committee reporting - nhs halton ccg care... · • £50 million worth of nhs supplied medicines...

Committee Reporting

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Primary Care Commissioning Committee Date: 11th January 2018

Report title: NHS Halton CCG Waste Campaign Proposal

Lead Clinician and/or Lead Manager: Lucy Reid, Head of Medicines Management

Purpose: To inform the committee of the proposal to run a local waste campaign

The Committee is asked to: Note the contents of the report

This Report supports the following CCG Strategic Objectives One: To commission services which continually improve the health and wellbeing of Halton residents. Two: To continually improve and innovate in our engagement with local people and communities to secure their participation in improving their own health outcomes. Three: To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations. Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Five: To develop the skills, knowledge and competence of the people who are working with us to create a high performing organisation that will allow us to build effective partnerships with other organisations and develop leadership from within. Commissioning Plan Implications Use of the Minor Ailments scheme promotes self care and improved use of primary care skill mix. Financial Implications Does this require financial support? Yes If Yes - Is there currently a budget for this? to have final approval at Performance and finance following COG in January 2018 Board Assurance Framework and Corporate Risk Register Does this report link to either the Board Assurance Framework (BAF) or Corporate Risk Register (CRR) or both? N/A If Yes - please state:

• the corresponding reference number.

Committee Reporting

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• state level of assurance this paper provides – detailed individually in the paper National Policy, Guidance, Standards, Targets or Legislation NICE Medicines Optimisation Right Care NHS Five Year Forward View Pharmaceutical waste reduction in the NHS (NHSE) Equality and Diversity and Human Rights Throughout the development of this paper and the policies and processes cited NHS Halton CCG has:

• Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it; and

• Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.

Committee Reporting

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NHS Halton CCG Proposed Medicines Waste Campaign 2018

In a 2010 report it was concluded that a robust estimate for gross annual cost of NHS primary and community care prescription medicines wastage in England is currently in the order of £300 million per year. It has been estimated that within that £300 million figure:

• £90 million worth of unused prescription medicines that are retained in individuals’ homes at any one time.

• £110 million returned to community pharmacies over the course of a year. • £50 million worth of NHS supplied medicines that are disposed of unused by care

homes.

These figures don't take into account the cost to patients' health if medicines are not being correctly taken. If medicine is left unused, this could lead to worsening symptoms, extra treatments and hospital admissions that could have been avoided. Alongside this material waste it is estimated that about 50% of medicines prescribed are not taken as intended, to provide optimal health outcomes. As a follow on piece of work that the Medicines Management Team have been doing around waste during 2017/18 and building on the projects that have already taken place or are planned for the coming 12 months it is proposed that we also run a CCG waste medicines campaign utilising materials provided by PrescQIPP, a nationally recognised resource that supports effective medicines optimisation. We will localise the materials with the key messages that we feel are important to changing culture with regards to medicines use. We will work with the Local Pharmaceutical Committee to ensure that local pharmacies agree with the key messages and will raise awareness with Healthwatch and other patient groups to ensure the messages are clear and effective. The proposed plan along with costings is included below but it is important to note that this has yet to be considered at Commissioning Advisory Group (CAG) and Performance and Finance Committee and as such is not yet approved.

Committee Reporting

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Action Distribution List By Who Cost TimescaleCommittee Approval MMWG

COG

Quality Committee

Performance & Finance (approval)Awareness raising Partnership Exec Board

PPB (Overview & Scrutiny)

Health & Wellbeing Board

Healthwatch

PCCC

Distribution of posters, leaflets and giveways (e.g.pens balloons, magnets & bookmarks)

• GP practices• Community pharmacies• Acute Trust (to be placed into discharge medicines (TTO) bags and waiting rooms)• Dentists• Libraries • Out of Hours (OOH)• Health and Wellbeing Centres• Voluntary sector, e.g. Age UK• Schools• Local supermarkets• Patient groups• Care/residential homes • Fire service (to be given out during their home assessment or “Safe & well“ visits and displayed in staff areas)• Local Football?Rugby club (to be given out during health promotion events) Halton Community Transport Bus stops Widnes Market/Halton Lea Vikings Swimming baths Gyms

Design & sourcing -

AS/BB Distribution -

MM Team, other CCG members

• 10,000 A5 colour

leaflets (single

sided) £410• 250 A4 colour

posters (single

sided) £50 Balloons £50, T-

shirts £50, Pens

Badges £50 Total - £610

Jan-18

Powerpoint in waiting rooms and pull up banners

GP practices, Community pharmacies, Acute Trust, Out of Hours, Health and Wellbeing Centres, Vikings stadium

Design & sourcing AS/BB

Distribution MM Team

6 pull up banners

£480Jan-18

Key message stickers

GP practices (to be used on repeat slips), Community pharmacies (to be used on prescription bage), Acute trusts (to be used on TTO bags), badges for HCPs

Design & sourcing AS/BB

Distribution MM Team

TBC Jan-18

Media Twitter/Facebook - media messages, Use of local press, County council free papersRadio InterviewsGP practice/CCG websites/patient newsletterStakeholder newsletter, social media and patient forums e.g. Age UK, Fire Service and Acute TrustsAdvertising in Vikings match programme

Email signatures Design a corporate email signature for external promotion of the campaign AS/BB N/A Jan-18

Public engagement Supermarkets

Patient Forums PPGsLocal family fun daysGP Practice open days, flu clinicsHPHFsHealth promotion eventsLiaise with CCG Patient Engagement Leads

Total - £1460

NHS Halton CCG Public Waste Campaign

LR N/A Dec & Jan 18

AS/BB

£320 full page paper advert. £50

for Facebook - Total -£370

AS/DC/BB/MM team N/A

Jan-18

BB N/A Jan-18

Q1 17/18

Primary Care Group Meeting

Wednesday, 13th December 2017 13.30 to 15.30

Maple Room, Runcorn Town Hall Members in Attendance:

Dr Gary O’Hare GP, Murdishaw Health Centre (Chair) Sarah Vickers Head of Primary Care Commissioning, NHS Halton CCG Salil Veedu GP, Bevan Group Practice Ifeoma Onyia Consultant in Public Health, Halton Borough Council Sarah Bloor Practice Manager, Tower House Practice Joanne Valade Practice Manager, Grove House Partnership Donna Hunt Practice Manager, Peelhouse Practice Maria Stacey Practice Manager, Murdishaw Practice Dr Smitha Joseph GP Diabetes Lead Carl Dawood Commissioning Manager, NHS Halton CCG Craig Walker Head of Information Governance & Quality Assurance, St

Helen’s & Knowsley HIS Apologies:

Karen Hampson Commissioning and Contracts Manager, NHS Halton CCG Julie Holmes Commissioning Manager, NHS Halton CCG Anita Corrigan Practice Manager, Appleton Village Surgery

Minutes:

1. Apologies/ Key Issues from Previous Meeting

All actions from the last meeting are closed with the exception of:

• Care Home Alignment – to provide an update at the next meeting on the alignment transition and development of the dashboard.

• Enhanced Service claims template – need to review to ensure ease of use and reduce burden of data collection.

• Hypertension – Development of one page summary highlighting key learning points for sharing with practices. To pick up following discussion and presentation of graphs at GP Development Group.

KH/JH KH/JH JH/IO

2. Diabetes Prevention Programme Carl Dawood and Dr Smitha Joseph provided an update on the Wave 3 national Diabetes Prevention Programme. The prospectus has been submitted and the delivery model is being developed in order to compliment the current local service. For example the national service could be an evening and weekend service. The group were asked to consider how patients should be targeted and invited to attend screening when the service commences in June 2018. All felt that identifying the patients can be easily actioned via searches in practice. However resource will be required to invite the patient in and test patients HbA1c

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prior to referral. The possibility of utilising the Health Trainers was discussed. It was agreed to share a standardised search developed at Murdishaw with all practices to understand potential number of patients and to review these numbers at the next meeting. ACTION: To share IGR search from Murdishaw with all practices and collect results. Also raise at next Practice Managers meeting in January. ACTION: Next Primary Group meeting to review patient numbers and further discuss process for inviting patients.

CD CD/JH

3. GDPR Training Craig Walker provided an overview of the implications of the GDPR for primary care, which come into effect on the 25th May 2018. See attached presentation. It was suggested that all practices need to consider the changes in readiness for the implementation date and any updates for the IG toolkit. The IG team are developing templates to assist with the different specified groups e.g. children and elderly. The group expressed concern at the changes regarding Subject Access Requests which means that practices will no longer be able to charge for copies of patient’s records. It is thought that this will increase requests, which already have a large impact on admin workload e.g. Tower House 1 wte on SAR. The IG team are looking at taking up the role of Data Protection Officer on behalf of the practices. It was agreed to hold an awareness raiding session end January / early February for Practice Managers, IT and IG leads, also senior GPs and receptionists / admin if appropriate. Craig committed to circulate information as it becomes available and confirmed that the practice IG training programme has been updated. ACTION: To set up Practice Awareness Session for GDPR end January / early February 2018.

SV/CW

4. GP Extra

The group highlighted that both the GP Extra Service and Out of Hours Service need to ensure that patients are made aware that it is their responsibility to arrange a follow up with their GP, if indicated. Suggested that patients record should state “patient told to contact own GP.” ACTION: To request that GP Extra Service and Out of Hours Service ensure that patients are made aware that it is their responsibility to arrange a follow up with their GP, if indicated.

SV

5. CMetabolic CQUIN – CCG Link

This item was deferred as Jane Sanderson was unable to attend the meeting.

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6. Zero Tolerance Scheme

The group was informed that following the unsuccessful expressions of interest exercise, discussion had commenced direct with providers. The GP Federation had offered to provide the service if a suitable alternative couldn’t be found. However discussions have commenced with PDS (Medical) Ltd who provide the service on behalf of 6 CCGs in Lancashire & Cumbria. It is anticipated that a paper will be taken to January’s PCCC for a decision on the new provider.

7.Halton Enhanced Scheme 2017/18 The scheme is progressing well and the results of the Hypertension Audit are being discussed at the forthcoming GP Development Group. The majority of practices are engaging and this is being monitored to support payments. 2018/19 A discussion paper was shared which will also be shared at the forthcoming GP Development Group. The paper includes some questions to consider on each of the project areas within the HES. The group suggested:

• Diagnostics: Agreed retain as part of PMS Premium.

• Quality Referral Meetings: Felt audit time consuming and individual practice feedback at meetings unhelpful. However appreciated opportunity for clinical discussion therefore could keep and each practice bring an SEA / incident relating to a stated pathway for discussion with the Consultant.

• GP Development Meetings: continue, could include discussion to explore

how practices are utilising Clinical Pharmacist role and training requirements, 10 High Impact Changes and focus on saving GP time.

• Safeguarding Vulnerable People: Agreed to not include as difficult to

arrange meetings. When meetings have been held practice engagement has been excellent.

8. NHSE Inequalities Report The NHSE Improving Access for all: Reducing Inequalities in General Practice Services was circulated with the agenda to understand if there is any learning to be shared with practices. As this is a lengthy document Marie Stacy committed to review and feed back to the group. ACTION: To review the NHSE Improving Access for all: Reducing Inequalities in General Practice Services to determine if any learning to be shared with practices.

MS

9. Complaints Report This item was deferred to the next meeting. A copy of this report will be taken to the January PCCC.

10. Committee Reporting • The group agreed that the key points to be highlighted to the PCCC are: • - Diabetes Prevention Programme • - Zero Tolerance Scheme • - Halton Enhanced Scheme – plans for 2018/19 • - Complaints Report

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11. Time and date of next meeting

21 February 2018, 1.30-3.30 , Maple Room, Runcorn Town Hall

12. AOB There was no other business to report.

Reflects Minutes

For Action Status/ Update

1. KH/JH KH/JH JH/IO

• Care Home Alignment – to provide an update at the next meeting on the alignment transition and development of the dashboard.

• Enhanced Service claims template – need to review to ensure ease of use and reduce burden of data collection.

• Hypertension – Development of one page summary highlighting key learning points for sharing with practices. To pick up following discussion and presentation of graphs at GP Development Group.

2. CD CD/JH

• To share IGR search from Murdishaw with all practices and collect results. Also raise at next Practice Managers meeting in January.

• Next Primary Group meeting to review patient

numbers and further discuss process for inviting patients.

3. SV/CW • To set up Practice Awareness Session for GDPR end January / early February 2018.

4. SV • To request that GP Extra Service and Out of Hours Service ensure that patients are made aware that it is there responsibility to arrange a follow up with their GP, if indicated.

8. MS • To review the NHSE Improving Access for all: Reducing Inequalities in General Practice Services to determine if any learning to be shared with practices.

Practice Managers Meeting

Date: Tuesday, 28th November 2017 10.30-12.30

Venue: The Civic Suite, Runcorn Town Hall Members in Attendance:

Sarah Vickers Head of Primary Care Commissioning, NHS Halton CCG (Chair)

Julie Holmes Commissioning Manager, NHS Halton CCG Karen Hampson Commissioning and Contracts Manager, NHS Halton CCG Lynda Bolton Practice Manager, The Beeches Medical Centre Anita Corrigan Practice Manager, Appleton Village Surgery Donna Hunt Practice Manager, Peelhouse Medical Centre Maria Stacy Practice Manager, Murdishaw Health Centre Wendy Davies Interim Practice Manager, Newtown Surgery Angela Clague Practice Manager, Hough Green Medical Practice Joanne Valade Practice Manager, Grove House Practice Sarah Bloor Practice Manager, Tower House Practice Dawn Heggarty Practice Manager, Brookvale Practice Dawn Gregory Practice Manager, Bevan Group Practice

In Attendance by invitation of the Chair:

Melanie Connell Federation Lorraine Dutton Alzheimer's Society Cheshire North & St Helens Amy Davies Alzheimer's Society Cheshire North & St Helens Lisa Taylor Halton Borough Council Dave Burrows Damibu John Callaghan Damibu Becky Birchall NHS Halton CCG

Apologies:

Diane Hanshaw Practice Director, Bevan Group Julie Shaw Practice Manager, Castlefields Health Centre Helen Patient Practice Manager, Oaks Place Surgery Dawn Randles Practice Manager, Weaver Vale Practice Gwyn Walker Practice Manager, Upton Rocks Surgery

Minutes:

1. Minutes of Last Meeting/Matters Arising Action

Accepted as a true and accurate record.

• GP Extra: The group was reminded to ensure GP Extra was advertised on practice websites. This was being informally monitored at a national level. Practices were using different codes when patients were seen by GP Extra. To accurately monitor usage a single code was being sought. It was agreed that practices should use a code that had been used in Grove House: OOH attendance note 9b0Z

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• OPEN: The link to Halton’s Older People’s Empowerment Network (OPEN) is below: http://haltonopen.co.uk/ (action closed)

• ZT Scheme: No responses to RfI were received. Currently in discussions with a number of potential providers. The model being adopted was one where the patient was not attached to a particular practice. Two new patients were requiring a placement and a temporary solution was being sought.

• GP PM Development Funding: A number of options were being considered by NHSE. It was discussed at a recent Primary Care Leads meeting when it was felt a wider conversation was required. If Halton took its share of funding the estimated allocation would be £3380. It was suggested that this could be used to hold a transformational change away day for PM’s. Agreed to put this proposal to NHSE and approach Jenni Fecitt as a potential facilitator for the day.

SV/JH

2. Federation Update

Action Discussed ENT service in Highfield Hospital. Practices asked to display leaflet. One practice mentioned that they couldn’t book on patients via the E-referral system. MC to look into this.

MC

3. Dementia Community Support

Action

An overview on the Single Point of Access for the Dementia team was provided. Anyone could refer into the service via phone or email. Patients were fully assessed and provided with regular contact. They were linked with other services and provided information on activities in their area. They were encouraged to plan for the future. The support provided was tailored to the individual and regularly reviewed as the patient’s needs changed. The team also provided support to carers. Agreed to share service flowchart (appended to notes).

4 Catch App

Action

The CATCH (Common Approach to Children’s Health) App was developed following a successful bid to the Innovation Agency. The App was a free health app for parents and carers of children aged 0-5. The aim was to empower parents and carers with the information necessary to decide when their child needed medical treatment or when self-care was more appropriate. It used information that was already available. Pop ups would also provide advice. It was planned to launch the App across Halton and advice was requested on the best way to do this. It was agreed that it would be more effective and appropriate to promote the App outside of the GP consultation. Therefore a promotional pack would be developed and brought back to the January meeting. The pack to include leaflets, standard wording for texts and websites, powerpoint slide for display screens etc. A link to the App would be shared.

LT LT/JH

5. Releasing Time for Care Event – 9 November

Action

An overview of The Releasing Time for Care Event was given. The morning session provided an overview of the ten High Impact Actions to release time for

http://haltonopen.co.uk/

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care. This was followed by four workshops. Of particular interest were the sessions on correspondence management (Brighton and Hove) and signposting (West Wakefield). Both offered training and support packages and it was agreed that further information would be sought. It was noted that Brookvale had already arranged for a representative from West Wakefield to attend practice on 5 December and everyone was welcome to attend. Another session focused on E-consult. It was discussed that E-consult was being rolled out across Halton but was waiting for support from EMIS. An update on the current timetable would be sought. It was also noted that the Halton DOS was being developed and again an update on the timeframes would be sought. It was agreed that the DOS should be a centralised hub where all information on services were stored. It was suggested that IntraDoc could be used to store the information.

