 13).

4.2 26.05.2016 Item 3.2 Minutes of the meeting held on Thursday 31st March 2016 – It was confirmed that value for money issues were routinely addressed within the routine premises workstream

Item Closed. reports.

4.3 24.11.2016 Item 5.16 Premises Workstream Progress Report –

AH reported that conversations with the lead for the Estates and

Technology Transformation Fund (ETTF) around schemes had

taken place and that he would continue to work closely with them on

Item Closed. the process.

4.4 24.11.2016 Item 6.3 General Practice Forward View update – HG

noted that the communication plan and strategy had been

Item Closed. implemented.

4.5 24.11.2016 Item 6.4 General Practice Forward View update – HG

advised that each practice transformation scheme had an evaluation

Item built in which would be reported on throughout the year.

Closed.

4.6 26.01.2017 Item 13.6 Primary Care Quality Report – It was

confirmed that quality indicators were now included within the

Item Closed. Primary Care Quality report.

5

Primary Care Premises – progress report on the premises workstream

5.1 AH introduced the progress report highlighting that there were 3 key areas covered including, committed/legacy schemes, new proposals (Including reference to ETTF) and Improvement Grants (including ETTF). The report was taken as read, and AH highlighted the key developments.

5.2 AH noted that the Tewkesbury Primary Care Centre had opened on 6th March 2017 and that work was underway within the new centre.

5.3 AH noted that Churchdown Surgery had signed a 20 year lease and construction was due to commence in April 2017 with a planned opening in March 2018.

5.4 AH highlighted that progress with Stow Surgery had halted, and that the CCG could not progress further at the present time due to financial issues. It was noted that the current scheme was led by local people and once they sell to a third party company, work towards development could resume.

5.5 AH informed members that the estimates of the cost of the Cheltenham Town Centre Surgery had increased from £2.9m to £4.37m. Two of five practices had committed to the scheme, with the remaining three practices raising concerns about the commitments of a long term lease. AH added that there was active liaison work with NHSE as the scheme would be at risk if practices did not sign. However he was confident that this would be worked through in order for a business case to be brought to the September meeting of the Committee.

5.6 DM highlighted that work at Springbank was due to commence and there were no risks attached to these premises.

5.8

5.9

AE queried the progress of Lydney. AH informed members that the proposal for Lydney had been reclassified as a Minor Improvement Grant and the funding responsibility had also been transferred to the CCG to manage as a separate approval process. AH noted that the practice had decided to rationalise the structural work to reduce final costs. JC queried if there had been any more developments regarding the impacts of the changes to PropCo. AH advised that no further information had been received, however there was some positive benefit expected.

6 Primary Care Offer

6.1 BB provided a brief update on the Primary Care Offer (PCO) contract specification for 2017/18.

6.2 BB noted that the Primary Care Offer specification had been developed to deliver Community Enhanced Services. The PCO had been reviewed by the Local Medical Committee (LMC) and the CCG Core Team. BB highlighted that £2.9m had been invested into the PCO.

6.3 JH presented the frailty aspect of the Primary Care Offer.

6.3.1 Practice based lead contacts for frailty JH highlighted that the frailty role in practices would be required to have frailty lead contact responsibility at each level to include:

Frailty Administration/Co-Ordination lead

GP Frailty contact lead

Practice Manager contact lead

Practice Nurse contact lead JH noted that the names of all of the frailty leads need to be provided to the CCG by 1st June 2017.

6.3.2 Training, Education & Awareness JH advised that podcasts and masterclasses were being developed

to feature various elements and to raise awareness on best practices on the management of frailty. It was noted that all frailty leads must attend the face to face masterclasses.

6.3.3 Communication JH noted that all GP practices would need to provide back-door telephone numbers to OPAL (Older Peoples Advice and Liaison Team) at Gloucestershire Hospitals NHS Foundation Trust (GHFT). JH advised that a GP must return a call to OPAL within one hour to discuss whether hospital admission was appropriate.

6.3.4 Primary Care Team meetings for frail patients JH noted that team meetings would take a cluster Multi – Disciplinary Team (MDT) approach lasting approximately 20-35 minutes, happening per week/fortnight depending on practice size. JH advised this would be a phased approach.

6.4 JC recognised the update as being comprehensive, however queried whether the 2 year care co-ordinator role had been evaluated. HG informed members that this was a national programme, and care co-ordinators provide a pivotal role to the Primary Care Offer providing consistency and structure. AS advised that evaluations were difficult due to practices having different processes in place.

6.5

6.6

6.7

AS explained that the cluster MDT approach could be difficult to implement due to commitment issues and the current clinical pressures leads were facing. CR attended the meeting to discuss the options to monitor and evaluate the frailty service and confirmed that a baseline was currently being reviewed. The South Cotswolds evaluation would be reviewed and important sections pulled out in order to take a whole system look. CR advised that once the baseline had been completed, this would then be monitored throughout the year. CR gave assurance that there was a robust approach in place around what could be measured. MG discussed the prescribing element of the PCO and advised that this would include polypharmacy and medicines optimisation and

involved trying to measure the use of higher risk drugs in the elderly. MG added that there were four areas of priority of the PCO including Gluten Free prescribing, Sip feeds, Pregabalin, and the Do Not Prescribe list and practices were being incentivised to achieve these targets. This was additional to the main frailty process.

6.8 JC questioned as to whether more qualitative assessments could take place to assess the impact that the PCO had on staff and patients. CR noted that an evaluation proforma was being worked upon with public health to look at what was being measured and to include more qualitative information.

6.9

CG queried whether the LMC had been involved in practice negotiations as limited monies could be accessed across the 81 GP Practices. HG confirmed that there had been GP development workshops looking at best practices. Workshops were run to test the delivery of the PCO, its value for money and clinical effectiveness. HG also noted that the workshops had demonstrated staff support of the PCO.

6.10

HG informed members that the PCO could be initiated week commencing 3 April 2017 once approved.

6.11 RESOLUTION: The Committee approved the Primary Care Offer Enhanced Service for 2017/18.

7 Primary Care Strategy Workforce Update

7.1 BB introduced a presentation relating to the Primary Care Strategy Workforce Update noting that the first update was completed in Summer 2016.

7.1.2 BB reported that the Gloucestershire Workforce survey was conducted in February 2017 with 78 GP practices responding to the survey. This demonstrated that that Gloucestershire currently had 26 practices with vacancies, making up 33% of the responses. It was noted that:

there were 123 partner vacant sessions;

94 salaried vacant sessions;

25 planned GP retirements.

BB also highlighted the national and local pressures within the recruitment and retention of the GP workforce.

7.1.3 BB noted that the Gloucester locality had the highest number of anticipated retirements, with 6 anticipated to retire in the locality. This may impact on the perception of the desirability of working within the Gloucester locality.

7.1.4 BB reported that the General Practice Forward View (GPFV) provides access to support and represents part of the solution to the various challenges.

7.1.5 BB advised that the workforce strategy was a key component of the overall Primary Care Strategy and was critical to the sustainability of primary care within Gloucestershire. The strategy was described as encompassing the following approaches:

Recruitment, retention and return of the GP workforce;

Education and training of the practice nurse workforce;

Development of the „skill mix‟ in primary care, including new roles.

7.1.6 BB updated the Committee on the multi-media campaign promoting GP working and living in Gloucestershire. The presentation highlighted that there was print and online support in the British Medical Journal (BMJ) with the inclusion of video and social media. For 2016/17, there was the provision of 1 branded recruitment package for each of the member practices with 47 GP Practices recruitment packages being utilised. BB highlighted that 2017/2018 plans were to continue with the integrated branded microsites available to GP practices and with recruitment support.

7.1.7 BB reported that 13 practices had shown an interest in overseas recruitment. It was noted that the CCG were negotiating with agencies that could provide a range of support activities including identifying candidates, support with screening applicants, relocation, GMC registration and performers list applications.

7.1.8 BB presented the Community Education Provider Network (CEPN) and advised that pump-priming funding had been achieved for setting up the training hub across Gloucestershire, supported by

Health Education England (HEE) and the West of England Academic Health Science Network (AHSN).

7.1.9 BB advised members of the newly qualified GP scheme. This scheme was developed to encourage Gloucestershire ST3s to practice within the County by bridging the gap between practicing as a locum or as a salaried GP. The scheme had been updated with additional flexibility in 2017 to include:

Choice of rotation periods between 4 and 12 months in at least 2 practices for the duration of the scheme;

Allocated pro rata funding towards postgraduate study or out of hours medical indemnity;

GP locational preferences considered when allocating practices;

Mentorship support expectation of host practices alongside CCG facilitated development and networking opportunities.

BB noted that to date 7 GPs and 21 practices had expressed an interest in the scheme.

7.1.10 BB discussed the GP retainer scheme and identified that Gloucestershire was continuing to promote the approach. It was noted that there were currently four retainers with an additional approved retainer due to start shortly. The CCG was awaiting guidance on an updated scheme from April 17 onwards (to be renamed “GP Retention Scheme”). The Committee agreed that retiring GP‟s expertise needed to be retained. The CCG had engaged with retiring GP‟s in offering them a portfolio career, but the response had not been positive.

7.1.11 BB advised that MAE and her team were working on the Practice Nurse Education and Training aspect of the scheme and were working across all localities on this.

7.1.12 BB concluded that the CCG were continuing to build upon the success of the work undertaken in the previous 2 years. BB highlighted that the 4 key points going forward were:

Encourage the next generation of GPs to practice in Gloucestershire;

Retain our retirees and those leaving practice early in some

capacity;

Attract national and international GPs to Gloucestershire;

Continue to support cluster and countywide work to support resilience, make efficiencies and consider and test new models of care and new skill mixes to support existing roles and continue to provide good quality Primary Care services.

7.2 HG commended BB for the work undertaken in support of the Workforce Strategy.

7.3 JC commended the work completed and asked if an equally comprehensive plan and strategy could be developed for the Nursing workforce in the light of national changes and the current limited supply of the Nursing workforce. HG agreed that a comprehensive plan was required and this would be brought to a future PCCC meeting to include information on the full Nurse development programme.

7.4

7.5

Members discussed the distribution of vacancies across the localities further. AS noted that several practices were carrying more than one vacancy. The Committee were of the view that correlation between vacancies and areas of deprivation and population size should be considered. MH agreed that health inequalities may need further consideration in terms of impacts within Primary Care.

7.6 CG queried the progress of recruitment within the Republic of Ireland. HG advised that the programme of work was still being developed and supported by Health Education England.

7.7 RESOLUTION: The Committee noted the Primary Care Workforce Update.

8 Place Based Models of Care

8.1 HE introduced the Place Based Models of Care paper and gave a brief overview. The paper was taken as read.

AI 8Place based model V5 inc cover sheet 21032017.docx

8.2 HE noted that there were two pilot localities, Stroud & Berkeley Vale

and Gloucester City encompassing four and five clusters

respectively, working in a place based way.

8.3 HE informed members that pages three, four and five of the report

highlighted the participating GP practices within the two pilot

localities.

8.4 HE added that the following pages, six, seven and eight provided an

update on the key pieces of work that had been undertaken.

8.5 HE advised that there were plans in place to extend the Place

Based approach across Gloucestershire in a phased way, where

communities have expressed an interest in doing so.

8.6 AE highlighted how positive the work was that had been carried out,

and particularly highlighted the recruitment of the Frailty Nurse and

the progression of the mental health pilot.

8.7 RESOLUTION: The Committee noted the Place Based Models of Care paper.

9 Delegated Primary Care Commissioning Financial Report

9.1

CL presented the Delegated Primary Care Commissioning Financial Report noting that the CCG continued to forecast a breakeven position for 2016/17 and had assessed all known commitments for the remaining months in the financial year.

9.2 CL reported that the CCG had an underspend of £25k against

delegated budgets at the end of February 2017.

9.3 RESOLUTION: The Committee noted the Delegated Primary Care Commissioning Financial Report.

10 2017/18 Delegated Primary Care Budgets

10.1 CL provided an update on the 2017/18 Delegated Primary Care Budgets noting that the CCG had received its Primary Care allocation for 2017/18 which had subsequently been updated, and the budget for 2017/18 was set on the updated allocation. The total allocation for 2017/18 was £79.968m, an increase of £1.445m.

10.2 CL reported that 1% of the allocation should be used to create a

reserve for non-recurrent spend with 50% of this reserve to be

uncommitted and held as a risk reserve. CL advised that 50% would

be available for the CCG to spend non-recurrently to support

transformation and change.

10.3

10.4

CL noted that Minimum Practice Income Guarantee (MPIG)

payments had been reduced by 1/7 during the year, in accordance

with national policy to eliminate MPIG payments by 2021. It was

also noted that the global sum price per weighted patient was

expected to be £85.35 from 1st April 2017 which represents a 5.91%

increase and this had been assumed within the budget.

AE highlighted point 5.2.5 of the report regarding CQC fees and

queried if there would be an increase in year in premises costs. CL

confirmed that this was slightly above the delegated budget and

would be a first call on the delegated contingency. AE requested

that the issue of budget sustainability was viewed carefully around

premises development. CL advised that business cases would be

completed and brought to the PCCC however dependent upon the

funding requested these may be forwarded to the Governing Body

for approval.

10.5 CG highlighted the potential difficulties arising each year with the

development of premises proposals, inflationary increases in costs

and rent reviews upon the budget, however accepted that

investment in premises development was important. CL confirmed

that a premises plan and revenue consequences were included

within the budget strategy. MH added that the schedule for the

coming years could be recirculated to members for information. AE

reiterated that premises development was important to ensure

suitable facilities were available as part of our overall approach to

primary care.

10.6 RESOLUTION: The Committee recommended the 2017/18 delegated Primary Care budget for onward approval by the

Governing Body.

11 Primary Care Quality Report

11.1 BP introduced the Primary Care Quality Report highlighting that there were 3 main domains within the report which included:

Planning for Quality;

Quality Improvement;

Quality Assurance.

11.2 BP informed the committee that the CCG Practice Nurse Facilitator

Team were currently undertaking a workforce profiling audit to gain

a full understanding of the profile of General Practice Nurses and

Health Care Assistants working across the county. This would

assist in planning future workforce, education and training strategies

and results will be presented to a future PCCC meeting.

11.3 BP reported that the organisation was anticipating national results of

areas of interest regarding medicine optimisation. BP also noted

that following substantial decline in Gluten Free prescribing the

focus had now moved to identifying those GP practices with a

comparatively high use of SIP feeds. Support had been provided to

these GP Practices to reduce reliance on sip feeds with the

approach to advise the use of “Food First” as detailed within the

CCG G-Care Pathway.

BP advised members that the CCG was supporting Rosebank

Surgery in a pilot to establish a repeat prescribing ordering hub

which was due to go live in May 2017, similar to the hub due to go

live in April within the Berkeley Vale Cluster.

11.4 BP reported that six reports to the NRLS (National Reporting and

Learning System) had been made by three Gloucestershire

Practices. These reports were relating to low or no-harm issues. BP

noted that serious incidents are normally called significant events,

and NHSE have agreed to continue review all GP serious incidents.

11.5 BP reported that NHSE have delayed work on the Primary Care

complaints dashboard due to poor feedback, and that an update

was due to follow after April.

11.6 BP highlighted that FFT (Friends & Family Test) responses in

Gloucestershire were very low at 0.33% and could not be deemed

statistically significant. BP noted that the Primary Care Contracts

Team had reminded Practices of the deadline for submitting FFT

data and that it is a contractual requirement.

11.7 JC queried point 3.2.5 of report regarding the application for funding

for Clinical Pharmacists and queried if the organisation had

recruited pharmacists as part of this. HG confirmed that Pharmacists

were not directly employed by the CCG.

11.8 JC noted that the report did not highlight the number of GP‟s who

had attended the safeguarding roadshows and requested

confirmation on the numbers. AS advised that over 90% of GP‟s had

attended the roadshows, but asked for figures to be included within

the next report to confirm.

11.9 AE expressed his thanks to MAE and her team for the report.

12 GP Forward View Plan

12.1 SR introduced the paper and informed members that the original GP Forward View Plan was submitted in December 2016.

12.2 SR informed members that all Clinical Commissioning Groups needed to update their GP Forward View plans and that this had to be done in accordance with NHSE RAG ratings.

