primary care commissioning committee , part 1 held in public … care joint... · blossom care...

1

Primary Care Commissioning Committee, Part 1 Held in Public

Wednesday 13th February 2019 2-3.30pm Council Chamber, Bexley Civic Centre DA6 7AT

AGENDA

Item

Time Description Enc Presented by

Standing items

1/19 2.00 Welcome and introductions - Paul Cutler

2/19 2.02 Declarations of Interest A Paul Cutler

3/19 2.05 Review of Minutes from the previous meeting on 12th December 2018

B Paul Cutler

4/19 2.07 Review of action log

C Paul Cutler

Items for decision

5/19 2.08 Littleheath Practice : Business case for additional partner

D1-D3 Jill Webb

6/19 2.18 Bexley Bid for unspent resilience funding in respect of Cairngall Medical Practice

E1-E2 Nisha Wheeler

Items for information

7/19 2.30 Cairngall Medical Practice: Caretaking update

F1-F3 Nisha Wheeler/Jill Webb

8/19 2.45 Crook Log Surgery : update briefing Verbal update

Nisha Wheeler/Jill Webb

9/19 3.00 NHS Long Term Plan – Overview and Implications for Bexley

G1-G2

Nisha Wheeler

10/19 3.10 Primary Care Finance Report

H1-H2 Malcolm Hines

Closing items

11/19 3.20 Questions from members of the public Any member of the public who wishes to ask a question at the Primary Care Commissioning Committee should send it in advance to [email protected] Members of the public are reminded that queries relating to individual staff or patients cannot be discussed. The chair reserves the right not to respond to queries relating to issues which are the subject of current confidential discussions or legal action or any other matter at his discretion without giving any reason.

1 Agenda

1 of 69Primary Care Commissioning (part 1 ) PUBLIC-13/02/19

mailto:[email protected]

2

Membership of the Primary Care Commissioning Committee (part 1) Public

Members with voting rights

Neil Ross Chair

(NR) Lay member, legal & procurement

Keith Wood (KW) Lay member, governance

Paul Cutler Vice Chair

(PC) Lay member, patient & public involvement

Neil Kennet-Brown (NKB) Bexley and Greenwich CCGs

Managing Director

Michael Boyce (MB) Bexley CCG Deputy Managing Director

Mary Currie (MC) Bexley CCG Governing Body Nurse

Dr Jhumur Moir (JM) Westwood Surgery

GP Member, Clocktower Locality Lead

Dr Varun Bhalla (VB) Belvedere Medical Centre

GP Member, North Bexley Locality Lead

Dr Sid Deshmukh (SD) Bexley CCG Clinical Chair

Dr Sonia Khanna-Deshmukh

(SKD) Sidcup Medical Centre

GP Member, Frognal Locality Lead

Malcolm Hines (MH) NHS Bexley, Bromley, Southwark CCGs

SEL CCGs Director of Finance & Acting Chief Financial Officer

Nisha Wheeler (NW) Bexley CCG Director of Primary Care, ICT & Information Governance

Non-voting members

Dr Anjan Ghosh (AG) London Borough of Bexley Representative for Health and Wellbeing Board, Director of Public Health and Deputy Director of Health & Wellbeing

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

Station Road Surgery

Jane Garfield-Field (JGJ) Healthwatch Bexley Manager

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

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

1 Agenda

2 of 69 Primary Care Commissioning (part 1 ) PUBLIC-13/02/19

NHS Bexley CCG, Primary Care Commissioning Committee members’ declaration of interest, 13th February 2019 – Public Meeting

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

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

Updates Signature

Dr Sid Deshmukh Bexley CCG Chair

1. Senior Partner Sidcup Medical Centre PMS Contract - Personal Interest - Materiality 50% 2. Shareholder Bexley Health Limited 3. Shareholder Frogmed Limited - Personal Interest (Dormant company) 4. Shareholder Blossoms Care Home Ltd - Personal Interest 15%. 5. Clinical Lead - Referral Management and Booking Service (RMBS) - Personal Interest 6. Clinical Lead - Dementia 7. Shareholder, Bexley Health Neighbourhood Care 8. Wife (Dr Sonia Khanna-Deshmukh) is a locality lead for Frognal and on the CCG governing body 9. Non-financial personal interest in Inspire Community Trust; a) Wheelchair service b) Joint Equipment Store c) Personal Health Budgets d) Information and service support for people with physical and sensory impairment.

Dr Varun Bhalla GB Locality Lead, North Bexley

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

Dr Jhumur Moir GB Locality Lead, Clocktower

1. GP Partner, Westwood Surgery 2. Shareholder, Bexley Health Ltd 3. Shareholder, Bexley Health Neighbourhood Care 4. Clinical Lead, Diabetes 5. GP Appraiser, NHS England 6. GP Trainer, Bexley VTS, HESL

ENCLOSURE: A AGENDA ITEM: 2/19

2.19 Declarations of Interest

3 of 69P

rimary C

are Com

missioning (part 1 ) P

UB

LIC-13/02/19



Updates Signature

Dr Sonia Khanna-Deshmukh

GB Locality Lead, Frognal

1. GP Partner at Sidcup Medical Centre 2. GP Appraiser for South London, 3. Blossom Care Homes Ltd: i) 15% Shareholding ii) Father is Director of Blossom Care Homes Ltd iii) Father and Husband are shareholders 4. Inspire Community Trust; Father (Vinod Khanna) is the Chief Executive Officer 5. Clinical Lead, 111 &UCC Services for Bexley CCG 6. Clinical Lead, Neurology 7. Shareholder, Bexley Health Neighbourhood Care; No profit share 8. Board Member, Bexley LMC 9. Husband, Dr Sid Deshmukh is: i) Senior Partner at Sidcup Medical Centre ii) Bexley CCG Chair 10. Involved in the developing a pathway for bladder problems in SE London.

1. I declare all my interests & update the register regularly. 2. During meetings I declare my interests separately at the start of discussion of relevant agenda item 3. I do not get involved in decision making where there is a conflict of interest

Keith Wood GB Lay Member for Governance and Audit

None

Paul Cutler GB Lay Member for PPI

1. Director, Paul Cutler Consultancy 2. Associate for the National Children's Bureau, Centre for Public Scrutiny, CAN-Invest, Participation Works 3. Consultant/ advisor to a variety of charities, social enterprises and local authorities across England (non in SE London) 4. Extended family member works for the Alzheimer's Society

Does not take on contracts with organisations within Bexley

Neil Ross GB Lay Member for Legal and Procurement

None


4 of 69P

rimary C

are Com


UB

LIC-13/02/19



Updates Signature

Mary Currie Governing Body Nurse

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

Malcolm Hines Director of Finance and Acting Chief Financial Officer, Bexley CCG

Director of Finance and Acting Chief Financial officer: - Southwark CCG - Bromley CCG

Michael Boyce Deputy Managing Director None

Nisha Wheeler Director of Primary Care, ICT & IG

None

Dr Anjan Ghosh Director of Public Health, LB Bexley

Director of Public Health for LB Bexley 2017

Dr Richard Money

Member, Medicines Management Sub-Committee

1. GP Partner, Station Road Surgery 2. Director & Chair, Bexley Health Ltd 3. Director, Bexley Neighbourhood Care 4. Chair, Local Medical Committee (LMC)

Jayne Garfield-Field

Member, Commissioning Strategy Committee (CSC)

Manager, Bexley Healthwatch.

Jill Webb Primary Care Commissioning Committee

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

Neil Kennett-Brown

Managing Director, Bexley and Greenwich CCGs


5 of 69P

rimary C

are Com


UB

LIC-13/02/19

1

ENCLOSURE: BAGENDA ITEM: 3/19

PRIMARY CARE COMMISSIONING COMMITTEEPublic Meeting

Wednesday 12th December 2018, 2.00-3.30pm Public Gallery West, Bexley Civic Centre DA6 7AT

Voting Members Present

Chair: Paul Cutler (PC) Lay member, patient and public Involvement Dr Anjan Ghosh (AnG) LBB Director of Public Health and Deputy Director of

Health & Wellbeing, Health and Wellbeing Board Representative

Dr Richard Money (RM) Bexley Local Medical Committee (LMC) Chair Dr Sid Deshmukh (SD) Bexley CCG Chair Dr Varun Bhalla (VB) GP Member, North Bexley Locality Lead Keith Wood (KW) Lay member, governance Mary Currie (MC) Registered Nurse Nisha Wheeler (NW) Director of Primary Care, ICT & Information Governance Theresa Osborne (TO) Managing Director

Non-voting members Jayne Garfield-Field (JGJ) Manager HealthwatchJill Webb (JW) Head of Primary Care, SEL Primary Care TeamMaxine Hastings (MxH) Assistant Head of Primary Care, SEL Primary Care

Team

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

Apologies Dr Jhumur Moir (JM) GP Member, Clocktower GP Locality LeadDr Sonia Khanna-Deshmukh GP member, Frognal Locality Lead(SK)Malcolm Hines (MH) SEL CCGs Director of Finance & Acting Chief Financial

Officer Michael Boyce (MB) Chief Operating Officer Neil Ross (NR) Lay member, legal & procurement

3.19 Previous minutes from 12-12-2018


2

Item No1. Standing items

65/18

65.18.1

Welcome and introductions

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

66/18

66.18.1

Declarations of Conflicts of Interest

The declarations of interest register was passed amongst attendees and signed by those present.

67/18

67.18.1

Review of minutes from the Primary Care Commissioning Committee meeting (held in public) on 17th October 2018

The committee approved the minutes of the Primary Care Commissioning Committee meeting (held in public) on 17th October 2018 as an accurate record.

68/18

68.18.1

Review of Action Log

The action log was reviewed and updated.

2. Matters Arising69/18

69.18.1

69.18.2

69.18.3

69.18.4

CROOK LOG UPDATE ON IMPROVEMENT PLAN

JW reminded members that the committee had decided to support a business case produced by the crook log practice. The business case had proposed the practice continue, subject to conditions including addressing quality issues and recruiting further partners to ensure resilience.

JW reported that improvements had been made in all the areas identified, and these conditions had been contractualised. A new GP partner had been recruited and work was under way to recruit a further GP partner, which was necessary to ensure resilience.

JW and NW thanked all those including Stella Babudoh and Sukh Singh who were working on the monthly monitoring meetings and praised the practice for their co-operative approach.

PC welcomed in particular the growth of the patient participation group at Crook log which indicated the health of the practice.

70/18

70.18.1

BEXLEY MEDICAL GROUP

NW noted that a business case had been submitted in relation to the extended use of premises. The business case had been reviewed by the PCCC in October but there remained unanswered questions and so a follow up meeting had been arranged with the practice to relay the feedback from the meeting and to enable the practice to consider how these suggestions might support them to meet the additional demand on the premises and thereby align with the Bexley estates strategy in optimising the use of all available space. Since the meeting, the practice had taken on board the comments and had proactively arranged visits to neighbouring practices to look at new ways of working such as e-consult.



3

71/18

71.18.1

71.18.2

71.18.3

71.18.4

71.18.5

CAIRNGALL CARETAKING UPDATE

NW updated members on the activities taking place in relation to the Cairngall surgery as outlined in the paper. A letter had been sent to residents informing them of the need to register with another practice, an easy-read version had been created and work had been on-going with Healthwatch, BVSC and the caretaker to identify patients who were vulnerable, housebound or frailty and consideration made as to what extra support could be offered. Four patient engagement sessions were scheduled to give patients the opportunity to talk to patients about any concerns they may have and to advise them of the support available to help them register with other practices. The patient experience team had received six contacts from patients with general comments and requests for advice.