JH SV

6. Correspondence Management

Action

The group of practice ‘experts’ had met a number of times and was in the process of developing a Halton approach to correspondence management. Existing practice protocols had been shared and pulled together into one document. Members of the group had been asked to review the document to understand how it would work in their practice. Once the Halton approach had been agreed, training would be discussed. It was felt that having an audit process was also essential. It was mentioned that the document circulated did not print out correctly. Updated document attached to these notes. The next meeting of the group would take place on 20th December, 12-1.30 in the Heath Conference Centre. Everyone was welcome to attend.

JH All

7. Translation Services when Referring Patients Action An issue had arisen in secondary care which delayed a patient’s care as the referrer had not indicated on the referral form that the patient required an interpreter. The Group was asked to remind all referrers to indicate on the referral form when an interpreter was required.

All

8. Public Engagement/Consultation - Widnes Action

• A Health Impact Assessment on Appleton’s closed list was planned on 5 December.

• A consultation on the closure of Hale Bank branch surgery to be undertaken in the New Year.

• Discussions ongoing on the re-location of the Beeches.

9. Travel Vaccinations Action

The Federations had been approached to see if it would be possible to have a federated approach to delivering travel vaccinations. This was currently being looked into.

10. New GMS1 Form It was discussed whether the new GMS1 form had to be printed and sent off. The general consensus was that it didn’t. It was noted that some Practices put the

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donor information on Open Exeter. 11. Patient Led Ordering Action

The service at Widnes had been live for a couple of weeks. If anyone was aware of any issues please contact the medicines management team. All medicines management staff would be returning to their normal duties from next week. An evaluation would be undertaken after Christmas. Concern was raised about distance pharmacies and how they were accessing information on patients. It was confirmed that this was a matter for the LPC and the issue had been raised with them. It would be raised again at the next working group. An issue was mentioned regarding the information given by pharmacies on out of stock medicines, claiming it was a national issue when it was a pharmacy one. Again any such issues should be raised with medicines management. A couple of queries regarding controlled drugs were raised. One around distance pharmacies posting controlled drugs to patients and another regarding the timeline of when controlled drugs can go EPS. An update would be sought.

All All BB

12. Whistle Blowing Policy – Freedom to Speak Up Guardian Action Michelle Creed was looking into the possibility of having a CCG Guardian. Other suggestions included using the Federation (Mel Connell had already agreed to undertake this role for one practice). Managers at two other practices had agreed to undertake this role for each other. It was noted that a training package and job description were currently being developed by NHSE which would support the understanding of who was best placed to undertake this role. It was noted that having a guardian was not yet compulsory in primary care.

13.Any Other Business i) ILM Programme – Murdishaw and Appleton had each taken on an apprentice

under this scheme but were having difficulties getting paid. Murdishaw had finally received payment and offered support to Appleton.

ii) Follow-up Requests from Secondary Care – GP’s were still receiving inappropriate follow up requests. DH was sending them to the HCCG’s Issues email but not receiving any responses. Not sure who was monitoring this address, agreed to look into. All letters received from practices were escalated to the contract lead to pick up contractually. Agreed to ask for an update.

iii) GDPR Training – the HIS had finalised training material and training would be included in all future IG training. How practices that had already had their IG training would access the GDPR training would be looked into. Craig Walker from the HIS was attending the PCG meeting in December to highlight the changes. Agreed to consider adding training to PLT event for GP’s.

iv) Syrian Refugees – the next, and final, cohort was due in January. Six families expected (this was subsequently increased to seven families) to be located across Widnes and Runcorn.

v) Website Translation - some practice websites had the functionality to translate information. It was suggested that any practice that wanted to have this facility, to help support their Syrian refugees, should contact their website supplier.

vi) Potential Scam Email – Grove House was concerned that an email they had received regarding delivery of equipment might be a scam. However it was possibly linked to a pilot being organised by Gareth Rustage. To be raised

JH SV SV SV/JH

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with Gareth. vii) GP Assistant Roles – a practice asked if anyone had taken on a GP

Assistant. Appleton confirmed that they had put in an application some time ago but had not heard anything. Agreed to chase up with NHSE.

viii) Jayex Machine – a practice asked if anyone had used their Jayex machines to collect other information such as smoking status, telephone numbers etc. Those that had stated they had stopped it as it created queues and patients often didn’t finish completing the information anyway.

ix) Referral Management Scheme – it was confirmed that a decision had been made to stop RMS. However an exit plan was currently being developed so the timings had not been finalised.

x) Red Bag Briefing – this was a new scheme to be piloted in care homes across Halton from 1 December 2017. (full briefing attached). The Red Bag would accompany care home residents should they have to go into hospital. It would contain six ‘must have’ documents including passport, ACP/DNAR, emergency care plan, MAR sheet, ‘This is me’ document and Red Bag Checklist.

xi) Diabetes Essential Support – practices were encouraged to respond to a request from Ellen Mitchell (dietician from Diabetes Essential) for her to come into practice and contact patients to encourage them to attend Diabetes Essential education. She had already been into three practices, including Hough Green. Angela confirmed that all Ellen required was access to a computer and list of patients.

SV

14.Date & Time of next meeting Action Wednesday, 24 January 2018. The Boardroom, Hough Green Health Park. 9.30am-10.30am – Federation Meeting 10.30am-12.30pm – Practice Manager Meeting Suggested agenda Items: Diabetes Essential, Clinical Practice Research Datalink (CPRD), Inappropriate Follow Up Requests, Catch App Promotional Packs, Dates of 2018/19 meetings.

Action Log

Reflects Minutes

For Action Status/ Update

1 SV Contact NHSE regarding practice manager development training funding.

1 JH Contact Jenni Fecitt regarding facilitating a transformational away day.

1 JH Ask NHSE to check their PM distribution list as some mangers felt they weren’t receiving information.

2 MC Look into the Beeches not being able to access the ENT service via C&B.

4 LT Develop practice pack to promote Catch App to patients. Bring back to future meeting.

4 LT/JH Share link to Catch App. 5 JH Obtain information and costings on training for

signposting and correspondence management from

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Brighton and Wakefield. 5 SV Update practices on progress and timeline to develop

Halton DOS.

6 JH Update correspondence management workflow document to ensure it printed out correctly.

6 All Everyone invited to attend next meeting of correspondence management group on 20th December, 12-1.30 in the Heath Conference Centre.

7 All Remind all referrers to indicate on the referral form when an interpreter was required.

11 All Contact Medicines Management team with any queries regarding Patient Led Ordering.

11 All Contact Medicines Management team with any issues regarding information being given by pharmacies on out of stock medicines.

11 BB Find out further information on distance pharmacies posting controlled drugs to patients and the timeline of when controlled drugs can go EPS.

13 JH Enquire whether the Halton Issues email address was monitored.

13 SV Provide an update on inappropriate requests for follow-ups from Trusts.

13 SV Find out what plans are in place for practices that have already received their IG training to receive the GDPR training.

13 SV/JH Ask Gareth Rustage to look into potential scam email. 13 SV Contact NHSE regarding Appleton’s application for a GP

Assistant.

GP Development Meeting

Thursday, 14th December 2017 13.30 to 15.00

Ditton Community Centre, Widnes In Attendance:

Sarah Vickers Head of Primary Care, NHS Halton CCG (Chair) Julie Holmes Commissioning Manager, NHS Halton CCG Karen Hampson Commissioning & Contract Manager, NHS Halton CCG Angela Clague Practice Manager, Hough Green Medical Practice Dr L Chalasani GP, Hough Green Medical Practice Dr Karl Botham GP, Peelhouse Medical Plaza Anita Corrigan Practice Manager, Appleton Village Surgery Dr Ian Schofield GP, Appleton Village Surgery Dr Jan Breeden GP, Bevan Group Practice Dr Serge Nugent GP, The Beeches Dr Araf Arain GP, Newtown Surgery Alex James Nurse Practitioner, Murdishaw Health Centre Dawn Randles Practice Manager, Weaver Vale Practice Dr Fenella Cottier GP, Weaver Vale Practice Dr David O’Brien GP, Brookvale Practice Dr Harjinder Sandu GP, Tower House Dr David Wilson GP, Grove House Partnership Rob Foster GP Health Connect - Federation Wendy Davies GP Health Connect – Federation/Newtown Surgery Mel Connell Platform 7 Highfield Ltd – Federation Dr Latha Meda GP, Oaks Place Surgery Kirsty Kendrick Grove House Practice Donna Hunt Practice Manager, Peelhouse Medical Plaza

In Attendance by invitation of the Chair:

Jane Briers British Heart Foundation Debra Russell British Heart Foundation Dr Ifeoma Onyia Consultant in Public Health, Halton Borough Council

Apologies:

Dr Gary O’Hare GP, Murdishaw Health Centre Lynda Bolton Practice Manager, The Beeches Dawn Heggarty Practice Manager, Brookvale Practice Minutes:

1. Notes of Last Meeting

• International GP Recruitment: bids had been submitted to NHSE. Positive feedback received. Application to be submitted by NHSE between Xmas and New Year. Agreed to share the bid (attached). Further information regarding next steps available in January. GP’s expected to arrive August/September 2018. There would be a matching process. Funding available for training, need to agree what local support to be offered. GP’s could be employed by the Federation.

SV

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A recent event to support GP recruitment hosted by the BMA was discussed. GP’s and practices were brought together in an informal environment to provide an opportunity for potential new GP’s to get to know practices. It was organised in the form of a speed dating event. Discussed that this might be something to explore in Halton. Agreed to find out further information.

SV

2. Clinical Correspondence Update As part of GPFV funding was available to train clerical staff on workflow management. Aim was to redirect administrative tasks away from GP’s to release capacity. Brighton and Hove had developed a robust protocol to allow clerical staff to review, Read code and where appropriate take action on incoming clinical correspondence, rather than the GP having to deal with every letter. This was based on the premise that on average only 20 percent of letters required direct GP input. Benefits to practice included: GP time saving of 40 minutes per day per GP, improved record keeping, opportunities to increase QOF income, potential improvement in quality of secondary care clinical letters (conversations based on evidence not anecdotes). Governance structures supported by MDU’s and no significant events in first 15,000 letters to be processed. Investing in administration staff in first instance and GP engagement was key to success. Locally a group of ‘experts’ had been pulled together from a number of practices. The Group had met twice and its aim was to develop a standard, Halton wide process which could be adapted by practices. The focus would be on standardisation and reducing variation. Some practices had already developed protocols which would form the basis of a Halton wide one. It was discussed that dual screens would be useful and this would be considered in the next round of IM&T funding. Governance process would also be important, especially for CQC. Training would be part of the next steps, and could include training on read coding (SNOMED). The Group was asked if they had any other training ideas to let Sarah or Julie know. There was also the opportunity for practices to buddy up to share learning. Agreed to get advice from MDU regarding training.

All SV/ JH

3. Hypertension Audit The Group was reminded that the hypertension audit was part of the Halton Enhanced Scheme. Practices had been asked to review data extracted by the HIS and develop a three point action plan. The HIS would re-run the search on 31st January 2018 when practices would review re-audited data and reflect on achievement of 3 point plan. The initial action plans demonstrated similar findings and action plans across practices. Standard templates for recording, and improving coding, were key themes. The BHF had developed a web based template to support quality and good management. The template was developed from a nursing perspective and covers areas such as identification, diagnosis, annual review, QOF etc. To help embed the template and support the management of hypertension, the BHF also offered training to GP’s and nurses. A dashboard was also available. It was discussed that the BHF template could be used to cross-reference practice own templates. It was agreed to share screen shots of the template (attached). If anyone interested in the training they should contact Sarah Vickers or Dr Ifeoma Onyia. It was mentioned that the audit graphs were purely an information tool and not meant as a benchmarking tool. They could be used to share best practice. It was raised that coding was an issue and didn’t reflect the work that was being undertaken. Also ABPM was being commenced in hospital for some patients and would not show up in the data.

DR All

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4. Halton Enhanced Scheme 2018/19

The figures for year three of the PMS re-alignment were now available, although it should be noted that they were based on this year’s GMS amount. Agreed to include two additional scenarios regarding the extra £5 per head – one which included the £1.50 only as this was definite, and another to include the extra £3.50 which was not guaranteed. If everyone was happy the figures would be circulated – agreed to circulate. Discussed that it was recognised that the value of the HES would decrease as GMS value increased and therefore needed to be mindful of workload. However all recognised that practices would need to demonstrate some additional work in order to secure HES payment. Keen to align contents of HES with wider Accountable Care System and Federation strategies and priorities in order to decrease workload and ensure aligned programmes of work. Spirometry, BP and ECG: activity data had been collected quarterly to establish a baseline. However there were gaps in the data and wide variation, particularly for spirometry and BP. Practices were asked to check their data to ensure accuracy and inform the Primary Care Team of any variation. Data could be consolidated in Q3. It was discussed that clear criteria were required regarding the data collected, to ensure consistency – particularly ABPM (home or ambulatory), definition of assessment for spirometry, did people code FEV1 as spirometry. Agreed should continue with clearer criteria. Quality Referral Meetings: some felt that nothing had happened following the meetings. However it was recognised that a lot of the work would not happen overnight. It was noted that a mop-up session was being planned. It was generally felt that the meetings should be more focussed and consultant led. Rather than reviewing large amounts of data, each meeting could focus on one particular issue, with practices bringing along a case study, e.g. Haematology or Mental Health at Warrington. Need to understand hospital services and the variation between trusts. Agreed could still be separate Widnes/Runcorn meeting. Agreed should continue with some amendments. Safeguarding: due to difficulties regarding appointment of a Chair, not many meetings had been held. However when they were held they were well attended. Agreed to remove. GP Development Meetings: there was generally good attendance at these meetings. Agreed to change focus from GPFV to practice issues. Discussed that every third meeting could be a hub meeting. Need to ensure congruence with Federation work. Agreed to continue with a different focus. Audit: discussed potential to use PRIMIS to undertake searches. A number of options for a new audit were discussed. It was agreed that a clinical correspondence audit would support the emerging work around workflow management. Agreed to continue with clinical correspondence audit. Hubs Working Together: not sure what work this could be. Could be about improving

SV SV SV/ KH/ JH

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how community teams and practices work better together. At the last GP Development Group new Hub arrangement was agreed, but unfortunately hadn’t yet been able to meet to progress next steps. It was felt that further discussion on the 2018/19 HES was required and practices were asked to consider options for the HES next year. 5. AOB

There was no other business raised.

8. Time and date of next meeting Date and time of next quality referral meeting: Thursday, 15th February 2018. 1.30-3.00 pm. Council Chamber, Runcorn

Halton CCG Corporate Risk Register 2017‐18 Cover Sheet

Current Version V1Previous Version Updated Date 20/07/2017

Strategic objectives

Leigh Thompson

Michelle Creed

David Cooper and Dave Sweeney

Michelle Creed

NHS Halton CCG Corporate Risk Register

Document File Path

1. To commission services which continually improve the health and wellbeing of Halton residents.

2. To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations.

3. To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place.

4. To create a high performing organisation that seeks to create excellence in its skill base enabling the building of effective partnerships with our staff and key stakeholders.

1. To commission services which continually improve the health and wellbeing of Halton residents.

ID Date Risk Added

Risk Manager

Risk handler

Committee Title Description of Risk(Description of the actual risk i.e. There is a risk that X risk caused by Y event resulting in Z effect)

Key controls and gaps.(What controls/ systems are in place to prevent the risk from being realised)

Assurances in place and gaps.(What controls/ systems are in place to prevent the risk from being realised)

Likelihood

Consequence

Current Score

Mitigating Action(What additional controls/ systems need to be put in place to reduce the risks rating)

Update On Mitigating Action(Update on the additional controls and progress)

Likelihood Post Mitigation

Consequence Post Mitigation

Score Post Mitigation

378 Apr-14 Leigh Thompson

Sarah Vickers

Primary Care Commissioing Committee

Pressure on Primary Care

Committee to discuss - should the risk be more specific?

Increasing pressure on General Medical Services due to increasing patient demand may impact on the ability to implement quality services.

The GP Forward view programme, a national response to ensuring sustainable General Practice which requires local implementation, will support development of initiatives and bring additional national and regional funding to Halton practices e.g. implementation of 10 High Impact changes in General Practice to free up time, Sign posting training, expansion of GP Extra, implementation of care navigation, expansion of Web GP, implementation of Emis Community. GPFV Implementation Plan developed, approved by PCCC in December 2016 and submitted to NHS England. Implementation commenced. Transformation through Innovation funding bid with Wirral CCG submitted to Innovation Agency. Bid looks to gather insights and co-create an approach to support patients to make informed decision on how they access services. GP strategy in place. The CCG utilises a number of tools and soft intelligence to highlight pressures and capacity to deliver. Primary Care Working Group ensures the delivery against these plans. Recruitment of Clinical Pharmacists in Practice, Web GP pilot, telephone triage in some practices to support capacity Urgent Care Centres available in both towns and GP Extra being developed in both towns.GP Extra Funds secured for 2016/17 to expand pilot into both towns.Examine your options promotion in place.

Projects which support reducing demand on General Practice are overseen by working groups and reported to PCCC.

New CCG PMO role in place and engaged with Head of Primary Care to ensure project management support, robust commissioning oversight and that CCG commissioning plans support the Primary Care agenda and do not impact negatively on the service.