12.3 SR reported that the GCCG GP Forward View Plan was sent to NHSE on 10 March 2017 and that the organisation was still awaiting feedback.

13 Primary Care Commissioning Committee Self-Assessment

13.1 AE presented the report which included specific responses to the self-assessment survey as completed by members, and noted how helpful the responses had been. AE expressed his thanks to the team supporting the Committee and identified for example the response to question seven which highlighted that the minutes from

meetings were accurate and reflect the challenges, actions and next steps articulated by members.

13.2 CG noted that the committee self-assessment was a good exercise. CG suggested that this be revisited again in 6 months to review progress.

14 Any Other Business

14.1 There was no other business.

The meeting closed at 12:32pm.

Date and Time of next meeting: Thursday 25 May 2017 in the Board Room at Sanger House.

Minutes Approved by Gloucestershire Clinical Commissioning Group Primary Care Commissioning Committee: Signed (Chair):____________________ Date:_____________

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Agenda Item 4

Primary Care Commissioning Committee (PCCC) Matters Arising – May 2017

Item Description Response

Action with Due Date Status

28/01/2016 Item 9.1

Any Other Business

CG suggested that a self-assessment was undertaken to reflect on the role as a Committee in order to improve on processes and identify areas for development where further training was required. 30.03.17 13.2 – CG suggested that this be revisited again in 6 months to review progress.

AE 28 Sept 17

Due Sept

24/11/2016 Item 5.22

Premises Workstream Progress Report

CG drew attention to Section 5.4 of the report relating to the arrangements with NHS England and PropCo for signing off the commissioner support letter. CG expressed his disappointment and requested that the process was modified and suggested that a letter was written highlighting that CCG had delegated authority for primary care. AH agreed that he would work this through with CL and HG.

HG/Andrew Hughes

25 May 17 For confirmation

30/03/2017 Item 7.3

Primary Care Strategy Workforce Update

JC commended the practice workforce work and asked if an equally comprehensive plan and strategy could be developed for the Nursing workforce. HG agreed that a comprehensive plan was required and this

HG 27 July 17 Due July

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would be brought to a future PCCC meeting to include information on the full Nurse development programme.

30/03/2017 Item 10.5

2017/18 Delegated Primary Care Budgets

CL confirmed that a premises plan and revenue consequences were included within the budget strategy. MH added that the schedule for the coming years could be recirculated to members for information.

CL/MH 25 May 17 For confirmation

30/03/2017 Item 11.8

Primary Care Quality Report – GP attendance at safeguarding roadshows

It was agreed that information on the number of GPs who had attended the safeguarding roadshows would be included within the next report.

HG 25 May 17 For confirmation

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Agenda Item 5

Primary Care Commissioning Committee

Meeting Date Thursday 25th May 2017

Title Standard Operating Procedure: Application

for consideration of a contractual merger

Executive Summary As an organisation with responsibility for

commissioning primary care, under a

Delegation Agreement with NHS England,

Gloucestershire CCG (CCG) is required to

consider and agree applications for a

contractual merger.

A Standard Operating Procedure (SOP) has

therefore been developed to standardise the

process for consideration of such requests, for

approval by the Primary Care Operational

Group (PCOG).

Risk Issues:

Original Risk

Residual Risk

CCG must ensure transparency and

consistency in handling applications for

merger, while also striving to ensure

continuous improvement in primary medical

care provision and complying with legislation.

Financial Impact The CCG should consider costs/value for

money as a contract merger is likely to merge

two or more contracts which could have

differing values which would lead to an

‘averaging’ effect, possibly resulting in a higher

cost per head of population under a single

contract.

The CCG should also bear in mind that once

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patients are under one contract, the Carr-Hill

formula (or any future equivalent) will be

applied and may increase the cost of the

transferring patients based on one of the other

factors such as rurality, when it may not have

applied to the terminating contract.

Legal Issues

(including NHS

Constitution)

The CCG must act within the terms of the

Delegation Agreement with NHS England for

undertaking the functions relating to Primary

Care Medical Services.

In determining all variations the following

guidance, legislation and regulations are

considered:

GMS Regulations

PMS Regulations and guidance

APMS Directions

Statement of Financial Entitlements

NHS Act(s)

European Union (EU) procurement

legislation

The Public Contracts Regulations

Department of Health Procurement

Guide

Principle and rules of co-operation

and competition (issued by the

Department of Health)

Impact on Health

Inequalities

Health inequalities will be considered within

each application.

Impact on Equality

and Diversity

Equality and diversity impacts are considered

within each application.

Patient and Public

Involvement

The SOP requires details of engagement with

patients prior to application and proposed

arrangements for involving wider patient

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engagement post the decision. The CCG will

provide support and advice with a stakeholder

and engagement plan as required.

Recommendation The PCOG is asked to:

Consider and approve the draft SOP for

branch surgery closure applications

Author Jeanette Giles

Designation Head of Primary Care Contracting

Sponsoring Director

(if not author)

Helen Goodey

Director Locality Development and Primary

Care

Appendix 1: Standard Operating Procedure: Application for consideration of a contractual merger

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Agenda Item 5


Thursday 25th May 2017

Standard Operating Procedure (SOP) for Application for consideration of a contractual merger

Prepared by: Primary Care and Localities Directorate, Gloucestershire CCG

Version draft 1.3

1. Introduction

1.1 There may be circumstances when GP practices may wish to

come together in varying ways to provide support for each other,

expand on services available and/or resolve premises issues and

achieve economies of scale, though each will have their own

reasons for considering such a union.

From 1 April 2015, NHS England has delegated to NHS

Gloucestershire CCG (GCCG) under section 13Z of the NHS Act

delegated functions in relation to the commissioning, procurement

and management of Primary Medical Services Contracts. This

delegation therefore includes the consideration and agreement of

applications for a contractual merger.

Prior to making any decision, the CCG must clearly demonstrate

the grounds for such a decision and fully consider any impact on

the GP practice’s registered population and that of the

surrounding practices. The CCG must be able to clearly

demonstrate it has entered into dialogue with the GP contractor

as to how any merger will be managed.

In making any decisions, the CCG must take account of its

obligations as set out in the Delegation Agreement in relation to

procurement, where applicable.

1.2 This document describes the steps required to undertake an

application for a contractual merger, the decision making process

and undertaking the associated contract variation. This ensures

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that any changes reflect and comply with national regulations.

The underlying principle for the CCG is to consider when any

such proposal is made to them what the benefit is for the patients

and what the financial implications are for the CCG.

This document focuses on primary medical care contracts in their

various forms, has been developed in line with national legislation

and regulations and will be reviewed regularly (at least annually or

sooner if a change in legislation/regulation requires it).

1.3 SOP statement

This SOP is based on the following principles:

To balance consistency and local flexibility;

Compliance with legislation;

Compliance with the Equality Act 2010;

Wherever possible to enable improvement in primary medical

care provision.

1.4 Scope

The scope of this SOP is to outline the principles and steps

required by practices and CCG when an application for

consideration of a contractual merger is received, in accordance

with the NHS England policy

https://www.england.nhs.uk/commissioning/wp-

content/uploads/sites/12/2016/01/policy-book-pms.pdf

When any such proposal is made to the CCG, the CCG must

consider:

Has the applicant been able to clearly demonstrate the grounds for merger

Have they fully considered any impact on the contractor’s registered population

Is the proposed merger aligned to NHSE/CCG primary care strategies

Consideration also needs to be given in respect of any financial impact to the CCG.

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/01/policy-book-pms.pdf

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/01/policy-book-pms.pdf

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1.5 Engagement

When considering an application for practice mergers the CCG is

required to undertake all necessary engagement when taking any

decision in relation to GP practice mergers including those set out

under section 14Z2 of the NHS Act (duty for public involvement

and consultation). The engagement or consultation undertaken

must be appropriate and proportionate in the circumstances and

should include the Local Medical Committee.

2. Application for consideration of a contractual merger

2.1

2.1.1

There are two ways in which practices may propose to merge:

By informal arrangements such as sharing staff which requires no change to the contracts as it is a private arrangement between the practices, or

2.1.2 By ‘merging’ the contracts which may be done by:

each contractor becoming a party to the other contractor’s contract (through variations of the contracting parties). Whilst the partnership is required to notify the CCG of any change in partners, in order that a contract variation can be generated, no approval is required for a GMS contract.; or

terminating one of the existing contracts, continuing the other contract but varying it to include the other contractor as a part to the contract; or

by terminating the two existing contracts and creating a single organisation or partnership which will enter into one new contract.

2.2 If one or both contracts are terminated, the relevant contractor must give notice to the CCG to terminate (giving either three or six months’ notice depending on the type of contractor and contract).

2.3 Merging contracts is a complex matter which should not be

approached lightly by either the contractors or the CCG.

The contractor should engage in open dialogue with the CCG in

the first instance to consider the reasons behind the application

and consequence and implications of the application.

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2.4 The CCG should also consider costs/value for money as a contract merger is likely to merge two contracts with differing values, this would have an ‘averaging’ effect, possibly resulting in a higher cost per head of population under a single contract.

The commissioner should also bear in mind that once patients are under one contract, the Carr-Hill formula will be applied and may increase the cost of the transferring patients based on one of the other factors such as rurality, when it may not have applied to the terminating contract.

Other financial arrangements should also be considered, e.g. impact of directions under the Statement of Financial Entitlements or any specific terms included in the individual contracts.

Other considerations are

premises reimbursements,

additional service and out of hours opt-outs

QOF (if merging contracts midway through a financial year)

Procurement and competition

2.5 The CCG should advise contractors to seek guidance from their representative’s bodies to ensure they follow due process and are fully aware of the implications.

2.6 Practices are responsible for engaging with their patients and local population on their proposals. The CCG will provide advice and support with the development of the practices’ Stakeholder Engagement and Communication plan.

Engagement and communication can take place in a number of ways including talking with Patient Participation Groups, frequently asked question sheets, posters, individual patient letters, etc. Information to patients should include details of the proposed change and the reasons for the change. It should be clearly stated how patients can provide feedback and how their feedback will be taken into account.

The CCG will engage with the following stakeholders as required1:

Members of Healthwatch Gloucestershire

Members of Gloucestershire Health and Care Overview and Scrutiny Committee (HCOSC)

1 Where the change is consider to be a ‘substantial variation’ (s14Z2, Health and Social Care Act, 2012), more

formal consultation may be required, The CCG will provide advice regarding this consideration.

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Members of Gloucestershire Health and Wellbeing Board (HWB)

Other public/community representatives, e.g. Local councils, MPs

Neighbouring practices in their area

NHS England (South West)

Local Medical Committee (LMC)

Local Pharmaceutical Committee (LPC) (where a dispensing practice affected)

3. Submission of application to merge

The practice must submit a formal application for a contractual

merger (Annex 1)

The practice’s application should include a service plan with detail

on:

how patients would access a single service

what the practice boundary will be

assurances that all patients will access a single service with consistency across provision, i.e. home visits, booking appointments, essential and additional services, opening hours, extended hours, single IT system, etc

premises arrangements

proposed arrangements for involving the patients about the proposed changes

communicating the change to patients and ensuring patient choice throughout

3.1 The CCG Primary Care Team will bring together all relevant

information and prepare a paper for the Primary Care Operational

Group outlining:

The reason for change;

Practice information

Impact/benefits for patients and local population

Financial implications

Details of who has been engaged and feedback received;

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3.2 The Primary Care Operational Group will assess the application

at the next available meeting and develop a recommendation

having considered:

benefits for the patients

what the financial implications are for the CCG.

Feedback from patient and local stakeholder engagement

Feedback from the Local Medical Committee;

Feedback from neighbouring practices;

Feedback from NHSE sub regional/neighbouring CCG(s) if

appropriate

Alignment with CCG Primary Care Strategy

This recommendation will then be escalated to the next Primary

Care Commissioning Committee for consideration and a decision.

3.3 The Primary Care Commissioning Committee will consider the

application in light of the recommendation of the Primary Care

Operational Group and make a final decision with clear reasoning.

This will then be communicated to the practice in writing, with the

reasons for the decision reached.

3.4 If the application is approved, the contractor must work closely

with the Primary Care Contracting Team to ensure all actions

required to progress to merger on the agreed date are delivered

to an agreed timetable/plan.

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Annex 1:

Application for consideration of a contractual merger (Please add additional pages if you have insufficient room to complete fully) Name and address of the practices wishing to merge: Practice A: Practice B: Practice code: Practice code: Type of contract: GMS/PMS/APMS Type of contract: GMS/PMS/APMS Please complete the following: 1. Which of these contracts you would prefer to continue with (CCG final decision in this respect would be required) ……………………………………………………………………………………………… …………………………………………………………………………………………….. 2. Indicate whether you intend to operate from all current premises yes/no a. If yes, which premises will be considered the main and which is to be considered the branch/s (if applicable): …………………………………………………………………………………………….. 3. Are there any changes to premises/hours, etc? ………………………………………………………………………………………………. …………………………………………………………………………………………….. 4. Full details of the benefits you feel the registered patients of all practices involved will receive as a result of this proposed merger. ……………………………………………………………………………………………… ………………………………………………………………………………………………

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……………………………………………………………………………………………… 5. Please provide as much detail as possible as to how the current registered patients from the existing practices will access a single service, including consistent provision across: • home visits; • booking appointments; • additional and enhanced services; • opening hours; • extended hours; • single IT system; and • premises facilities. ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… …………………………………………………………………………………….……… 6. Merger of clinical systems will require lead time. Please confirm the practice has approval for the clinical system merger and has considered the lead time for the merger: ……………………………………………………………………………………………….. ………………………………………………………………………………………………. 7. Details of the proposed merged practice boundary (please provide a map): ……………………………………………………………………………………………… …………………………………………………………………………………………….. 8. Describe your engagement with patients to date and how you propose to engage with your wider patients about this proposal, communicate actual change to patients

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……………………………………………………………………………………………… ……………………………………………………………………………………………… …………………………………………………………………………………………….. 9. Please confirm that a process of due diligence has been undertaken by each of the merging parties for each of the following areas:

Practice Name Organisational Financial Clinical (including record keeping)

Other, e.g. partnership agreements

10. Please identify the proposed date the merger will take effect from: ………………………………………………………………………………………………….. To be signed by all parties to both contracts being proposed for merger Practice A: Signed: ……………………………………………………………………………….…… Print: ……………………………………………………………………………………… Date: ...…………………………………………………………………………………… Signed: …………………………………………………………………………………… Print: ……………………………………………………………………………………… Date: ....…………………………………………………………………………………… Signed: …………………………………………………………………………………… Print: ……………………………………………………………………………………… Date: ...……………………………………………………………………………………

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Signed: …………………………………………………………………..……………… Print: ……………………………………………………………………………………… Date: ………………………………………………………………………………………. Practice B: Signed: ……………………………………………………………………………….…… Print: ……………………………………………………………………………………… Date: ...…………………………………………………………………………………… Signed: …………………………………………………………………………………… Print: ……………………………………………………………………………………… Date: ....…………………………………………………………………………………… Signed: …………………………………………………………………………………… Print: ……………………………………………………………………………………… Date: ...…………………………………………………………………………………… Signed: …………………………………………………………………..……………… Print: ……………………………………………………………………………………… Date: ………………………………………………………………………………………. Please continue on a separate sheet if necessary Note: this application does not impose any obligation on the CCG to agree to this request. Please return to: Primary Care and Localities Directorate, NHS Gloucestershire Clinical

Commissioning Group, Sanger House, 5220 Valiant Court, Gloucester Business

Park, Brockworth, Gloucester, GL3 4FE.

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Agenda Item 6



Report Title General Practice Forward View: Gloucestershire’s updated plan

Executive Summary

The General Practice Forward View (GPFV) was published in April 2016 with the explicit aim of addressing the pressures being felt by GPs and their teams, such as reduced funding, increased workload and insufficient workforce.

An update to the December 2016 GCCG plan was requested by NHS England (NHSE) for submission on 10 March 2017. This was electronically approved by PCCC prior to submission and presented for information at the March meeting.