RM advised that the LMC felt the concerns they had raised had not yet been addressed, particularly in regard to questions around funding. JW noted that a meeting held with the LMC had addressed a number of concerns including what funding might be available to support practices who may need to take on a large number of patients previously registered at Cairngall. The CCG was in a financially challenged position, and was not able to give additional support to practices outside the small allocation of resilience funding available.Conversations regarding the CCG’s proposal, in supporting the local practices within the mile and who would be most affected by the dispersal, took place with LWLMC colleagues who acknowledged and supported this.

NW noted that it was the intention of the CCG to keep the LMC updatedincluding at meetings such as this, and through the briefing report presented at the PCCC meeting today. RM noted it would be useful to have an update before the next PCCC or at the LMC liaison meeting.

Action: NW to arrange to update the LMC on progress with Cairngall before the next LMC liaison meeting.

KW enquired regarding the patients remaining to be re-registered who have not moved by the end of March. JW advised that significant numbers of patients who had reregistered so far had done so ahead of formal notification of the need to move which was encouraging. At the beginning of December a formal letter wassent out, and it was expected that patients would be written to up to again by early February. However from previous experience of dispersals across south east London, there will always be some patients who would not have registered. . Their records would be safeguarded and held in abeyance on behalf of primary care support NHS England until they choose to re-register.

72/18

72.18.1

72.18.2

PMS UPDATE

SS referred the committee to the proposed changes to the Personal Medical Services which had been presented to the last committee. Engagement had continued with GPs and patients, and the next step was a communication to practices together with a clear guide to the changes.

VB asked when the information would go out to practices noting that an early communication would be helpful. SS advised that practice communications would be sent out prior to the end of December.



4

3. Items for Decision73/18

73.18.1

73.18.2

73.18.3

73.18.4

73.18.5

73.18.6

73.18.7

PRIMARY CARE STRATEGY IMPLEMENTATION PLAN

SS outlined the implementation plan which had been requested at a previous committee. The plan had been subdivided into various areas, with milestones identified when delivery was expected to be complete. The plans were expected to evolve to include new schemes and the implementation of lessons learned.Implementation leads had been identified for each area.

∑ On workforce the plan was to acquire baseline data, as well as implementing training and up-skilling practice staff. A number of recruitment schemes were being implemented.

∑ Digital plans included empowering patients, as well as an interoperability tool so that clinicians could access records across south east London. Work would also be done to promote accredited NHS apps.

∑ Estates plans linked to key priorities such as Erith and Lakeside as well as the growth strategy.

∑ Sustainability and resilience would be assisted by the productive general practice programme due to complete in mid-march.

∑ Improving access provision of standardised guidance on patient registrations and share best practice ,

∑ Mental Health SMI physical health checks review. Funding secured to support physical health checks for those with SMI and to up-skill general practice staff.

∑ Learning Disabilities the primary care team were working with the LD subgroup to see what could be done to improve in this area.

PC welcomed the update which he thought reflected the things local people cared about in primary care.

AG asked if the system-wide prevention strategy could be linked in to the primary care strategy. SS confirmed this was the intention MC asked why some of the dates in the strategy were so far in the future. Noting that practice nurses were difficult to recruit, she asked what the CCG was doing at south east London level

SS noted that work was already underway. The CCG already had data on workforce, and so the implementation documentation focused on the on-going strategy. NW added that a number of schemes and initiatives are in train on each of the areas outlined above with some schemes such as best practice packs, videos and a programme of work on international recruitment have already been completed. Liz Nicholls was leading a ten-point nursing programme to bring in more nurses in collaboration with the CEPN and south east London STP.

RM relayed a comment from the LMC who had noted that the strategy did not relate to the 10 year plan. They also commented that although money had been provided for training on the serious mental illness reviews, there was no mention of funding for practices to carry out the reviews, and therefore a question about whether they could be completed in view of the challenges for practices.

The primary care commissioning committee APPROVED the implementation plan for the primary care strategy.



5

4. Items for Discussion74/18

74.18.1

74.18.2

PRIMARY CARE FINANCE REPORT

TO commented that previous reports had shown that the CCG had insufficient funding to meet the demands on the primary care allocation. The main pressures on the budget included the Cairngall dispersal as well as general practice pay awards. Representation to NHSE had not been successful in securing funding for the gap. The new REMOS scheme had been developed to replace the previous diabetes LES and PCIF payments and communications and training was under way. A small year-to-date underspend was being reported at month 7. Planning guidance had not yet been released for 2019/20. RM enquired about the reduction in notional rent for the Cairngall practice. TO confirmed that there would be some saving on this however it would be offset by the registration of patients at other practices at higher cost.

The primary care commissioning committee NOTED the primary care finance report.

5. Closing items75/18

75.18.1

75.18.2

Questions from members of the public

Sabi Ghosh commented that last year a successful patient and doctors meeting had been undertaken at his practice.

Hilary noted the positive news that crook log PPG had been increased and advised the Albion PPG had benefitted from the experience of Crook Log PPG members.

76/18 Any other businessThere was no other business.

6. Date of next meeting: Wednesday 13th February 2-3.30pm, Bexley Civic Centre



ENCLOSURE: C AGENDA ITEM: 4/19

Action Meeting Date

Action Agreed Lead Action Taken Date for completion

Status

71.18.5 12/21/2018 NW to arrange to update the LMC on progress with Cairngall before the next LMC liaison meeting and PCCC.

Nisha Wheeler

2/13/2019 open

Primary Care Commissioning Committee (public) Action log updated 12/12/2018

4.19 Review

of action log

11 of 69P

rimary C

are Com


UB

LIC-13/02/19

1

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

DATE: 13 February 2019

TitleProposal for a single-handed GP at Dr Thavapalan & Partners (Little Heath Surgery) to take on an additional signatory to the PMS contract

This paper is for decision

Recommended action for the primary care commissioning committee

The Primary Care Commissioning Committee (PCCC) is asked to approve:

1. The appointment of an additional signatory to Dr Thavapalan & Partners (Little Heath Surgery) PMS agreement with immediate effect.

Potential areas for conflicts of interest

N/A

Executive summary

Dr Thavapalan is currently a single-handed GP with a PMS contract at Dr Thavapalan & Partners (Little Heath) in Bexleyheath, Bexley. The raw list size as at 1.10.2018 is 4550 patients and Dr Thavapalan operates from a single site which is a converted house.

It is proposed that Dr Davies will become a contract holder with Dr Thavapalan at Little Heath with immediate effect. Neither Dr Thavapalan nor Dr Davies have been identified as having any issues of concern cases which might affect their abilities to hold a PMS contract.

The attached business case (Appendix 1) states that by forming a partnership it will provide stability and secure the ongoing future for the practice. It will enable Dr Thavapalan to reduce his sessions with a view to retire in 2020. Dr Davies will consider arrangements including engagement at a suitable point, of a further partner to hold the contract after Dr Thavapalan’s retirement. This will provide resilience to the practice and continuity of care for patients. The addition of Dr Davies will enable patients to see a female GP and patients will also be able to access services that are not currently available to them such assexual health and contraception including IUCD and implant services.

Little Heath currently has 1.3 WTE covering 10 sessions.

Little Heath’s performance is very good. The practice was inspected by the

ENCLOSURE: D1

AGENDA ITEM: 5/19

Primary care commissioning committee (held in public)

5.19 Littleheath Practice Business Case


2

CQC on 5th May 2016 and rated as ‘Good’ overall for the standard of care provided and for every domain. According to the GP Indicator Practice Rating the practice is the only one in Bexley to be a ‘Higher Achieving’ practice. Based on 15 ratings, NHS Choice user’s overall rating for the practice is 4.5 stars. The practice’s FFT rating for ‘% likely to recommend GP service to friends and family’ is consistently high at 92% and currently 97% of patients say they find it easy to get through on the phone on the GP Patient Survey.

The practice does not currently have a PPG with which to consult, however the Business Case confirms that the practice had a pre-arranged meeting with the CCG patient experience team in January to discuss establishing one.

Recommendation:

The Primary Care Commissioning Committee is requested to approve the appointment of an additional signatory at Little Heath with immediate effect for the following reasons:

- Dr Thavapalan has been a single-handed GP since 2009- The practice list size is steadily growing, partly due to the dispersal of a

local practice. Little Heath is already absorbing the second highest number of patients which is predicted to rise right up to the closure of the practice at the end of March 2019

- The practice is a ‘higher achieving’ practice with consistently high FFT results, 4.5 stars on NHS Choices and 97% of patients say that they find it easy to get through on the phone (GP Patient Survey)

- An additional signatory will provide stability and secure the ongoing future of the practice, thus ensuring sustainability and resilience of medical services for the patients of the area

- Dr Davies will provide services that are not currently available to the patient population, e.g. sexual health and contraception including IUCD and implant services

- A partnership will strengthen the clinical team and support Dr Thavapalan

- The partnership will allow for continuity of care for patients- The addition of a signatory is cost neutral to the CCG

The recommendation is subject to:

- a Business Case coming forward, in parallel with Dr Thavapalan providing notice of his intention to retire, to confirm the remaining Contractor’s proposals in respect of patient care after Dr Thavapalan retires

- The practice confirming that they have established a Patient Participation Group (PPG)

-



3

What are the organisational implications

Key risks

If the PCCC was not to approve an additional signatory to the PMS contract, the current single-handed contract holder would remain vulnerable with respect to sustainability and resilience

Equality

The addition of this new signatory will provide both existing and future registered patients with access to a broader range of primary medical services than is currently provided

FinancialNo additional costs to the CCG for adding a signatory to the contract.

Author: Sally-Ann Sheppard, Commissioning Manager (SELPCT)

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

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

Attachments

Appendix 1 (Business Case)Appendix 2 (Criteria for considering an additional clinical Contract signatory)



of 7

BUSINESS CASE

Additional Partner

Pamela Clark Practice Manager

[email protected] 449327

November 2018

DR. THAVAPALAN & PARTNERS

55 LITTLE HEATH ROAD BEXLEYHEATHKENT DA7 5HL



of 7

Contents

PageNo.

1 Executive Summary 32 Proposal 33 Practice/s Information 34 Case for Change 35 Financial Costs of the Proposal – Recurrent and

Fixed4

6 Comments / Issues 47 Appendices 4



of 7

1. Executive Summary

The purpose of this Business case is to seek approval from Commissioners to take on Dr. Davies from with immediate effect.The recent influx of patients due to a local Practice closure due in March 2019 has increased the Practice list size from 4300 at 1st April 2018 to current date of 4785. In the past year a relocation of another Practice premises locally (Bexley Group Practice) and its branch closure also resulted in patients registering with this Practice rather than travel further to the new premises.

The Practice prior to 2000 was originally a three Partner Practice, two female and one male. From 2002 the Practice became a two male Partner Practice. At present this is a single-handed Practice since 2009/2010 with the addition of a Salaried Partner, both male. The Practice list size did initially fall from 6000 in the year 2000 partly due to loss of female Partners, which would be addressed by Dr. Davies joining the Practice and will help with continuity of care in areas such as childhood assessment and family planning in the absence of the Senior GP.

Increased and enhanced services will be provided by the addition of another Partner to help with thecontinuing workload enabling the remaining partners and other clinicians to concentrate on specialist areas for example joint injections, family planning, childhood immunisation and under 5 years clinics. which at the moment is being provided by only one GP.