GP Forward View plan submitted to NHSE for assurance and to PCCC for approval.

PCCC will then monitor delivery of the plan and act as process for escalation if any problems with delivery.

PCCC will monitor performance of local practices through robust reporting

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The CCG does not currently have a systematic strategy for self care locally though a number of local areas of development these are required and need to be pulled together for the GP forward view to support management of demand.In order to devise effective programmes to impact on the demand in General Practice, need to understand root cause of increase. For example is increase due to social needs rather than medical need?Implementation of new national Community Pharmacy contract may impact on the sustainability of Community Pharmacy as an alternative access point. Limited oversight of CCG projects supporting strategic direction, interdependencies and impact on General Practice with regards to reducing demand in General Practice.

ETTF technology funding secured to support expansion of Web GP across all practices. Project Plan under development. Wave 2 Clinical Pharmacists in practice announced and Head of Medicine Management working with GP Federation Leads to develop Wave 2 bid, building on Wave 1. GP Extra Runcorn awaiting outcome of CQC registration to commence service delivery.Receptionist signposting training dates and attendees booked for February and March 2017 and Training Needs Assessment as an online survey nearing completion to assist in planning for 2017/18. Further clarity required regarding self-care work stream and how this sits with CCG commissioning intentions. However note national programme on self care and appropriate use of GP to commence as noted in contract negotiations 2017/18.GPFV Plan approved by NHSE with minor amendments. Funding to support practices to work together on implementing GPFV secured and requirements detailed in the Halton Enhanced Services Specification to be approved at Primary Care Commissioning Committee on 18 April 2017.Sept 17 update - GP Extra now providing additional GP appointments, evenings and weekends across both Widnes & Runcorn. Delivery of GP Forward View Implementation Plan continues. GP Federations are developing strategies to encourage consistent ways of working across practices. GP Federations secured GP Resilience fund monies from NHSE to develop a GP staffing pool across GP Health Connect and Widnes Highfield Limited.

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2A Oct-17 Leigh Thompson

Sarah Vickers

Primary Care Commissioning Committee

Failure to commission a Zero Tolerance Scheme Direct Enhanced Service (DES)

There is a risk that there is no service Zero tolerance DES due to no General practice provider expressing and interest in delivering resulting a small number of patients unable to access primary medical care within Halton.Under the NHSE and CCG primary care delegation agreement the CCG is required to commission a Zero Tolerance DES. This aim of the service is to deliver high quality general medical primary care within a secure environment. It aims to accommodate patients who have demonstratated challenging or agressive behaviour in thier GP Practice. The risk has arisen as no local practices has expressed an interest and the contract with the current provider ceased on 30th September 2017.

Expressions of Interest circulated to all Halton Practices in August prior to the contract end date of Sptember. Also raised at SDC and Practice Managers in September.Initial options paper presented to PCCC in September 2017.

5 patients are registered on the scheme, 3 patients are due an annual review with a view to being able to register with any practice chosen. The remaining 2 patients will require transfer to the new provider.

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Sought advice from NHSE. Reviewed the model in place in Eastern Cheshire CCG. Taken procurement advice from the CSU regarding procurement options. Placed a request for information on Contracts Finder to assess interest in bidding for this service. Shared the RFI with potential local providers within Cheshire & Merseyside (all General Practices and Trusts.)

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2. To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations.

ID Date Risk Added

Risk Manager

Risk handler

Committee Title Description of Risk(Description of the actual risk i.e. There is a risk that X risk caused by Y event resulting in Z effect)

Key controls and gaps.(What controls/ systems are in place to prevent the risk from being realised)

Assurances in place and gaps.(What controls/ systems are in place to prevent the risk from being realised)

Likelihood Consequence Current Score

Mitigating Action(What additional controls/ systems need to be put in place to reduce the risks rating)

Update On Mitigating Action(Update on the additional controls and progress)

Likelihood Post Mitigation

Consequence Post Mitigation

Score Post Mitigation

Date Reviewed Trend Target score

374 ? Dec 16 Leigh Thompson

Sarah Vickers


Failure to develop and implement a robust workforce plan for General Practice locally

To be discussed at PCCC regarding does risk need to be more specific and separated into appropriate risk handlers.

There is a risk of failure to develop and implement a robust workforce plan for out of hospital locally could lead to the failure of the CCG to commission high quality out of hospital services and transform services. This could impact on patient care and the ability of the CCG to deliver its statutory functions.

This risk as allocated to the PCC is clearly not focused on primary care workforce so PCC will ensure delivery across the patch. Annual workforce capacity survey undertaken by HEE.Good local participation in new schemes to address workforce development e.g. Pharmacists in practice, GP Access Fund, GP FederationNational GP Forward View launched which recognises national workforce issues and includes additional funding streams to support development programme.Local Cheshire & Merseyside discussions commenced on how CCGs can work together to develop joint development programmes and maximise economies of scale. One local Halton practice successful in a bid to GP Forward View Targeted investment in Returning Doctor’s SchemeNational Practice Nursing Strategy including training and succession planning in development. General Practice workforce control Payment to practices for Maternity/paternity/adoption locum cover, sickness locum cover, retainer scheme and returner scheme passed to CCG from 1 November 2016 providing greater intelligence on local workforce issues

Governance to oversee development of work force plan is in place via Primary Care Group and PCCC which will monitor this with reporting to Governing Body. A framework for the Workforce Strategy will commence development in January 2017 and be available by the end of March 2017, with the wider strategy being available later in 2017.

The annual survey has poor reporting for Halton action is to work with practice to improve their submissions, Robust Primary Care workforce plan required which includes strategies for mitigating against an ageing workforce, early retirement, poor supply of new GPs, Nurses and Practice Managers, shift in work life balance expectations, impact of clinical commissioning on available time. Action to develop a workforce strategy through a Task and finish Group starting in January 17. Workforce plan should explore use of GPsSIs, skill mix in practice and inter practice working.Workforce review and planning Group to be established, linked to LDS - no national GP workforce strategy in place, otherr than that outlined in the GPFV, national direction is awaited. Additional gap in control identified at December 2016 PCCC with the implementation of changes to the national Community Pharmacy contract which may impact on the sustainability of local pharmacies.

Participation in NHS Digital Workforce census now a mandatory contractual requirement (GMS negotiations 2017/18) therefore supporting more robust workforce planning.Planning to support development of workforce strategy commenced including review of other areas and literature search undertaken. Planning meeting arranged with Federation leads to support collaborative development. Initial scope reported to PCCC 21/02/17 and consideration being given to partner organisations.Reception and admin training for signposting and clinical correspondences booked for February & March 2017 and Training Needs analysis near completion to assist in planning for 2017/18. Workforce identified at NHSE level as priority and awaiting NHSE set-up of LDS/STP Working Group. New models to be discussed with practices apart of GP Development Meetings GP FV as outlined in the Halton Enhanced Scheme to be approved by Primary Care Commissioning Committee 18 April 2017.Sept 17 update - Quarter 1 and Quarter 2 (July - August) Update: Local Task & Finish Group not commenced due to increasing discussion across STP that workforce is an area that NHSE can support therefore NHSE work programme under development. NHSE set up a Cheshire & Merseyside Workforce Strategy Group, CCG Head of Primary Care is Alliance LDS manager representative. Workforce Strategy Group commenced development of a Cheshire & Merseyside International GP Recruitment bid and development of a Cheshire & Merseyside Workforce Strategy, supported by local CCG strategies. All practices submitting a local workforce data collection tool to support development of bid and strategy. Data will be available at CCG level to support local discussions and allow comparisons to contractually submitted data in Primary Care Web Tool. Discussions commenced with GP Federation on developing new models of Primary Care which will inform workforce requirements. New Deputy Chief Nurse in post to work with Head of Primary Care on local workforce strategy. NHSE published General Practice Nursing 10 Point Plan and Cheshire & Merseyside action plan developed in response. NHSE lead Nurse has met with CCG Chief Nurse regarding plan.

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Halton CCG Corporate Risk Register 2017‐18 Risk Matrix

ConsequenceLikelihood5 Almost Certain 5 10 15 20 254 Likely 4 8 12 16 203 Possible 3 6 9 12 152 Unlikely 2 4 6 8 101 Rare 1 2 3 4 Q2

Risk Score ColourLow 1-3Moderate 4-6High 8-12Extreme 15 - 25

Level Descriptor

1 Negligible

2 Minor

3 Moderate

4 Major

5 Catastrophic

Level Descriptor

1 Rare

2 Unlikely

3 Possible

4 Likely

5 Almost Certain

• The event is expected to occur in most circumstances. • Missing the target is almost a certainty. • Key project will fail to be delivered or fail to deliver expected benefits by significant degree.

• None or very minor injury.• No financial loss or very minor loss up to £100,000.• Minimal or no service disruption.• No impact but current systems could be improved.• So close to achieving target that no impact or loss of external reputation.

• Minor injury or illness requiring first aid treatment e.g. cuts,bruises due to fault of CCG.• A financial pressure of £100,001 to £500,000.• Some delay in provision of services.• Some possibility of complaint or litigation.• CCG criticised, but minimum impact on organisation.

• Moderate injury or illness, requiring medical treatment (e.g. fractures) due to CCG’s fault.• Moderate financial pressure of £500,001 to £1m.• Some delay in provision of services.• Could result in legal action or prosecution. • Event leads to adverse local external attention e.g. HSE, media.

• Individual death / permanent injury/disability due to fault of CCG.• Major financial pressure of £1m to £2m.• Major service disruption/closure in commissioned healthcare services CCG accountable for.• Potential litigation or negligence costs over £100,000 not covered by NHSLA. • Risk to CCG reputation in the short term with key stakeholders, public & media. • Multiple deaths due to fault of CCG.• Significant financial pressure of above £2m.• Extended service disruption/closure in commissioned healthcare services CCG accountable for.• Potential litigation or negligence costs over £1,000,000 not covered by NHSLA.• Long term serious risk to CCG’s reputation with key stakeholders, public & media.• Fail key target(s) so that continuing CCG authorisation may be put at risk.

• The event may occur at some time. • 40-60% chance of missing target.• Key project is behind schedule by between 3-6 months.• Less important projects fail to be delivered or fail to deliver expected benefits by significant degree. • The event is more likely to occur in the next 12 months than not.• High probability of missing target.• Key project is significantly delayed in excess of 6 months or is only expected to deliver only 50% of expected benefits.

Risk Matrix

1 Insignificant 2 Minor 3 Moderate 4 Major 5 Catastrophic

Significant Risks

A risk which attracts a score of 8 or above on the risk grading matrix constitutes a significant risk and must be recorded on the Corporate Risk Register.

Risk Ratings

Significant Risks

Consequence Score for the CCG if the event happensDescription

Likelihood Score for the CCG if the event happensDescription• The event could occur only in exceptional circumstances. • No likelihood of missing target.• Project is on track. • The event could occur at some time. • Small probability of missing target.• Key projects are on track but benefits delivery still uncertain.• Less important projects are significantly delayed by over 6 months or are expected to deliver only 50% of expected benefits.

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Thursday, 9 November 2017 10.00am

Civic Suite, Runcorn Town Hall, Runcorn. WA7 5TD Members in Attendance: Ingrid Fife (IF) Chair and Lay Member NHS Halton CCG

Leigh Thompson (LT) Director of Commissioning NHS Halton CCG

David Merrill (DM) Lay Member NHS Halon CCG

Michelle Creed (MC) Chief Nurse NHS Halton CCG

Dr Julie Langton (JL) Secondary Care Doctor NHS Halton CCG

David Sweeney (DS) Interim Chief Officer NHS Halton CCG In Attendance by invitation of Chair: Sarah Vickers (SV) Head of Primary NHS Halton CCG Louise Murtagh (LM) Senior Committee Administrator NHS Halton CCG Dr Gary O’Hare (GOH) GB GP Member and Primary Care Lead NHS Halton CCG Paul Brennan (PB) Primary Care Finance NHS Halton CCG

Dr Ifeoma Onyia (IO) Public Health Consultant Halton Borough Council Aysha Gunal (AG) Primary Care Support Officer NHS England Sarah Johnson-Griffiths (SJG)

Public Health Consultant Halton Borough Council

Martin Stanley (MS) Head of Acute NHS Halton CCG Karen Hampson (KH) Commissioning Manager NHS Halton CCG

Apologies: Paul Cooke (PC) Healthwatch Representative Halton Healthwatch

Bertha Brown (BB) Local Pharmaceutical Committee Representative

Local Pharmaceutical Committee

Councillor Marie Wright Portfolio Holder – Health & Wellbeing Halton Borough Council Lucy Reid Head of Medicines Management NHS Halton CCG Rose Gorman Senior Commissioning Manager NHS England Eileen O’Meara (EO) Director of Public Health Halton Borough Council Councillor Marie Wright Portfolio Holder – Health & Wellbeing Halton Borough Council Dr David Lyon CCG Chair NHS Halton CCG


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1. Welcome, Introductions, Declarations and Apologies Introductions were made and the Chair welcomed all present to the meeting. Apologies were noted as per table above. GOH declared an interest in Item 5 as a Board Member of GPHC. 2. Minutes and Action Log 14 September 2017 (PCCC 06-17) The minutes of the meeting held on 14 September 2017 were agreed as a correct record. Action Log: Performance Dashboard (PCC16-17) – It was noted that this would be taken to PPG+ prior to consideration by PPGs. With this addition the action could be closed. Annual Complaints Report (PCC19-17) – LT and MC had advised members that NHSE was not sending the CCG complaint details routinely. NHSE had replied that this was due to the number of CCGs that it covered and a lack of resources. Potentially it could report a quarterly basis. It was agreed that the Primary Care Group would be best placed to receive in the first instance and the Committee following this. Action to remain open with a further update to be provided in January 2018. SJG confirmed that there was nothing currently to report from the Winter Flu Group. When a CCG decision was required this would be taken to an Urgent Issues Committee. The Committee ratified the minutes of 14 September 2017. 3. Finance Update (PCC30-17)

PB provided an update on the latest financial position based on information at September 2017. This included a full year forecast outturn against the delegated primary care allocation plus additional investment made by the CCG to support Local Enhanced Services. The CCG had received a primary care allocation of £17,943k to support the commissioning of primary care medical services during 2017/18. This equates to £137.00 per patient. Above the primary care allocation received for 2017/18, the CCG had made additional funds available which enabled the commissioning of Local Enhanced Services. In addition two allocations had been received to support plans outlined in the GP Forward View. These allocations were for the delivery of Wi-Fi access in GP practices and to provide signposting and clinical correspondence training. Members discussed allocations and the accuracy of list sizes as the report had advised of an overspend of £115k on PMS. PB confirmed that he had seen similar in the two other CCGs that he supported and had approached PCSE for further information relating to list sizes. The general

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feeling was the data was correct but just for extra assurance PB had contacted practices in these areas for their list sizes for comparison. This exercise had shown that the two data sets matched. Once PB received the Halton information from PCSE he would investigate further. SV suggested that information could also be sourced from the HIS and Practice Managers for comparison. It was currently projected that the primary care allocation would achieve a breakeven position in 2017/18. There remained a number of key risks which may potentially impact on the current forecasts. These were highlighted in appendix 2 of the report. QOF – the total financial QOF achievement for 2016/17 was £128k greater than the provision included in the annual accounts due to a national problem with the CQRS (Calculating Quality Reporting Service) system. The CCG had applied to NHSE for financial support to mitigate this risk but the request had been rejected. Locum costs – the CCG reimbursed GP practices that incurred locum costs due to adoption, maternity, paternity and sickness leave. The current budget was £70k. There was a risk that this would be insufficient to support locum costs in 2017/18. To mitigate the risks, and to identify future costs at the earliest opportunity, the CCG now managed the application process for all locum claims. This had previously been the responsibility of NHSE. Premises - Current Market Rents (CMRs) were reviewed every 3 years by the District Valuation Office. Any increase to the valuation was risk to the CCG. To mitigate risk an estimate of potential funding arrears was included in the 2016/17 accounts. However, there still remained a risk that the actual valuation is greater than the estimate. On positive notes a central contract had been agreed with NHSE for waste service for Cheshire and Merseyside. For Halton the projected saving was £35k and would be included in future finance update reports to the Committee. Halton Borough Council was conducting a business rates review and this would potentially result in a re-imbursement to the CCG. Members discussed the report and noted the risks, mitigation and QIPP target. PB made members aware that, based on current projections, it will be necessary to make use of the primary care reserve to achieve a balanced position. LT therefore confirmed the importance of being vigilant across all areas to try to identify and potential savings. The Committee received and discussed the report. 4. Zero Tolerance Scheme (not numbered)

SV reminded members that a number of options to secure a new provider for the Zero Tolerance Scheme were discussed by the Committee on 14 September 2017. The paper provided an update on progress. Members had agreed that the current service specification and contract value should be reviewed and re-issued to local practices as an expression of interest. Subsequently the CCG had informed PCSE that it did not have a provider for the scheme and had sent a further request for expressions

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of interest to practices. This informed them that a review of the contract value was being undertaken and inviting them to discuss their financial requirements. No expressions of interest were received. Due to the tight timescales and the knowledge that no local practice was interested in taking on the scheme, the decision was taken to undertake a procurement of an APMS provider (option 3 of options appraisal) across Cheshire and Merseyside. No responses to this were received. As the procurement process had failed to produce an interested party the CCG was now free to approach providers. The CCG has contacted East Cheshire who run its service through its GP Federation. The model offered a telephone booking service where a patient was offered an appointment at an agreed location. SV proposed this model could be replicated in Halton with the service located in the UCC. SV confirmed that the CCG was free to discuss requirements with any potential providers, including Federations, and further details would be reported to the Committee when appropriate. The Committee noted the update and agreed the continuation of the process. 5. Federation Support (PCC31-17)