Following this submission, GCCG received a letter from the Director of Commissioning, NHS England South (South Central), assuring our plan. The ratings were as follows:

This strong rating across our plan recognises the significant progress we have made in Gloucestershire in planning and implementing the General Practice Forward View, much of which is integral to the ambitions set out in our Primary Care Strategy. While ‘Workforce’ has been given an Amber rating, we have been informed this is consistent with

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NHSE’s approach across South (South Central) given workforce pressures across the region.

While the plan has been rated ‘Green’, we have been asked for some supplementary information across these areas and for the plan to then be resubmitted to NHSE by the end of May, following sign off by our Governing Body. This paper therefore presents this updated version for PCCC recommendation for approval to the Governing Body.

The changes in this update to the previously submitted document, with contributions from the relevant experts across the appropriate GCCG and CSU teams, can be summarised as follows:

Workforce section – This has been updated to respond to NHSE’s request on how GCCG are investing in GP leadership and plans for Multi-Disciplinary Team development. International Recruitment plans have also been added to the document.

Access section – Further detail has been added on how GCCG are currently approaching this scheme. The criteria by which GCCG will assess expressions of interest have also been added.

Infrastructure section – This section has been updated with regards to estates and technology. This includes GCCG progress on the Primary Care Infrastructure Plan along with further information on Joining Up Your Information (JUYI) and the Wi-Fi rollout in General Practice.

Workload section – The latest update on the

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Time for Care Programme plans and progress made has been added.

Organisational Form section – This has been updated to provide details on how the General Practice Resilience programme has been locally implemented.

Engagement section – Further detail has been added regarding the patient engagement carried out through the PPG Network events, the patient-friendly Primary Care Strategy developed with Healthwatch and the GPFV meetings which have been established.

Key Issues

The General Practice Forward View addresses the sustainability and resilience of Primary Care nationally. This Plan sets out how GCCG are implementing this locally in Gloucestershire, with significant progress already made and plans in place to continue this work.

Risk Issues:

Original Risk (CxL)

Residual Risk (CxL)

None identified regarding this particular paper. Risks regarding delivery of the General Practice Forward View plan are stated within the document.

Management of Conflicts of Interest

None identified regarding this particular paper. Conflicts of Interest with regards to any GPFV programmes are being handled in accordance with the latest policy, with the PCCC being responsible for decision making under the GCCG delegated commissioning arrangements.

Financial Impact None identified regarding this particular paper. The financial impact of the GPFV is included within the plan submitted.

Legal Issues (including NHS

We are ensuring adherence to the NHS Operational Planning and Contracting Guidance 2017-2019, while also acting within the terms of the Delegated

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Constitution) Agreement between NHS England and GCCG dated 26 March 2015.

Impact on Health Inequalities

N/A

Impact on Equality and Diversity

N/A

Impact on Sustainable Development

N/A

Patient and Public Involvement

GCCG Primary Care Strategy, which included the implementation plans for the GPFV, was informed by two rounds of engagement and feedback. For patients, this was focused through representative bodies, in particular Patient Participation Groups and Healthwatch Gloucestershire.

Recommendation The PCCC is asked to:

Recommend the GPFV Plan for approval to the GCCG Governing Body.

Author Stephen Rudd

Designation Head of Locality & Primary Care Development

Sponsoring Director

(if not author)

Helen Goodey, Director Locality Development and Primary Care

NHS Gloucestershire CCG: GPFV – Transformation Plan

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Agenda Item 6

Area of plan Description

Vision A clear narrative on the vision for and delivery of sustainable general practice that reflects the ambition set out in the General Practice Forward View

Background and Vision

NHS Gloucestershire Clinical Commissioning Group (GCCG), in conjunction

with its member practices and partners, has developed an ambitious 5-year

strategy for the future of Primary Care in Gloucestershire as part of our „One

Gloucestershire‟ Sustainability and Transformation Plan, reflecting the national

ambitions of the General Practice Forward View, alongside those generated by

our member practices.

This Strategy was formally agreed by our CCG Governing Body in September

2016 with the following vision:

The six components of our Strategy are set out below:


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1. Access

This section of our Strategy sets out our commitment to provide

patients with improved access to primary care, including extended

evening and weekend access that is joined up, easy to navigate

and provided locally.

Our approach will be informed by evaluation of our local GP Access Fund

(GPAF) „Choice Plus‟ pilot that has been in place across our localities and other

local services and we will work with practices, patients and providers to design

our long-term models of care in the context of the access requirements set out

within the General Practice Forward View (GPFV).

We will also further develop our approach to Community Connector Service

(Social Prescribing). These initiatives, in all our localities, are helping practices

to manage demand and support people with broader, non-medical needs to

improve their well-being and access sources of community and social support.

Finally, we will also utilise the funding provided for care navigation and handling

clinical correspondence joined-up with the wider GPFV workstreams,

particularly sustainability and transformation of primary care.

2. Primary Care at Scale

There is an increasing trend towards delivery of „Primary Care at

Scale‟, with the traditional small GP partnership model often

recognised as being too small to respond to the demographic and financial

challenges facing the NHS.

This should result in a number of benefits including access to a wider range of

local services for patients within the local community, increased staff resilience,

improved staff satisfaction, work life balance and learning opportunities, and

improved financial sustainability.

3. Integration

Through our localities, we will support GP practices to work as

part of an integrated (joined-up) team of multi-disciplinary

professionals (including community, voluntary and hospital services) for

the benefit of a defined population of approximately 30,000 patients. This is

likely to involve an extended team of GPs, nurses, allied health professionals

and specialists offering easy access to a wide range of health and care close to

people‟s homes.

Our Strategy also sets out plans for developing a joined up, seven-day urgent

care system, with centres and services to meet the needs of local communities.

4. Greater use of technology

Through implementation of our IM&T Strategy and local „digital


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Area of plan Description roadmap‟, we will work to provide secure access to patient records for clinicians

and care workers, where and when they are needed and provide access for

patients and their carers to their digital health records.

We will also empower patients and their carers to take greater responsibility for

their health through increased use of technology-based support tools and other

on-line resources, including information on local services and support.

We will also look to extend the role of technology to support direct patient care,

including on-line video consultations and e-consultation, accelerated by the

national funding from 2017/18.

5. Estates

Our Strategy describes how we will implement our five year

Primary Care Infrastructure Plan. The Plan sets out where

investment is anticipated to be made in either new or extended buildings to

enhance the practice team and patient environment and to support modern

healthcare. The Plan is informed by evidence of future population growth and

need as well as considering current provision, condition of buildings and existing

schemes in various stages of development. In some cases, it may be beneficial

for practices to look at shared premises to meet the needs of their local

populations, but not in every case – it is very much dependent on a range of

local circumstances.

Buildings will need to be developed in a flexible way to take into account future

demand, new technology, and the bringing together of other community, care or

leisure services.

6. Developing the workforce

This component is critical to the sustainability of primary care in

Gloucestershire.

Our Strategy describes our approach to recruitment, retention and return of the

GP workforce, the education and training of the practice nurse workforce and

development of the „skill mix‟ in primary care, including new roles to support

current professionals in providing care, such as clinical pharmacists.

We have already made significant early progress across these components and

in implementing the GPFV, details of which can be found in the sections below.

Investment in primary care

The investment plan (revenue and

GCCG has already demonstrated a clear investment in general practice. Our

CCG was in the first wave to take delegated commissioning arrangements for

Primary Care, with the direct intention of increasing the resourcing of general


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capital) in primary care to deliver all aspects of the General Practice Forward View, locally.

practice and to commission across pathways so we can shift activity from

secondary to primary care. For example, we invested £1m recurrently to

support the Unplanned Admissions DES which has subsequently been re-

invested in our „Primary Care Offer‟ for all our practices that has improved the

quality of general practice provision with investment of c.£3 per patient (c.£2m)

in addition to the £1m recurrent funding.

We have also invested in the leadership development of seven new GP

Provider Leads to represent their localities with regards to the GPFV and who

are all members of our New Models of Care Board (NMOCB), which reports to

the STP Delivery Board. They are each funded at 3 sessions per month

recurrently, demonstrating the early additional investment we are making in

local delivery of the GPFV and the voice of Primary Care in the future of our

Gloucestershire STP and organisational structure.

Furthermore, the GPFV sets out that CCGs must invest £1.50/head in 17/18

and 18/19 non-recurrently to fund transformation. GCCG is committed, in

addition to proposals on delegated budgets, to invest at least £3 per head (over

£1.9m) into practices across 2017/18 and 2018/19 as part of a transformational

support package. To ensure this is transformative we have asked practices to

coalesce in units of c.30,000 registered populations, in accordance with our

Primary Care Strategy, to develop transformative ideas that support the

sustainability of both primary care and the wider system; equating to over £1.2m

recurrent funding each year.

The innovative projects that the practice transformation fund is supporting are

as follows:

Scheme Progress update

Clinical Pharmacists

Eleven clusters have opted to employ clinical pharmacists as part of their practice teams. The practices within the clusters are working together to do this, with the resource being shared equitably between them in order to work differently through diversifying the skill mix in general practice. GCCG have been working with all eleven clusters to determine employment models and support recruitment, with clusters having now either employed or in the final process of recruiting.

Repeat Prescribing

One cluster is setting-up a back-office repeat prescribing hub for all their practices. This is based on evidence from models established in Swindon and Coventry & Rugby. GCCG Medicines Management Team has supported the set-up which is now rolling out across the cluster.

Urgent Care Urgent visiting service: a shared urgent visiting paramedic service to relieve pressure on the practices within the cluster, working with SWAST.

Frailty service

Three clusters are developing elderly care services to support frail patients, enabling them to be cared for in their own home


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through improved local care provision. The corollary is also reduced pressure on general practice. One cluster has already recruited, one is in the process of doing so, while the other is finalising the scope of the service.

Furthermore, we are ensuring all funding set out for Primary Care within the

GPFV reaches general practice. For example, with regards to the funding

allocation for care navigation and clinical correspondence, GCCG received £55k

in 16/17 and anticipate £110k in 17/18 through to 20/21. We made this a focus

of one of the breakout sessions at our Gloucestershire GPFV event on 24

January 2017. Clusters have been encouraged to utilise either a training

provider listed within the NHS England Directory of Providers, or to assure

themselves of the provider‟s training based on NHS England‟s „Essential

Features‟, and to ensure the training provider meets the needs of their cluster.

At the time of writing, nearly all clusters have either booked or commenced the

start of that training programme and we confirm that every practice and every

cluster will receive this training, with support from GCCG to enable them to

organise their chosen training provider.

The Primary Care allocation for delegated commissioning has increased by

1.8% in 2017/18 from the previous year. The allocation is forecast to increase

by a further 1.9% in 2018/19; both increases being predicated on an annual

population growth of 0.7%. With additional investment by GCCG for Practice

Transformation under the GPFV, along with GPAF investment, the primary care

uplift is as follows, which compares favourably to the GCCG core allocation

increase of 2% in each year:

Support and grow the primary care workforce

A baseline assessment of workload, demand and supply side numbers. A plan to: - develop

initiatives to

In order to better understand the workforce and recruitment needs of our

practices, we undertook a survey in February 2017. Practices were asked to

confirm whether they have any GP vacancies, the number of partner and

salaried vacant sessions and

whether they are aware of any

planned or anticipated GP

retirements.

78 of our 81 practices

responded, demonstrating a

stark comparison in GP

vacancies between our

localities, particularly in

Item 2016/17 2017/18 2018/19

Delegated baseline 78,523 79,968 81,511

Practice Transformation (GPFV)

1,000 1,240

GPAF 2,910 3,658 3,706

Revised total for year 81,433 84,626 86,457

Revised %age uplift with slippage

3.92% 2.16%


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attract and retain GPs and other practice staff

- develop expanded multi- disciplinary primary care teams

Gloucester City where a significant number of vacancies are being carried (12

WTE with a further 6 anticipated in the near future) and Forest of Dean (5.1

WTE, a further 3.3 WTE anticipated).

We are utilising this information to continue to inform the CCG‟s support of our

member practices including adaptations to existing schemes to meet new

requirements.

In addition to this survey, we also have used the Health Education England

survey data to provide a baseline assessment of our workforce numbers, which

was then utilised within our STP forecasting. Our baseline (establishment)

therefore at 2015/16 was:

GPs: 341 WTE

GP support staff: 939 WTE

Commissioner Administration Staff: 218 WTE

Forecasts within the STP show the growth of these figures in accordance with

baselining against national trend alongside our local plans for recruitment of

clinical pharmacists, health visitors for the elderly, mental health workers in

primary care and a recruitment drive for GPs (both to fill vacancies and also for

growth). The employment model for the pharmacists was assumed to be on

basis of GCCG employment but three employment models have since emerged

across our clusters.

The forecast (establishment) employment by end of 2020/21 as a result of these

actions is as follows:

GPs: 381 WTE

GP support staff: 984 WTE

Commissioner Administration Staff: 254 WTE

Our approach to supporting the workforce of our 81 member practices has been

focused around the recruitment, retention and return of the general practice

workforce, following the NHS England, Health Education England (HEE), the

General Practitioners Committee (GPC) and the Royal College of General

Practitioners (RCGP) produced GP workforce 10 point plan. The work

programme has been developed with our GP-led Primary Care Workforce and

Education Workstream Group. Going forward, our plans for developing the

general practice workforce will also be supported by our newly-established

Gloucestershire Community Education Provider Network (CEPN or training hub)

and the workforce development needs identified by our clusters of general

practices.


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Area of plan Description Recruit:

Countywide Recruitment Events

GCCG, alongside the other main Gloucestershire Health and Social Care

providers, held a recruitment event to support promotion of the health and social

care job opportunities in the county in November 2016. General Practice

shared their clinical and non-clinical vacancies and this showed the breadth of

opportunities available to those looking to move to Gloucestershire. The event

was a good opportunity for all providers to work together and we plan to hold

another in the future to support Gloucestershire providers including General

Practice, in the spirit of the STP.

Be a GP in Gloucestershire: Promoting local Primary Care campaign

To support recruitment costs, GCCG has provided

significant investment to support member

practices to recruit general practitioners, by

producing a multi-media campaign (print, online,

social media) and provision of campaign

branded recruitment advertisements and

materials for practices with the British

Medical Journal (BMJ) during 2016/17. The

aim is to produce a campaign to support the

short-term recruitment pressures on our

member practices as well as the longer term requirement for a primary care

workforce that works in a more collaborative and sustainable way. The

campaign promotes Gloucestershire as a place to be a general practitioner, but

also highlights the benefits of the county‟s healthcare system alongside benefit

to residents such as recreational, sporting and cultural activities1. At the time of

writing:

o 47 GP recruitment packages have been utilised.

o The 2016/17 campaign resulted in around 13 GPs being

recruited to roles in Gloucestershire.

o The CCG and Primary Care workforce group plan to continue

with an integrated branded microsite to support practice

recruitment with the BMJ, which features a live link to current

Gloucestershire roles advertised in the journal and is supported

by social media activity.

International Recruitment

We will be working with NHSE to explore international recruitment opportunities.

We have received 13 expressions of interest from our GP practices for

employing International GPs as part of our recent workforce survey. We have

engaged with the LMC, our PCCC, HEE and the GPFV Project Group, who are

all supportive of this approach and we therefore intend to develop a proposal for

1 https://jobs.bmj.com/minisites/beagpinglos/

https://jobs.bmj.com/minisites/beagpinglos/


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Area of plan Description Phase 2 of the International GP Recruitment Programme.

Retain:

Newly Qualified GP Scheme

The workforce group identified a need to support GPs that have trained in

Gloucestershire to practice in the county once qualified. Currently it is likely a

proportion will either return to practice nearer to home (e.g. Bristol) whilst some

of those who will practice in Gloucestershire will choose to do so as a locum, at

least to begin with. It is known from engagement with ST3s that there is some

demand for an offer that bridges the gap between a salaried or partnership

position and the flexible but sometimes less supported locum option. Working

with current ST3s and other stakeholders we are developing the offer to support

this retention scheme which will most likely include:

Flexible rotations of between 4 and 12 months per practice, with a

minimum commitment to work in two different practices over the term to

be defined with the individual.