2. Proposal

The Business Case for Dr. Thavapalan & Partners is necessary to enable the Practice to secure a future for both the Practice and the patients going forward. To enable patient care in partnership with other health care providers both in the community and secondary care.

The objectives of the Practice are continued personal service to the patient population. Providing continuing healthcare and support by a dedicated team.

The need for an additional GP Partner with the eventual retirement in 2020 of the existing Senior Partner is essential. The plan is a staged retirement with Dr.Thavapalan already reducing his working days from four days a week to two days a week. As part of Dr Thavapalan’s retirement and in order to maintain practice resilience, the incoming partner is looking at options such as engaging a further partner following Dr Thavapalan’s retirement.

3. Practice/s Information

The Practice has served the local population since 1974. The Practice population in the past was of a higher of proportion of elderly patients, this is slowly changing with more 25 to 65-year olds joining the list, although the elderly population is still high the 25 years to 65 years are steadily increasing.

November FFT report scoring 91% and 94% in December 2018 placing us 7th in the locality, not falling below 88% since April 2018 recommendation by patients. (See exert from PCART).



of 7

Friends & Family Test Responses (Latest 12 months) - Dr Thavapalan & Partners

Month Responses Rank* RecommendedNot

RecommendedNeither

Jan 2018

49 1 100% 0% 0%

Feb 2018

50 16 88% 6% 6%

Mar 2018

50 12 90% 6% 4%

Apr 2018

51 15 88% 2% 10%

May 2018

49 2 96% 0% 4%

Jun 2018

50 8 94% 0% 6%

Jul 2018

50 2 96% 2% 2%

Aug 2018

49 10 92% 2% 6%

Sep 2018

49 7 94% 2% 4%

Oct 2018

51 7 94% 2% 4%

Nov 2018

53 13 91% 4% 2%

Dec 2018

50 7 94% 4% 2%

NHS Choices rating is 4.5 out 5 stars.

With the maximum QOF points earnt in 2017/2018 a total of 555.08 on 31.03.2018.(See below data from PCART).

Achievement Domains

Financial Year

Practice Achievement

%

Bexley CCG

Average %

England Average

%

Clinical Domain Achievement

2013/14 88.4 % 92.2 % 92.3 %

2014/15 97.4 % 96.7 % 94.5 %

2015/16 97.8 % 96.8 % 95.1 %

2016/17 98.2 % 97.4 % 96.1 %

2017/18 99.0 % 95.5 % 97.1 %



of 7

Public Health 2013/14 94.0 % 95.2 % 93.6 %

2014/15 100.0 % 97.6 % 95.3 %

2015/16 100.0 % 97.2 % 95.7 %

2016/17 100.0 % 97.0 % 96.8 %

2017/18 100.0 % 95.8 % 97.8 %

Public Health Additional Services

2013/14 100.0 % 96.9 % 97.2 %

2014/15 100.0 % 99.1 % 97.3 %

2015/16 100.0 % 99.2 % 96.9 %

2016/17 100.0 % 99.1 % 97.0 %

2017/18 100.0 % 98.4 % 98.0 %

Overall 2013/14 91.4 % 94.0 % 92.4 %

2014/15 98.0 % 97.0 % 94.7 %

2015/16 98.3 % 97.1 % 95.4 %

2016/17 98.6 % 97.5 % 96.4 %

2017/18 99.2 % 95.8 % 97.4 %

Prescribing in the Practice is minus 5% within Bexley CCG.

The Practice CQC rating in July 2016 was overall ‘Good’.

The population of the Practice as at

The breakdown of patients is as follows,

∑ under 25 year olds = 1141, ∑ 25 year old to 65 years = 2434∑ Over 65 years = 1182 which is 24.8% of the patient population

The patient disease register is varied across the various chronic diseases.

The Staff team is made up:

Senior Partner - Dr. M. Thavapalan - MBBS, MRCS,LRCP, MRCGP, DFSRH – 4 sessionsSalaried GP - Dr. S. Shah - MBBS, MRCGP – 6 sessionsNurse Prescriber - Sharon Gull – SRN, - 6 sessionsHealth Care Professional - Carla Williams – 4 sessionsAssistant Practitioner - Lisa Belsey – 4 sessions

Dr. Davies is currently working 4 sessions in the Practice awaiting approval to sign the contract as a Partner. Dr. Thavapalan at the present time takes the lead role for many areas within the Practice. This could be shared with Dr. Davies, for example Dr. Davies has already agreed to take the lead for palliative care.

Practice Manager - Pamela Clark - AMSPAR DPCHM – 24 hours per week(Diploma in Primary Care & Health Management)



of 7

Practice Administrator - Doreen Wiltshire – 30.00 hours per weekPractice Secretary - Elaine Sharpe- 32.00 hours per weekSenior Receptionist - Rita Mumford – 30.00 hours per weekReceptionist - Sally McLellan – 22.50 hours per weekReceptionist - Anne Green – 23.50 hours per weekReceptionist - Sandra Green – 17.50 hours per weekReceptionist - Suzane Crook – 17.50 hours per weekReceptionist - Sharon Platt – 23.0 hours per week

4. Case for Change

The reason for the proposal for an additional Partner is the eventual retirement of the Senior Partner in future years, and to give stability for the future of the Practice and continuity of care for patients.

There is also an increase in Practice patients due to a local Practice closure in March 2019. Patients from the closing Practice have been informed by NHSE and CCG of the closure and that we are within the Practice catchment area. As a result, we have a steady stream of patients registering with us. This will continue until March 2019.

With this increase in patient population there is a need for additional GP sessions. The plan to recruit an additional Partner who is also a female will be an asset to the Practice, particularly with the increased ability to offer female patients not only a female to female consultation but also increased ability for the Practice to provide sexual health and contraception appointments and treatments, including IUCD and implant services. Previously only Dr. Thavapalan provided these services in addition to minor surgery and joint injections. We don’t have a PPG; however I have a pre-arranged meeting with Lotta Hackett CCG on 17th January 2019 to advise on setting up a PPG, which Dr. Davies is interested in taking the lead role to work with the PPG.

With a view to set up a patient participation group to include all the previously registered and newly registered patients working together to develop the Practice going forward into the future.

Which enables the Practice to provide an enhanced service delivery to all patients with the possibility of additional sessions or possible changes to the Practice opening hours.

The current structure of the Practice is a converted house with a third consulting room not being used at present which can accommodate an additional Partner. Allowing the need to evolve to fit in with future commissioning frame work in General Practice. Workload as in all Practices has increased over the years and will continue to increase.

With the addition of a new Partner these challenges could be met by changes in the workforce to enable the workload and sustainability for the Practice and patients in the future.

Access to services will be increased with the possibility of additional clinical support in the future.Enabling continuity of patient care within an established General Practice.



of 7

5. Financial Costs of the Proposal – Recurrent and Fixed (Where applicable)

The affordability of the proposal will be sustained by agreement between the Partners to divide the profits of the Practice.

The Leasehold will remain with Dr. Thavapalan as the sole owner. Cost neutral to Bexley CCG.



Changes to Contract Signatories

London Area TeamsSingle Handed PMS Practices - Criteria for consideration of an additional clinical Contract signatory

Practice Name Dr Thavapalan & Partners (Little Heath Surgery) Raw List Size 1.10.2018 4550Single Handed PMS Providers’ Name

Dr Thavapalan CCG Bexley

Date Application Made 5/11/2018 Area Team SELPCTReport Template Completed by

Sally-Ann Sheppard Date completed 05/01/2019

Date of PCCC 13 February 2019 Outcome Approved/Approved with Conditions/RejectedPanel Members

All of the following criteria will need to be met for the application to be approved:

Assessment Criteria Guidance Notes/Evidence that needs to be attached

Presentation of Case

There is a strategic need for the practice to be retained, from an SELPCT & CCG perspective

Include relevant background – number of WTE providers, teaching practice, local demography, has this practice had multiple signatories in the past. Evidence of feedback from the CCG. Detail the links to the primary care strategic direction locally e.g. information about relationship with local practices, new developments, engagement with CCG priorities

- Single handed PMS provider- Currently 1 single hander looking to add 1 new signatory, Dr Davies, to

the PMS Agreement- According to the National Workforce Reporting System on the Primary

Care Web Tool, the practice has 1.3 WTE covering 10 sessions per week- Dr M Thavapalan covers 4 sessions per week with a patient list size of

4550 (1.10.18)- 1 Salaried GP Dr S Shah covering 6 sessions per week- In addition, Dr A Davies currently works 4 sessions per week- 1 Nurse Prescriber covering 6 sessions per week- An analysis of list size changes over the past 2 years shows there has

been an increase in patient numbers (175) (4375 patients 1.10.2017 to 4550 patients 1.10.2018)

- The Business Case states that the practice is taking on patients as a direct

5.19 Littleheath Practice B

usiness Case

22 of 69P

rimary C

are Com


UB

LIC-13/02/19

result of a dispersal of a local practice. This is confirmed by the tracking of patients by PCSE from the dispersing practice which shows that from2.8.2018 – 3.1.19, Little Heath has registered 240 patients from this practice which equates to 7% of the total (the second largest number of patients a local practice has taken on)

Demographics – the practice has a higher than average percentage of over 65 (24.5%) and 75 (10.4%) year olds compared to both the CCG (16.6%, 7.9%) and national (17.3%, 7.8%) averages. It has a social deprivation score of 10.2 which is considerably lower than the CCG average (16.2) and national average (21.8).

- The practice has confirmed that it does not currently have a Patient Participation Group (PPG) which needs to be remedied as this is a contractual requirement. However, the Business Case confirms that the practice had a pre-arranged meeting with the CCG patient experience team in January to discuss establishing one.

- The proposal is cost neutral to NHS Bexley CCG- The retention of the practice will provide additional choice of provider

for patients, thus ensuring that the CCG fulfils its requirement to ensure patient choice

- Dr Thava has confirmed that he intends to start to reduce his sessions over the next 2 years in preparation for his full retirement in 2020. The addition of Dr Davies will provide patients which continuity of care and the practice with stability, offering patients the chance to have access to a female GP and additional services such as sexual health and contraception including IUCD and implant services

Performance of the single handed Contractor does not give cause for concern

If any provider linked to the Contract is voluntarily not working, suspended by the GMC or NHS England, or unable to work by virtue of Bail conditions, this would automatically give cause for concern

Neither Dr Thavapalan nor Dr Davies have been identified as having any issues of concern cases which might affect their abilities to hold a PMS contract.


usiness Case

23 of 69P

rimary C

are Com


UB

LIC-13/02/19

Practice performance does not give cause for concern

Evidence should include information for the past three years in relation to:

- QOF- GPOS/GPHLI performance- Contractual Sanctions

And, where applicable, evidence that action plans are in place and being actioned. Feedback from NHS Choices

Current Practice Performance

- GP Indicator Practice Rating (Primary Care Web Tool): The practice is a ‘Higher Achieving’ practice with only 1 Level 1 trigger for Cervical Screening. This is the only practice in Bexley to have this rating

- NHS Choices – based on 15 ratings, NHS Choices user’s overall rating for the practice is 4.5 stars

- The practice’s FFT rating for % likely to recommend GP service to friends and family is 92% (CCG average 87%)

- GP Patient Survey 97% of patients say that they find it easy to get through on the phone (CCG average 65%)

- 98.6% QOF achievement for 17/18 (CCG average 98%)

There are no contractual sanctions for the practice on file.