Prior to discussion on this item GOH declared an interest as a board member of GP Health Connect. SV report provided background to NHS Halton CCG’s approach to expanding GP provision following on from the requirements of the 2016/17 Prime Minsters Challenge Fund (re-branded as the GP Access Fund). The model adopted in Halton was for the two federations to offer additional weekday evening and weekend GP appointments. The scheme for Widnes practices became operational in 2016 and it had been hoped that the Runcorn service would be operational prior to the end of the 2016/17 financial year; however estates development work and CQC registration delayed the start date to April 2017. As the service was not fully operational this resulted in an underspend of £80,000 against the 2016/17 GP Access Fund budget. This purpose of this paper therefore was to outline a proposal and seek approval on re-investing the 2016/17 GP Access Fund underspend of £80,000. This funding sat outside of PMS and was ring-fenced for re-investment. The proposals had been put forward by the Federations as follows: • Strategic developments - Investment required of £28K. It is proposed to combine this with the

£25k secured from NHS England via the GP Resilience Fund. • Clinical development - Investment required of £32K • Business development - Investment required of £20K The report listed a number of considerations for members including that the re-investment need s

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to demonstrate an improvement in GP access. .. Members were asked to note that funding to practices was only paid for seeing patients. If the CCG wanted practices to help develop new models of care which includes engaging in the development of the GP Federation, then reimbursement for clinical time would be required. Members agreed that it was imperative to use the money for the purposes it was designed for. DS asked if it was possible to draw up plans this year and implement in the following. However, the funding was for 2015/16 so it was unlikely that the CCG would be allowed to carry over for a further year. In addition to this, if clinicians were not funded they would be unable to leave practice for collaborative work and then none of the transformational work could begin until April 2018. MC advised that although the report provided a level of detail into how the money would be spent, the CCG needed to see the project plans to show the return on the investment. GOH suggested that the Federation Managers be invited to the next Committee meeting and present the project plans. The Committee • agreed that the £80k be invested in Primary Care in Halton • agreed to the high level proposals as listed in the report • requested that the detailed progress plan be presented to members in January 2018 ACTION: SV and GOH to invite the Federation Managers be invited to the next Committee meeting to present the project plans, and develop an appropriate payment schedule to ensure appropriate and timely release of funding 6. GP Extra Progress Report (PCC32-17)

KH confirmed that the two Halton GP Extra sites were up and running and that NHSE had set out 7 core requirements in order to secure future funding for these. The 7 requirements and areas of compliance by the CCG were detailed in the report but members specifically discussed Commissioned weekday provision in evenings (after 6:30pm) – to provide an additional 1.5 hours a days and weekend provision of access to pre-bookable and same day appointments. The CCG had to provide robust evidence, based on utilisation rates, for the proposed disposition of services throughout the week. The data indicated that the weekend bookable appointments were not well used but the reason for this was yet to be determined and if so it was too early to say if the capacity needed to be moved to weekdays. There was a possibility that the issue could be one of promotion. DS suggested using digital marketing methods to promote the service better. Members discussed the potential use of this extra weekend capacity in the UCCs considering the expected winter pressures on the service. However, this was currently discounted as NHSE provided the funding for pre-bookable appointments. There was an issue to address going forward

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due to expense in covering these ‘slots’ that were not being used. KH agreed that there was work required in signposting patients to using the right service with SV adding that once NHS111 are able to book patients direct into GP Extra, utilisation may improve. It was hoped that this would be in place for the winter period. All other core requirements were taken as read. IF asked if the CCG did not hit the targets as listed would this affect funding? SV confirmed that as a lead CCG for this work with the majority of core requirements already in place, it is unlikely that funding would be affected. The Committee discussed and noted the report. 7. Halton Enhanced Scheme Progress Report (PCC33-17)

The report highlighted to the committee the progress and outcomes to date of implementing the Halton Enhanced Scheme (HES) in 2017/18. IF summarised the report identifying one outlier practice in Halton. The Committee was being asked to authorise that the Primary Care Group be responsible for making payments to the practices for providing HES services. SV advised that in addition to this the Committee had previously asked for information on the outcomes of the HES and how these would be reported to members. The paper provided this. SV confirmed that there was one practice that was not engaging and potentially the CCG would hold back payment on this basis. The report also highlighted that funding for next year’s scheme had not been agreed and SV needed to know if this would be provided in order to start building the scheme. On this final point the Committee requested that SV present a report to Performance and Finance Committee and then to Governing Body. DS confirmed that this would need to be on the basis of an ‘invest to save scheme’. LT agreed that it needed to show the CCG commitment to investment into Primary Care. SV asked for comments on outcomes from this year as it would help to feed into next year’s scheme. It was noted that it was difficult to demonstrate the positive affects the investment had provided in primary care and if it had reduced activity in secondary care, but support was given without this data. In terms of the payments to the practice MC, LT and SV would discuss outside of the meeting. The Committee: • noted the progress to date on implementing the Halton Enhanced Scheme • noted the outcomes of each area of the scheme to date • agreed that MC, LT and SV discuss outside of the meeting, how practice achievements and

payments would be managed

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• requested that SV present a report to the Performance and Finance Committee and Governing Body outlining the request for funding of the Halton Enhanced scheme for 2018/19.

8. Estates, Technology and Transformation Fund Update (PCC34-17)

The paper provided Members with an update on the progress to date on Estates and Technology Transformation Fund (ETTF) projects. DS asked if there were timescales for when we would be EMIS live. LT advised that she had been advised that this was likely to be mid-2018 and DS requested that Emma Alcock, Transformational Change Manager, provided timescales and set a target for implementation with the next update. The Committee noted the update. 9. Referral Management System (no number)

The purpose of the paper was to provide an update on the utilisation of the Referral Management System (RMS) within Halton and also considerations for the Committee in relation to wider CCG priorities and financial constraints. Nationally, paper based referrals would be switched off by the end of February 2018. MS advised that since implementation of the system the CCG had seen improved rates. With respect to this the system had been successful but NHSE wanted RMS systems to further reduce demand management. To achieve this there was a requirement to have a clinical triage element. NHS Halton CCG had taken a decision not to implement this as there was little opportunity for demand to be moved into the community and each referral would cost an additional £5. This would total an additional cost to the CCG of approximately £500k without any guarantee of delivering changes. The issue had been discussed at the Clinical Advisory Group and members recommended that the CCG stopped using RMS and moved to ERS. This would also provide an Advice and Guidance programme that would reduce referrals. MS also confirmed that ERS would offer clinical triage. The contract with the CSU expired in January 2018 so if members supported RMS switch-off then a decision was required quickly. There would be a demonstration of the ERS system by Dr David Wilson (Clinical Lead, Primary Care Informatics) at the next PLT and further training would be provided to practice staff. The Committee: • Recommended to the Urgent Issues Committee that the RMS contract was not renewed in

January 2018. It was noted that there could be a requirement to negotiate a short extension to the current contract leading to the move to ERS

• Requested LT to contact NHS England to advise of the decision • Requested that MS add a risk to the Risk Register relating to the transfer from RMS to ERS.

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10. Primary Care Group Notes (PCC35-17)

SV confirmed that since the last Primary Care Commissioning Committee meeting the GP Development Group had met. A copy of the minutes for this meeting was provided for information. The Committee received the notes. 11. Corporate Risk Register (PCC36-17)

Members noted the risks as updated. Risks descriptions were discussed for 374 and 378 and it was agreed that these were very generic. MC confirmed that outside of the meeting she SV and Sarah Balogh (SB), Risk Manager, would meet up to discuss. LT confirmed that this was the case for all Committees’ risks. The Committee • Discussed the risk register • Requested that SB organise a meeting to discuss Committee risks with MC and SV. Any Other Business

IF advised members that in July 2017, NHSE issued new guidance in respect of the management of conflicts of interest which in particular included a provision dealing with decision making when a conflict arises relating to primary medical care. The guidance makes explicit reference to the arrangements relating to delegated commissioning. The guidance stipulated that a standing invitation would be made to the CCG’s local Healthwatch and Health and Wellbeing Board to appoint representatives to attend joint commissioning committee meetings but that these representatives would not form part of the membership of the committee. The CCG valued the input from the Health and Wellbeing Board member to the Committee and was currently looking to change the timings of the meeting to allow attendance by the representative. Further information would be shared with members as soon as possible. SJG provided an update from the flu group. Members were advised that the vaccination on 2 and 3 year olds was the responsibility of Primary Care and in previous years Halton had missed the target for this target group. Feedback indicated that parents found it difficult to attend appointments. She advised members that discussions had taken place with a number of local nurseries to vaccinate children whilst in day care. Once the child had been vaccinated the GP practice would then receive payment.

9


The overall cost to the CCG would be £1600 and of this £900 would go to practices. Members discussed the difficulty in the CCG clawing the funding from each individual practice. SV also asked how the effectiveness of the programme would be measured as a number of the children would normally be vaccinated in practice. MC, SV and SJG agreed to discuss the issue further outside of the meeting. Date and time of next meeting: Thursday, 11 January 2018, 10.00am

10



Action Log

9 November 2017

Item Reference Action Responsible

Officer

Date Due Status/Update

13/07/2017 Annual Complaints Report (PCC19-17)

LT to consider a way in which practice complaints could be fed into the Committee. Updated Action 9/11/17. Primary Care Group would receive in the first instance and the Committee following this.

Leigh Thomson January 2018

On agenda

9/11/17 Federation Support (PCC31-17)

SV and GOH to invite the Federation Managers be invited to the next Committee meeting to present the project plans, and develop an appropriate payment schedule to ensure appropriate and timely release of funding

Sarah Vickers Gary O’Hare

January 2018

On agenda

Committee Reporting

1

PRIMARY CARE COMMISSIONING COMMITTEE Date: 11 January 2018

Report title: Procuring a Special Allocation (Zero Tolerance) Scheme in Halton

Lead Clinician and/or Lead Manager: Sarah Vickers, Head of Primary Care Julie Holmes, Commissioning Manager

Purpose: To agree the most appropriate way to procure the Special Allocation (Zero Tolerance) Scheme in Halton.

The Group is asked to:

• Review contents of paper. • Agree the proposal to appoint PDS

(Medical) Ltd as the provider of the Zero Tolerance Scheme in Halton.

• Agree the proposal to commission the CSU to provide a pre-registration screening service.

This Report supports the following CCG Strategic Objectives One: To commission services which continually improve the health and wellbeing of Halton residents. Three: To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations. Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Commissioning Plan Implications This is a Directed Enhanced Service; therefore the CCG must establish and operate a Zero Tolerance Scheme for its local population. Financial Implications Does this require financial support? Yes If Yes - Is there currently a budget for this? Yes, although extra resource may be required. Board Assurance Framework and Corporate Risk Register Does this report link to either the Board Assurance Framework (BAF) or Corporate Risk Register (CRR) or both? Yes If Yes - please state:

• Added to risk register – number tbc.

• state level of assurance this paper provides - High National Policy, Guidance, Standards, Targets or Legislation 2017 18 DES Directions

http://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/GMS/2017%2018%20DES%20Directions.pdf

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Equality and Diversity and Human Rights Throughout the development of this paper and the policies and processes cited NHS Halton CCG has:



1. Introduction and Background

(To note and for information only: Other terminology previously used in relation to special allocations of this type have included, Violent Patient Scheme (VPS) or Zero Tolerance Scheme (ZT S). Following the publication of NHSE’s Primary Medical Care Policy Manual in November 2017, the scheme is now referred to as the Special Allocation Scheme (SAS)).

The SAS is a national scheme introduced in 2004 with the aim of providing a secure environment in which to accommodate patients who have exhibited challenging and sometimes violent behaviour when visiting their GP Practice. The scheme offers an alternative environment where patients can receive general medical services. As a delegated commissioner of primary medical services NHS Halton CCG is required to commission a SAS as part of its duty in ensuring all Halton residents can access primary medical care. Halton CCG currently does not have a SAS provider. An early engagement opportunity exercise undertaken on Contracts Finder in late October demonstrated that there was no interest in bidding for this scheme. At the November Primary Care Commissioning Committee meeting it was therefore agreed that the CCG would enter into direct negotiations with potential providers.

2. Potential Providers In November 2017 temporary placements for two new SAS patients were required to be sought at short notice. Subsequently two current providers of the SAS scheme were approached to see if they would be interested in taking on the patients on a temporary basis – a general practice in Warrington and PDS (Medical) Ltd in Lancashire. Both did agree to see the patients; however one patient no longer needed to go onto the scheme (at least temporarily) and the practice where the other patient was registered agreed to keep the patient until a permanent provider could be secured. During negotiations both providers expressed an interest in providing the scheme on a longer term basis. The Warrington practice stipulated that patients would have to travel to Warrington, which would potentially incur taxi expenses and be less convenient for patients. PDS Medical stated they would see patients in Halton. Taking this and the fact that commissioning another practice may not offer long term sustainability, it was decided to approach PDS Medical. Discussions were also held with Halton’s two Federations who

Committee Reporting

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agreed that approaching an existing provider was the most sensible option; however remain committed to supporting the provision of this service if an alternative provider cannot be secured. A meeting was subsequently held with PDS Medical, when they expressed a willingness to take on the contract.

3. PDS (Medical) Ltd PDS Medical was founded in 2004 and in 2015 became a subsidiary FCMS (NW) Ltd, a ‘not for profit’ social enterprise providing health and wellbeing services across Lancashire and Cumbria. FCMS is made up of 33 Fylde Coast GP members and owns 35% of the shares of PDS Medical, with the remainder being owned by individual shareholders. Between them they provide both urgent and planned care, call handling and dental services. In mid-2017 PDS Medical was awarded a five year, APMS contract with Lancashire and Greater Manchester NHSE (Preston office) to provide a SAS on behalf of six CCG’s across Lancashire and Cumbria. The CCG’s took the decision to jointly commission an external provider as they were concerned about the long term sustainability of the service being delivered by individual GP practices. (This approach was recently suggested at a meeting of primary care leads in Cheshire and Merseyside where the group expressed interest in hearing about our experience of working with a regional provider.) The service is commissioned to see up to 120 patients. They currently have 94 patients registered, 66 of whom are actively being seen. Their ethos is to build good relationships with patients based on mutual respect and to ‘repatriate’ patients back into mainstream primary care as soon as appropriate. 3.1 Service Delivery Model PDS Medical proposes to use the same model of service delivery in Halton as it does in Lancashire and Cumbria. This reflects the model that was already being developed in Halton. This means they could commence service delivery in early 2018. A summary of the model is outlined below:

• Main focus is to provide a virtual GP service as far as possible, with the option of face to face appointments.

• Telephone lines are open Monday-Friday, 8.00am to 6.30 pm. They are manned by two highly trained receptionists.

• Face to face appointments available on a regular basis and usually within 7 days. • Venues are pre-booked on a regular basis and at a regular time. • Patients have to travel to their appointment at their own cost, but no further than 10

miles. • Security is arranged for every appointment. • Consultations are provided by local GP’s from Lancashire and they currently have

good access to doctors. However, PDS Medical would be keen to recruit local Halton GP’s. In their experience patients do not identify with the GP’s own practice, but with PDS Medical.

• Patients have access to the same range of general medical services as any other patient, including screening, vaccinations and annual reviews.

• The clinical system used is EMIS and records of all consultations are recorded directly onto the patient’s notes via mobile devices, where applicable.

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• A key focus is to ensure patients receive their medication on time as they understand this is a main concern for many patients.

• Patients that need to be seen urgently are referred to either A&E or walk-in centres as appropriate.

• Patient information is shared with other providers as appropriate. • The service works within local referral pathways and builds links to local services.

3.2 Registration Process All potential SAS patients are initially reviewed by the Midlands and Lancashire CSU’s security team, who risk assess the patients to determine if they are eligible for the scheme. If they are deemed to be ineligible, a meeting can be arranged with the de-registering practice to discuss the outcome. The review process takes an average of 7-10 days. This can be reduced to 2-3 days for urgent cases. Once the patient is accepted onto the scheme (initially for six months) they receive a standard letter from NHSE and a ‘welcoming’ letter from PDS Medical. This clearly explains what has happened, how the patient books appointments/telephone calls and outlines ground rules and expectations regarding behaviour etc. Patients are then triaged by a GP by phone (or Skype if possible). Triage calls are undertaken by the GP Directors of the company. 3.3 Review Process Patients are reviewed every six months by a multi-disciplinary team, including the police and other services as appropriate. Patients do not attend this meeting. 3.4 Issues The main issue experienced so far is securing suitable venues. They are currently looking into using Community Pharmacies as a lot have consulting rooms and are already used to dealing with these kinds of patients. However, we do not expect this to be an issue in Halton as it is proposed to utilise the two Urgent Care Centres. Both Centres have been approached and to date one has responded to say they are willing and able to help. They have also experienced problems with some referrals being refused as patients are deemed to be out of area, e.g. the service address is Blackpool and a Blackpool practice might be rejected by a local Trust without NHSE and CCG support. NHSE has been requested to support raising awareness of PDS Medical amongst a range of providers.