CCG facilitation between newly qualified GPs and general practices

based on reasonable requirements such as geographical location, with

employment by the individual practices.

Allocated funding per Newly Qualified GP to cover postgraduate study

or medical indemnity for Out Of Hours work.

Mentorship and support expectation of practices for the newly qualified

GP alongside additional CCG-arranged development and networking

opportunities.

We believe the gain for the GPs on the scheme, which could enhance the

potential for them to take up local employment, would be to begin their careers

with the benefits and stability of working in a practice for an extended period of

time, without a full partnership commitment but with additional benefits. These

include the opportunity to try a small number of different practices, mentor

support, and the opportunity to continue to study and develop new skills for use

in general practice or be supported with MDU costs. The mentor support in

particular may be attractive as newly qualified GPs may find they miss the

support mechanisms they had as a trainee.

GCCG has engaged with the Gloucestershire ST3s and have found that there is

a good level of interest in the proposed scheme. We expanded it to include GPs

in their first five years post CCT and also promoted nationally in the BMJ to

increase take up. The trainees present felt the scheme would provide the

flexibility and stability they are looking for, and would bridge the gap between

the opportunity to work as a locum and working as a salaried GP. We are

therefore supporting the 8 ST3s to join the scheme.

GP Retainer Scheme


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Area of plan Description GCCG continues to work closely with stakeholders to promote the

Gloucestershire GP retainer scheme, for example via the LMC newsletter, to

raise the profile of relaunching this opportunity in county. This advertising has

led to a number of enquiries from GPs who have expressed an interest in

becoming retainers due to their personal circumstances. The workforce group

will continue to support GPs to join the retainer scheme as appropriate in order

to enable them to continue to practice.

Portfolio career offer for those considering leaving general practice

The workforce group have developing methods to encourage GPs considering

leaving general practice or retiring early to work in a different way in order to

retain their skills and experience within primary care in Gloucestershire. GCCG

held an engagement event in 2016 to assess the requirements of the GPs that

expressed an interest in the scheme. We continue to work closely with identified

individuals looking for support to continue to practice, albeit in a different way, in

order to retain their expertise in the Gloucestershire workforce. National

developments to the GP Retainer Scheme to include GPs looking to retire but

maintaining a small number of clinical sessions, has further enabled us to

support this group.

Setting up a Community Education Provider Network

GCCG, of behalf of all practices in Gloucestershire, submitted an expression of

interest in obtaining support to set up a Community Education Provider Network

(CEPN) to improve provision of education and training for all roles in primary

and community care. Following submission of a formal bid GCCG was

successfully approved to set up the CEPN.

HEE SW has a contract with the West of England Academic Health Science

Network (AHSN) to host and deliver the CEPNs, and as such Gloucestershire is

benefitting from the cross-regional experience of the AHSN. The funding

available for the CEPN is at this stage only short term, with a view to developing

a sustainable structure following the pilot period. The Gloucestershire CEPN

was set up in 2016 and includes various stakeholders with an interest in

supporting and developing the workforce.

The CEPN is aligned to our local plans to join-up services, bring care closer to

home and support our member practices by promoting working in primary care

and community-based roles. GCCG sees value in the CEPN supporting our 81

member practices to work in a more collaborative way, for example in practices

providing training for groups of primary care professionals. The CEPN will

support our pre-existing structures and plans to empower our primary care

colleagues to play a role in developing provision of local services for their

patients, in this case by enhancing the short, medium and long term

sustainability of the primary care workforce. Identified early priorities of the

CEPN include:


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Piloting the integration of Mental Health practitioners into primary care,

bridging the gap between primary and secondary mental health

services, improving access for patients and supporting the sustainability

of general practice.

Broaden membership and expand education and training provision

across both clinical and non-clinical roles.

Establish a CEPN Education Lead role for a senior clinician to provide

leadership to this area of the CEPN. Recruitment commenced in March

with a view to having the CEPN Education Lead in post as soon as

possible on a part time contractual basis.

Practice Nurse Education and Training

This group, with practice nurse representation from all seven localities, is held

bi-monthly. The purpose of the group is to provide informed, expert advice and

strategic direction to support the development of nurses in General Practice and

facilitate the implementation and development of an educational/career

framework for nurses in General Practice.

A number of schemes have already been agreed following the work of this

group, notably;

Practice Nurse Facilitators across all seven localities

Advanced Nurse Practitioners – Funding for course and backfill in each

locality agreed February 2016 to complete by 2021.

Consistent approach to mandatory training for Practice Nurses.

Practice Nurse Development Forums.

Health Care Assistant Development Forums.

Practice Nurse Education and training needs analysis and increasing the number of practice nurses with LTC courses.

Practice nurse placements.

Nursing Associates: CCG in collaboration with provider organisations started this new course in April 2017. 1 student employed by the CCG.

BSc Nursing: University of Gloucestershire have approval to commence this course. We are working with them to encourage student placements in General Practice.

UWE Contract 17/18: reduced amount of funding. Will concentrate on clinical examination course.

New skill mixes in Primary Care

The CCG has been supportive of working with its constituent practices and

stakeholders to develop new roles and skill mixes in primary care. Examples

include:

Clinical pharmacists in general practice to alleviate some of the


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Area of plan Description pressures on GP time, both as part of supporting practices in the

national scheme (we had successful bids in both Wave 1 and Wave 2)

and developing their ideas for the transformation funding we are making

available (which is, for example, resulting in c.15 additional WTE clinical

pharmacists being available to general practice).

Mental Health practitioners working within General Practice as part of a

broader MDT, working closely with 2gether to design, develop and

implement the pilots;

Paramedics working both in practice and as support to urgent visiting

services across a cluster;

PAs are being considered as part of the future General Practice

workforce in Gloucestershire, with one cluster in Gloucester City

currently providing a placement for a PA from the University of

Worcester to better understand the potential for the role. Feedback from

this will be shared and will inform future plans to introduce PAs.

A number of clusters have identified the potential for physiotherapists in

general practice to alleviate the current demand on GP time for patients

who may be best supported by this professional group. Pilot clusters will

be determined during 2017/18 to progress this new skill mix.

We will continue to work with our CEPN, HEE and the West of England

Academic Health Science Network to further support new skill mixes and benefit

from national best practice. This will be vital to the successful implementation

of new models of care as part of the Gloucestershire STP, and to alleviate the

workforce pressures felt by Gloucestershire practices currently carrying GP and

other vacancies or anticipating vacancies in the future as a result of planned

retirements.

Developing Clinical Leadership to support at-scale provision

As mentioned earlier within this Plan, we have also invested in the leadership

development of seven new GP Provider Leads. In addition, for those localities

with clusters, we are also funding GP Cluster Leads too, meaning that all 16

clusters have funded Clinical Leadership to support at-scale provision. Through

this funding being made available by GCCG, all clusters are making significant

progress in delivering the national ambitions of the GPFV, along with our local

ambitions set out in this plan and our Primary Care Strategy. These identified

local clinical leaders have been undertaking development opportunities such as

the General Practice Improvement Leaders Programme, visits to Vanguard

sites, the GP Provider Leads are all members of the NMOCB, networking

meetings and so on. We intend to do more for these local leaders by working

with NHSE‟s Sustainability and Improvement Team to host a two-day

Gloucestershire General Practice Improvement Leaders programme in early

Summer.

Multi-disciplinary Team Development


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Area of plan Description As described earlier, and throughout this Plan, we are diversifying the workforce

within Primary Care as well as supporting our clusters to form closer

relationships with their provider colleagues in the „place-based‟ approach.

Learning from the Dudley MCP Vanguard, we are designing an MDT process

bringing together primary and community care, social care, the new roles in

practice such as clinical pharmacists, social prescribing and mental health. A

phased test and learn approach to embed cluster based MDTs into

Gloucestershire clusters is envisaged and will be based on national best

practice. MDTs have therefore been added this year to the Primary Care Offer.

Improve access to general practice in and out of hours

A baseline assessment covering local variation in access, in-hours and out of hours plus an assessment of current extended hours practices

A plan to implement enhanced primary care in evenings and weekends – with a clear trajectory for delivery by 2020

A description of how the plan for access to general practice is linked into the wider integrated urgent care system including 111.

The Gloucestershire GP practices are open from 8am to 6.30pm and 85% are

currently providing extended hours through the Extended Hours DES. A

number of practices are working at a cluster level to review integrated primary

and community urgent care to provide better links and reduce duplication

between providers across in hours and out of hours.

GCCG is a GPAF Wave 2 pilot; offering “Choice Plus” appointments across

weekdays, evenings and weekends, which are available to patients registered at

all our practices across the seven localities. This pilot is averaging over 30

minutes per 1000 patients as per the national core requirements and has been

extended to March 2017 with the objective of developing a plan towards

achieving 45 minutes per 1000 patients. There is also a focus on ensuring the

appointments are provided based on population need and demand and to

increase utilisation of the appointments offered. As a GPAF site, we will receive

£6/head of funding (weighted) to continue to commission extended access in

accordance with national guidance.

We are therefore working with all our 16 clusters to determine their interest in

piloting alternative, innovative, models to commence in October 2017.

Expressions of interest are to be made by 15 May to GCCG and the PCCC will

determine the pilots to be taken forward in-year. Evaluation will focus on time of

appointments, utilisation, patient experience, location, access criteria, skill mix,

clinical effectiveness, capacity, innovation and impact on the system. We are

taking a pragmatic approach to non-core hours that integrate extended access

with extended hours provision, and we will look to increase to 45 minutes where

demand dictates it. In the meantime, we are working with GDoc to continue the

existing Choice+ project to ensure patient access to these extended

appointments continues.

As we look to our future model from April 2018 and beyond, we will be

considering:

How the service fits with system wide plans (STP), the GPFV and the

local work on the integrated primary and community based/led urgent

care services.

Maximising appointment utilisation against population need/patient

demand and reducing any inequalities in access across geographical


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Area of plan Description locations.

The cluster workforce model, potential skill mix and training and how

this can be done in a sustainable way for primary care and the wider

system.

Appropriate performance measures and outcomes.

We have good provision of dentists, optometrist and community pharmacists

across Gloucestershire and access to urgent provision is widely shared. We will

work with NHS England, as the commissioners of these contractor groups, to

bring wider primary care into the delivery of our strategy to support enhanced

access arrangements and as part of placed-based working.

Choice Plus appointments can already be accessed by Out of Hours at

weekends to support surges in demand. For bank holiday periods in and out of

hours, opening hours and capacity is reviewed and shared with all providers.

In conjunction with the recommissioning of OOH and 111, GCCG is undertaking

a review of primary and community urgent care which is considering how these

services fit together to ensure patients are seen by the right professional at the

right time to reduce duplication and better manage urgent, same day, demand

within an integrated urgent care system for Gloucestershire.

As requested, this update should be read in conjunction with the UNIFY

submission on 27 February.

Transform the way technology is deployed and infrastructure utilised

A map of current estates and

technology initiatives. A plan to deliver the requirements set out in the GP IT Operating Model 2016/18

A clear primary care estates and infrastructure strategy linked to the wider strategy

Our Primary Care Strategy has estates and technology

as two distinct components reflecting their importance

to the successful future of primary care.

Technology

The Gloucestershire IM&T plan on a page sets out how we will ensure delivery

against the National Information Board (NIB) “Personalised Health and Care

2020” framework to action and how we will transform health and care services

through data and technology:

Enable me to make the right health and care choices;

Transforming general practice;

Out of hospital care and integration with social care;

Acute and hospital services;

Paper-free healthcare and system transactions;


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for integrated out of hospital care.

Confirmation that primary care requirements have been included in Local Digital Roadmaps

Data for outcomes and research.

GCCG commission and oversee the delivery of high quality core and mandated

GP IT services. In addition, as part of the Sustainability and Transformation Plan

(STP), steps are taking place to deliver a fully interoperable health and care

system by 2020 that is paper free at the point of care.

Enhanced and transformational primary care IT services will complement core

and mandated GP IT services and will align with and support the delivery of

CCG strategic objectives, service improvement initiatives, Local Digital

Roadmap (LDR) and the STP.

In the implementation of our LDR and as part of our IM&T Strategy, we will

improve clinical effectiveness, decision making and the health and wellbeing of

the population through:

o Moving towards a fully interoperable health and care system,

connecting primary care providers with each other and all other

providers.

o „Paper-free‟ at the point of care and available to all providers 7 days

a week, with mobile working solutions for clinicians to access

securely.

o Access for patients (and their carers) to their digital health records.

o Extending our online offering to patients,

taking learning from our development of our

innovative “ASAP” app to bring more services to fingertips.

o Utilising remote monitoring technology, building on the Telehealth,

Telecare and health alerting systems already in place.

The Universal capability plan within the LDR outlines plans to provide access to,

share and electronically transfer information for patients and providers, this

includes the implementation of all national digital systems such as the Summary

Care Record additional information, Patient Online, GP2GP, e-referrals and

electronic prescriptions.

It is recognised locally and nationally that the kinds of transformative change

required to meet the challenges outlined in the STP and LDR cannot be

achieved without the use and extensive deployment of digital technology. This

includes delivering primary care at scale, securing seven day services,

supporting new care models and transforming care in line with key clinical

priorities along with the promotion of self-care.


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One Place, One Budget, One System (STP) – Place based services will require

several different digital enablers for example: the ability to share primary care

data and to write back into the record, mobile working, e-consultations and

decision support tools. The CCG bid for funds from the Estates and Technology

Transformation Fund (ETTF) for the redesign of primary care IT seeks to ensure

that these services are provided as close to home as possible, support seven

day working and help patients to take more responsibility for actively managing

their own health. The proposal has three core objectives:

Clustering of GP practices to support urgent, on the day appointments and

extended hours appointments.

Greater patient self-care- sources of information and apps to manage and

record data relating to long term conditions. Improving patient access to their

electronic health record both in primary care and other secondary and

community care providers.

Improved capacity and efficiency in primary care.

The proposal requires not only new ways of working (clustering/remote triage)

but also flexible, intuitive and adaptive technology to provide new methods of

interacting with primary care: apps, web-based authoritative and evidence-

based service information, e-consultation requests and access to extended

hours via a variety of interfaces, e.g. direct appointment request (either directly

to practice or via a digital HUB), telephone triage or email directly to the GP via

completion of a symptom based questionnaire. With regards to e-consultations,

an evaluation is being undertaken on the existing pilot that has taken place as

part of the original PMCF, while other solutions are being appraised for when

the online consultations guidance is released by NHS England.

A second ETTF bid was also submitted to deliver a common Wi-Fi platform for

mobility, interoperability and to work in conjunction with other projects such as

Server Upgrade/Single GP AD Domain which will facilitate integrated team

working. The project‟s core objectives are:


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Improving access to information from any location by implementing Wi-Fi in

practices – for both staff and the public

Migrating and upgrading the 81 practices to new servers, while replacing

any redundant server hardware.

Giving clinicians the mobile tools that they need to be able to work out of any

location e.g. tablets, laptops, VPN.

To ensure clinicians can access the clinical system in care homes and

hospices.

Details of the funding lines by EFFT scheme are below:

The ITT for the Wi-Fi solution for the GP Practices was issued and orders

placed in March. The procurement for the WI-FI solution has now taken

place and the contract has been awarded to EE.

Surveys will now be completed at each of the Practices followed by an install

of the infrastructure, with the first practices going live in July 2017.

We have a number of schemes within the second funding stream, including

Vision Outcome Manager, upgrade of Docman to version 10 for GP

Practices, development of a BI strategy and JUYI (see below) interfaces.

Joining Up Your Information

The Joining Up Your Information (JUYI) project will help

securely share important patient healthcare information

across primary, community and secondary care, as well

as mental health and social care teams on a read-only

basis. This will include:

Medication and any changes to it made by a clinician

Medical conditions

Operations/treatment received

Contact details for next-of-kin and others involved in care

Tests that GPs or hospital clinicians have requested or carried out

Appointments (past and planned) and recent visits to out-of-hours GPs and

minor injury and illness units

Documents, such as care plans and letters about treatment (for example

“discharge summaries” following a hospital stay).