The practice has confirmed that they do not have a PPG so have not consulted with regards to the addition of a partner. However, the Business Case confirms that the practice had a pre-arranged meeting with the CCG patient experience team in January in order to discuss establishing one.

Has premises that are fit for purpose in accordance with minimum standards set out in 2013 GMS Premises Costs Directions, or has Business Plan to achieve within no more than 12 months

Provide available information about the premises and any commitments made by the Contractor to address outstanding issues within the required timeframe. Outcome of infection control visit and outcome of CQC inspection if either or both have been undertaken

The surgery is a converted residential dwelling and the business case confirms that they do have adequate room and one consulting room is not currently being used. This will accommodate another partner and predicted future growth of services.

Outcome of last CQC inspection on 5th May 2016:

The practice was rated overall as ‘Good’ for the quality of care provided. The practice was rated as ‘Good’ for all 5 of the following domains: ‘are services safe?’, ‘are services effective?’, ‘are services caring’, ‘are services responsive?’ and ‘are services well-led?’


usiness Case

24 of 69P

rimary C

are Com


UB

LIC-13/02/19

The practice’s last Infection Control visit was in October 2015 and the practice was compliant.

Has specified a clear plan of service improvements that will arise as a result of changes in numbers of partners

A business case should be supplied by the practice that sets out their future plans (it is not expected that an application which facilitates 24hr retirement of the Contractor will meet the criteria). At the minimum this should include a commitment that GP premises and phone lines will be open throughout core hours

The practice has submitted a business case outlining their future plans (see attached Appendix 1). The additional signatory will provide services that are not currently available to the patient population, e.g. sexual health and contraception including IUCD and implant services

Has a list size that can demonstrably sustain proposed WTE extra partner increase

The business case should demonstrate this (this would typically be 5000+ patients)

The list size can sustain the proposed partner increase. Little Heath currently has 1.3 WTE covering 10 sessions per week (Dr Thava covers 4 sessions and the Salaried GP Dr Shah covers 6 sessions).

CV of proposed new provider does not give commissioners cause for concern

The CV should be attached. If the proposed new provider is not yet known it is possible to approve the request subject to review of the CV prior to final approval

The proposed new Partner is not on the Medical Directorate’s Issue of Concern list.

SELPCT recommendation to the panel

Any other relevant information not included elsewhere

Commissioner’s recommendation is to approve the application for the following reasons:

- Dr Thavapalan is a single-handed GP- The practice is a ‘higher achieving’ practice with consistently high FFT

results, 4.5 stars on NHS Choices and 97% of patients say that they find it easy to get through on the phone (GP Patient Survey)

- The practice list size is steadily growing, partly due to the dispersal of a local practice, Little Heath is already absorbing the second highest


usiness Case

25 of 69P

rimary C

are Com


UB

LIC-13/02/19

number of patients which is predicted to rise right up to the closure of the practice at the end of March 2019

- A partner will provide stability and secure the ongoing future for the practice, allowing for the staged retirement of Dr Thavapalan

- A partner will strengthen the clinical team and support Dr Thavapalanwith clinical governance and leadership

- Dr Davies will provide services that are not currently available to the patient population, e.g. sexual health and contraception including IUCD and implant services

- The premises is suitable for the addition of a partner and allows for future growth

- Continuity of care for patients- Cost neutral to CCG


usiness Case

26 of 69P

rimary C

are Com


UB

LIC-13/02/19

1

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

DATE: 13th February 2019

Title

Bexley bid for unspent resilience funding 2018/2019 in respect of Cairngall Medical Practice

This paper is for approval


That the primary care commissioning committee members are asked to note the contents of this paper and to endorse the suggested methodology proposed in support of implementing a consistent process for distribution of resilience funds if a future need arises. The information in this paper relates to a recent bid made by the CCG for unspent resilience funding 2018/2019 in support of the significant increase in workload being undertaken by those practices in the near vicinity of Cairngall Medical Practice which is currently in the process of being dispersed. All remaining registered patients are being encouraged to register at alternative practices by 31st March 2019.


Those practices directly affected by the dispersal including Belvedere Medical Practice which due to its proximity to Cairngall Medical Practice is being impacted the most by the numbers of new registrations.

Executive summary

On the 8th January, SEL CCG’s primary care leads received communications from the STP that confirmation had been received from the regional London HLP team that South East London will be receiving additional 2018/19 GP Resilience funding. Whilst this funding was allocated to STP areas based on a 50% fair shares and 50% needs based approach, SEL STP agreed that bids at such short notice needed to satisfy the criteria set out below. The overall London allocation has been confirmed from the regional London HLP team as £879k.

Local areas were invited to submit proposals for the additional GP Resilience funding before the 16th January including evidence of how their proposal would meet the following criteria;

ENCLOSURE: E1

AGENDA ITEM: 6/19


6.19 Bexley Bid for resilience funding


2

• Evidence that funding will stabilise access to primary care following dispersal of a large number of patients and/or • Evidence that funding will support practices to deliver on CQC actions and • Evidence that funding is required and will be used in the last quarter of 2018/19 The attached proposal sets out the rational for the additional funding being sought by Bexley CCG in support of the Cairngall Medical Practice dispersal and the proposed methodology and distribution of sums awarded

to support this process. The total funding requested was £178,732 and was set out into 3 distinct categories as follows: 1. Patient registration activities - £133,834 Through the benefit of fortnightly monitoring of patient flows for this dispersal, it has been possible to estimate a reasonably accurate forecast of patient transfers from Cairngall Medical Practice to those practices in the local area. The workload burden involved for these practices can be significant and can add additional strain on workforce, access to appointments, patients experience and potentially premises. Therefore it has been proposed that a payment of £20 per newly registered patient is made to practices that have seen an increase in list size by a minimum of 2% of their registered patient list size. 2. CCG support - £9,293 The proposal outlines a case for support towards costs that the CCG has undertaken in light of the need to increase both communications activities and support activities to ensure all registered patients, including those with protected characteristics are f adequately informed of the dispersal and supported as necessary to re-register at a new practice. This also includes support towards the administrative redundancy costs that have arisen as a consequence of this practice closure. 3. Cairngall Medical Practice closure activities - £35,605 Through regular communications with the caretaker, concerns were raised relating to undisclosed contracts that were agreed prior to the caretaking contract coming into effect. There are two contracts in particular – these being Niche Health – provision of patient record storage and Intradoc – practice collaboration and sharepoint tool. Neither of these contracts were disclosed by the GP contractor prior to her resignation and neither of which the caretaker had signed up to. In addition to this, it is clear that further close down activities relate to the physical closure of the practice and its premises involving the safe transfer of equipment, destruction of old files, safe transfer of records, printing and transfer of records to PCSE for those patients who have not transferred to another practice by the deadline and on-going support for the management of correspondence and patient



3

transfers for six months post practice closure. The SEL response to the proposal that was submitted for Bexley CCG resulted in an award of £104,000. Recommendations were received as follows:

1. Patient registration activities - £100,000 was supported and recommended as a contribution to this cost.

2. CCG support - £2,500 supported and recommended for the work undertaken to assist practices with managing registrations for vulnerable patients.

3. Subsequent to the award notification, confirmation of a further £1,500 was received from the SEL primary care team in lieu of slippage from other funds.

Members are reminded that in addition to this award, the CCG had reserved £7,307 of its resilience funding allocation for this year which was to be used to provide a modest contribution to practices. This will now be combined with the SEL STP award providing for an overall sum total of £111,307 to support the final stages of this dispersal. Recognising the constraint in the budgetary target awarded, members are asked to further consider the need to reduce the proposed sum of £20 per new patient registration to £15 which would amount to a total of £100,375 which would be broadly in line with the sum awarded for patient registration activities. If this were approved then there would remain a funding gap of circa £35k which the CCG would need to identify. There are a number of options which could be explored to cover this small difference namely;

CCG is currently challenging circa £15k of the potential costs which are related to the Cairngall undisclosed contracts;

Review the primary care financial position to establish if there are any further prior year accruals which could be reversed to cover some or all of the shortfall;

Review current year accruals to establish if there are any areas which are currently being over accrued e.g. locum, PMS premium, caretaking arrangements etc

PCCC members are asked to discuss the contents of this paper and to endorse the methodology proposed in support of implementing a consistent process for distribution of resilience funds if a future need arises and approve the reduced sum proposed per new patient registration based on the limitations of the award received.



4


Key risks

Practices in the surrounding area of Cairngall Medical Practice are taking significant numbers of new registrations requiring considerable additional administration activities leading to lack of resources and capacity.

Equality

To enable a fair and transparent methodology of providing additional resilience assistance to those practices affected by this dispersal.

Financial

Through the SEL STP bidding process for unspent resilience underspend funding, the CCG has been awarded £104,000 to support both the practices impacted by the dispersal and some of the close down activities identified in relation to the practice closure. In addition, the CCG had reserved £7,307 of its resilience funding allocation for this year which was originally going to be used to provide a modest contribution to practices. This will now be combined with the SEL STP award providing for an overall sum of £111,000 to support the final stages of this dispersal.

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

Clinical lead: Dr Sid Deshmukh, Chair Bexley CCG

Executive sponsor:

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

Attachments Appendix 1 Proposal



of 3

Additional 18/19 GP Resilience Funding It has been confirmed from the regional London HLP team that South East London will be receiving additional 2018/19 GP Resilience funding. This will be allocated to STP areas following a 50% fair share and 50% need based approach. Exact amounts are yet to be confirmed, but the overall London allocation has been confirmed from the regional London HLP team as £879k. Funding will be prioritised for local proposals against areas of immediate and pressing need to support resilience in SEL (and funding will not, therefore, be equally split between CCGs).

Local areas are invited to submit proposals for the additional GP Resilience funding before the 16th January including evidence of how the proposal will meet the following criteria;

Evidence that funding will stabilise access to primary care following dispersal of a large number of patients and/or

Evidence that funding will support practices to deliver on CQC actions and

Evidence that funding is required and will be used in the last quarter of 2018/19 Please provide brief responses to the question below, attaching any relevant evidence as appropriate, including draft proposal documents that may already developed. Please return to [email protected] by 16th January.

STP South East London

CCG Bexley

Name of Practice Belvedere Medical Centre

Proposal title Support for Cairngall Medical Practice dispersal

Proposal cost £178,732.94

Current CQC rating Good

Heatmap information Achieving practice

Proposed by (name) Nisha Wheeler

Date 10/01/19

Email [email protected]

Tel 0208 298 6195

1. Explanation of why the proposal for funding is required:

Cairngall Medical Practice (CMP) in Bexley is one of the larger practices in Bexley and which is subject to a dispersal after an earlier procurement process in the year had to be withdrawn due to the landlords (3 GP partners and one executor of a deceased GP partner), not being able to come to a consensus for making available the premises for on-going healthcare provision. This is a significant dispersal and the largest in London at 9,000 patients and this proposal is seeking resilience funding to be awarded to support practices within close proximity of CMP, who are taking significant numbers of registrations from dispersed patients and having to deal with the administration, management and handling challenges that this brings. Belvedere Medical Centre (BMC), is currently the care-taking provider for CMP, and is also the closest located GP practice in the vicinity of CMP at 0.3 miles away. It is anticipated (based on current trends) that BMC will take on two-thirds of the dispersed patients (approximately 6,000 patients) from Cairngall Medical Practice. There are 5 other local practices within 1 mile of CMP who are also taking on significant numbers of patients and are also struggling to manage the volume of patients and administrative duties

ENCLOSURE: E2

AGENDA ITEM: 6/19





of 3

required in the safe and secure registration of new patients. This proposal aims to recognise the additional workload challenges that these practices are facing, in particular Belvedere Medical Centre, as a consequence of the largest practice list dispersal and consequently is seeking support to help them address the sheer volume of work that is now required of them.