4. Costs

4.1 Contract Value PDS Medical has indicated they could provide the service for £4000 per patient per year.

This would be an all-inclusive cost (IT, Security, buildings etc.), and would include prescribing too. They have stipulated one condition precedent that they would need to be paid for a minimum of four patients per year, whether there were four patients on the scheme or not. The monthly charge to Halton would be £1333 until such a point that that there were more than four people registered and then it would increase by £333 per patient per month.

Committee Reporting

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PDS Medical have indicated that if they can secure more SAS services in Cheshire and Mersey (or anywhere that is more local to the Halton area), they would look at reviewing this condition, with the intention to remove it as they would be able to spread some static costs across services. This is the same value as the contract with NHSE Lancashire and Greater Manchester i.e. a block contract based on £4000 per patient per year. As anticipated this is significantly higher than the previous contract value of £3,000 per annum, excluding security (plus up to £5000 for security changes to a building’s infrastructure). However, based on 12 months activity data for 16/171, £16,000 p.a. (i.e. 4 patients at £4000 each) equates to £302 per consultation. This compares favourably to an estimated cost of £379 per consultation (based on £772 for half hour GP time; £1793 for security; £1234 administration). This excludes room hire and prescribing costs. There are currently two patients on the scheme, with the potential for two more. 4.2 Pre-registration Screening As described in 3.2 above the contract with NHSE includes a pre-registration screening process to assess patient’s eligibility to be put on the scheme. This is delivered at an extra cost by the Midlands and Lancashire CSU. PDS Medical have indicated that they would be willing to work without this process, however it is good practice as in their experience it helps to keep numbers to a minimum, as a number of patients have already been rejected. The potential cost of the CSU delivering this service for Halton is being sought. 4.3 IT It is not anticipated that there will be any set up costs for IT. PDS Medical will pay all ongoing IT costs within their contract.

5. Contracting The contract with Halton would be relatively small so the possibility of contracting via a SLA and letter of intent is being considered. Discussions will also be held with NHSE regarding the possibility of contracting across a wider, Cheshire and Merseyside, footprint.

6. 6.1 Advantages

• Long term sustainability assured. This is especially important as experience has demonstrated that the options to commission the scheme are very limited.

• Patients can still be seen close to home. • Patients will still have access to a full range of general medical services. • Patients will benefit from a service being delivered by highly trained and motivated

individuals. • Service delivery can commence almost immediately. • Local GP’s will have the opportunity to deliver consultations.

1 There were 53 face to face and telephone consultations during 2016/17. 2 Based on figures from the National Audit Office 2017. 3 Actual current cost of Select Security per consultation. 4 Based on 0.25 WTE mid-point Band 4 Administration Staff.

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• The CCG will be fulfilling its statutory duty to provide a SAS scheme. • The burden of service delivery will be relieved from local practices.

6.2 Disadvantages

• Higher contact value. • Local primary care funding will be going out of the area.

7. Recommendations The Committee is asked to consider the following recommendations.

• That PDS (Medical) Ltd is appointed as the provider of the SAS scheme in Halton for a period of up to 5 years, in line with their current contract with NHSE.

• That the CSU is contracted to provide a pre-registration screening service.

Committee Reporting

1

PRIMARY CARE COMMISSIONING COMMITTEE Date: 11th January 2018

Report title: 2018/19 Halton Enhanced Scheme

Lead Clinician and/or Lead Manager: Sarah Vickers, Head of Primary Care Gary O’Hare, GP Clinical Lead

Purpose: To outline to the committee the plans for the 2018/19 Halton Enhanced Scheme

The Committee is asked to:

• Note the draft outline of the Halton Enhanced scheme for 2018/19,

• Make recommendations for improvement in preparation for final approval of the scheme in March 2018.

• Consider how the scheme could support the strategic development of the Accountable Care System and neighbourhoods.

This Report supports the following CCG Strategic Objectives One: To commission services which continually improve the health and wellbeing of Halton residents. Three: To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations. Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Commissioning Plan Implications This report supports the Primary Care Commissioning Plan and wider pathway development work. Financial Implications Does this require financial support? Yes If Yes - Is there currently a budget for this? Yes – the Halton Enhanced Scheme brings together the Personal Medical Services re-aligned delegated primary care budget and additional funding from the CCG budget. Board Assurance Framework and Corporate Risk Register Does this report link to either the Board Assurance Framework (BAF) or Corporate Risk Register (CRR) or both? No

Committee Reporting

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If Yes - please state:


• state level of assurance this paper provides National Policy, Guidance, Standards, Targets or Legislation The GP Forward View https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf Equality and Diversity and Human Rights Throughout the development of this paper and the policies and processes cited NHS Halton CCG has:



1.0 Introduction and Background

1.1 The Halton Enhanced Scheme was developed with Member Practices throughout

2016 – 2017 in response to the national review of Personal Medical Services (PMS) and GP Forward View requirements. The scheme provides the overarching structure to support and encourage collaborative working, and the implementation of sustainability and transformation programmes relating to both General Practice and wider health economy agendas.

1.2 During 2017/18 The Halton Enhanced Scheme brought together two funding streams – the PMS Premium from the delegated Primary Care Budget and an additional £5 per registered patient investment from the wider CCG budget. This additional £5 per registered patient includes the investment required of CCGs as detailed in the GP Forward View, which locally was agreed as £1:50 in 2017/18 and £1:50 in 2018/19. 1.3 The total value of the PMS premium during 2017/18, which was year 2 of the four

year distribution period, was £874,076 with £437,038 (half of the total premium) being available for redistribution across all practices. During 2017/18 the PMS premium funded the following schemes:

• ECG enhanced service • Spirometry enhanced service • Ambulatory BP Monitoring / Home BP monitoring as detailed in NICE • Completion of a Clinical Audit based on NICE Guidelines

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

Committee Reporting

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• Review of Practice Safeguarding processes for vulnerable people

The total value of the additional CCG investment was £652,650 which funded the following two schemes:

• Bi-monthly Quality Referral meetings • Bi-monthly GP Development meetings

1.4 The Primary Care Commissioning Committee at its meeting of 9th November received a progress report on the 2017/18 scheme which described the on-going work which will continue until 31st March 2018.

2.0 2018/19 Halton Enhanced Scheme Budget

Delegated Primary Care Budget – PMS Premium 2.1 The Primary Care Accountant has prepared draft contract values and the potential PMS redistribution value for 2018/19, which is year 3 of the PMS redistribution process. 2.2 These draft figures are based on practice populations at 1st October 2017 and the 2017/18 General Medical Services (GMS) value until the 2018/19 value and uplift requirements are announced nationally. However this will give commissioners and providers an initial view of the impact of year 3 PMS redistribution i.e. the amount to be received as core contract and the amount available to be redistributed and re-invested back into General Practice. As it is expected that the value of GMS will increase this is likely to mean that that the amount to be received as core contract will be greater than modelled, leaving a smaller amount to be re-invested as a local incentive scheme. 2.3 A further caveat is that as we enter year 3 of the PMS distribution period it may now be more financially viable for a practice to convert to GMS, and all PMS practices retain the right to convert to GMS if they so choose. If this occurs further financial modelling will be required to understand the impact on the amount available to be re-invested as a local incentive scheme. It would be helpful to start to understand with practices if converting to GMS is a potential option for 2018/19, however this may be difficult to understand until the 2018/19 GMS value is announced. 2.4 Final 2018/19 contract payments will also need to be based on practice populations at 1st April 2018. 2.5 Based on the current information the year 3 PMS premium available for reinvestment into General Practice is £669,241.

Committee Reporting

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Additional CCG Investment 2.6 The CCG is required to invest £1.50 in 2018/19 as part of the 2017/18 National Planning Guidance and GP Forward View requirements. Using practice populations at 1st October 2017 this equates to an additional £196,266 of investment. 2.7 Agreement is to be sought as to whether the CCG can continue to invest the reaming £3:50 in 2018/19, at a value of £457,954. It is hoped that by developing a robust scheme which supports the strategic direction and QiPP agenda that the additional £3.50 may be secured.

3.0 Proposed Scheme Content 3.1 The Primary Care Group of the 13th December 2017 and GP Development Group of the 14th December reflected on the 2017/18 scheme and recommended potential areas for inclusion in the 2018/19 scheme:

Spirometry, BP and ECG Local Enhanced Service: activity data has been collected quarterly to establish a baseline. Ongoing work is required to ensure data quality is improved in Quarter 3. The criteria for monitoring also need greater clarity to ensure consistency. Agreed should continue with clearer criteria and improved monitoring.

Clinical Audit: discussed potential to use PRIMIS to undertake searches to support other Long Term Condition areas such as COPD. Undertaking a clinical correspondence audit was suggested to support the emerging work around workflow management. Agreed to continue with the clinical correspondence audit.

Safeguarding Meetings: There have been difficulties in securing meeting dates. When meetings have been held they were well attended therefore inclusion in the scheme has promoted engagement, however benefits to remaining in the scheme are not clear. Agreed to remove from scheme. Quality Referral Meetings: Support to continue clinically focused meeting with consultants in attendance. Recognise that pathway development work takes time therefore may not see immediate benefits. Suggestion that rather than reviewing large amounts of data, each meeting could focus on one particular issue, with practices bringing along a case study, e.g. Haematology or Mental Health. Practices agree need to understand hospital services and the variation between trusts. Agreed should still be separate Widnes/Runcorn meetings. Agreed should continue with some amendments.

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GP Development Meetings: there is generally good attendance at these meetings. It was agreed to expand focus from GP Forward View to include practice issues. It was suggested that every third meeting could be a neighbourhood meeting. Need to ensure congruence with Federation work. Agreed to continue with an expanded focus.

3.2 In order to support the strategic direction regarding the development of the Accountable Care System a new area of work is proposed focused on groups of practices working together within their neighbourhoods.

At the October 2017 GP Development Group the new Hub arrangements were agreed, based on populations of 30,000-50,000 patients. The proposed neighbourhoods are:

Widnes Neighbourhood 1: Widnes Neighbourhood 2: Appleton Village Surgery Bevan Group Practice Beeches Medical Centre Newtown Health Care Centre Hough Green Health Park Upton Rocks Primary Care Peelhouse Medical Plaza Oaks Place Surgery

Runcorn Neighbourhood 1: Runcorn Neighbourhood 2: Brookvale Practice Grove House Partnership Weaver Vale Practice Tower House Practice Castlefields Health Centre Murdishaw Health Centre

3.3 There is potential for the Halton Enhanced Scheme to continue this work on neighbourhood development. For example it could include work on improving how community teams and practices work better together. Each neighbourhood could look to identify an area for improvement or development. Further discussion is required on defining how this work would develop, link to ACS development, and be congruent with GP Federation plans, whilst also understanding resource requirements. However it is important to consider this opportunity to drive forward the next steps regarding neighbourhood development.

3.4 The Primary Care Commissioning Committee is asked to:

• Note the draft outline of the Halton Enhanced scheme for 2018/19 • Make recommendations for improvement in preparation for final

approval of the scheme in March 2018. • Consider how the scheme could support the on-going development of

the ACS and neighbourhoods.

Committee Reporting

1

PRIMARY CARE COMMISSIONING COMMITTEE Date: 11 January 2018

Report title: NHSE Complaints Data

Lead Clinician and/or Lead Manager: Sarah Vickers, Head of Primary Care Julie Holmes, Commissioning Manager

Purpose: To update the PCCC on practice complaints data received by NHSE

The Group is asked to: • Note contents of paper.

This Report supports the following CCG Strategic Objectives One: To commission services which continually improve the health and wellbeing of Halton residents. Three: To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations. Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Commissioning Plan Implications Financial Implications Does this require financial support? No If Yes - Is there currently a budget for this? Board Assurance Framework and Corporate Risk Register Does this report link to either the Board Assurance Framework (BAF) or Corporate Risk Register (CRR) or both? No If Yes - please state:

• Added to risk register

• state level of assurance this paper provides National Policy, Guidance, Standards, Targets or Legislation Equality and Diversity and Human Rights Throughout the development of this paper and the policies and processes cited NHS Halton CCG has:


• Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this

Committee Reporting

2

might reduce health inequalities.

1. Introduction

Further to a request from Primary Care Commissioning Committee this paper provides an overview of the complaints submitted to NHSE by patients, about GP practices between May 2015 and September 2017. Once the complaints are received they are recorded and grouped into themes. They are then investigated by the NHSE complaints team and the outcome documented.

2. Review of Complaints Data During the 30 month period a total of 35 (Table 1) complaints were received involving 13 GP practices. Table 1: Number of complaints received by year Year Number of Complaints Received 2015/16 14 2016/17 13 2017/18 (until September 2017) 8 2.1 Themes and Outcomes

Figure 1 shows that nearly half of the complaints were regarding clinical care, followed by access, prescriptions and removals, staff attitude, communications and a confidentiality breach.

Of the 16 complaints received about clinical care, three related to delays in cancer diagnosis. All three complaints, from different practices, were upheld, two with recommendations. A further three complaints were in relation to care received prior to a patient’s death. Again these were regarding different practices. One was partially upheld with recommendations, one was already being managed by the

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16 2 1

4

4

3

Figure 1: Complaint Themes

Access

Clinical Care

Communication

Confidentiality Breach

Dispensing Error/Prescriptions

Removal from practice list

Staff Attitude

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provider and the third was awaiting the medical records from the provider. The remaining 10 were unrelated complaints about quality of care ranging from burns suffered from removing a skin tag to the GP withdrawing medication. There was no theme regarding the five complaints received about access and only one was in relation to the practice’s appointment system. Three of the complaints were either fully or partially upheld, but none with any recommendations. Of the four complaints about removals, two were in relation to being removed under the Zero Tolerance scheme. Two of the complaints received about staff attitude concerned named GP’s, one of which was partially upheld with recommendations. Only one of the complaints about prescriptions related to dispensing errors, but was not upheld. Figure 2 shows that in general, nearly half of all complaints (16) were either sent to the provider to resolve locally or were already being managed by the provider. An equal number of complaints (nine) were either not upheld or partially or fully upheld. Of the nine upheld six contained recommendations. One complaint is still outstanding.

. 2.2 Practices

Thirteen practices received complaints during the period (Figure 3). Castlefields received the most complaints at eight (0.06% of practice population). It should be noted that Castlefields is one of the larger practices and was the provider of the Zero Tolerance scheme until September 2017. Only two of the complaints received were upheld partially (one with recommendations). The remainder were either not upheld or were being managed by the practice. Upton Rocks received the second highest number at five (0.14% of practice population). One of the complaints was upheld with recommendations, one was not upheld and the remaining three were being managed by the provider.

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9

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9

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3 1

Figure 2: Complaint Outcomes

Already being managed byproviderNot upheld

Partially upheld norecommendationsPartially upheld withrecommendationsSent to provider to resolve locally

Upheld no recommendations

Upheld with recommendations

Outstanding

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Two of the three complaints received by Murdishaw were in relation to patients being deregistered under the Zero Tolerance scheme. Otherwise there was no pattern or theme in the complaints received by practices. Similarly there were no key themes by practice relating to the outcomes of complaints (Figure 4).

3. Summary The number of complaints received by NHSE over the 30 month period only represented approximately 0.03% of the total registered population. Two practices did not receive any complaints – Appleton and Tower House. Although the majority of practices did receive one or more complaints, there was no obvious theme by practice in terms of the nature of the complaint(s) and the outcome(s). Overall there were no key themes in the type of complaints received, although three of the 35 complaints were in relation to delays in cancer diagnosis, and a further three related to care received prior to a patient’s death. Only a quarter of complaints were either fully or partially upheld, with another quarter not being upheld.

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Figure 3: Number of complaints received by practice

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Figure 4: Outcomes of Complaints by Practice

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Fully or partially upheld

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NHS England

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Cheshire and Merseyside Application

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Contents

1. Executive Summary ...................................................................................................................... 3

2. Introduction ................................................................................................................................... 5

3. The Local Picture .......................................................................................................................... 7

4. Workforce ..................................................................................................................................... 8

5. GP Federations ............................................................................................................................. 8

6. Vanguard Sites ............................................................................................................................. 9

7. Practice Vacancies and Evidence of Need .................................................................................... 9

8. Engagement with Practices for the Programme .......................................................................... 10

9. Living and Working in Cheshire and Merseyside ......................................................................... 11

10. Cheshire ..................................................................................................................................... 12

11. Merseyside ................................................................................................................................. 12

12. Transport .................................................................................................................................... 13

13. Retention of Internationally Recruited GPs ................................................................................. 14

14. Implementation Support .............................................................................................................. 14

15 Clinical Support to Recruited GPs ............................................................................................... 15

16 Pastoral Support to Recruited GPs ............................................................................................. 16

17 Other Measures to Support Integration ....................................................................................... 17

18 Contract Lengths ........................................................................................................................ 18

19 Clawback Measures .................................................................................................................... 19

20 Supporting the existing workforce ............................................................................................... 19

21 Clinical Workforce ....................................................................................................................... 20

22 Clinical Non- Medical Workforce ................................................................................................. 21

23 Wider Workforce ......................................................................................................................... 23

24 At Scale Working ........................................................................................................................ 23

25 Funding ....................................................................................................................................... 25

26 Governance and Assurance ........................................................................................................ 26

27 Conclusion .................................................................................................................................. 27

3

1. Executive Summary 1.1. The Five Year Forward View was published in 2014 and set out the challenges facing the

NHS.