Gloucestershire NHSE ETTF Budget 2016/ 2017 Budget 2017 / 2018

£ £

ETTF Glos GP WIFI and Mobile Working 51714 93,000 463,000

ETTF Glos GP WIFI and Mobile Working 51714 Slippage 400,000

ETTF New Ways of Working Revenue 51715 93,000 185,000

ETTF new Ways of Working Revenue 51715 slippage 400,000

Grand Total IM&T 986,000 648,000


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Area of plan Description Patient, carer and voluntary sector representatives have been involved in the

project from the start, providing valuable insight into the best way to

communicate JUYI to local residents. The project piloted sharing primary care

information in a small number of practices and community teams in 2015/16

ahead of a wider rollout. A procurement process has been undertaken for the

first phase of implementation with the contract being awarded to KANOS and

phase 1 go live expected late summer 2017. The intention is that a future

phase of JUYI will enable patients to access their shared records. More

information can be found at:

http://www.gloucestershireccg.nhs.uk/joiningupyourinformation/index.php.

The JUYI project, along the successful ETTF bid award to integrate secondary

care data with Primary Care data to provide clinicians with a view of a single

patient record via the JUYI solution, will support:

domiciliary outpatient appointments within multi-disciplinary teams;

new ways of working;

7 day access;

increased capacity for services out of hospital in locality hubs.

GP Portal

GCCG has invested in a talented Primary

Care and Localities Information Team to

improve information flow and provide GP

practices with easily accessible activity

information that enables them to examine

and audit areas of variation which are

material and unwarranted. In April 2016,

„the Portal‟ was launched, providing activity,

trend and variation analysis that can be

aggregated and disaggregated as required,

with access for practices to their own patient data. This is being continually

developed, with recent releases including interactive budgetary spend analysis,

in-depth prescribing reporting and reporting available by practice, locality, or by

the new cluster groups, in addition to taxonomy group (similar practice

groupings) views. This tool is therefore supporting clusters to identify the

priorities for their practices and patients at a place-based level.

Online Consultations

With regards to online consultations, we are awaiting details from NHS England

(was expected Autumn 2016) on the expected requirements in order to be able

to plan our approach. However, we can confirm we fully intend to ring-fence

100% of this funding for the purpose of online consultations. In terms of the

pilots undertaken of online consultations through the GPAF, we have the

following learning to use when the details are provided by NHSE on the rollout

http://www.gloucestershireccg.nhs.uk/joiningupyourinformation/index.php


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Area of plan Description of this element of the GPFV scheme funding:

18 Gloucestershire practices signed up to use an e-consultation system. 12

practices actually used the system and the feedback suggests that practices

found it difficult to implement themselves. In terms of utilisation, as at Oct

2016 (latest information) 935 e-consultations had been carried out of which

609 were medical. While doctors felt it had not saved them time, patient

feedback has been positive. The CSCSU are undertaking a more in-depth

evaluation for us to utilise for online consultation rollout (once details

known).

4 practices signed up to use video consultations, although only one found it

to be a viable option on a frequent basis.

We are working with our „at scale‟ GP Federation Gloucestershire Doctors

(GDoc), to ensure we build on the experience and learning from these pilots

– both the best practice from those that have made these schemes work,

and from the learning of those that struggled.

Estates

Recognising the importance of our Primary Care estate to our ambitions, we

have a specific workstream covering the following core areas:

1) Ensuring the delivery of the committed premises developments to practical

completion.

2) Progressing the priorities identified in the Primary Care Infrastructure Plan

(PCIP), including proactively working to kick start development opportunities

and supporting business case development.

3) Ensuring local practices take full advantage of national funding initiatives

such as the Estates and Technology Transformation Fund (ETTF).

4) Working with other key delivery partners particularly NHS Propco where joint

responsibility for business case development exists.

5) Managing local improvement grant processes.

6) Ensuring the CCG operates within Premises Directions and uses these

regulations appropriately.

7) Ensuring delivery of the committed premises

developments to practical completion.

8) Ensure good patient and public

involvement takes place within this field of

work.

These will ensure we are well set to deliver the ambitions of


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Area of plan Description the GPFV. Most importantly, we have a clear five-year prioritised Primary Care

Infrastructure Plan (PCIP – approved in March 2016) that forms an integral part

of our overall Primary Care Strategy. The PCIP sets out where investment is

anticipated to be made in either new or extended buildings, subject to business

case approval and available funding. The Plan reflects our strategic intent to

deliver primary care at scale, where there is an opportunity to do so.

Primary care infrastructure Plan 2016 to 2021 approved.pdf

Progress and future plans are set out against each of the core areas below:

1. Ensuring the delivery of the committed premises developments to

practical completion

o The CCG has an agreed Primary Care Infrastructure Plan that

supports model of care requirements, meets demographic need,

supports / delivers NHS constitution and other relevant standards

and the Plan is reviewed annually.

o Plan approved March 2016 by the PCCC and Governing Body.

Progress & review reported to the PCCC 3 times per year.

2. Progressing the priorities identified in the Primary Care Infrastructure

Plan (PCIP), including proactively working to kick start development

opportunities and supporting business case development

o Working with all 12 identified priorities on business case

development.

o Currently a number of business cases are being progressed and

expected to be completed during 2017/2018, including Cheltenham

Town Centre‟s 5 practice development; Beeches Green 3 practice

development, Minchinhampton and Cinderford Health Centre.

o Business cases in early stage of development that that could be

completed in 2017/2018, but more likely during 2018/2019, includes

Romney House, Tetbury; Phoenix Surgery, Cirencester; Avenue & St

Peters Surgery, Cirencester and Coleford Health Centre.

o Business cases not expected until 2018/2019 as follows: Gloucester

City Health, Brockworth & Hucclecote joint development; Regent

Street Surgery; North West Cheltenham (the Elms) new surgery

provision for new centre of population.

3. Ensuring local practices take full advantage of national funding

initiatives such as the Estates and Technology Transformation Fund

(ETTF)

o Developed local process for support to all practices seeking

applications.

o Worked closely with core priorities.

o Invested £30k in professional to support applications.


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Area of plan Description o Four successful applications and almost £5m allocated: Cheltenham

Town Centre, Culverhay Surgery, Lydney and Springbank (these last

two being managed as improvement grants).

o Close liaison with NHS England during process and will remain

involved as oversight as NHS England manage the process direct

with successful practices (albeit Lydney and Springbank surgeries

being managed by CCG as now improvement grants).

4. Working with other key delivery partners particularly NHS Propco

where joint responsibility for business case development exists

o Additional support commissioned with business case input funded by

CCG for Beeches Green proposal.

5. Managing local improvement grant processes

o 2016/2017 improvement grant priorities agreed for 2016/2017 and a

number of priorities funded and currently being delivered.

o 2017/2018 improvement grant process now in progress.

6. Ensuring the CCG operates within premises Directions and uses the

regulations appropriately

o Clear governance structure in place.

o Consistent processes.

o Rent review processes enacted.

o Fees policy.

o Effective use of district valuations.

7. Ensuring the delivery of the committed premises developments to

practical completion

o New Churchdown Surgery (additional financial support from CCG,

practical support with land purchase and planning) – construction

now commenced and expected to be open Spring of 2018.

o New Kingsway Surgery, Gloucester (additional financial support with

extra £200k for fees). Planning permission granted in April 2017.

Construction due to start in summer of 2017 and new building open

summer/autumn of 2018.

o Glevum Surgery refurbishment and extension, Gloucester (additional

CCG support with revenue costs and enabling works) – work

commenced at the start of 2017.

o Tewkesbury Primary Care Centre – opened in March 2017.

o Stow Surgery (additional financial support from CCG with fees and

practical support). Planning permission and current developer

reviewing delivery approach. It is anticipated that construction will not

commence before Autumn of 2017 at the earliest.

o Longlevens Surgery extension (support from CCG on rent

reimbursement) – now completed and open from December 2016.


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Area of plan Description o Stoke Road Surgery refurbishment and extension (additional

practical CCG support to speed up delivery of requirements). Due to

be completed by end of May 2017.

o Sevenposts Surgery new surgery (practical CCG support to confirm

financial envelope and negotiation of shared benefits). Planning

permission granted and construction due to start in the summer of

2017.

8. Ensure good patient and public involvement takes place within this

field of work

o Formal arrangements set out in the CCG‟s PCIP on Practice

requirements for patient and public involvement in new proposals.

Fully aligned with NHS England policy.

o PCIP fully discussed at CCG sponsored PPG Countywide network

event. Premises proposals continue to be discussed at these events.

o Locality proposals frequently discussed at various local stakeholder

forums (e.g. Gloucester City Locality Stakeholder Forums, which

includes representatives from City‟s PPG groups, voluntary sector

representation, Healthwatch, Gloucester City Council and

Tewkesbury Borough Council).

o CCG teams provide practical support to patient and public events

relating to premises developments and programme of engagement

work being coordinated as and when appropriate.


22 | P a g e


Better manage workload and redesign how care is provided

A plan to improve the capacity in general practice through redesign (e.g. LEAN / Releasing Time to Care) and collaboration (such as shared clinical services and back-office functions)

When consulting our members on the future of primary care in the development

of our Primary Care Strategy, reducing workload was a common request. In

order to tackle this we have developed several approaches, leveraging the

strength of the GPFV:

With the support of our GP Provider Leads, Locality Chairs and the Local

Medical Committee (LMC), we submitted a „Releasing Time for Care‟ bid

for our 81 practices to have a CCG-wide (and therefore STP-wide)

programme in 2017. We have now been accepted on to the programme

and are working with the NHS England Sustainability and Improvement

Team to develop a Time for Care programme that focuses on the

specific high impact actions that are important to our practices, that

improves capacity and collaboration and delivers against our Primary

Care Strategy. Having met with the Development Advisers allocated to

Gloucestershire, we have developed an outline programme which we will

now form in more detail with our GP Provider and GP Cluster Leads and

the GPFV Project Team.

We held an all-day Gloucestershire GPFV event

in January 2017 for all practices to attend,

focusing on the “Ten High Impact Actions”, with

Robert Varnam as our key note speaker and

breakout sessions with national and local

speakers. We had over 200 attendees and

received excellent feedback, with practices

telling us that they now understand the GPFV

and feel positive about the future and new

models of care.

Through the transformation funding we have enabled our emerging

clusters of practices to work together to employ shared additional clinical

and back-office staff. For example, through this process alone we are

anticipating an additional c.15 clinical pharmacists working in general

practice. One cluster is also re-organising how repeat prescriptions are

ordered, with a shared back-office function. Others are looking at

utilising paramedics in a home-visiting service. This has also triggered

discussions between practices and the 2gether Trust on bringing mental

health workers into primary care in the inner-city areas where this will

significantly support the workload of GPs and support patients better

with their needs.

Building on the successful GPAF pilot whereby, working with our „at

scale‟ GP Federation Gloucestershire Doctors (GDoc), we implemented:

o „Choice Plus‟ for urgent on the day appointments;

o Social prescribing rollout to all seven localities and 81 practices;

o E-consultations;


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Area of plan Description o Remote consultations.

Enforcing the new NHS Standard Contract with our local acute trust that

reduces workload on our practices, such as preventing the hospital from

re-referring patients back to their GP following an outpatient non-

attendance.

Rolling out „Pharmacy First‟ minor-ailment scheme, so that patients can

be supported by their local community pharmacist in the first instance.

Organisational Form

A description of the current organisational form of general practice within the CCG The ambition for primary care at scale underpinned by a delivery plan

Our Primary Care Strategy is a key system enabler within our One

Gloucestershire STP Governance Structure.

We have 81 practices in Gloucestershire, which has reduced slightly over the

last couple of years with one practice closure and a small number of mergers.

Up until the summer of 2016, these practices have worked within a locality

commissioning infrastructure of seven localities, aligned with our GCCG

constitution:

Cheltenham

Forest of Dean

Gloucester City

North Cotswold

South Cotswold

Stroud & Berkeley Vale

Tewkesbury, Newent & Staunton

While that structure still exists, as mentioned in the previous section, we have

supported the development of „grass-root‟ initiated clusters to start the delivery

of our ambition of „primary care at scale‟ set out within our Primary Care

Strategy. The 16 clusters that have now formed are as follows:

As described throughout this Plan, we are supporting clusters with the next


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Area of plan Description stages of their development and funding GP Provider and Cluster Leads to lead

these conversations locally. Our support to the development of these c.30,000

cluster provider models extends to appropriate managerial (change and project

management), informatics and finance support. We are utilising this „at scale‟

approach across the GPFV, i.e. care navigation and clinical correspondence

training, transformation funding, resilience funding, online consultations and

extended access.

The General Practice Resilience Programme is a good example of how we have

implemented this approach. For Resilience, we developed a process with our

RCGP GP Ambassador and the LMC that has encouraged practices to work

together in their clusters. The purpose of this work has been building longer-

term resilience and maintaining an open process for clusters to self-nominate for

the coming years, thereby providing an equitable solution for the whole county.

This process is supported by our CCG Locality Development and Primary Care

Directorate, with nominated leads for each cluster to provide additional support.

For 16/17, those clusters who have self-nominated for resilience have been

supported in developing their plans and funds allocated accordingly – this was

across 12 clusters covering over 60 practices. All funding has now been paid to

these clusters. The four remaining clusters are now being supported to develop

their resilience bids during Q1 17/18; thereby ensuring equity. Predominantly,

resilience bids have been for progressing ideas for working at greater scale,

such as:

Merger

Federation

Change management advice for collaboration ideas

Merging back-office functions

Sharing staff

In terms of further developing our wider organisation form, we have developed a

Memorandum of Understanding with our providers that enables us to

commence „working without walls‟ across the previous organisational

boundaries. We have termed this the „place-based‟ approach and are trialling

this with the Stroud & Berkeley Vale cluster and the Gloucester City cluster,

reporting to the New Models of Care Board described earlier. We intend to then

rollout this programme in 2017/18 across all clusters, commencing with the

Forest of Dean. These „Integrated Locality Boards‟ will form the infrastructure

for providers working closer together in an „alliance‟ structure as we develop

new models of care for the future.

Engagement

A description of how the CCG is engaging local primary care professionals and the local population

In the development of our Primary Care Strategy, the overall plan that sits within

the Gloucestershire STP and describes our implementation of the intentions and

ambitions of the GPFV, we commenced with a countywide general practice

event with over 100 attendees from across our practices. This set the priorities

that were important for them within the context of the original Five Year Forward

View and commenced the early discussions of how they could consider working

together to bring about transformation in future.


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and patients in the development and delivery of the Transformation Plan.

Through the development of the Strategy, we held two almost month long

engagement exercises; the first around the early draft agreed by our Primary

Care Commissioning Committee; the second around an updated version

inclusive of all feedback from the first round of engagement. Both rounds of

engagement included our GP practices, our Gloucestershire Patient

Participation Group Network, County, District and Parish Councils,

Gloucestershire Hospitals, Gloucestershire Care Services, 2gether Trust, South

West Ambulance Service, the West of England Academic Health Science

Network, VCS Alliance, Healthwatch Gloucestershire, Gloucestershire Police

and Crime Commissioner and the Local Medical Committee.

Since this, as mentioned earlier, we have also had an all-day Gloucestershire

GPFV event on 24 January 2017, with over 200 attendees from across our

practices, with clusters staying in the evening to determine how they would

implement the ideas and schemes from the day.

Furthermore, the Sustainability and Transformation Plan will be supported by

the STP communications and engagement approach which will be delivered in

two phases. In developing this format, we have drawn upon published national

guidance, as well as our local experience of what works well in Gloucestershire.

This builds upon our earlier Joining Up Your Care engagement, when over 2000

local people were involved in shaping our current thinking. Phase One ran from

autumn 2016 to early spring 2017. Phase Two will support our legal duty to

consult with the public regarding more detailed proposals for service change,

which will commence during summer 2017.