2. Outline of the proposal (including links to current or on-going work):

Support for patients in completing registration forms. Care taker will help to identify all vulnerable patients and support them to re-register at another practice, making them aware of the choices available and supporting them to complete forms as necessary Healthwatch support for re-registering vulnerable patients, including:

Learning Disabilities

Mental Health register

Dementia register

Frailty diagnosis

Palliative register

Child protection

Housebound

Homeless or living in Hostel Support for retrieval of medical records from Niche Health Support for practices that register more than 2% or more of the patient list size in the process of summarising and registering patients at the practice Support for additional communication to patients (SMS and letter) on the closure Support with physical practice closure i.e. safe transfer of records, secure destruction of old files, transfer of equipment Support for remaining unregistered patients printing and transfer of records to PCSE Support for management of correspondence and patient transfers post-practice closure Support with on-going telephony provision and mail redirects post practice closure Continued clinical system access to that the caretaking provider can support on-going activities post practice closure for a further 6 months Support for payment of Cairngall Medical Practice redundancy costs

3. Has the Practice previously received resilience funding? If so, please state when and how much.

The CCG were allocated a small resilience fund of £30,327 of which £7,307 was allocated to practices receiving more than 50 patients pro rata to the number of patients registered post registration. This funding excluded Belvedere Medical Centre as they have an open book arrangement for costs to be reconciled post practice closure. With the opportunity of accessing additional resilience funding, the CCG would like to apply a more consistent and systematic approach to the support arrangements in place for practices receiving dispersed patients and in so doing could also include Belvedere Medical Centre in this process than to rely on an open book process for reconciliation post the dispersal. With this in mind, the proposal would be to support those practices who register 2% or more of the patient list size and provide £20 per patient over the 2% in support of the increased administration, management and handling required for these patients.

4. Overview of costs, timescales and proposed implementation dates:

As the Cairngall Medical Practice dispersal has been on-going since July 2018 and is due to



of 3

complete by the 31st March 2019, it is fair to say that the dispersal activities and trends in patient behaviours have subsequently enabled more accurate forecasting of support costs requested in this bid and which are illustrated in the spreadsheet attached. Support requested as below:

Patient registration activities outlined below - £133,834.58 o Support for practices that register more than 2% or more of the patient list size in

the process of summarising and registering patients at the practice

CCG support outlined below - £9,293.00 o Healthwatch support for re-registering vulnerable patients, including:

Learning Disabilities Mental Health register Dementia register Frailty diagnosis Palliative register Child protection Housebound Homeless or living in Hostel

o Support for additional communication to patients (SMS) on the closure o Support for payment of Cairngall Medical Practice redundancy costs

Cairngall closure activities - £35,605.36 o Support for retrieval of medical records from Niche Health o Continued clinical system access to that the caretaking provider can support on-

going activities post practice closure for a further 6 months o Support with physical practice closure i.e. safe transfer of records, secure

destruction of old files, transfer of equipment o Support for remaining unregistered patients printing and transfer of records to

PCSE o Support for management of correspondence and patient transfers for 6 months

post-practice closure

5. If applicable, what is the evidence that funding will stabilise access to primary care following dispersal of a large number of patients:

Belvedere Medical Centre have a significant challenge to overcome in continuing with care-taking provision of Cairngall, supporting the closure of the practice and the re-registration of approximately 6,000 patients at their own practice. The dispersal of this volume of patients presents a significant challenge across Bexley practices, but is felt most by Belvedere Medical Centre, without funding support, this has the potential to de-stabilise access to primary care for patients of both CMP and Belvedere Medical Centre.

6. If applicable, what is the evidence that funding will support practices to deliver on CQC actions:

N/A

7. Evidence that funding will be used in the last quarter of 2018/19:

Practice closure will conclude at the end of March 2019. Funding will be used within this period.



1


Title

Cairngall Medical Practice update

This paper is for information


That the primary care commissioning committee note

1. Actions since the last update to PCCC 2. Communications with the current caretaking provider 3. List size changes 4. Timeline of activities to date

*delete as applicable


Local practices who may take on registration of Cairngall patients and caretaking provider

Executive summary

The following paper provides an update on Cairngall Medical Practice (CMP) since the last Primary Care Commissioning Committee in December 2018.


Key risks

Actions taken look to mitigate risks that patients and local practices may not be sufficiently supported to ensure adequate general practice provision.

Equality

Ensuring equitable support and access available to all patients registered at Cairngall Medical Practice.

Financial

Communications and engagement processes may incur financial and resource costs.

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

Clinical lead: Dr Sid Deshmukh, Chair Bexley CCG

Executive sponsor:

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

ENCLOSURE: F1

AGENDA ITEM: 7/19


7.19 Cairngall - caretaking update


1

Cairngall Medical Practice update – February 2019 The following paper provides an update on Cairngall Medical Practice (CMP) since the last Primary Care Commissioning Committee in December 2018.

Patient engagement A letter reminding patients of the impending closure of the practice and the actions they need to take to re-register at alternative practices has been sent to all CMP registered patients on 1st December 2018. A further letter has been sent to patients on 31st January 2019, including an easy read letter version to those patients on the learning disabilities register. The CCG has been working closely with CMP and Healthwatch to identify vulnerable patients who may need additional assistance in registering with a new practice. At the time of writing this report, the number of patients requiring re-registration has dropped from 226 patients identified by CMP in December, to 118 patients, which includes patients with the following characteristics:

Learning Disabilities

Mental Health

Dementia

Frailty diagnosis

Palliative care

Child protection

Housebound

Homeless or living in Hostel Four patient information sessions in December 2018 and January 2019 were held with very low uptake, a total of 12 patients attended the events and were provided with an opportunity to raise any concerns or questions they may have in relation to the practice closure and registration process. Following the patient information sessions, the frequently asked questions (FAQ’s) document was updated and republished as a result of the questions raised. There have been 5 patient contacts made to the CCG’s patient experience team regarding CMP in December 2018 - January 2019 which covered the following:

Flu vaccination enquiry

Registration queries, including how long it takes for records to transfer, support for repeat medications and general advice/guidance

ENCLOSURE: F2 AGENDA ITEM: 7/19



https://www.cairngall.co.uk/mf.ashx?ID=c5bc464d-54ec-4533-aaf1-2b520aefa8bf

2

Communications with the current caretaking provider A fortnightly contact with the caretaker continues to take place which allows the practice to raise any questions that have arisen in the month and enable officers to address and support as necessary. Where urgent matters arise in between this period, the caretaker makes direct contact with the primary care team who will support as necessary. In addition the CCG have submitted a bid for additional 18/19 London GP resilience unspent funding available to support practices who are undertaking significant work in the registration processes, patient communications and registration support for vulnerable patients

List size changes for Cairngall

Cairngall Medical Practice G83005

Quarter Raw Patient list

size Transferred Patients in the previous fortnight

01/07/2018 Q2 18/19 8868

05/07/2018 Q2 18/19 8868

19/07/2018 Q2 18/19 8739 -129

02/08/2018 Q2 18/20 8588 -151

16/08/2018 Q2 18/21 8414 -174

30/08/2018 Q2 18/22 8181 -164

13/09/2018 Q2 18/23 7892 -266

27/09/2018 Q2 18/24 7658 -217

11/10/2018 Q3 18/19 7383 -238

25/10/2018 Q3 18/19 6967 -381

08/11/2018 Q3 18/19 6596 -341

22/11/2018 Q3 18/19 6191 -287

06/12/2018 Q3 18/19 5766 -372

20/12/2018 Q3 18/19 5266 -412

03/01/2019 Q4 18/19 5041 -188

17/01/2019 Q4 18/19 4567 -428

The July data above is for July 1st (8868), latest figures available for 17th January show 4567 patients currently registered at the practice – 3,748 registrations elsewhere.

Updated timeline of activities to date

Date Event

December 2017 Sole partner resigns with 1 months’ notice

December 2017 Caretaker procurement launched publication of the procurement documentation for the caretaking contract took place on the 22nd December 2017 with the subsequent contract award being notified on the 25th January 2018 to Belvedere Medical Centre.



3

The temporary contract started on the 1st February 2018

January 2018 In parallel to caretaking procurement, the CCG had been working with NHS England colleagues leading the London APMS Tranche 6 procurement programme for the substantive contract for Cairngall Medical Practice due to commence from 1st October 2018

February – June 2018

Various discussions with landlord representatives to align on-going lease or sale of property to GP property services company

February 2018 – present

Monthly meetings with caretaker to ensure PC provision being maintained

April 2018 Caretaker puts forward business case to close Cumberland Drive branch surgery with effect from 1st July 2018

May/June 2018 Several meetings with Stuart Rowbotham to advise of estate issues and what CCG was doing

12th June 2018 Meeting with Councillor Diment (Councillor Newton on leave)

18th June 2018 PCCC urgent planned meeting

18th June 2018 Meeting with landlords

22nd June 2018

Meeting with Councillors Diment and Newton

26th June 2018 All Belvedere ward councillors sent an email and letter

28th June 2018 Email and letter sent to Councillor Ogundayo (OSC leader of opposition and Teresa Pearce MP

2nd July 2018 Letter sent to all patients of CMP advising of decision made

5th July 2018 Meeting with Cairngall Medical Practice Patient Participation Group (PPG) to discuss decision made and approach for engagement of patients

10th July 2018 Easy read letter sent to 43 patients identified by practice

26th July 2018 Meeting with Belvedere ward councillors (councillor Putson joined very bear the end and therefore missed the conversation)

1st August 2018 Email from Councillor Francis – responded to when Director of Primary Care returned from leave 4th September



4

18th September 2018

Further meeting held with PPG to discuss additional letter that has been developed to give to routine patients of Cairngall Medical Practice highlighting nearby practices and support available to them for registering with a new practice in the local area

10th October 2018

CCG meeting with clinical system supplier to agree approach to managing the practice closure

9th November 2018

CCG meeting with Londonwide LMCs to discuss Cairngall Medical Practice dispersal and support available for local practices

14th November 2018

CCG Information Governance Officer met with Cairngall Medical Practice to discuss plans for secure closure of site

19th November 2018

Practice identified list of Cairngall Medical Practice vulnerable patients to be supported in re-registration

22nd November 2018

Final version of patient letter agreed

1st December 2018

Patient letter despatched to Cairngall Medical Practice patients, including easy read letter version to those patients on the learning disabilities register

7th December 2018

SMS message sent to patients regarding closure and need to re-register

10th December 2018

Primary care paper including Cairngall Medical Practice update presented to Overview and Scrutiny Committee

17th December 2018

Two patient engagement sessions held at 2pm and 6:30pm at Cairngall Medical Practice, providing patients with the opportunity to discuss and raise any questions regarding the practice closure

10th January 2019

Meeting with Cairngall Medical Practice provider to discuss and agree closure plan and actions

10th January 2019

Two patient engagement sessions held at 2pm and 6:30pm at Cairngall Medical Practice, providing patients with the opportunity to discuss and raise any questions regarding the practice closure