1.2. The Cheshire and Merseyside Sustainability and Transformation Plan (STP) describes how we will come together to address these challenges head on.

1.3. We know that people are living longer, but not always living healthier lives. We know that care is not always joined up for patients in their local community, especially for the frail, elderly and those with complex needs. As a result, we see an over-reliance on acute hospital services that often does not provide the best setting for patients, that there is a need to support children, young people and adults more effectively with their mental health challenges.

1.4. General Practice is recognised as one of the greatest strengths of the NHS, heavily relied upon by the general public for the provision of health and wellbeing services for themselves and their families.

1.5. The GP Forward View published in April 2016 described the challenges facing primary medical care but also provided a focus and a range of commitments to enable general practice to strengthen and transform to continue to deliver high quality care into the future.

1.6. Acknowledging the need for a strong Primary Care foundation, development, investment and support for Primary Care is a theme running through the Cheshire and Merseyside STP.

1.7. Creating a strong and sustainable General Practice is crucial to the delivery of the Sustainability and Transformation Plan to ensure we are able to provide a high quality, patient centered health care for our population.

1.8. The GP Forward View describes how nationally over the last 20 years demand for appointments, alongside increased patient complexity has grown beyond recognition. Conversely the numbers of doctors choosing General Practice as a career path has declined, and extra pressure added to the system occurs from increasing numbers of GPs retiring or leaving the profession early. As a result General Practice is experiencing significant challenges in relation to its existing workforce and succession planning for the future.

1.9. Cheshire and Merseyside are experiencing similar challenges to those seen across the Country, with a declining GP workforce, and an aging and more complex population. In response to these challenges we have developed this application for the International GP Recruitment Scheme in an attempt to secure an additional 122 GP’s by 2020 to complement and enhance our existing workforce.

5

2. Introduction 2.1. This application has been developed by NHS Liverpool Clinical Commissioning Group

(CCG) in partnership with Cheshire and Merseyside (C&M) Clinical Commissioning Groups to participate in the International GP Recruitment Scheme.

2.2. NHS Liverpool CCG together with our partner CCGs recognise the unprecedented challenges facing the NHS to deliver a sustainable primary medical care service. We know that the Health and Social Care landscape is changing, and we need to be able to respond to these changes and transform how primacy care is delivered across Cheshire and Merseyside. To do this we need to establish a strengthened and sustainable general practice across Cheshire and Merseyside.

2.3. Our application seeks to recruit international GPs in order to increase the GP workforce; to enable improved access for patients and ameliorate the workload of the existing clinical staff. The GP Forward View describes how transformation of the current Primary Care workforce will include other health care professionals, for example clinical pharmacists, physician associates, and these groups will form part of our overall workforce strategy. However our workforce modelling identifies that additional GPs are required to deliver the standard of care required for our patients.

2.4. Recognising the demonstrable difficulties with local recruiting and retaining of GPs, the planned retirement of our current GP workforce (approximately 20% of C&M existing GP workforce are aged over 55) and also the anticipated increase in patient population, our application aims to recruit 122 GPs over the next three years as part of the International GP Recruitment programme.

2.5. We believe the benefits of the programme will provide increasing numbers of GPs across the system which in turn will increase levels of access for the whole population, including hard to reach groups and areas with high deprivation and health need. The increased pipeline of GPs will ensure that locally we are proactively positioned to respond to anticipated turnover and population increase, to continue to deliver a high standard of care to our population.

2.6. Our existing GP workforce tell us they are feeling the pressure of the increasing demands from patients particularly those with more complex needs. We are aware there are workforce gaps and other challenges facing us but by working and collaborating with our partners we will make general practice in Cheshire and Merseyside a great place to work.

2.7. We believe that GPs wanting to relocate to Cheshire and Merseyside, with its excellent transport network, will find the ability to live within one area of the footprint but work in another, an attractive proposition, as it will offer opportunities for a more varied work life balance, and the potential for portfolio working.

2.8. The announcement in August 2017 of the expansion of the International GP Recruitment programme, described how it is vital that the work is connected to local practices. Cheshire and Merseyside CCGs have been engaging with practices to promote the programme and its benefits, in particular within those areas where there is a shortage of GPs and Practices are struggling to recruit.

2.9. Cheshire and Merseyside CCGs recognise the value in developing a single application across the STP to fully articulate the challenges currently being experienced in General

6

Practice locally, and to illustrate how we are working together to achieve our ambition to deliver first class primary medical care.

2.10. Cheshire and Merseyside CCGs are fully supportive of this application, and have committed to continue that support to ensure a successful outcome once we are in a position to welcome internationally recruited GPs into the area.

2.11. We believe our Primary Care workforce offers significant opportunities to play a central role within new models of healthcare, which could address the challenges and system wide issues within the wider Health and Social Care system. This means that strengthening the supply of GPs will support the pivotal role Primary Care has in the delivery of future healthcare in Cheshire and Merseyside.

7

3. The Local Picture 3.1. Demographic 3.1.1. Cheshire and Merseyside has a population of over 2.5 million people, with a very diverse

demographic, ranging from areas of high depravation with high patient demand for long term and multiple complex conditions, to very affluent areas which benchmark well against national averages. The challenge of managing these groups of patients is often very different.

3.1.2. Numerous studies have shown that geographical variations in life expectancy can largely be accounted for by individual and area-based deprivation. The Marmot Review published in 2010 highlighted the fact that people living in the poorest neighbourhood’s will on average, die seven years earlier than people living in the richest neighborhoods’. The difference in disability-free life expectancy is even greater, with the average difference between the most and least deprived areas being 17 years.

3.1.3. GPs in our most deprived areas describe how trying to improve health outcomes and life expectancy of their patients can be very challenging, often due to a number of environmental factors such as poor housing, low education, unhealthy lifestyles, but they also describe the rewards from making a difference to this very disadvantaged group of patients.

3.1.4. CCGs across Cheshire and Merseyside have developed ambitious plans to improve the health and wellbeing, reduce inequalities, and create a healthy place to live for their population.

3.1.5. Appendix 1 provides a link to the CCG websites describing how they aim to deliver against these plans.

http://www.instituteofhealthequity.org/

http://www.lancashire.gov.uk/lancashire-insight/health-and-care/health-inequalities/healthy-life-expectancy.aspx

8

4. Workforce 4.1. Our GP workforce is changing. Table 1 below illustrates the age and gender profile across

Cheshire and Merseyside. It also describes how this will change over the next 10-15 years as more of the younger GPs are female. We need to understand this change in career path and look at how we encourage more males back into General Practice, recognising that doctors entering the profession want a better work life balance than is currently experienced by GPs.

Table 1

5. GP Federations 5.1. Comparable to the national picture, development of GP Federations across C&M is at

varying stages.

5.2. CCGs across Cheshire and Merseyside are working with their GP Federations to determine how the emerging Federations can support general practice and in particular support the development of new models of care.

5.3. Recognising that GP Federations will have a huge part to play in the delivery of Primary Care in the future, Cheshire & Merseyside GP Forward View Programme Board has elected to support development of GP Federations.

5.4. In order to progress this we have recently commissioned Primacy Care Commissioning to conduct a review across the footprint to identify maturity of individual federations are and how we can support and enable them to grow.

9

5.5. The review will focus on discussions and surveys of Federations, member practices and LMC representative to ensure all stakeholders have an opportunity to input into this programme of work.

5.6. As part of the General Practice Resilience Programme we have supported bids from Federations where they have described development of at scale working across practices.

6. Vanguard Sites 6.1. Cheshire and Merseyside has adopted a proactive approach to opportunities to pilot or

model new ways of working. The result of this has seen a number of CCGs benefiting from additional funding to introduce transformation at an early stage, for example seven CCGs across Cheshire and Merseyside are in receipt of funding for extended access from the Prime Ministers Challenge Fund.

6.2. New Models of Care are improving the quality and access to health and social care services for patients and local people across the country. Across Cheshire and Merseyside we have four vanguard sites delivering new care models to focus on designing a new approach to improve the overall efficiency, effectiveness and value of local health care systems.

6.3. Learning from these vanguards will enable our CCG partners across the footprint to introduce and establish new ways of working at an accelerated rate, to improve the health offer to our patients.

7. Practice Vacancies and Evidence of Need 7.1. The current shortage of GPs is a national issue which is experienced to varying degrees

right across the Country; this is replicated across Cheshire & Merseyside. We have areas which are in immediate crisis, in terms of shortages of GPs, versus areas where currently the complement of GPs is above the national average for GP to patient ratio. However our workforce data highlights for those areas not experiencing challenges at present, a significant proportion of their workforce is approaching retirement age within the next three to five years.

7.2. As part of this programme CCGs have encouraged practices to make consideration for succession planning so that as a system, we can prepare for the reduction in our GP workforce as a result of retirement.

7.3. CCGs advise locally there is heavy reliance on locum cover. Whilst we recognise this staff group play an important role to support general practice, high usage often results in increased financial cost to the practice and a reduction in overall clinical support. Practices have expressed their preference is to employ GPs to build a strong and committed practice team.

7.4. Appendix 2 sets out in more detail vacancies and evidence of need across the area.

7.5. Table 1 below illustrates the level of participation across Cheshire and Merseyside:

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[Table 1: Expressions of Interest for International Recruited GPs by CCG]

8. Engagement with Practices for the Programme 8.1. Cheshire and Merseyside CCGs actively commenced a programme of engagement

following approval for a Cheshire and Merseyside application for the International GP Recruitment programme and this is heavily supported by the NHS England local area team.

8.2. A communications plan for the programme was developed by the NHS England Communication team to support CCGs in engaging with practices. [See Appendix 3].

8.3. C&M CCGs have been engaging with their member practices to highlight the benefits that are to be realised from participation within the programme, and to gain an understanding of the level of interest using a variety of mediums, for example Members Forums, Protected Learning Time Events, and Primary Care Committees.

8.4. The emerging GP Federations and LMCs have also been regularly informed of progress and are fully supportive of this application.

8.5. CCGs have been liaising with Practices who have expressed an interest in participating in the programme to ensure a good understanding of the programme, recognising the expansion of the programme brought about some significant changes in terms of the recruiting, training and relocation of candidates. The list of participating practices is contained in Appendix 4A.

8.6. Subsequently all practices who have committed to be part of the programme have completed a readiness template to allow CCGs to understand the level of support required as the programme progresses. [See Appendix 4B].

TOTAL 122

125

141362429

Number of GPs Requested

793

14

5

1425923019

106132614

3328

352922

793

107

NHS Liverpool CCGNHS South Sefton CCGNHS Southport & Formby CCG

CCG

NHS West Cheshire CCGNHS South Cheshire CCG & NHS Vale Royal CCGNHS Eastern Cheshire CCGNHS St Helens CCGNHS Warrington CCGNHS Halton CCGNHS Knowsley CCG

Number of GP Practices

Number of Expressions of Interest from GP Practices

11

9. Living and Working in Cheshire and Merseyside

Cheshire and Merseyside is situated in the North West of England and has a population of over 2.5 million people. Cheshire and Merseyside offers a fantastic quality of life with a rich and diverse mix of experiences. From its stunning rural landscapes and outdoor offer, including cycling and walking to its rich cultural and musical heritage; the close proximity to a number of beaches provides plenty of opportunities for water sport activities and family fun days out, there is something for everyone.

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10. Cheshire 10.1. Cheshire has a very diverse economy with significant sectors including agriculture,

automotive, bio-technology, chemical, financial services, food and drink, ICT, and leisure and tourism. The county is famous for the production of Cheshire cheese, salt and silk. A mainly rural county, Cheshire has a high concentration of villages.

10.2. Agriculture is generally based on the dairy trade, and cattle are the predominant livestock. The chemical industry in Cheshire was founded in Roman times, with the mining of salt in Middlewich and Northwich.

10.3. Cheshire is considered to be an affluent county. However, towns such as Crewe have significant deprivation. The county’s proximity to the cities of Manchester and Liverpool means counter urbanisation is common. West Cheshire has a fairly large proportion of residents who work in Liverpool and Manchester, while the town of Northwich and area of eastern Cheshire falls more within Manchester's sphere of influence.

10.4. The historic city of Chester is a classic contemporary city bursting with must see treasures, 2000 years of history and spectacular shopping.

10.5. Amongst its many attractions is Chester Zoo, which offers fantastic family fun days out, Chester Racecourse offering a range of events such as family fun days, ladies days, evening and midsummer race events. Chester also has a wealth of hotels, many offering spa facilities, a wide selection of restaurants, and much more.

10.6. Understandably tourism in Cheshire from within the UK and overseas continues to perform strongly. Over 8 million nights of accommodation (both UK and overseas) and over 2.8 million visits to Cheshire were recorded during 2003.

11. Merseyside 11.1. Merseyside is a metropolitan county in North West England, it encompasses the

metropolitan area centered on both banks of the lower reaches of the Mersey Estuary, and comprises five metropolitan boroughs: Knowsley, St. Helens, Sefton, Wirral, and the city of Liverpool. Merseyside borders Lancashire (to the north-east), Greater Manchester (to the east), Cheshire (to the south and south-east) and the Irish Sea to the west. North Wales is across the Dee Estuary.

11.2. There is a mix of high density urban areas, suburbs, semi-rural and rural locations in Merseyside, but overwhelmingly the land use is urban. It has a focused central business district, formed by Liverpool City Centre, but Merseyside is also a polycentric county with five metropolitan districts, each of which has at least one major town centre and outlying suburbs.

11.3. Liverpool is a maritime city in northwest England, where the River Mersey meets the Irish Sea. A key trade and migration port from the 18th to the early 20th centuries, it is also, famously the hometown of The Beatles. Ferries cruise the waterfront, where the iconic mercantile buildings known as the "Three Graces" – Royal Liver Building, Cunard Building and Port of Liverpool Building – stand on the Pier Head.

https://en.wikipedia.org/wiki/Cheshire_cheese

https://en.wikipedia.org/wiki/Salt_in_Cheshire

https://en.wikipedia.org/wiki/Roman_Britain

https://en.wikipedia.org/wiki/Salt_in_Cheshire

https://en.wikipedia.org/wiki/Manchester

https://en.wikipedia.org/wiki/Liverpool

https://en.wikipedia.org/wiki/Counter_urbanisation

https://en.wikipedia.org/wiki/Metropolitan_county

https://en.wikipedia.org/wiki/North_West_England

https://en.wikipedia.org/wiki/Metropolitan_area

https://en.wikipedia.org/wiki/Mersey_Estuary

https://en.wikipedia.org/wiki/Metropolitan_borough

https://en.wikipedia.org/wiki/Metropolitan_Borough_of_Knowsley

https://en.wikipedia.org/wiki/Metropolitan_Borough_of_St_Helens

https://en.wikipedia.org/wiki/Metropolitan_Borough_of_Sefton

https://en.wikipedia.org/wiki/Metropolitan_Borough_of_Wirral

https://en.wikipedia.org/wiki/Liverpool

https://en.wikipedia.org/wiki/Lancashire

https://en.wikipedia.org/wiki/Greater_Manchester

https://en.wikipedia.org/wiki/Cheshire

https://en.wikipedia.org/wiki/Irish_Sea

https://en.wikipedia.org/wiki/North_Wales

https://en.wikipedia.org/wiki/Dee_Estuary

https://en.wikipedia.org/wiki/Liverpool_City_Centre

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11.4. The Liverpool urban area is the fifth most populous conurbation in England, and dominates the geographic centre of the county, while the smaller Birkenhead urban area dominates the Wirral Peninsula in the south.

11.5. Liverpool is a city with unique attractions, exciting events, world class sporting offerings, unrivalled musical heritage and famously warm welcomes. With the largest collection of museums and galleries in the country outside of London, Liverpool’s culture and heritage are at the very heart of the city.

11.6. Amongst Liverpool’s many attractions are the world famous Liverpool and Everton football clubs, Aintree Race Course, home to the Grand National race event, alongside many other family fun events.

11.7. The recently developed Liverpool ONE, located right by the iconic waterfront is an open-air shopping district that is home to more than 170 stores, bars and restaurants, including high street and designer favorite’s and the only Beauty Bazaar Harvey Nichols in the country.

11.8. Liverpool also benefits from two amazing cathedrals, located either end of the aptly-named Hope Street, Liverpool Anglican Cathedral and Liverpool Cathedral of Christ the King (Catholic) are vastly different in architecture but both majestic and beautiful.

Appendix 5: Thinking about being a GP in Cheshire and Merseyside, describes in further detail the benefits of living and working in the area

12. Transport 12.1. An outstanding public transport system operates across Cheshire and Merseyside

enabling easy access across the whole area.

12.2. Local rail and bus services provide first-rate connections to enable travel across the Cheshire &Merseyside footprint.

12.3. Excellent road links across the whole of the region, permits commuting from almost any part of the area, including motorway connections to allow travel across England, Scotland and Wales.

12.4. Additionally the local train services provides link to most of the major cities, including London in two hours, Birmingham in 90 minutes and Manchester in 30 minutes, as well as trains to Leeds, and across the border to Scotland.