In addition, we have also engaged with the PPG Network, presenting updates

across our Primary Care Strategy and the General Practice Forward View,

including facilitated tables to gain feedback from patients on our approach and

describing the initiatives we are undertaking that are set out in this plan. We will

continue to undertake this engagement at a countywide level, while also

discussing plans locally with patients through Locality Reference Groups or

similar. Working alongside Healthwatch Gloucestershire, we also have

produced a patient-friendly version of the Primary Care Strategy, which was

published in February 2017.

In terms of wider engagement, we have been working with the LMC, HEE and

our local RCGP GP Ambassador in developing and implementing our GPFV

plans and have now formalised this by establishing a GPFV Project Team, to

which the NHSE GPFV Transformation Lead for Gloucestershire is also invited.

Risks and Mitigation

A description of the key risks and mitigations.

Risks Mitigation

Practices will not grasp the importance of acting now to work

with their cluster colleagues in delivering transformation and primary care at scale, thereby

risking their future sustainability and furthermore the resilience of

Established the 7 GP Provider Leads to lead this locally

Hosted an event in January 2017 for all practices countywide

Successfully applied to the national NHSE „Releasing Time


26 | P a g e


neighbouring practices for Care‟ programme on behalf of the whole county, working with the LMC and RCGP Ambassador

Investing resource in the cluster development of their „at scale‟ models

The resource available within the CCG is insufficient to support the

cluster‟s emerging ambitions of how they want to deliver the GPFV

GCCG are utilising existing resource through re-prioritisation and re-alignment of work programmes in order to release sufficient capacity. For example, we are currently restructuring our locality commissioning infrastructure for 2017/18 to align this with the clusters, thereby reducing duplication of functions and investment by both CCG staff and GPs. Clusters have also recognised their need for specialist support and have bid for General Practice Resilience Programme Funding, which we are supporting as a delegated CCG.

Key agreed estates developments are not supported by the local

people, patients and key stakeholders, which hinder

implementation.

Key strategic priorities were supported by the development and implementation of an engagement framework and communications strategy.

There is insufficient financial resource to fund the development of necessary premises requirements,

which means that practices are unable to provide the right level of service to patients leading to less

effective care

Financial framework developed

Use of ETTF to offset some costs

Development of larger centres, wherever possible to maximise estate efficiency

Prioritising and scheduling of developments

Governance

A description of the governance arrangements to provide the CCG with assurance that the plan is being delivered fully and on time.

As described throughout this document, our Primary Care Strategy is the plan which describes our ambitions and intentions for Primary Care in Gloucestershire.

The CCG is committed to establishing effective governance procedures to

ensure that it discharges its duties effectively and with due regard to mandatory

regulations and voluntary guidance. This also applies to the risk of real, or

perceived, conflicts of interest.

The Primary Care governance structure below demonstrates how we achieve

this. It is in accordance with the Delegated Agreement between NHS England

and GCCG dated 26 March 2015. The structure minimises the risk of conflicts

of interest occurring while maintaining important clinical input to the design and

delivery of our primary care commissioning responsibilities.


27 | P a g e



The purpose of the Primary Care Commissioning Committee (PCCC), as a

committee of the GCCG Governing Body, is to manage the delivery of those

elements of the primary care healthcare services delegated by NHS England to

the GCCG. The Committee have delegated responsibility for primary medical

care decisions relating to:

The award, design and monitoring of GMS, PMS and APMS contracts;

Locally defined and designed enhanced services;

Local incentive schemes;

Procurement of new practice provision;

Discretionary payments (e.g. returner/retainer schemes);

Practice mergers;

Contractual action such as issuing branch/remedial notices and

removing a contract.

The Committee – which meets in public and is made up of CCG Executives, lay

representatives, and representatives from Healthwatch/the Health and

Wellbeing Board/NHS England – also report on, and make recommendations to,

the Governing Body on the following:

Primary Care Strategy;

Premises improvement grants and capital developments.

Primary Care Operational Group

The Primary Care Operational Group (PCOG) has been established to

implement and monitor the progress of the operational functions that delegated

commissioning responsibilities provide, while making recommendations to the

PCCC where decisions are required. In addition, the Group also has

responsibility, on behalf of the PCCC, for oversight and delivery of the

workstreams.


28 | P a g e


Governance of the Primary Care Strategy

Approving the Primary Care Strategy

In accordance with the above, the approval process for the Strategy was via our

CCG Governing Body, with progress reported through the Primary Care

Commissioning Committee, which is held to account for delivery by the

Governing Body. Operational delivery of the Commitments set out against the

six components is managed by the Primary Care Operational Group.

Oversight of GCCGs Sustainability and Transformation Plan and New

Models of Care

Overseeing delivery of GCCG‟s Sustainability and Transformation Plan, of

which the Primary Care Strategy is an enabler, is the Gloucestershire Strategic

Forum along with a separate STP Delivery Board for oversight of

implementation. The Primary Care Strategy delivery is therefore reported to the

STP Delivery Board.

As a key element of our Sustainability and Transformation Plan is the design

and delivery of new models of care, a „New Models of Care Programme Board‟

has been established to drive and oversee these models across our County.

This New Models of Care Programme Board, reporting to the STP Delivery

Board, has Executive membership from across our Providers, with Primary Care

represented by our GP Provider Leads as described earlier. The GPFV delivery

is therefore reported to the NMOCB too.

In this governance structure, we therefore have statutory accountability for

delivery through our CCG Primary Care Commissioning Committee, while we

also recognise the importance to the whole system through reporting to the STP

governance framework.


29 | P a g e

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Agenda Item 7



Delegated Primary Care Commissioning Financial Report as of March 31st 2017

1 Introduction 1.1

This paper outlines the financial position on delegated primary care co-commissioning budgets at the end of March 2016.

2 Financial Position 2.1 2.2

The CCG reported a breakeven position against delegated budgets at the end of March 2017 (see table below). This represents a reduction of £25k on the underspend reported in February. The contingency of £393k was fully spent in 2016/17 on a non-recurrent basis; predominantly on premises development costs and practice support. The System Risk reserve was held as uncommitted during the year in line with NHS England guidance, This was intended to be released for investment in Five Year Forward View transformation priorities to the extent that evidence emerged of risks not arising or being effectively mitigated through other means. In the event, the national position across the provider sector has been such that NHS England has been unable to allow CCGs’ 1% non-recurrent monies to be spent. Therefore, to comply with this requirement, Gloucestershire CCG has released its 1% reserve to the bottom line, resulting in an additional surplus for the year.

2.3

The main variances are as follows: Contract payments in total overspent by £95k. The underspend on GMS contract payments is due to Global Sum demographic growth being lower than expected following the NHSE list cleansing exercise. The overspend in PMS contract payments is due to the full effect of inflation applicable to PMS practices being higher than that budgeted. As list sizes were very late being published in

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2016/17 the full effect of these changes was not known until late in the year. Enhanced Services underspent by £127k primarily due to a lower than expected claim rate for Minor Surgery. Other GP Services were overspent by £249k due primarily to one-off costs relating to premises business cases and targeted support to vulnerable practices. The outturn position also includes a non-recurrent amount (£70,089) for the 2016/17 setting up of the cluster schemes relating to the GP Forward View in preparation for 2017/18.

3 Recommendation(s)

3.1 The PCOG are asked to:

Note the contents of the paper

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March 2017

Area

2016/17

Total

Budget

2016/17

Outturn

Spend Variance

2017/18 Total

Budget

£ £ £ £000's

SPEND Contract Payments - GMS 46,747,154 46,639,439 -107,715 49,076.1

Contract Payments - PMS 3,356,147 3,494,308 138,161 3,597.0

Contract Payments - APMS 1,379,509 1,444,425 64,916 1,596.6

Enhanced Services 4,216,184 4,088,378 -127,806 2,341.2

Other GP Services 2,174,661 2,423,274 248,613 2,126.1

Premises 8,147,486 8,100,391 -47,095 8,608.2

Dispensing/Prescribing 3,125,231 3,137,425 12,194 3,155.4

QOF 8,198,783 8,017,560 -181,223 8,267.8

TOTAL 77,345,155 77,345,201 46 78,768.5

FUNDING Allocation (revised) 16/17 78,523,000 79,968.0

Less :- nationally mandated adjustements

1% headroom (785,230) (799.7)

0.5% contingency (392,615) (399.8)

77,345,155 78,768.5

SURPLUS/DEFICIT 0

Global Sum (GMS contract payments) represent a 5.33% increase on 2015/16

Global sum per weighted patient moved from £76.51 to £80.59 in April 2016

Other GP Services includes:

Legal & professional fees Doctors retainer scheme

Seniority Locum/adoption/maternity/paternity payments

Other general supplies & services

Gloucestershire CCG

2016/17 Delegated Primary Care Co-Commissioning budget

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Agenda Item 8



Report Title Primary Care Quality Report

Executive Summary This report provides assurance to the Committee that quality and patient safety issues are given the appropriate priority and that there are clear actions to address them.

Key Issues

Failure to secure quality, safe services for the population of Gloucestershire.

Risk Issues: Original Risk (CxL) Residual Risk (CxL)

Failure to secure quality, safe services for the population of Gloucestershire

Management of Conflicts of Interest

Not applicable

Financial Impact There is no financial impact

Legal Issues (including NHS Constitution)

Compliance with the NHS Constitution, NHS Outcomes Framework and recommendations from NICE and CQC.

Impact on Health Inequalities

A focus on the delivery of equitable services for the residents of Gloucestershire and which will reflect the diversity of the population served.

Impact on Equality and Diversity

There are no direct health and equality implications contained within this report.

Impact on Sustainable Development

There are no direct sustainability implications contained within this report.

Patient and Public Involvement

This report provides information about Patient and Public involvement, engagement and experience activity.

Recommendation The PCCC is asked to note the content of this report.

Author Marion Andrews-Evans

Designation Executive Nurse and Quality Lead

Sponsoring Director (if not author)

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Agenda Item 8



Primary Care Quality Report 1.0 Introduction

This Primary Care Quality Report focuses on three key domains. Planning for Quality, Quality Improvement and Quality Assurance and details the progress within Primary Care to date.

2.0 Planning for Quality

2.1 Workforce – Gloucestershire Clinical Commissioning Group Practice Nurse Facilitator Team

2.1.1 The CCG Practice Nurse Facilitator Team have been in post since April 2016. The team consist of three whole time equivalent experienced Practice Nurses. There are five Practice Nurse Facilitators covering all localities.

2.1.2 The Practice Nurse Facilitators Team have established Practice Nurses forums/ Practice Lead forums within Cheltenham and South Cotswolds. Forest of Dean already has an established Practice Nurse forum which is being supported by the Practice Nurse Facilitator. Within the other localities the Practice Nurse Facilitators are in the process of developing forums. The aims of these forums are to provide informed, expert advice and direction to support the development of nurses in General Practice and to provide a forum to ensure good communication between Practice Nurses and the CCG.

2.1.3 The Practice Nurse Facilitators team have a work plan for 2017/18 (See appendix 1). This plan includes increasing the number of Practice Nurses with a recognised Sexual Health qualification. This is in recognition of the changes in Sexual Health Services within the county. Increasing the number of Practice Nurses with an MSc Advanced Practice acknowledges the issues in General Practitioner recruitment.

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2.2 2.2.1

Education and Training CCG has been working with the University of Gloucestershire to develop the BSc Nursing programme. The role of General Practice Nursing will be highlighted within this programme to encourage student nurses to choose Practice Nursing as a career.

2.2.2 GCCG Practice Nurse Facilitator Team are working with the University of Gloucestershire and practices to support student nurse placements.

2.2.3 GCCG Practice Nurse Facilitator Team are supporting partner organisations with placing trainee Nursing Associate students in General Practice as part of their “hub” placements.

2.2.4 CCG Practice Nurse Facilitator Team have provided specific training activities to practice nurses to support the delivery of the clinical programmes. This has included Cancer Care Survivorship, Frailty and Dementia Assessment and Care, Wound Care, Respiratory Care, Diabetes and the ENT Ear Wax pathway.

2.2.5 In response to requests from Practice Nurses and Practice Managers the CCG Practice Nurse Facilitator Team has organised immunisation update study days for each locality which have been reviewed positively.

2.3 2.3.1

Community Education Provider Network (CEPN) CEPN is a partnership of Primary Care organisations that coordinate education and workforce planning and is commissioned by Health Education England (HEE). The Gloucestershire CEPN group has been established with the aim • To better support general practice by providing support for workforce planning and development, responding to local needs and enabling the redesign of services within primary care and the community. • To improve education capability and capacity in primary and community settings through the development of multi-

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professional educators and the creation of additional learner placements. • To support general practice by improving education quality and governance and act as a local coordinator of education and training for primary and community care. Priorities include the recruitment, retention and return of Primary Care health care staff.

3.0 Quality Improvement

3.1 Medicines Optimisation

3.1.1 Gluten-Free Prescribing and Sip Feeds Spending on gluten-free prescribing continues to fall following the CCG recommendation to cease prescribing, with epact data for February 2017 showing a spend of £1,419 compared to £29,991 in February 2016. CCG Dietitians continue to support practices to address any small areas of continued prescribing and to promote the CCG panel for consideration of exceptional circumstances to address any variation in prescribing. The CCG have prepared a response to the national consultation on the issue. A pilot to address the prescribing of Oral Nutritional Supplements („sip feeds‟) showed that practices can achieve significant savings through the implementation of a „food first‟ approach as an alternative to sip feeds where appropriate. This is now being rolled out across all practices and forms part of this year‟s Prescribing Incentive Plan and Primary Care Offer where we are aiming for at least a 50% reduction in spending. The method will be for the PSPs to review those currently receiving sip feeds with support from the CCG dietitians and encourage a food first approach instead where appropriate. In Care Homes there will be a more direct method of stopping all sip feeds (with very few exceptions) and this is supported by the CCG dietitians and the GCS Care Homes Support Team. Additionally the practices will be educated on restricting future sip feed prescribing by encouraging the “food first” approach instead.

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3.2.2 Pharmacists Working within GP practices in Gloucestershire Definitions of GP Practice pharmacists: For the purpose of this section, there are several Pharmacist definitions to be aware of, namely Prescribing Support Pharmacist (PSP) and a Clinical Pharmacist (CP), with or without Independent Prescribing (IP) qualification. A pharmacist will have attended (currently) a four year Pharmacy degree course, followed by a year‟s vocational pre-registration training. Following this pre-reg year a registration examination needs successful completion, and then the pharmacist is eligible to join the professional register for pharmacists, held by the General Pharmaceutical Council (GPhC). This is a statutory body (a little like the GMC and GDC) whose role is to regulate and ensure that registered pharmacists maintain a minimum range of standards. Following registration the pharmacist is able to work in this legally “protected role”. Pharmacists work in and across many healthcare sectors, notably community pharmacies (the traditional “chemist”), hospital pharmacy (both dispensing and ward rounds) and in the most recent decade or two, primary care roles within GP practices. A pharmacist is usually required to have worked for a minimum number of years in either community pharmacy or hospital pharmacy to gain enough experience, before being able to move into the more specialised primary care roles. Prescribing Support Pharmacists: Gloucestershire CCG (and PCT before that) has provided Prescribing Support Pharmacists (PSPs) for many years. Typically each GP practice has access to half a day of PSP time each week, and the PSP helps the practice to improve their prescribing in general. They typically carry out patient medication searches, make recommendations to the GPs about possible changes to a patient‟s medication for quality or cost benefits (often both simultaneously), and also work closely with practices to develop a good understanding of pharmaceutical issues around training and use of medications to best effect. There is usually minimal direct patient contact. Clinical Pharmacists (may or may not have Independent Prescribing): A clinical pharmacist is a pharmacist who uses a patient‟s

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clinical record to make suggestions or decisions about a patient‟s treatment, for NHS cost-effectiveness reasons, safety reasons or to enhance the effectiveness of their current medication regimen. This is carried out within the GP practice with regard to primary care clinical pharmacists. A Clinical pharmacist will typically have significantly greater patient contact than a PSP, either by telephone or within face to face consultations. Often a clinical pharmacist will cover a certain range of conditions, based on experience and competencies. A clinical pharmacist (without IP qualification) is unable to prescribe, but would offer suggestion to the regular GP, who would decide whether to prescribe on the strength of the clinical pharmacist‟s recommendation. We plan to encourage distinction between the PSP and Clinical Pharmacist role to avoid too much overlap. Overlap could occur when certain elements of the Prescribing Improvement Plan, usually managed by the PSP, may fall into the work-plan for the CP such as polypharmacy and frailty reviews. Experience gained over the coming year will further advise the best model to manage any overlap. Independent Prescribing Clinical Pharmacists (IP CP) An Independent Prescribing clinical pharmacist is a clinical pharmacist who has completed a further 6 months intensive university course specifically to prepare them for the prescribing role. Upon successful completion of this training, they are then able to register a further qualification with the GPhC. Only upon successful completion and registration are they then able to commence prescribing, within their area of competence (which could be few or many different clinical areas, depending on experience). The clinical pharmacist role described above will apply, with the distinct difference that they will now be able to prescribe independently without the prior approval of a GP. However in situations where patients are particularly complex, or fall outside of the area of prescribing competence, the independent prescribing clinical pharmacist will refer to the appropriate medical prescriber.