25th January 2019

Meeting with councillors Francis, Putson and Hinkley to update on current position at Cairngall Medical Practice

1st February 2019 CCG update to LMC liaison meeting regarding current position at Cairngall Medical Practice and impact on neighbouring practices



1

Cairngall Urgent Planned PCCC Decision to withdraw Procurement & Comms Plan

Timeline and Key Milestones

Date Activity Lead Resources Required

Update as of the 28th January 2019

Week commencing 21st May

Refresh capacity assessment and obtain updated map

SEL PCT Approved template and script

Complete Capacity audit TBC completed by the 31st May –

Week commencing 21st May

Finalise Urgent Planned Decision Meeting date (18th or 21st June) Inc invitation to LMC, LA and Health Watch

Nisha N/A Complete Meeting confirmed 3pm 18th June –

ASAP Clarify status of lease discussions between Dr Bhalla and the Landlords and whether an option to extend can be included

Nisha / Liz N/A Work in progress – Landlords have confirmed they would support 6 month lease extension – Complete – 20th June

ASAP Instruct DV to carry out CMR assessment and VFM report once lease / heads of terms have been provided by Dr Bhalla

Jill/ Maxine Rents and Rates team to action on an urgent basis

Work in progress. Marcus Durkie, Senior DV has been instructed by Jill. Complete unless landlords do not accept recommendations. Landlords Complete confirmed attendance

Week commencing 28th May

Develop commissioning options paper for

Jill / Maxine Senior or Commissioning Manager

Complete

ENCLOSURE: F3

AGENDA ITEM: 7/19


39 of 69P

rimary C

are Com


UB

LIC-13/02/19

2



PCCC

14th June Agree final paper with CCG

Jill Theresa, Nisha, Jill and Maxine

Complete Paper agreed and finalised on 15th June and presented to PCCC 18th June

18th June PCCC Meeting CCG and SEL PCT

Complete – 18th June Recommendation to extend caretaking arrangements for 6 months agreed by PCCC

18th June Meeting with Cairngall Landlords following PCCC meeting to discuss premises

Jill, Maxine and Nisha

Complete On 20th June, Landlords confirmed they were unable to reach a joint decision about the long term use of the premises therefore premises cannot be secured

18th June Discussion with current caretaker Dr Bhalla re outcome of PCCC and extended caretaking arrangements

Nisha Complete 20th June. Meeting with Dr Bhalla to take place on 27th June to share CCG’s communication plan.

ASAP after 20th June

Cabinet member briefing/ meeting with Cllr Newton Letters to Teresa Pearce MP & Cllr Newton

Nisha/Jill JW and NW to meet virtually or face to face with Counsellor Francis

Letters sent to MP & Cllr Newton on 26th June. HOSC chair has suggested adding subject under AOB to OSC meeting on the 9th July, subject to Belvedere Councillors views. The latter have asked for a meeting. Outcome awaited. NW liaising to find suitable date.

ASAP after PCCC

Notify APMS Programme Lead of outcome of decision and agree message

Nisha Julie Dunn to facilitate

Notified on 20th June. Message to bidders needs to be sent out urgently – Complete message sent by procurement team on 21/06/18


40 of 69P

rimary C

are Com


UB

LIC-13/02/19

3



to go to bidders.

WEF 18th June

On-going advice to the caretaker provider in managing staff in closedown period

Dr Varun Bhalla

On-going

19th – 23rd

June Patient and Stakeholder letter to be drafted for sign off following PCCC outcome – Letter to inform patients of caretaking extension and also to update on lack of premises and subsequent cancellation of procurement as a result

SEL PCT SEL PCT with input from CCG comms, Healthwatch, PPG

Complete. Patient letter sent on 2/7/18. Stakeholders letter sent on 2/7/18.

27th June – 2nd July

CCG to obtain quote for patient letter postal costs

CCG N/A Complete. Patient letter sent on 2/7/18. Stakeholders letter sent on 2/7/18

27th June Closure of Cumberland Drive – draft patient letter shared with PCCC. Bexley Comms Team amended and Healthwatch invited to input

CCG/SELPCT

CCG/SEL PCT

Complete

27th June Meeting with CCG/SEL CCG/SEL Complete


41 of 69P

rimary C

are Com


UB

LIC-13/02/19

4



Cairngall caretakers to discuss Comms plan and handling

PCT & Cairngall Caretakers

PCT Refer to separate action notes for agreements

28th June Final draft shared with Cairngall PPG

CCG to send to caretaker

Caretaker Provider support

Complete

27th June Practice Manager Informed

Cairngall Caretaker

Patient Letter

Complete

28th June Practice staff informed of developments

Cairngall Caretaker

Patient Letter

Complete

29-2nd June/July

Patient letter posted CCG Patient Letter

Complete

29th June Stakeholder letter to be sent

SEL PCT Stakeholder Letter

Complete

1st July Closure of Cumberland Drive

SEL PCT Close down plan

Complete

6th July Patient and Letter Stakeholder to be posted

CCG Imail to practices

Patient letter sent on 2/7/18. Stakeholders letter sent on 2/7/18

w/c 9th July Further discussions with local practices to establish what actual support they need to increase their list sizes by end March 2019. The CCG have now completed discussions with local practices to identify

CCG PC Team

Capacity plan responses from local practices (part of PCCC urgent unplanned decision

Complete


42 of 69P

rimary C

are Com


UB

LIC-13/02/19

5



capacity the support needed. CCG has made available 37,307k resilience funding to support local practices to take on more patients, which will be distributed pro rata to number of patients excepted at the end of March 2019

paper)

w/c 9th July Create Activity Log of patient contact, Qu’s and Concerns with: CCG (Contactus – Annie Gardener), SELPCT & PPG. Generate a FAQ from the log to be included on the practice website and this can be shared with the PCCC. All Q&As should be conveyed to Sukh on a weekly basis

CCG PC Team & SEL PCT

Activity Log On-going

w/c 9th July Establish fortnightly SEL PCT PCSE On-going


43 of 69P

rimary C

are Com


UB

LIC-13/02/19

6



info to track patient registration to other practices. Fortnightly patient registration information is provided to assist with monitoring the patient list size.

Cooperation

26th July Meeting convened with Cllr Francis, Cllr Hinkley and Cllr Putson on 26th July, with Theresa and Jill

CCG/SEL PCT

Complete

31st October CCG to determine arrangements and cost for sending closedown letter to patients, including vulnerable patients (PCSE or IMail) - CCG requested quote 31st Oct -

CCG In progress Complete

7th November Agree patient letter contents and liaise with Health Watch

CCG/SEL/HEALTH WATCH

Complete

8th November CCG meeting with Councillor Francis to discuss concerns re communication to patients and staff

CCG Complete


44 of 69P

rimary C

are Com


UB

LIC-13/02/19

7



regarding the future of the practice

8th Nov – 16th November

Patient letter to be drafted & sent to CCG who will liaise with the PPG

SEL PCT Complete

9th November CCG meeting with LMC to discuss dispersal arrangements

CCG Complete

21st November

Patient Letter to be sent to the printers (including easy read)

SEL PCT/CCG

Complete

21st November

Confirmation that caretaker provider has identified vulnerable patients and will contact them after patient letter is received - Vulnerable patient details requested from caretaker

CCG and Caretaker

Complete

26th November

PPG meeting at which CCG lead will be present to discuss letter being sent to patients and patient engagement events

CCG Complete

4th December Agree Stakeholder CCG /SEL Complete


45 of 69P

rimary C

are Com


UB

LIC-13/02/19

8



Letter and circulate 4th December

Patient Letter (including easy read) and Stakeholder Letter to be sent

PCSE/SEL PCT

Complete

7th December SMS message to patients

Practice

12th December

Provide Update to PCCC and share with Councillors. Primary Care paper going to OSC on the 10th December.

SEL PCT / CCG

Complete

7th January Update FAQ’s for patients following patient events and make available on practice website and hard copies in surgery

CCG Complete

10th January Close down meeting between SEL PCT, CCG and caretaker provider

SEL PCT Close down checklist

Ongoing

25th January Meeting with Councillors Francis, Putson and Hinkley to update on the current position with CMP and latest patient list

CCG Complete


46 of 69P

rimary C

are Com


UB

LIC-13/02/19

9



size numbers.

31st January Utility suppliers to be notified of cease date

Practice

31st January IG PIA for practice closure

CCG In progress

31st January Inform IT suppliers/partners and relevant bodies (i.e. ICO, 111)

CCG/ Practice

In progress

1st February Further Patient Letter (including easy read) to be sent

CCG/ PCSE/ SEL PCT

Complete

1st February SMS message to patients

Practice Complete

1st February LMC liaison meeting with CCG to update on the current position at CMP and impact on neighbouring practices

CCG Complete

1st February Notify hospital departments of practice closure to ensure clinical correspondence is appropriately dealt with

CCG

1st February Update practice phone line with

Practice Complete


47 of 69P

rimary C

are Com


UB

LIC-13/02/19

10



message regarding closure

28th February Further Patient Letter (including easy read) to be sent

CCG/PCSE/SEL PCT

28th February SMS message to patients

Practice

1st March-29th March

Practice operational close down actions to be completed

Practice/CCG/SEL PCT

W/c 25th March

Practice close down walk around meeting

SEL PCT Provider & CCG to attend

1st April to 30th June 19

Financial reconciliation

SEL PCT/provider

CCG

1st April to 30th June 19

List size monitoring every two weeks

SEL PCT To be shared with CCG & provider

April and June PCCCs

Updates in public part of meeting

CCG SEL PCT

Updated 31st January 2019


48 of 69P

rimary C

are Com


UB

LIC-13/02/19

1


Title NHS Long Term Plan - Overview and Implications for Bexley



That the primary care commissioning committee note1. the enclosed report on the NHS Long Term Plan and the

implications for primary care in Bexley


None

Executive summary

On 7th January 2019, the NHS long-term plan (formerly known as the 10-year plan) was published setting out key ambitions for the NHS over the next 10 years. The enclosed paper highlights the key primary care and digital themes with a summary of how these align with current work underway in Bexley as well as any implications that will need to be considered.

On 31st January, NHS England published the GP contract changes for 19/20 which translates commitments in the NHS Long Term Plan into a five-year framework for the GP services contract. The enclosed paper provides highlights of this new contract which is described as the biggest reform to GP services in 15 years. Over coming weeks there is likely to be further details published on new specifications and there will be the need to reconcile any overlap between existing primary care contracts and new primary care contracts.


Key risks Any overlap with existing contractual arrangements that will have to be varied to avoid duplication.

EqualityThe implementation of the London NHS Plan seeks to reduce health inequalities and this new investment in primary care will build the resilience, capacity and capabilities of primary care services.

FinancialNew investment for practices.

ENCLOSURE: G1AGENDA ITEM: 9/19


9.19 NHS Long Term Plan


2

Author:Sukh Singh, AD of Primary CareSarah Birch, Head of Primary Care

Clinical lead: Dr Sid Deshmukh, ChairExecutive sponsor:

Nisha Wheeler, Director of Primary Care, ICT and IG

9.19 NHS Long Term Plan


1

NHS Long-term plan briefing paper

Background

On 7th January 2019, the NHS long-term plan (formerly known as the 10-year plan) was published setting out key ambitions for the service over the next 10 years. This paper highlights the key primary care and digital themes, a summary of where Bexley iscurrently placed and any associated implications.

Primary Care summary

Primary care Implications for Bexley

Funding

• At least £4.5bn increase in funding for primary and community care by 2023/24.