12.5. We understand that Internationally Recruited GPs who wish to relocate to another Country may also want to have the ability to return home to visit family and friends. The close proximity to both Liverpool and Manchester airport’s allows easy access to other parts of the country, Europe and the rest of the world.

https://en.wikipedia.org/wiki/Liverpool_Urban_Area

https://en.wikipedia.org/wiki/List_of_conurbations_in_the_United_Kingdom

https://en.wikipedia.org/wiki/Birkenhead_Urban_Area

https://en.wikipedia.org/wiki/Wirral_Peninsula

https://www.visitliverpool.com/things-to-do/liverpool-one-p149761

https://www.visitliverpool.com/things-to-do/shopping/beauty-bazaar-harvey-nichols-p328931

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13. Retention of Internationally Recruited GPs 13.1. Experience from previous international recruitment programmes describes integration as

key to ensuring practices are able to retain internationally recruited GPs. Enabling internationally recruited GPs to establish a connection, both in their place of work and where they choose to live, reduces the likelihood that they will chose to return to their country of origin.

13.2. Equally it is important that internationally recruited GP are integrated to be able to understand and navigate the local health care system to support their peers and colleagues and offer high quality standard of care to patients.

13.3. Appendix 6 describes local support for integration.

14. Implementation Support 14.1. Cheshire & Merseyside CCGs are committed to supporting their local practices who have

applied to employ an internationally recruited GP. We recognise that internationally recruited GPs will have undergone appropriate assessment and training to ensure they are able to fulfil a GP role, however we are aware that these GPs are more likely to require additional support whilst they establish a full understanding of General Practice in England.

14.2. Implementation Project Group:

C&M CCGs together with NHS England will establish a project group to support those practices employing an Internationally Recruited GP. The aim of this group will be to ensure C&M CCGs are fully able to support each practice preparing to employ an international GP by offering:

14.3.1 Support to Practices: A number of practices named within this application have been unable to recruit a GP for a significant period and are already facing challenges as a result of this, We anticipate that they will have limited capacity to fully plan and prepare for the arrival of an internationally recruited GP, therefore the implementation of this group will provide support to those practices so that they are able to be in a state of readiness to receive the international GPs for example develop induction plans [Appendix 7]

14.3.2 Practice Peer Support Network: We will support practices participating in this application to create a peer support network. This will enable practices to develop ‘buddy systems’ share and learn from each other to reduce the impact felt by individual practices. Across Cheshire and Merseyside there is a number of international doctors who relocated as part of a previous recruitment drives who have offered their support to our newly relocated international GPs.

14.3.3 Peer network: We will make contact with other areas across the Region implementing the International Recruitment Programme within their area to develop a peer network. The purposes being to share learning and good practice as internationally recruited doctors are placed around the country.

15

14.4 The attached Project Plan describes implementation of the programme [See Appendix 8].

15 Clinical Support to Recruited GPs 15.3 Following completion of the Induction and Retention Scheme and subsequent approval for

full GP status, (in recognition that internationally recruited GPs may require additional support once they have completed the INR process) we will design a package of support that will build on and complement the training provided. This will be tailored to suit the needs of the individual candidates.

15.4 Health Education England (HEE): HEE will provide facilitated training sessions for Clinical and Educational supervisors. They will also provide support for those leading educationally within each practice, as we are aware that not all participating practices are training practices. Funding for this will be factored as follows, payment for HEE provision and also for backfill to practices attending the training.

15.5 Training Programme: As part of the package of support, C&M CCGs, together with NHS England will provide ongoing training set around the needs identified by receiving practices. This will be in the form of a training programme to deliver both clinical and non-clinical session to the internationally recruited GPs. This programme will be established and facilitated by the Clinical Lead for the application.

15.6 GMC Training Sessions: The GMC offer free sessions to GPs new to England to help with integration. Practices who are participating in the programme will be encouraged to support their newly appointed GP in attending these workshops as part of their clinical practice. These half-day sessions are for doctors who are new to UK practice called ‘Welcome to UK Practice’.

15.7 The course is offered on a monthly basis at the GMC offices in Manchester and London. However, if there are sufficient numbers it can be delivered more locally, dependent on the numbers of GPs relocating we will look to some local sessions being facilitated. The session helps doctors new to practice, or new to the country, to understand the ethical issues that will affect them and their patients on a day to day basis and covers the following:

• The role of the GMC, their standards and guidance on what makes a good doctor • Learning from the real life experiences of senior UK doctors through their video

'Things I wish I'd known' • Works through interactive ethical scenarios on issues faced by doctors new to UK

practice, including consent, confidentiality, raising concerns, 0-18 care and prescribing

• Create their own learning log with tips and reflections. [See Appendix 9].

15.8 Mentoring: An international doctor may find that working in General Practice can be a daunting proposition, especially in smaller practices where there is less opportunity for peer support. Where possible and appropriate, through supervisory expertise, we will

16

encourage experienced GPs to provide support to international GPs dealing with the increasing demands on Primary Care.

15.9 CPD: C&M CCGs together with NHS England will work with employing Practices to support internationally recruited GPs to understand and undertake their CPD responsibilities. We will assist practices where necessary and appropriate to develop a CPD programme outlining how the recruited GPs can obtain CPD accreditation.

16 Pastoral Support to Recruited GPs 16.3 Pastoral support for internationally recruited GPs choosing to relocate to Cheshire and

Merseyside, either singularly or with their families, is a key element of our integration plan. Newly recruited GPs will require access to advice and guidance in a new and challenging environment, alongside the provision of a supportive peer network. Lessons learnt from previous internationally recruited GPs programmes has identified that social connections have played a significant role in ensuring that GPs feel part of a community and start to make local links and embed themselves, and their families into the area.

16.4 For those candidates who choose to work in a practice in a different area to where they wish to live, the peer support group will enable practice’s to make links with other GPs and health professionals in the area.

16.5 C&M CCGs together with NHS England will support practices in developing an understanding of what pastoral support may need to look like, for example:

• Establishing a ‘buddy system’ within each practice or across a number of practices dependent on location.

• Coordinate provision for networking opportunities, either arranging meetings or use of technology, skype, social media groups, again dependent on the preference of the candidates.

16.6 A number of C&M CCGs have well established locality meetings arranged on a regular basis. We will encourage attendance at these meetings for the newly recruited GPs in order to assist them in building links with their local peer support group.

16.7 C&M CCG Locality Managers will conduct engagement interviews in months 3, 6 and 12 to ensure both the GP and the practice are happy with the arrangements and that expectations from both sides are being met.

16.8 Support for families: International doctors relocating with their families may need to establish links across the wider community, for example schools of employment for other members of their family. To facilitate this requirement, internationally recruited GPs will be provided with a package of support. This will take the form of an Induction and Welcome pack and will include features such as information about the NHS in England, an explanation of some of the cultural and working differences, and some more practical elements for example, details of residential housing areas, new developments , maps of the local area, shops, banking, public transport etc. Individual practices will offer a ‘buddy’ approach making sure that the new recruits are fully supported during their induction period and beyond.

17

17 Other Measures to Support Integration 17.3 Flexible Approach 17.3.1 Locally we have good examples of how individual practices are introducing a flexible

approach to how GPs are employed, for example part time working, term time working, late start surgeries, all day surgeries. As GPs and practices experience and share the benefits of a more flexible working pattern, there is a drive to encourage more practices to adopt this and start to make General Practice a more attractive place to work.

17.4 Initiation 17.4.1 Newly recruited GPs must meet the required standard in order to attain full GP status;

however we recognise that there will be a period of time where internationally recruited GPs will require additional support to fully perform the role of a GP in England. This may to take the form of longer appointment times and/or regular contact with exiting GPs within their practice for mentorship.

17.4.2 Learning from previous waves of the programme where recruited GPs have been placed in practices already facing significant challenges due to clinical shortage, these GPs have struggled to integrate due to the lack of capacity within the practice

17.4.3 To support the newly recruited GPs, C&M CCGs will work closely with these practices to ensure that the establishment of appropriate systems and processes for induction are in place and that they can plan accordingly, for example; continued locum cover whilst the internationally recruited GP is fully embedded into the practice.

17.4.4 For those GPs and or practices where this is identified then the recruiting practice may need to offer a reduced salary to reflect the reduced level of work to be undertaken by the new GP and also to financially support the continuation of locum cover if required.

17.4.5 Table 2 below is a guide for practices considering how to integrate international GPs

18

[Table 2: Guide to practice integration and payscale]

18 Contract Lengths Contracts of employment will be offered with an outline of the appropriate terms of employment, salary commitment and a mutual obligation to commit three years minimum employment to provide stability and certainty for GPs employed as part of this process, and for the employing practice. Appendix10 & 11 illustrate example contracts reflecting the BMA model contract.

Year 1 Funding Year 2 Funding Year 3Month 12-18 Practice Salary: Circa

Extended appointment length

Reduced to reflect longer appointment

Month 3-6INR Process

Month 6-12 Practice Salary: Circa £55-£60K Month 18-24 Practice Salary:

Extended appointment

length 30 minutesReduced to reflect longer appointment times

Appointment length 15 minutes

Circa £75K in line with BMA Contract

Month 12-24 Practice Salary:Appointment length

15 minutesCirca £75K in line with

BMA ContractMonth 3-6

INR Process

Month 6-12 Practice Salary: Circa £65K



Month 12-24 Practice Salary:Appointment length

15 minutesCirca £75K in line with

BMA ContractMonth 3-6

INR Process

Month 6-9 Practice Salary: Circa £65-£70K



Practice Salary:

Circa £75K in line with BMA Contract

Assessment Level: High Support

Assessment Level: Mid Support

Assessment Level - Low Support

NHS England

Month 1-3 Observership

NHS England

Practice to determine salary

NHS England

Month 9-12


NHS England


NHS England



NHS England

19

19 Clawback Measures 19.3 We fully recognise the significant investment made by NHS England within this

programme. As such C&M CCGs will fully support the claw back measures process as determined by NHS England should an internationally recruited GP express a wish to leave the UK prior to the end of the stipulated 3 year contract.

20 Supporting the existing workforce 20.3 We recognise that a strong workforce is key to the delivery of General Practice;

strengthening the Primary Care workforce will ensure GP’s are free to provide personalised care face to face for people with complex needs and through supervisory expertise, providing support to junior doctors dealing with the increasing demands on Primary Care.

20.4 The STP plan describes how the overall size of the Primary Care workforce has not kept pace with patient demand.

20.5 However, whilst steps have been taken to increase the future supply of Primary Care clinicians, the current availability of GPs is insufficient to meet existing demand. Most health systems continue to plan for a reduction or future lower growth in hospital provision, this implies further increases in demand for patient care and support in a local primary and community based model.

20.6 There is also considerable existing variation in the skill mix within General Practice both in terms of doctor to nurse to HCA as well as the use of the skills of such staff within practices.

20.7 Supported by NHS England, Cheshire and Merseyside CCGs are developing a workforce strategy, initially to understand our existing primary medical care workforce but also to determine what this will need to look like in the future, and how it will support our existing GP workforce.

20.8 To strengthen General Practice we need to involve the whole workforce in our plans. We need to ensure we are utilising our wider workforce appropriately to support our existing GP workforce. There is a wealth of evidence describing how much of the work undertaken by GPs could be better placed with another clinician, for example nurse’s, Pharmacist’s, Physiotherapist’s or equally some of the more administrative tasks could be undertaken by other members of the practice team.

20.9 We are supporting the development of our workforce as a whole and encouraging uptake of all opportunities to upskill our staff. The benefits of utilising our workforce more efficiently will impact on the patients in that they will see the right person the right time, the wider staff groups on increasing job satisfaction, and importantly on our GP workforce to reduce the stress placed on GPs.

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21 Clinical Workforce 21.3 Targeted Recruitment Programme 21.3.1 The Cheshire and Merseyside Targeted Recruitment Programme supports practices who

have been identified as having vacancies or who anticipate vacancies in the near future. The programme aims to build resilience and promote new models of care and care redesign when practices are in a position to change, rather than supporting practices at a crisis point.

21.3.2 The programme will evaluate practice level workforce data, capacity and demand at the practice and gap analysis, using the Local Health Check Tool to determine the workforce needs and to understand areas of potential change.

21.3.3 Locally seven practices have been engaged with the pilot. These practices have been identified through local intelligence, via CCGs. Five practices are currently participating and have completed or are completing the Health Check Tool and the appointment audits.

21.3.4 The practices are experiencing different challenges with regard to recruitment and as a team we are working closely to understand their requirements as part of the recruitment process, and intend to share the learning across other practices who are struggling to recruit.

21.4 GP Retention Scheme 21.4.1 Following the refresh of the GP Retention scheme as part of the GP Forward View,

Cheshire and Merseyside have adopted a proactive approach in promoting the scheme, and we currently have 16 GPs remaining in General Practice that would otherwise have left the profession.

21.5 Physician Associates 21.5.1 Investment by HEE in the training of 1,000 Physician Associates to support the delivery of

General Practice has enabled several practices across Cheshire and Merseyside to be actively involved in the training programme. This has been done by practices from across all areas of the STP offering placement opportunities to trainee Physician Associates, allowing them to spend time in General Practice and to understand the benefits of Primary Care as a career choice. Once training of the first cohort has been completed in 2018 it is anticipated that Physician Associates will be recruited into General Practice across Cheshire and Merseyside.

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22 Clinical Non- Medical Workforce 22.3 Nursing 22.3.1 Maximising the collective impact of nurse leaders: Locally we are facing challenges

within the Primary Care nursing workforce, with a high proportion of General Practice nurses approaching retirement age. This will result in a potential workforce gap that will no doubt adversely impact on our GP workforce and patient care.

22.3.2 In response to this challenge, Cheshire and Merseyside Directors of Nursing and CCG Chief Nurses together with Health Education England and NHS England have developed a strategic plan and a programme of work aimed at maximising the collective impact of nursing across Cheshire and Merseyside. This output is a more streamlined nurse programme with a strong emphasis on retaining the existing workforce, including attracting more student and newly qualified nurses into General Practice. This programme has the full support and financial backing of the Local Workforce Action Board (LWAB).

22.3.3 Trainee Advance Nurse Practitioners (ANP): Health Education England in the North West (HEENW) has made significant investments in supporting the development of Advanced Clinical Practitioners. HEENW can support further ANP trainees across the North West provided that any applicants can be supported to commence a programme within this financial year 2017/18.

22.3.4 A joint Cheshire and Merseyside expression of interest has been submitted for 20 trainee places with employer support; an initiative, if successful, will complement and support the GP workforce.

22.4 Clinical Pharmacists in General Practice Programme 22.4.1 The General Practice Forward View committed over £100m of investment to support an

extra 1,500 clinical pharmacists nationally to work in General Practice by 2020/21. This is in addition to over 490 clinical pharmacists already working across approximately 650 GP practices as part of the initial pilot that launched in July 2015.

22.4.2 Cheshire and Merseyside Commitments from 2017/18 – 2019/20 (3 years). An allocation of 25 clinical pharmacists across Cheshire and Merseyside has been confirmed for 2017/18.

22.4.3 As a result of NHS England’s Clinical Pharmacists in General Practice programme, an additional thirty nine Clinical Pharmacists and eight and a half WTE Senior Clinical Pharmacists are currently working within General Practice across Cheshire and Merseyside. These numbers will increase when a further three Senior Clinical Pharmacists and seven Clinical Pharmacists are rolled out during 2017/18.

22.4.4 Having Clinical Pharmacists in General Practice enables GPs to focus their skills where they are most needed, for example on diagnosing and treating patients with complex conditions. This in turn helps GPs manage the demands on their time. National feedback from practices involved in the NHS England programme suggests that by employing Clinical Pharmacists many practices have been able to reduce waiting times for appointments, increase access to healthcare, improve screenings an diagnosis of chronic

22

and common ailments, reduce A&E admissions and attendances and reduce medicines wastage and overuse.

22.4.5 An example of this in Cheshire and Merseyside involves a group of six Clinical Pharmacists carrying out 500 medication reviews over the course of two months across seven practices. This work would have previously have been carried out by a GP and would have taken a much longer period of time. This in turn created a better patient experience and increased quality within those practices.

22.4.6 Across Cheshire and Merseyside, the Programme is promoted through a number of ways:

Distribution of guidance and enhanced service documentation to CCG Primary Care Leads

Meetings with CCG Primary Care Leads to offer support with the application process, particularly in those CCG areas that do not currently have a pilot in place from either phase of the programme

22.4.7 A Steering Group for pilot programme Leads was established in 2016 under phase one and this has been expanded to introduce phase two. The Steering Group allows for best practice sharing and offers support across the Cheshire and Merseyside pilots. This will continue throughout the duration of this programme of work.

Pilot Area

No of Clinical

Pharmacists (WTE)

No of Snr Clinicial

Pharmacists (WTE)

No of Practices

Whole CCG Population

Pilot Patient Coverage

Percentage of CCG Population

Cheshire & Merseyside Population

Halton 6 1 6 125,970 65,504 52%

Knowsley 6 1.5 8 147,200

37,683 (Knowsley)9594 (Wirral)

19,630 (St Helens)7558 (Halton)

25.6% (Knowsley)10% (St Helens)

6% (Halton)3% (Wirral)

Liverpool 5 1 7 501,619 95,308 19%

South Cheshire

7 0.5 11 173,000 110,351 63%

Vale Royal 5 0.5 6 102,000 59,160 58%

Warrington 10 4 26 207,900 207,900 100%

TOTAL PHASE ONE 39 8.5 64 1,257,689 612,888

Wirral 2 1 9 335,116 79,815 24%

West Cheshire

3 1 17 260,000 122,561 47%

Eastern Cheshire

2 1 12 204,000 108,565 53%

TOTAL PHASE TWO 7 3 38 799,116 310,941

TOTAL ALL WAVES 46 11.5 102 2,056,805 923,629

Phase One Schemes

Phase Two Schemes

The nine schemes

cover 923,629 patients,

which equates to 36.5% of

the Cheshire and

Merseyside patient

population (2,530,070)

23

23 Wider Workforce 23.3 The GP Forward View set out commitments to support the wider workforce to implement

transformational change required in General Practice. 23.4 Medical Assistants 23.4.1 During summer 2017 Health Education England announced a pilot programme to support

the development of a new role to support GPs in making time for their patients and clinical duties. The GP Assistant role will support the GP by helping surgeries run smoothly, reducing paperwork and supporting consultations.