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Pharmacist Type

Medication reviews on computer

Suggestions to GP about medication choices

Has Patient Clinics or Patient Contacts

Prescribing

PSP Y Y N N

Clinical pharmacist without IP

Y Y Y N

Clinical Pharmacist with IP

Y Y Y Y

Clinical Pharmacist and Independent Prescribing CP Provision: Prior to 2016 there were very few independent prescribing clinical pharmacists within the county. Since the introduction of NHS England‟s pilot Clinical Pharmacists in GP Practices there has been a surge in interest and uptake for these roles. NHS England Clinical Pharmacists in GP Practices Pilot The NHS England pilot (including subsequent waves) has provided a national training course and funding for GP practices towards the costs of the pharmacists to be employed directly by the practices. NHSE “Wave 1” saw the introduction of 5WTE Clinical Pharmacists across 7 practices within Gloucestershire. Under these schemes a pharmacist is employed by the GP practice as a Clinical Pharmacist, and then works to undertake the Independent Prescribing course during the first year, if not already held. They then became an IP Clinical Pharmacist. The scheme demonstrated the benefits of having a clinical pharmacist within the practice, as well as the extra benefit of the IP qualification. When a pharmacist becomes qualified as an IP, their salary is reviewed. NHSE “Wave 2” submission was successful in a small number of bids, and is currently being recruited for (1.7wte) across a number of GP practices within the Gloucester City locality. NHSE Wave 3 is currently pending submission. Local Transformational Funding Scheme Due to the observed success of the NHSE pilot, a number of Gloucestershire localities have opted to use their transformational funding to provide access to a clinical pharmacist, with intention to complete the IP course. We are currently recruiting for a further 4.4wte to start within GP

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Practice clusters within localities (actual number of pharmacist currently unclear), which will add to the already active team of pharmacists, made up of 26 pharmacists, between them working approximately 14.9wte. The funding for these roles is currently broken down as follows- • Practice funding Wave 1 5WTE • Practice funding Wave 2 1.7WTE • Practice directly 1.2WTE • Practice Transformation Funding 7WTE By the end of this current recruitment phase there will be approximately 19.3WTE clinical pharmacists, of which 11WTE have an IP qualification (representing 18 pharmacists), and the remainder are working towards their IP qualification.

3.3 Collaborative Working System Wide

3.3.1 The STP Organisational Development and Workforce Strategy Group has established three thematic groups to take forward the priorities that have been identified in the June 2016 STP submission. The three thematic groups are Capacity, Capability and Culture. The CCG are working with these three groups to ensure Primary Care is represented.

3.3.2 The Capability Thematic Group purpose is to ensure that current and future staff have the right skills to deliver the STP health and social care workforce ambitions. The group aims include: • To oversee the development of nurse career pathways within Gloucestershire including the degree programme, Nurse Associate, Nurse Practitioner, Advanced Nurse Practitioner and Apprenticeship Degree Programme. • To share best practice and develop a county-wide approach on increasing the delivery of apprenticeships. • To develop a 5-year Education, Learning and Development Plan for the STP. • To contribute to the design and development of an Improvement Academy for the STP. • To develop a “training passport” for the STP footprint to enable statutory and mandatory training to be transferable across organisational boundaries.

3.4 Quality Premium (QP) Antimicrobial Resistance (AMR)

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3.4.1 The QP 17/19 aims to reduce Gram Negative Bloodstream Infections (GNBSIs), reduce inappropriate antibiotic prescribing for Urinary Tract Infections and sustain a reduction of inappropriate antibiotic prescribing in Primary Care. The CCG is leading on a system wide “Clinical Programme” approach to Urinary Tract Infections which aims to reduce the number of GNBSIs and reduce inappropriate antibiotic prescribing for Urinary Tract Infections. The CCG are establishing a county wide Antimicrobial Stewardship group led by a trainee Public Health Consultant. This group will be based on the CCG Kernow model. One of the aims of this group will be to improve awareness and understanding of antimicrobial resistance through effective communication, education and training. This group will also aim to reduce inappropriate antibiotic prescribing.

3.5 Gloucestershire „Red Bag‟ project

3.5.1 The aim of the Gloucestershire „Red Bag‟ project is to improve the quality and timeliness of the Hospital Transfer Pathway for Care Home residents. It has been set up as a pilot to test out using a Red Bag to support care homes, ambulance services and local hospitals to improve the quality of patient experience, patient flow, clinical paperwork and day to day communications; and specifically to facilitate safer person-centred transfers of care from care homes to hospital and vice-versa. The Red Bag holds personal items and clinical information for safe transfer between care home and acute and/or community hospital, also when moving wards within hospital, then return to the care home on discharge. The pilot is being led by the manager of Millbrook Lodge Nursing Home (OSJCT) with manager of GCS Care Home Support Team (CHST). It is in early stages with 5 care homes signed up and planning to use 2 Red Bags per care home.

4.0 Serious Incidents

4.1 In General Practice, Serious Incidents are normally called

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„Significant Events‟. These should be reported via a GP eform (https://report.nrls.nhs.uk/GP_eForm) which will automatically alert the National Reporting and Learning System and NHS England. Since the last report, NHS England has confirmed that they will be delegating Primary Care „safety‟ to CCGs. This means that we have the opportunity to help Primary Care develop transparency around significant events and expand the learning culture other providers aspire to all healthcare settings in the county.

4.2 In April 2017, two significant events were recorded on the NRLS. These reports were both recorded by the GP as „low harm‟. One featured a delayed discharge summary being sent, the other a missing letter from an out of county hospital.

5.0 Patient Safety

5.1 The CCG recently met with key members of the healthcare community to start working on a framework for „Safety‟. The group was vocal about the need to bring Primary Care into this work to improve safety across all healthcare settings and reduce variation. Although in the very early stages of development, it is hoped this can dovetail into the work of the Practice Nurse Facilitators and will tie in to the STP.

6.0

Complaints and Concerns

6.1 As a result of a Quality Team reassignment to focus on Patient Safety and AQP Quality Contract Management CCG complaints will be overseen by the Associate Director, Experience and Engagement and handled by the Quality Liaison Officer, on a day-to-day basis. Responsibility for complaints and concerns in relation to primary care remains with NHS England.

6.2 NHS Complaints Managers Autumn Conference 2017 The autumn conference will be on 13 October 2017. Topics involve Learning from CQC Inspections; Empathy; Dental Protection and hopefully there will be speakers from NHS Improvement; The Health Service Inspection Branch; The

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PHSO. It is our intention to send a CCG representative to this event.

7.0 GP Services Friends & Family Test

7.1 Friends and Family Test (FFT) gives patients the opportunity to submit feedback to providers of NHS funded care or treatment, using a simple question which asks how likely, on a scale ranging from extremely unlikely to extremely likely, they are to recommend the service to their friends and family if they needed similar care or treatment. Data on all these services is published on a monthly basis. The GP FFT dataset includes FFT responses for the latest month from GP practices. Data is submitted directly to NHS Digital‟s Calculating Quality Reporting System (CQRS) each month. The FFT results for GP Practices in Gloucestershire present a mixed picture. The full data for February 2017 is available on the FFT website at: https://www.england.nhs.uk/ourwork/pe/fft/friends-and-family-test-data/ It should be noted that only 41 practices in Gloucestershire submitted data in February 2017; in most cases the response rates, in line with other areas nationally, are very low and therefore cannot be considered to be statistically significant when looking at one month‟s data in isolation.

7.2 The Primary Care Clinical Quality Review Group and reviews the FFT data alongside the national GP Patient Survey data. Practice Patient Participation groups have been reminded to ask their practices for a copy of the FFT results and to promote FFT within their practices.

8.0 Patient Participation Groups (PPGs)

8.1 GCCG has established a Gloucestershire Patient Participation Group (PPG) Network.

https://www.england.nhs.uk/ourwork/pe/fft/friends-and-family-test-data/

https://www.england.nhs.uk/ourwork/pe/fft/friends-and-family-test-data/

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The Practice Participation (PPG) Group network held a successful meeting in April 2017. The meeting focussed on Cancer. Presentations and lively discussions were enjoyed on the topics of Macmillan Next Steps; Living With and Beyond Cancer - Diet & Exercise; Engaging patients; Holistic Needs Assessment (HNA) & Treatment Summaries; A Patient‟s Real Life Story; and the CCG Cancer Patient Reference Group (PRG). Members of the CCG Engagement Team continue to be invited to attend a number of individual PPG meetings to discuss developments and to provide advice and guidance. Recent discussions have focussed on a possible merger between practices and new capital developments. In March and April 2017, groupings of PPGs came together at two events in Stroud and Dursley to debate PPG support and developments. The CCG is currently surveying practices to ascertain the status of their individual PPGs. Response rate is currently approximately 50%. A reminder has been sent to practice managers to complete the survey as all GP practices are contractually required to establish and maintain a PPG. Members of the CCG Engagement Team continue to support individual practices and PPGs providing advice and guidance as requested.

9.0 Safeguarding

9.1 Safeguarding Adult Reviews „KH‟ and „Ted‟ reviews have been recently published on the GSAB website. Both cases are linked to Self-Neglect.

9.1.1 HE‟ Review is being presented to GSAB in May for publication on GSAB website in June this year. This case is of a younger person (26 years) with a complex mental health diagnosis, significant in that she had a care packages in place with more than one agency. „HE‟ died as a result of sepsis (presented at Southmead Hospital), as a result of Self-Neglect, with capacity and refusing treatment for her health / medical needs.

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9.1.2 GSAB successfully held 4 x half day Roadshows with themed workshops (Safeguarding in Self-Neglect and Modern Day Slavery). 6 GPs attended in total, viewed as extremely positive given the time commitment required.

9.1.3 GCCG Safeguarding Team is facilitating bespoke Safeguarding Adult Level 2 Training, delivered by a GSAB Approved trainer at Primary Care Locality, within GP PLT sessions. Uptake and engagement has been excellent to date; 2 sessions complete – total of 150 attendees, including GPs (73), PNs (55) and other Practice staff (Admin/Staff Nurses/HCAs). A further 4 more sessions are planned.

9.2 9.2.1

Serious Case Reviews „Megan‟ SCR still pending publication due to ongoing criminal proceedings. The SCR is complete with multi-agency work on the action plan in progress. NHS England has been asked to respond in relation to the process within Primary Care whereby a patient may be de-registered after a period of non-attendance.

9.2.2 The „William‟ SCR is ongoing (3 month old child died in August 2016). Criminal processes are currently ongoing with both parents under charges. This baby was not registered with a GP. The Review is working to time with good agency engagement.

9.2.3 The named GP will continue to raise awareness of signs of neglect both in adults and children.

10.0 Health Care Associated Infections (HCAI)

10.1 There have been 9 MRSA cases attributed to the community reported 2016/17. A Post Infection Review (PIR) of each case was undertaken within 14 days as required by Public Health England. The purpose of the PIR is to identify how a case of MRSA bloodstream infection occurred and to identify actions that will prevent it reoccurring. As a result of these PIR one of these 9 cases was found to be a contaminant (the isolation of MRSA in blood cultures that has no adverse clinical correlation). Three were attributed to a third party (no healthcare intervention that could have resulted in MRSA bacteraemia infection).

10.2 The C. difficile threshold for 2016/17 remained the same as

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2015/16 with 157 for the wider health community. 2016/17 performance is 177 in the wider health community with 121 cases of C. diff reported as community acquired. All community acquired cases are robustly reviewed by Practice Support Pharmacists and the GCCG Quality Team. Previous Public Health England analysis of cases of C. difficile within the community have found no cause for these numbers other than the normal risk factors for C. difficile (increasing age, severity of underlying diseases, non-surgical gastrointestinal procedures, anti-ulcer medications, duration of hospital stay, duration of antibiotic course, administration of multiple antibiotics). The Practice Support Pharmacists and the GCCG Quality Team are working with prescribers to reduce inappropriate prescribing of medications that increase the risk of C. difficile. The threshold for 2017/18 remains at 157.

10.3 In 2015/16 there were 286 cases of E.Coli. There was no threshold set for E.Coli infections in 2016/17. 2016/17 performance is 283 community acquired cases of E.coli. The threshold for 2017/18 is 257. All community acquired cases are to be reviewed by Practice Support Pharmacists and the GCCG Quality Team. The CCG is leading on a system wide “Clinical Programme” approach to Urinary Tract Infections which aims to reduce the number of E.coli urine infections.

11.0 Immunisation and Vaccination

11.1 Gloucestershire immunisation programmes are commissioned by NHS England and are delivered by a range of providers including Primary Care.

11.2 Uptake for MMR dose 2 has been below 90% for the last 3 quarters. PHE have continued to attended Practice Managers‟ forums during 2016/17 where MMR was discussed. PHE have attended Practice Nurse forums in Gloucestershire where MMR is discussed and best practice shared.

11.3 Gloucestershire Immunisation Group has identified MMR dose 2 as the programme to focus on in the short term. A MMR sub group has been set up to develop initiatives aimed at addressing the declining MMR uptake. CCG Practice Nurse Facilitator Team have been working with practices who have low uptake rates of MMR dose 2.

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11.4 The Adult Shingles programmes - new cohorts (main and catch-

up) started on 1st September 2016. Published data for April 2017 show the uptake for 70 years (47.3%) and 78 years (51.5%).

11.5 Maternal Pertussis - All pregnant women are invited to their GP practice for a single dose of the vaccine. Midwives are also able to administer the vaccination. Between April 2016 and March 2017 uptake rate was 67.3% (65.3% 2015/16).

11.6 Season influenza uptakes rates- The CCG is a member of the BGSW Seasonal Flu Immunisation group. The group has developed a work plan for 2017/18 to increase uptake of Seasonal Flu Immunisation. For the season 2017/18 PHE have commissioned Gloucestershire Care Services NHS Trust to provide a schools based seasonal influenza service. The aim is to increase the number uptake rates for children aged 5-7 years. Evidence suggests a higher uptake of influenza within a school based programme.

12 Quality Assurance

12.1 CQC Inspections

12.1.1

All practices have now been inspected. All practices that have received any “Requires Improvement” in any of the ratings will be re-inspected by CQC. The Primary Care CQRG will continue to offer support as necessary to practices who are considered to „Require Improvement‟.

13.0 Appendices 1. Practice Nurse Facilitator work plan 2016/17 and 2017/18

Appendix 1

Page 1 of 13

Gloucestershire Clinical Commissioning Group Practice Nurse Facilitator Team

The Practice Nurse Facilitators (PNF) are responsible for supporting the development of nurses in General

Practice, ensuring that nurses can access education and development to meet the needs of General

Practice. In addition, they work towards the retention and expansion of the Practice Nurse workforce to

meet the current and future needs of General Practice. There are five PNFs within the county who are

appointed localities as detailed below. The number of days each PNF is allocated is based on population,

number of practices and geographical location.

All of the PNFs also work in General Practice so that they remain in clinical practice.