• A shared savings scheme will hand primary care networks part of any funding they save by reducing avoidable A&E admissions and for admissions preventing delayed discharge or reducing avoidable outpatient visits or over-medication.

• The NHS plans to improve efficiency in primary care, mental health and community health services - with a health service-wide cash-releasing productivity growth target of 1.1%.

• Development of Primary Care Networks (PCN’s), aligned to existing LCN’s to support development of these funding schemes

• To be contractualised via GP contract and through a primary care network contract

• Need to consider any implications of overlapping with local incentive schemes already in place

ENCLOSURE: G2AGENDA ITEM: 9/19

9.19 NH

S Long T

erm P

lan

51 of 69P

rimary C

are Com


UB

LIC-13/02/19

2

GP contract

• GP practices will be expected to sign up to network contracts that tie them into practice networks covering 30 - 50,000 patients.• These network contracts will sit alongside practices’ existing GMS, PMS or APMS contracts.

• Practices in networks will be funded through a designated single fund through which all network resources will flow.

• Most local enhanced services commissioned by CCGs will be moved into network contracts rather than deals with individual practices.

• The QOF will undergo significant changes – with a new quality improvement element being developed in collaboration with the RCGP. Indicators deemed least effective will be dropped, with new targets to be added to promote more personalised care.

• Standards, funding and procurement of GP vaccinations and immunisation will be reviewed with the goal of improving uptake.

• Practices agreeing to be part of a network

• Alignment to 30 - 50,000 patient coverage, which two of the existing current localities are larger than – notably North Bexley (105,845) and Clocktower (83,020).Frognal locality just over the stipulated range at 53,978. Recognising that the 3 localities across Bexley are now synonymously aligned with the borough’s Local Care Networks (LCNs)

• Not to lose good relationships already in place via existing LCN work (i.e. development of Bexley Care services)

• Ensuring contractual requirements are not conflicting between network contracts and existing GP contracts KPI’s e.g. Imms and vacs

• Consider implications for care homes LES and plans to commission SMI health checks

9.19 NH

S Long T

erm P

lan

52 of 69P

rimary C

are Com


UB

LIC-13/02/19

3

Workforce• A workforce implementation plan will be published later this year once the government has set a budget for training, education & and CPD.

• The government and NHS England remain committed to recruiting an extra 5,000 full-time equivalent GPs as soon as possible and will develop incentives to boost numbers of doctors trained to match specialty and geographical needs, especially in primary care.

• Medical school places are already increasing from 6,000 to 7,500 a year, and options such as more part-time study places and accelerated four-year degree programmes will be explored.

• Medical schools will be allocated training places based on the production of medical graduates who meet the primary care and specialty needs of the NHS.

• Newly qualified doctors and nurses entering general practices will be offered a two-year fellowship under plans proposed in the GP partnership review, to provide a secure contract of employment alongside a portfolio role designed to support the individual and the needs of the local health economy.

• National scheme to support NHS organisations recruiting from overseas.• New routes into nursing and other disciplines, including apprenticeships, nursing associates, online qualification, and earn and learn support, are all being backed, together with a new post-qualification employment guarantee.

• Ensure CEPN are sighted on the workforce implementation plan and develop a local strategy/plan in line with the expectations identified

• This builds on existing workforce initiatives in Bexleythat have already been implemented or are underway, including the GP fellowship programme, the international GP programme, a new mentorship programme being set up to attract and retain newly qualified GPs and returners, nursing associates, support for nurses moving from secondary to primary care, apprenticeships.

9.19 NH

S Long T

erm P

lan

53 of 69P

rimary C

are Com


UB

LIC-13/02/19

4

Integrated care

• The plan promises to move all practices into networks to deliver fully integrated community-based healthcare for the first time since the NHS was created.

• Expanded community teams will be developed alongside networks, with a requirement for teams including GPs, pharmacists, district nurses, community geriatricians, dementia workers, physiotherapists, social care and voluntary sector staff to be brought together around network areas.

• NHS111 will be able to book patients directly into GP practices and appointments at pharmacies from this year.

• General practice will be linked more closely to care home support, with the NHS planning to roll out nationally its 'enhanced health in care homes' vanguard scheme. The scheme will link primary care networks to care homes, with named GP support for all patients and networks collaborating with emergency services on out-of-hours care.

• Builds upon existing LCN work that has already seen the integration of adult social care and Oxleas adult services into “Bexley Care.”

• Technology may impact on direct booking capabilitiesas clinical system suppliers will need to develop this functionality

• GP practices and pharmacies will need to consider how appointment provision is managed with the implementation of NHS111 direct booking

• Plans are already underway to re-design the care homes LES in Bexley to be aligned with the enhanced health in care homes agenda. As part of the new GP contract there will be an enhanced health in care homes DES that will come into effect for 2020/21. This makes it explicit that networks of practices will be responsible for delivering the DES which will help take the pressure of care homes away from a few practices and hopefully provide a more resilient model.

• Benchmarking against the requirements of the enhanced health in care home requirements has been completed with work underway to implement areas currently not in place or change those that need improvement.

9.19 NH

S Long T

erm P

lan

54 of 69P

rimary C

are Com


UB

LIC-13/02/19

5

NHS organisations

• Integrated care systems (ICSs) will be rolled out across England by April 2021, growing out of the current network of sustainability and transformation partnerships (STPs).

• The reform could lead to a dramatic cut in CCG numbers. There are 44 STPs, and the long-term plan says there will be typically a single CCG for each ICS area. CCGs will become leaner, more strategic organisations.

• ICS’s will have full engagement with primary care, with a named clinical director within each primary care network – and board-level representatives from networks.

• CCG mergers

• Re-design of governance structures

• Re-modelling of workforce required

• The new GP contract makes it explicit that each network will have a named accountable Clinical Director, responsible for delivery. Existing LCN Directors may take on this role or depending on PCN configuration there may be new Directors coming forward. The network will receive an additional ongoing entitlement to the equivalent of 0.25 WTE funding per 50,000 population size.

9.19 NH

S Long T

erm P

lan

55 of 69P

rimary C

are Com


UB

LIC-13/02/19

6

Health inequalities

• An extra 110,000 patients will be offered physical health checks every year by 2023/24 - taking the total to 390,000.

• Uptake of annual health checks in primary care by patients with a learning disability will be increased to 75%, and health checks for patients with autism will be piloted.

• GP practices that are carer-friendly will be awarded quality marks designed by the CQC.

• The NHS will offer all smokers admitted to hospital, smoking cessation support, alongside new initiatives to tackle diabetes and obesity, and targeting of funding at areas with the greatest health inequalities.

• NHS health checks being commissioned via the GP federation - Ensure targets align with what has been commissioned and what is now required

• Uptake of LD health checks needs to improve significantly, work already underway with local authority and Oxleas

• Public Health prevention strategy should also be aligned to support this work.

9.19 NH

S Long T

erm P

lan

56 of 69P

rimary C

are Com


UB

LIC-13/02/19

7

Digital summary

Requirement Implications for BexleyLocal Shared Care Records

• Local health and care records derived from GPs and other health providers, by 2024. By 2023, summary care records and care plans will be moved to these regional records

• Mandate and rigorously enforce technology standards (asdescribed in The Future of Healthcare) to ensure data isinteroperable and accessible.

• Ensure that clinicians can access and interact with patient records and care plans wherever they are.

• By 2023/24, a digital flag in the patient record will ensure staff know a patient has a learning disability or autism.

• Improve utilisation across primary care of Connect Care and the South East London Virtual Care Records.

• South East London STP part of One London Local Health & Care Record Exemplar

• Ensuring patients with LD or autism are appropriately identified and flagged

NHS App and Online Consultations• NHS to provide all patients with access to online or video consultations for GP and hospital outpatient’s appointments within five years.

• Over the next five years, every patient will have the right to online digital GP consultations

• Digital NHS ‘front door’ through the NHS App will provide advice, check symptoms and connect people with healthcare professionals - including through telephone and video consultations.

• Need to consider NHS App implications upon NHS online Bexley app. NHS app has planned full deployment across London by end of June 2019, but with basic functionality only.

• Need to ensure that there is straightforward digital access to NHS services, to help patients and their carers manage their health.

• Disparate online consultation providers across South East London which may need to change

9.19 NH

S Long T

erm P

lan

57 of 69P

rimary C

are Com


UB

LIC-13/02/19

8

• To consider development of user friendly video consultation offerings

• If all patients are to have access to digital GP consultations, the requirement needs to be contractualised.

Apps and digital resources to support self-care and patient empowerment

• Continue to support the development of apps and online resources to support good mental health and enable recovery.

• The connecting of home-based and wearable monitoring equipment will increasingly enable the NHS to predict and prevent events that would otherwise have led to a hospital admission

• Trial the use of innovative devices such as smart inhalers for better patient care and remote monitoring of conditions

• Invest in the nhs.uk platform so that everyone can find helpful advice and information regarding their conditions

• Support people who are newly diagnosed to manage their own health by further expanding provision of structured education and digital self-management support tools, including expanding access

• Make greater use of the NHS apps library to signpost and promote to patients

• CCG working with Local authority on assistive technology programme. A DOCOBO tele-health pilot is already underway at a Care Home to monitor and manage residents. Meetings and discussions have taken place to look at opportunities for national funding for technological enabled care solutions.

• Working with Academic Health Science Network to be a demonstrator site for one or more of the published themes.

• Practice websites are currently promoted above

9.19 NH

S Long T

erm P

lan

58 of 69P

rimary C

are Com


UB

LIC-13/02/19

9

to HeLP Diabetes an online self-management tool for those with type 2 diabetes.

• Maternity digital care records are being offered to 20,000 eligible women in 20 accelerator sites across England, rising to 100,000 by the end of 2019/20. We will continue to expand the roll-out of maternity digital care records. By 2023/24, all women will be able to access their maternity notes and information through their smart phones or other devices.

NHS.uk, further consideration needed on how NHS.uk is developed and promoted

• Need to ensure that there is straightforward digital access to NHS services, to help patients and their carers manage their health.

Cyber security

• By summer 2021, 100% compliance with mandated cyber security standards across all NHS organisations in the health and care system.

• On-going training for GPIT providers to ensure compliance

• CCG Cyber security essential accredited

• The CCG has developed various policies to support the confidentiality, integrity and availability of the information stored and processed within the CCG.

• Anti-virus server upgraded which supports the CCG, all GP Practices, BHL, Urgent Care Centres and the 8-8 hubs

Population Health

• In 2021/22, we will have systems that support population health management in every Integrated Care System across England, with a Chief Clinical Information Officer or Chief Information Officer on the board of every local NHS organisation.

• South East London STP working towards development of population health solution

• Bexley Federation working at a local level to determine population health solutions across the borough until a SEL STP wide solution is in place.

9.19 NH

S Long T

erm P

lan

59 of 69P

rimary C

are Com


UB

LIC-13/02/19

10

Child protection

• By 2022/23, the Child Protection Information system will be extended to cover all healthcare settings, including general practices.

• An integrated child protection information system will replace dozens of legacy systems and will deliver a screening and vaccination solution.

Digital workforce

• Digital GP models can help expand the GP workforce participation rate by offering flexible opportunities to part-time GPs

• Enhancing the digital leadership of the NHS by further expanding the successful NHS Digital Academy programme.

• Support the workforce to develop the digital skills they need to make effective use of these tools and mobile access to digital services to allow health and care workers to work more flexibly.