23.4.2 The Spinney Medical Centre in St Helens, Merseyside has been announced as being the training hub for this programme for the North West area. To date, within Wave 1 and Wave 2 of the programme, Cheshire and Merseyside practices have secured 53 of 90 places available with Wave 3 anticipated for early 2019. Cheshire and Merseyside practices have also registered a high level of demand on the placements available within the third cohort.

23.5 Care Navigators & Social Prescribing

23.5.1 CCGs across Cheshire and Merseyside have introduced programmes to train staff to act

as Care Navigators who will signpost patients to the most appropriate service provider or clinician. Whilst the implementation is in its early stages, practices are able to describe the benefits of this role, in particular, upskilling of staff to be better able to manage patient demand more effectively.

23.5.2 A number of our CCGs are in discussion with practices and are planning to commission the next level of training. This will further develop staff, enabling them to offer social prescribing support to those groups of patients who have greater needs, but that are not necessarily health based, but do impact adversely on health provision. Providing focused support to this group of patients not only addresses their health needs but has been proven to reduce the number of appointments to GPs following these type of interventions

24 At Scale Working 24.1 The GP Forward View describes how health professionals will increasingly work at different

organisational levels, for example their own practice, a neighbourhood of practices and across the local health economy. Cheshire and Merseyside CCGs are encouraging and supporting this approach recognising the benefits of at scale working, both for the workforce in terms of economies of scale and also for patients in terms of improved access to the most appropriate health professional and a more streamlined health care offer.

24.2 Across Cheshire and Merseyside, member practices routinely operate at a neighbourhood

or locality level in terms of services they provide to their local population. Increasingly

24

practices are looking at ways to establish more formal links having experienced the benefits of closer working with their local colleagues.

24.3 Portfolio Working

24.3.1 Clearly recognising the requirement for International GPs to be employed within a single practice or organisation, practices across Cheshire and Merseyside are also exploring opportunities to offer portfolio working, reflecting the changes in how GPs are choosing to work.

24.3.2 These new ways of working will not only reduce the pressure on our existing GP workforce, but will also provide opportunities for GPs to have a more varied role. GPs will become enabled to choose to develop a focus within a clinical domain both within their own practice and across neighbourhoods, or to develop other interests within the scope of general practice. This is in acknowledging that the future delivery of General Practice will look different to the current model.

24.3.3 Examples of how CCGs are working with practices to introduce new ways of working including upskilling of the wider clinical and non-clinical workforce are contained within Appendix 12 of this document.

24.4 Advances in Technology

24.4.1 New technology is enabling increased ability for agile working, and thus supporting general practice to work more flexibly. The ability to review patients’ records, results, referrals and prescriptions remotely is transforming the offer to GPs and patients.

24.4.2 There is growing evidence that the use of new and innovative technology is enabling people to be better engaged with their health provider and empowering patients to take more control of their own health. For example online consultations, video consultations, text messaging from practices.

24.4.3 Across Cheshire and Merseyside we have supported 30 Digital and Technology investment schemes. The schemes are wide ranging in their benefits with proposals directly supporting the following:

supporting improved clinical workforce agile working. improved patient access. speedier diagnostic results transfer. greater AED diversionary capacity into Primary Care via increased clinical

appointment capacity in practice settings. patient self-care and empowerment through innovative investment in and

deployment of assistive technology. improving information sharing and interoperability potential between NHS care

settings.

24.4.4 Specific schemes have invested in the roll out of the e-consultation programme and providing GPs with mobile working technology that includes secure access to patient records which enables care delivery outside of the practice environment. A number of schemes have been supported to implement IT interoperability to enhance links across primary and secondary care. We have also supported the development of the “My Health Choice” to empower Halton residents to access health care and service information.

25

24.4.5 Appendix 12 describes local measures to support our existing GP workforce.

25 Funding 25.3 This application is seeking approval to recruit 122 International GPs. The funding request

to support our application is a total of £305,000 to deliver the programme.

25.4 The breakdown of the costs is as follows:

Element Cost per GP Total Cost

Health Education England training for Clinical Supervision and Mentorship 11 sessions @ £450 per session

£4950

Locum cover to Practices attending Health Education Sessions. 122 x £700 £700 £85,400

Provision of monthly clinical training sessions 36 x £700 £700 £25,200

Funding to CCGs for integration in Practice.

£1,500 £183,000 Menu of support to be offered:

Additional hours for in-house staff to provide training, mentoring, Understanding community provision, EMIS training, pastoral support by practice. 3 x Annual market place event for International Recruited GPs £6,450

Total £305,000

26

26 Governance and Assurance 26.3 The GP Forward View Programme Board has oversight of the application and provides

assurance to the STP with regard to progressing the application.

26.4 The Programme Board is made up of representatives from the following representation:

Organisation Position

NHS England

Director of Commissioning Medical Director Head of Primary Care Head of Primary Care Head of Digital Technology Public Health Deputy Director of Nursing Head of Finance Deputy Medical Director Snr Administrator (Notes)

Mid Mersey

Director of Commissioning, NHS Halton Clinical Commissioning Group Chair of NHS Warrington Clinical Commissioning Group and Clinical Lead Local Medical Committee Representative Healthwatch Representative

Cheshire & Wirral

Head of Primary Care Chair of NHS South Cheshire Clinical Commissioning Group and Clinical Lead Local Medical Committee Representative Healthwatch Representative

North Mersey

Director of Transformation Vice Chair of NHS South Sefton Clinical Commissioning Group and Clinical Lead Local Medical Committee Representative Healthwatch Representative

RCGP Lead Royal College of GPs Representative 26.5 A Task and Finish Group has been established to oversee the application for the

programme, chaired by Dr Rosie Kaur, GP and Clinical Primary Care Lead Liverpool CCG with attendance from CCG Primary Care Leads, NHS England Cheshire and Merseyside. This group reports directly into the GPFV Programme Board.

26.6 The Task and Finish Group will continually engage with the practices involved in the programme, and will seek feedback on their experience. CCGs are a key member of this

27

group and will receive key performance outcomes and assurances on progress, which will be feedback into the various CCG formal committees.

27 Conclusion 27.3 NHS Liverpool Clinical Commissioning Group together with CCGs from across Cheshire

and Merseyside has developed this application to seek approval to participate in the International GP Recruitment programme. Our participation will facilitate an increase in the numbers of additional GPs across Cheshire and Merseyside by 122 and contribute to the expansion of the GPFV International Recruitment programme to attract up to an extra 2000 appropriately trained and qualified doctors from overseas by 2020.

27.4 Large parts of Cheshire and Merseyside are currently under-doctored and struggling to recruit, if we do not intervene now we will be facing an impending Primary Medical Care workforce crisis.

27.5 We will continue to support the Primary Care workforce of Cheshire and Merseyside through our workforce strategy to train, learn and introduce new models of care based on the needs of the local population. We will ensure that workforce planning addresses the population and its needs with the right people, with the right skills, and meets our patients’ needs in the most appropriate settings.

27.6 The International GP Recruitment Programme aligns with our efforts to recruit and retain GPs within Cheshire and Merseyside. Our leaders are committed to creating the right environment for Primary Care integration, investment and sustainable growth ensuring we have the workforce to deliver the planned future care to our population.

27.7 Our practices have demonstrated their need and the local demand for GPs and their will to employ International GPs as soon as possible.

27.8 Finally, Cheshire and Merseyside CCGs are committed to continuing to support those practices participating in this application both during the planning stages and once they have successfully employed an international GP. This support will assist in the delivery of a coordinated programme and ensure successful programme implementation which attracts and retains international new recruits into the Cheshire and Merseyside Primary Care family.

28

Appendix 1: Cheshire & Merseyside CCG Contact Details

Cheshire & Merseyside CCG Cont

Appendix 2: Evidence of Need - Practice Vacancies

031017 CM International GP Recr

Appendix 3: Cheshire & Merseyside Engagement Plan

281117 CM international GP recru

Appendix 4a: Practice Readiness Template

International GP Recruitment -Practice

Appendix 4b: Participating Practice by Clinical Commissioning Group


Appendix 5: What does Cheshire & Merseyside Offer? (Geographical Picture)

031017 C&M International GP Recr

Appendix 6: Support for Integration and Retention


Appendix 7: Example Induction Plan

Example Induction.docx

Appendix 8: Project Plan

2017 11 02 IR Project Plan draft.xlsx

Appendix 9: GMC Examples

Day in the life of a GP_DL_leaflet (2).pdf

29

GMC-RLS-PromoDocs0914.pdf

Welcome to UK practice flyer.pdf

Appendix 10: Example of Model Contract (GMS)

IR Model Contract.doc

Appendix 11: Example of Model Contract (PCO)

IR Model Contract PCO.doc

Appendix 12: How Application Supports Existing Workforce


Committee Reporting

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Primary Care Commissioning Committee Date: 11th January 2018

Report title: NHS Halton CCG Minor Ailments Scheme (MAS) (Care at the Chemist) Data platform

Lead Clinician and/or Lead Manager: Lucy Reid, Head of Medicines Management

Purpose:

To inform the committee of the decision to consolidate web platform for delivery of the minor ailments scheme in line with good governance and IG requirements.

The Committee is asked to: Note the preferred proposal

This Report supports the following CCG Strategic Objectives One: To commission services which continually improve the health and wellbeing of Halton residents. Two: To continually improve and innovate in our engagement with local people and communities to secure their participation in improving their own health outcomes. Three: To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations. Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Five: To develop the skills, knowledge and competence of the people who are working with us to create a high performing organisation that will allow us to build effective partnerships with other organisations and develop leadership from within. Commissioning Plan Implications Use of the Minor Ailments scheme promotes self-care and improved use of primary care skill mix. Financial Implications Does this require financial support? Yes If Yes - Is there currently a budget for this? Yes Board Assurance Framework and Corporate Risk Register Does this report link to either the Board Assurance Framework (BAF) or Corporate Risk Register (CRR) or both? N/A If Yes - please state:


Committee Reporting

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• state level of assurance this paper provides – detailed individually in the paper

National Policy, Guidance, Standards, Targets or Legislation Equality and Diversity and Human Rights Throughout the development of this paper and the policies and processes cited NHS Halton CCG has:



Committee Reporting

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NHS Halton CCG Minor Ailments Scheme (MAS) (Care at the Chemist) Data Platform

Alongside other CCG/NHSE colleagues from Liverpool, Knowsley and St Helens, the Medicines Management Team have been looking into the data platform that currently supports the MAS service across the current footprint. Currently the platform is currently managed by Webstar ServicePact.

Webstar Service Pact Pharmacy sites = 29

The charges for the period Apr 2017 –Mar 2018 were as follows: • CCG Licence fee: £1,000/Annum plus VAT

• Data Processing fee: £120/Pharmacy/Annum plus VAT

• The total cost to the CCG for a fully managed service is currently = £4,480 plus VAT per annum

Total cost of £5376 per annum (Nov 17 – Oct 18)

This is paid annually between January and March and these prices have not changed since 2013. If additional pharmacies wish to deliver the MAS then the CCG will need to pay extra £120 per pharmacy. If the CCG wished to utilise the same platform for an additional service e.g. palliative medicines then there would be an additional cost dependent on the size of the service and the module to be utilised. The module that we use to deliver the MAS is maintained by Webstar and any changes that we require need to be emailed to their service desk and can take a time to be actioned e.g. a number of weeks on occasions. There have been data quality issues in the past that have meant duplicate entries were being generated, along with duplicate charges and although this has since been rectified it took approximately six months to get to the bottom of the issue as we had to go through Webstar for the data trawl and data analysis. The Webstar system generates invoices at the end of each month based on activity through each pharmacy and sends them straight through to SBS for processing, there have recently been invoicing delays that have impacted on contractors and this was outside of the control of the CCG. In terms of the GDPR legislation we are yet to receive any confirmation or assurances that this system will be compliant by May 2018. The Webstar system relies on commissioners to update them regarding price changes and as such has the potential for contractors to be paid incorrectly and for commissioners to be paying the wrong prices for medicines supplied. This has been the case recently within our area.

Committee Reporting

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PharmOutcomes

Pharmacy sites that could access the platform = 36

The charges for the period Nov 2017 – Oct 2018 would be as follows: • CCG Licence = £3,950.00 plus VAT

• Total including VAT = £4740.00

Total cost £4740.00 per annum (Nov 2017 – Oct 2018) The above system has several advantages in that the CCG has used them until recently for the Prime Ministers Access Fund (PMAF) projects and as such a full PIA has already been completed making the transfer over to a DPIA more straightforward. The company have already provided assurance regarding the GDPR legislation, have trained staff and have produced guidance for the transition. In terms of changes to the system this can be done locally by the CCG and in real time which would support effective management of safety concerns and supply issues. The CCG can create and customise the platform for the various services needs and as such can build in as much or as little as we would want to get out of it in order to provide effective reporting and troubleshooting, again this can be done in real time. Invoices can be set up as we wish them to be, they can go straight to SBS or a nominated CCG individual. Drug prices are linked to the NHSBSA Dictionary of Medicines and Devices (DM+D) and as such are automatically updated when prices change, this would ensure correct payments to contractors and reassurance for the commissioner that they are paying the correct amount for drugs supplied. The CCG currently has an account with PharmOutcomes although the licence expired at the end of October 2017. Halton Borough Council Public Health also commission this platform to support management of their local community pharmacy services. NHSE also use the same platform for a number of their enhanced service across Cheshire & Merseyside. As a result pharmacy contractors are using multiple platforms to provide services. In order to reduce costs, improve efficiency and improve the service for contractors and commissioners in line with the upcoming GDPR legislation we are proposing consolidate all services onto one platform by moving the MAS onto PharmOutcomes. This is the same for all 4 CCGs that currently commission the same MAS service Liverpool, Knowsley, St Helens and Halton. Options for Commissioning PharmOutcomes

1) Option 1 – As explained above commission PharmOutcomes directly to provide the data platform as a stand-alone CCG licence Total cost £4740.00 per annum

Committee Reporting

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2) Option 2 -There are opportunities to reduce costs even further by continuing to commission jointly with Halton Borough Council as this would reduce the cost by about 40%. PharmOutcomes separate the data so each commissioner can only see their own services but in order for this to happen we will be required to pay an annual separation charge. The CCG would be required to pay the full amount up front but would then recharge half of this to HBC. This has already been the arrangement until October 2017.

Jointly with HBC the charges for the period Nov 2017 – Oct 2018 would be as follows: • CCG/HBC Licence = £3,950.00 plus VAT

• PharmOutcomes Annual Data Separation Charge £592.50

• Subtotal £4,542.50

• Total VAT 20% = £908.50

Total cost £5,451.00 per annum for Joint licence CCG/HBC (Nov 2017 – Oct 2018)

CCG pays £5451.00 to PharmOutcomes but recharges £2725.50 to HBC therefore annual cost to CCG = £2725.50

3) Option 3 - There is also the option for us to utilise the LPC licence for PharmOutcomes for £58.40 per contractor plus VAT. This would cost the CCG £2522.88 (incl. VAT) for up to 36 contractors (same as current CCG/HBC licence). For 29 contractors as is the case for the MAS as it stands at the moment costs under the LPC licence would be £2032.32 (incl VAT)

Issues around options

All options have governance issues which will be addressed via a DPIA (under the new GDPR legislation)

We have taken advice from our IG team and they have advised that as long as we are in line with guidance it is our choices as a CCG to decide which option is best for our service and as long as we ensure all DPIA’s are in place (which IG will assist us with) before the service goes over to the new platform.

Our preferred option is to commission PharmOutcomes directly to provide the Data platform with Halton council i.e. Option 2. This is due to a number of reasons but in the main is down to IG and data issues rather than being driven by costs. All options are cheaper than the current situation:

Committee Reporting

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• This will address any concerns about what the LPC will do or may do with the data and allowing us to proceed with the service as we see fit

• This option would only require one DPIA between ourselves and PharmOutcomes (the LPC option would require two DPIA’s one between ourselves and the LPC and one between ourselves and PharmOutcomes

• Any issues with creating the forms on the PharmOutcomes system would require us to contact the LPC who would then have to contact PharmOutcomes for a solution, if we commission PharmOutcomes directly we can contact them around any issues.

• If we wished to add in further services it would not cost us anything additional. With the LPC licence there may be additional costs but have not had this confirmed.

• There are real opportunities to work jointly with the LA with regards to Community Pharmacy and this would be a move towards that.

The Committee are asked to note this preferred option. The current provider has been given the required notice and the changeover will be taken forward by the Medicines Management Team including completing the DPIA and discussing any IG issues with our IG team. .