Locality Locality Population

Number of Practices

Working days

PNF appointed When employed

Cheltenham 153,000 17 practices 2 days Maria Altham Feb 2016

Forest of Dean/ Tewkesbury

63,000 42,000

16 practices 4 days Maggie Pugh Feb 2016

Gloucester City

167,000 19 practices 2 days Teresa Berry Sept 2016

North and South Cotswold

86,000 13 practices 3 days Helen Davies-Smith

Feb 2016

Stroud and Berkeley Vale

120,000 20 practices 3 days Sian Davies Sept 2016

The first year of this exciting and innovative new role has primarily been introducing this new role to

Practice Nurses, Practice Mangers, General Practitioners and other members of the Primary Care team.

The PNFs have concentrated on meeting Practice Nurses from the surgeries within the localities. This has,

at times, been challenging due to time pressures on Primary Care.

The PNF have been collecting workforce and education data from the individual Practices Nurses and

more latterly Health Care Assistants. Previously there was little information regarding workforce and

education to plan any future developments in Primary Care.

The work plan 2016/17 and locality report demonstrates the achievements of the PNFs in their first year of

employment by the CCG.

The 2017/18 ambitious work plan will respond to developing and changing priorities within Primary Care

and the CCG.

Appendix 1

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Practice Nurse Facilitator Team Work Plan 2016/17

Aim Action Update/Status

Support Practice Nurses with new Nursing and Midwifery Council revalidation requirements

Attend national NMC revalidation events

Organise and deliver local revalidation workshops in all localities (x10)

Communicate with GPs and PMs re revalidation

Support individual practice nurses to revalidate. PNF acting as “confirmer” and or “professional reflective discussion”

10 revalidation workshops commenced

Communication via “What’s new this week” and CCG live

Individual Practice Nurses continue to be supported to revalidate

Achieved and ongoing

Start a bespoke “What’s new this week” newsletter for Practice Nurses” as currently do not receive a specific Practice Nurse newsletter.

Communicate with Practice Nurses to ask what they would like in the newsletter.

Complete draft copy for comment

Add link to newsletter from CCG live.

“What’s new this week for Practice Nurses” commenced.

Expanded to other health professional within General Practice.


Establish a Practice Nurse Education and Training Group Practice Nurse Education and training ad hoc, not quality assured and not based on training needs

Advertise in “What’s new” for interested Practice Nurses

Invite University of West of England (UWE), University of Gloucestershire (UoG)

Liaise with Local Medical Council

Liaise with other education and training providers e.g G.Doc

PN representative from each locality attends

PNFs attend

Priorities for Education and training discussed Achieved and ongoing

Create a workforce/ education database of Practice Nurses working in General Practice. Currently workforce and education data not available to inform future developments

Discuss with interested parties what information they would like in the database

Work with informatics to develop a database

PNFs to meet with individuals and practices to collect data

PNFs visiting practices to network, introduce their role and collect data for the database.

Cheltenham: 17 surgeries, 16 visited, Gloucester City: 19 practices, 9 visited, North Cots: 5 surgeries, 5 visited, South Cots: 8 surgeries, 8 visited Forest of Dean and Tewksbury: 15 surgeries, 14 visited Stroud : 19 surgeries, 9 visited


Produce a “Mandatory Training” schedule for General Practice

Collaborate with other provider organisations re their mandatory training.

Develop and distribute to practices

Developed and distributed to practices Achieved

Increase Pre-registration Meet with University of West of England, University of Met with UWE and U of G re increase number of placements.

Appendix 1

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students nurse placements in General Practice Currently only 7 placements in General Practice. Increasing number of placements will expose student to a PN career

Gloucestershire

Advertise benefits of having a student nurse in “What’s new”.

Meet with practice managers to encourage them to have student

Number of placements increased to 10 Achieved and ongoing

Promote Educational/career development appraisals At present some Practice Nurses do not have access to an educational /career appraisal

All PNFs to complete UWE appraisal project study days

Advertise in “What’s new” availability of PNFs to carry out appraisal with Practice Nurses

PNFs have carried out appraisals Achieved and ongoing

Introduce Cancer Care Review (CCR) by Practice Nurses At present practice Practices Nurses do not carry out CCR. CCR will be part of the Primary Care offer

Work with Clinical Programme group to develop training package.

PNF to develop their competence in CCR by attending Macmillan funded course

Deliver training package

2 PN facilitators attended Macmillan funded course.

Training package developed

Training package delivered in localities. Achieved and ongoing

Contribute to ENT ear wax pathway Currently there is not an ear wax pathway

Work with Clinical Programme group to develop pathway Meetings completed

Pathway put on hold Ongoing

Introduction of National Diabetes Prevention Programme

Work with Clinical Programme group to introduce pathway

Pilot in 4 practices across Gloucester City before rolling out county wide

Programme group has met regularly

Pilot Achieved and ongoing

Appendix 1

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Introduce “Map my Diabetes” ensuring patients with diabetes access to structured education.

Liaising with company to ensure uptake in locality before rolling county wide

Pilot in Glos and FOD

Met with company

Good uptake in Forest of Dean compared to Gloucester city Achieved and ongoing

Review of Blood Glucose Meters and Strips

Contact Medicines Optimisation team

Provide expert advice regarding Blood Glucose Meters and Strips

Develop formulary with Medicines Optimisation team

Met with Medicines Optimisation team

Formulary developed

Promoted formulary at PLT Achieved and ongoing

Organise Immunisation and Vaccination training Currently no Immunisation and Vaccination training available in the county

Contact Health Education England re updates for both nurses and HCAs

Organise study day in all localities (x5)

5 study days in each locality organised Completed

Improve childhood immunisation invitation letter Currently feedback from parents and Practice Nurses letter not fit for purpose

Contact Gloucestershire Immunisation working group

Develop sub group re improving letter

Work with Child Health and NHSE to introduce new letter

New letter introduced Completed

Increase uptake of immunisations Some localities have uptake rates below county and national averages.

Contact Gloucestershire Immunisation working group

Develop work plan

Develop and introduce “Best Practice” guidelines for practices.

Visit practices who have low rates of immunisation uptake

Work plan commenced

“Best Practice” guidelines introduced

PNF work with individual practices who have low immunisation uptake rates


Develop an updated Non Medical Prescribing (NMP) policy Current policy out of date

Work with Medicines Optimisation team to update NMP policy

Update policy to include NMP pharmacist

Working with Medicines Management team

3rd

draft completed end of April Ongoing

Support MRSA Post Infection Reviews (PIR) as requested by Public Health England

Write process template for carrying out MRSA PIR

PNF to be involved in investigation, gather information from GP and other providers involved.

Organise meeting, minutes and action plans

Complete documentation.

One PNF now able to complete MRSA PIR Achieved and ongoing

Appendix 1

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Investigation of cases needs to be sustainable. Currently only one person in the CCG can do this

Support C. diff death investigations Investigation of cases needs to be sustainable. Currently only one person in the CCG can do this.

Write process template for carrying out CPNF to be involved in investigation, gather information from GP and other providers involved.

Organise meeting, minutes and action plans

Complete documentation

One PNF now able to complete. diff death investigations Achieved and ongoing

Increase the number of Practices Nurses involved in research

PNF to contact Research lead for Gloucestershire

Organise meeting for Practice Nurse interested in research

Meeting with Research lead Ongoing

Appendix 1

Page 6 of 13

2016/17 PNF report from each locality

Cheltenham locality: 17 surgeries

PNF has visited 16 of the 17 practices to introduce themselves and PNF role. Workforce and

education/training data has been collected and added to database.

PNF has introduced a Practice Nurse Leads group which meets bi-monthly. The Cheltenham

Practice Nurse Leads Group aim is; to provide informed, expert advice and direction to support the

development of nurses in General Practice, to provide a forum to ensure good communication

between Practice Nurses and the CCG and to contribute to the development of the Gloucestershire

CCG. Meetings have included information regarding Gloucestershire STP, Primary Care Strategy,

student nurse placements, immunisation uptake rates and Medicines Optimisation updates. The

group also acts as an informal clinical supervision /support group.

Several Practice Nurses have been supported in their NMC revalidation with the PNF undertaking

“the professional conversation” with the Practice Nurse. Additionally the PNF has acted as “the

confirmer” by approving and signing off the Practice Nurse portfolios.

The PNF has met with locality GP leads and the CCG locality manager for Cheltenham. The PNF is

encouraging Practice Nurses to be invited and attend locality events.

Individual Practice Nurses have been supported with both professional and employment issues.

Gloucester City locality: 19 practices

PNF has visited 9 of the 19 practices to introduce themselves and PNF role. Workforce and

education/training data has been collected and added to the workforce/education database.

The PNF has met with locality GP leads and the CCG locality manger lead for Gloucester City.

Executive and locality meetings have been attended by the PNF to introduce themselves and their

role. The PNF is encouraging Practice Nurses to be invited and attend locality events.

A locality Practice Nurse forum is being developed by the PNF. Specific issues within surgeries have

been supported by the PNF. These issues include awareness of indemnity and working away from

Appendix 1

Page 7 of 13

practice site, not working beyond clinical competence, career progression and clinical support

regarding diabetes.

PNF has a special interest in Diabetes and has been working with four practices to introduce the

National Diabetes Prevention Programme. “Map my Diabetes” ensuring patients with Diabetes have

access to structured education has also been introduced by the PNF in this locality. The PNF has

also been working with Forest of Dean Practices to introduce this programme.

North Cotswolds locality: 5 surgeries

PNF has visited all 5 surgeries to introduce themselves and PNF role. Workforce and


The PNF has met with locality GP leads and the CCG locality manager for North Cotswolds.


role.

A Practice Nurse lead group / Practice Nurse forum is being scoped at present.


“professional conversation” with the Practice Nurse. Additionally the PNF has acted as “the


Specific issues within surgeries have been supported by the PNF which include cold chain policy,

ambulatory ECG problems and prescribing competency concerns.

South Cotswolds locality: 8 surgeries

PNF has visited all 8 surgeries to introduce themselves and PNF role. Workforce and


The PNF has met with locality GP leads and the CCG locality manager for South Cotswolds.


role.

Appendix 1

Page 8 of 13

PNF has introduced a Practice Nurse Forum in this locality. Meetings have included information

regarding Gloucestershire STP, immunisation uptake rates and dressing formulary updates. The

group also acts as an informal clinical supervision /support group

Specific issues within surgeries have been supported by the PNF. These issues include infection

control advice, immunisation updates and supporting practice nurses to become mentors.

Forest of Dean and Tewksbury localities: 15 surgeries

PNF has visited 14 of the 15 surgeries to introduce themselves and PNF role. Workforce and


The PNF has met with locality GP leads and the CCG locality manager for Tewkesbury locality.

Practice nurse workforce and education and training have been discussed. Executive and locality

meetings have been attended by the PNF to introduce themselves and their role.

The established Practice Nurse forum has been supported by the PNF.


“the professional conversation” with the Practice Nurse.

Specific issues within surgeries have been supported by the PNF. These issues include: Supporting

a GP practice with Practice Nurse work force issues (including looking at skill mix and job

descriptions within the practice team), Accessing CCG Live and referral forms and sign posting

regarding diabetes competencies.

PNF has been working with locality manager to present a frailty workshop to Practice Nurses within

locality.

The PNF is a Queens Nurse. Queen’s Nurses are committed to learning, leadership and high

standards of practice and patient care. The PNF encourages Practice Nurses within the locality to

apply to become a Queens’s nurse.

Stroud locality: 19 surgeries

PNF has visited 9 of the 19 surgeries to introduce themselves and PNF role. Workforce and


Appendix 1

Page 9 of 13

The PNF has met with locality GP leads and the CCG locality manager for Stroud locality.


“the professional conversation” with the Practice Nurse. Additionally the PNF has acted as “the


Specific issues within surgeries have been supported by the PNF. These issues include: provision

needle stick injury protocol, creation templates for wound care consultations, immunisation and

vaccination advice and advice to Health Care Assistant who has an overseas nursing qualification

wishing to register with the NMC.

Two new Lead Practice Nurses have been supported by the PNF. This support includes advice

about leadership and managing Practice Nurse Teams.

A practice that “required improved” by the CQC has been supported by the PNF. Some of the issues

highlighted by the CQC included infection control and prevention and medicines and vaccine

storage. The PNF has provided advice and information regarding policies and procedures in relation

to these issues.

PNF has been working with Stroud Council Housing Team on the Homelessness Prevention Project.

A working group, which the PNF is part of, has been commenced with the aim to increase

awareness regarding homelessness, risk factors and health. This group aims to develop a risk

assessment tool to identify patients at risk of homelessness that can be used in primary care and

other agencies across Stroud and Berkeley Vale locality.

The uptake of MMR within this locality is below both the county and national average. The PNF has

been working with Public Health England and the practices to support them to increase vaccine

uptake. A “good practice” guide has been developed and introduced into these practices.

PNF has been working with locality manager to present a frailty workshop to Practice Nurses within

Stroud locality.

Appendix 1

Page 10 of 13

Appendix 1

Page 11 of 13

Practice Nurse Facilitator Team Work Plan 2017/18

This work plan is evolving as priorities develop and change within Primary Care and the CCG.

Aim Action Update/Status

Introduce Trainee Nursing Associate (TNA) placements in General Practice

Meet with University of Gloucestershire regarding TNA

Advertise in “What’s new”

Liaise with partner organisations who want to include practice placements for their TNA students

Lease and support practices who would like to have a student.

Increase number of Mentors in practice

Advertise benefits of taking students

Be available to talk to practice regarding taking students.

Promote Practice Nursing as a career for student nurses and qualified students

Work with universities to promote Practice Nursing to student nurses.

Attend career events

Encourage practices to adopt HEE General Practice Nursing Services Education & Career Framework (2015)

Promote career pathway to Practice nurses and practice managers

Increase number of Practice Nurses with MSc advanced practice

Advertise in “What’s new” funding opportunities.

Meet with UWE Advanced Practice lead

Support Practice Nurses during course

Support Practice Nurses working at an Advanced level to achieve RCN credentialing process

Meet with University regarding Advanced practice

PNF to apply for credentialing

Promote credentialing to experienced Practice Nurses working at an advanced level

Increase numbers of Practice Nurses with Non-Medical Prescribing

Promote Non-Medical Prescribing qualification

Support student during course

Appendix 1

Page 12 of 13

qualification

Develop an updated Non Medical Prescribing (NMP) policy Current policy out of date

Work with Medicines Management team to update NMP policy

Update policy to include NMP pharmacist

Validate policy via CCG

Promote CCG NMP policy

Update NMP page on CGG live

Working with Medicines Management team

3rd draft completed end of April

Organise a NMP “Hot topics” study day

Contact U of G to see if interested in joint study day

Work with Medicines Optimisation team regarding topics to be discussed

Organise and evaluate day

U of G contacted, keen to be involved

Increase awareness of Antimicrobial Stewardship

Signpost to education opportunities

Promote audits of antibiotic prescribing

Include AMS NMP Hot Topics day

Increase number of Practice Nurses with Sexual health qualification Changes in Sexual Health Services with Gloucestershire will result in more General Practice Sexual health consultations.

Meet with UWE and GCSNHST Sexual Health team regarding current course and placements

Secure funding to support Practice Nurses

Deliver Frailty workshops as part of the Primary Care Offer

Work with Frailty leads

Organise and deliver presentation in localities

Met with Frailty lead

Develop a “training passport” to enable statutory and mandatory training to be transferable across organisational boundaries

Work with the STP and general practices

Scope what mandatory training currently and whether achieves standards.

Appendix 1

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Raise awareness of The National Reporting and Learning System (NRLS)

PNFs to be familiar with NRLS

PNF promote NRLS at PN forums

Support Patient Participation groups

Liaise with Patient Participations groups

Provide advice and information to these groups

Met with patient engagement facilitator

Delivered End of Life and Cancer Care Reviews in Primary Care information to Coleford group

Develop an Practice Nurse induction pack for new nurses

Scope inductions packs

Collaborate with GPs, PMs and PN re the induction pack

Support MECC (Making Every Contact Count)

Liaise with MECC lead.

Promote MECC training to practice staff

Met with MECC lead

Develop a repository of policies and procedures to share best practice

Liaise with practices re their policies and procedures.

Liaise with other organisations

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