• Increase training in digital capabilities for the health and care workforce and focus on attracting excellent technical expertise and skills, particularly in newer digital fields so that our workforce can continue to deliver our technology strategy.

• Senior leaders need to be capable of driving the transformation of their organisations and non-executive directors able to support and demand increasing digital maturity over the next five years

9.19 NH

S Long T

erm P

lan

60 of 69P

rimary C

are Com


UB

LIC-13/02/19

11

GP Contract Changes

A new five-year contract for general practice across England will see billions of pounds of extra investment for improved access to family doctors, expanded services at local practices and longer appointments for patients who need them.

The deal - the biggest reform to GP services in fifteen years – was approved by NHS England on 31st January 2019. NHS England chief executive Simon Stevens said it is the first major pillar implementing the NHS Long Term Plan, coming just three weeks after the Plan was published.

Among many other measures in the Contract, some of the key aspects of it are:

∑ Establishing primary care networks across the whole country by July 2019, backed by £1.8 billion of funding by 2023.∑ A new £300 million Fund by 2023 will include networks making faster progress in achieving the outcomes described in the

NHS Long Term Plan. This will mean that general practice will benefit from the impact their work has in reducing avoidable A&E attendances, admissions and delayed discharge, and from reducing avoidable outpatient visits and improvements in prescribing through medication reviews.

∑ From April 2019, clinically-proven improvements in the management of diabetes, blood pressure control and cervical screening, through reforms to the GP Quality and Outcomes Framework, with further changes in the pipeline on heart failure, asthma, COPD, and mental health.

∑ From April 2019, new support for quality improvement, starting with prescribing safety and end-of-life care.∑ Additional funding of IT which will allow both patients and practices to benefit from the latest digital technologies. All patients

will have the right to digital-first primary care, including web and video consultations in 2021. They will also be able to order repeat prescriptions electronically from April 2019 and have digital access to their full records from 2020.

∑ From April 2019, direct booking of calls from NHS 111 into GP surgeries. ∑ Protecting the principle that general practice remains free on the NHS, through a new ban on advertising or hosting private

GP services.∑ Ensuring public confidence to invest in the GP partnership model, through increased transparency of NHS earnings, and a

new mechanism to protect against unexpectedly high or low earnings.

9.19 NH

S Long T

erm P

lan

61 of 69P

rimary C

are Com


UB

LIC-13/02/19

12

∑ Solving the indemnity funding crisis, through a new NHS Resolution Clinical Negligence Scheme for general practice to start from April 2019. All general practice will be covered, including out of hours and all staff groups as well as new recruits. It means they won’t pay indemnity cover and they will be protected from future inflated indemnity costs.

There are a number of contractual changes that will need to be implemented over coming months as a consequence of the new contract and the CCG will need to review any areas where there is overlap with existing schemes. While this paper provides a high level summary of the contract changes, more detailed work will be required to fully assess the work that will need to be undertaken to fully understand the implications, especially as there may be some duplication with existing CCG of funding the CCG will be required to redirect funding to something else.

Next Steps

In terms of taking forward delivery of the new contract, the primary care team at Bexley CCG will take a lead in assessing the implications upon the teams work plan and also identifying any areas where there may be duplication with existing CCG primary care funding streams within 2019/20. Any changes will then need to be taken through appropriate governance. The CCG will continue to work with the South East London Primary Care Team of NHS England to ensure that the implications of the new contract are fully embedded.

The CCG and federation leads will continue to participate in the various STP work streams to ensure there is alignment across South East London in delivering the Long Term Plan.

9.19 NH

S Long T

erm P

lan

62 of 69P

rimary C

are Com


UB

LIC-13/02/19

1


Title Delegated Primary Care Finance Report on Month 9 2018-19



That the primary care commissioning committee;

1. NOTE the update on the Month 9 2018-19 position including the forecast overspend and the additional potential associated risks which could deteriorate the position further.

2. NOTE the delegated primary care allocation and the agreed budget setting process for 2019/20.


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

Executive summary

The committee has previously received a number of papers regarding the 2018/19 budget setting process and the fact that there is a negative budget included in the overall budget to ensure that the budget allocation of £29,321k is not exceeded; this is even taking into account the allowable contingency.

As indicated in the previous report to PCCC, there are two main financial issues which will put additional pressure on the delegated primary care budget. The first is the requirement for the caretaking arrangements at one of our practices to continue to the end of the financial year, following which there will be the potential costs of the dispersal of this substantial patient list plus some admin costs related to additional capacity linked to the re-registration process and also potential redundancy costs for staff at the closing practice. The second issue has been the announcement of the General Practice Pay Awards which equate to approximately 2%, the CCG set aside 1% for pay awards and so there is a funding gap at present of circa £113k. Representation has been made to NHS England for additional funding to bridge this gap but the CCG has now been advised that there is no further funding available for this.

ENCLOSURE: H1

AGENDA ITEM: 10/19


10.19 Primary Care Finance report


2

At this point, there are no primary care QIPP schemes in place for 2018/19and it is now too late for any to be undertaken which will impact on the 2018/19 position. However, it should be recognised that primary care colleagues are becoming more involved and supportive in a number of the QIPP schemes for 2018/19 and those being developed for 2019/20. In fact the primary care team is leading on the requirement from NHS England to visit all GP practices to discuss referral management following the national and local increases in referrals to secondary care. The initial round of meetings has now been completed and generally primary care colleagues have been positive about the work required and action plans for practices have been constructed and agreed with them. The second tranche of visits have just begun having been organised for approximately 8 weeks after the first and so these will be completed shortly. The purpose of these visits will be to obtain an update on progress with the practice action plans, discussions on 2 week wait referrals and also mental health referrals.

In 2018/19, any payments relating to 2017/18 should be offset by year end accruals. At month 9, the primary care team have been able to release £320k of unused accruals into the financial position with the potential that there may be more to release in future months. There has been no movement in this position since month 7 but this will be reviewed in month 10. A number of pre 2017/18 creditors have also been settled and these have been recharged to NHS England which will provide a cash benefit to the CCG – this will be reviewed again prior to the year-end.

At month 9 (see Appendix 1), the delegated primary care budgets are being reported as showing a year to date underspend of £7k which is mainly due to the release of additional prior year creditors with a year-end forecast of an overspend of £96k which accounts for the extension of the caretaking arrangements for one of our practices plus the unfunded 1% of the pay award. There may be some scope to reduce this if the overall practice list size growth is less than expected and locum costs are lower than budget but it is too early in the year to determine if this will be the case. A review of the delegated budget will be undertaken to see if there is any scope to improve the position but it is felt that this is unlikely to be the case as there is also another emerging cost pressure regarding the admin costs of re-registering patients from the practice which is due to close at the end of March 2019, also there may be some potential redundancy costs which need to be taken into account.

In terms of risk, the CCG is not including the potential cost of the dispersal of the significant list at the caretaking practice as patients are already moving to other practices, although an admin cost pressure has now been identified as has a small potential redundancy cost both of which will be included in the month 10 position. No further risks have been identified but this position will be reviewed on a monthly basis.

The planning guidance and allocations for 2019/20 has now been



3

published with a requirement to submit a draft plan in mid February. The allocation for delegated primary care for 2019/20 is £31,512k which is an increase of £2,200k compared to last year. This represents a circa 6.58% uplift on the previous year. The SE London Primary Care finance team are currently calculating draft budgets for 2019/20 which will be brought to a future PCCC meeting for approval following an internal discussion with the Primary Care finance team, contracting team, CCG finance lead and Director of Primary Care.

On 31 January the NHSE published a new primary care vision and funding details for the next five years. The link is to this information is;

https://www.england.nhs.uk/2019/01/five-year-deal-to-expand-gp-services-and-kick-start-nhs-long-term-plan-implementation/

The CCG and primary care finance and contracting team will be analysing this settlement’s impact and report in March, together with a proposed budget for the year in detail.


Key risks

The main risk is the overspend against this budget is not able to be managed within the overall CCG’s financial position. Factors already impacting on the FOT position reported are the extension to the caretaking arrangement and the part funded pay award. Additional risks are that despite appealing to NHS England for additional funding to close the gap relating to the pay award this is not forthcoming, costs may be required to be accrued in respect of the dispersal of the practice list for the practice which is due to close on 31/03/2019 plus any potential redundancy costs related to the practice which is closing and any further unknown risks in the system which are yet to arise.

EqualityN/a

Financial

Inability to contain spend in this area results in an additional cost pressure for the CCG which would need to be covered by additional QIPP and given that the CCG has declared a £10m deficit in month 9 this would be an extra challenge for the organisation.

Author: Julie Witherall, Deputy Director of Finance

Clinical lead: Dr V BhallaExecutive sponsor:

Malcolm Hines, Director of Finance





Primary Care Medical Services Bexley 135178Financial Summary - 18/19 Dec-18

Description Annual Budget YTD BudgetYTD Actual

ExpenditureIn Month Accruals

£000 £000 £000 £000

PMS Essential and Additional Services 16,508 12,381 12,610 0PMS Premium Services 2,011 1,508 1,468 40GMS Global Sum & MPIG 1,726 1,294 1,308 0GMS Premium Services 118 88 85 4APMS Essential and Additional Services 1,237 928 895 0APMS Premium Services 84 63 60 3

Caretaking - Management Fee 88 66 131 0Subtotal Core contract 21,771 16,328 16,557 46Population/List Growth ear-marked fund 265 199 6 23Total Core contract 22,036 16,527 16,563 69

QOF aspiration 2,002 1,501 1,423 79QOF achievement 954 716 0 716Total QOF 2,956 2,217 1,423 794

Minor Surgery DES 164 123 82 41Extended Hours DES 458 344 333 10Learn Dsblty Hlth Chk DES 40 30 12 18SAS/Violent patients scheme 16 12 12 3Out of area registration DES 1 1 0 1Total enhanced services 680 509 441 72

Rent 1,763 1,322 1,265 59Rent - CHP/NHS PS 482 362 331 33In-year revaluation budget 66 50 0 50Business Rates 495 371 253 120Business Rates - CHP/NHS PS 37 28 30 4Service Charges 0 0 0 0Other Premises 276 207 278 (60)Total Premises Reimbursements 3,121 2,340 2,157 205

Seniority 187 140 118 22Locum reimbursements 140 105 73 32PADM Prescribing Fees Admin 185 139 87 52CQC Fees reimbursement 151 113 95 18Total PCO administered 663 497 372 124

Other 27 20 5 15



Indemnity - transfered to GPFV Mth 3 (245) (184) 0 0Clinical waste 84 63 2 62MOU costs 0 0 0 0Prior Year 17/18 0 0 (785) 465Prior Year - pre April 17 0 0 0 0Contingency 0 0 0 0Savings Target 0 0 0 0Total Other Medical Services (134) (100) (778) 541

Total Primary Care Medical Services 29,321 21,989 20,178 1,804

Summary £000 £000 £000 £000Core contract 19,471 14,603 14,813 0Population/List Growth ear-marked fund 265 199 6 23Caretaking Management 88 66 131 0Premium Services 2,213 1,659 1,613 46QOF 2,956 2,217 1,423 794Enhanced Services 680 509 441 72Premises and other reimbursements 3,121 2,340 2,157 205PCO administered 663 497 372 124Other (134) (100) (778) 541

Ledger Total 29,321 21,989 20,178 1,804



YTD Reported Spend

YTD Variance YTD commentaryForecast Out-turn

Forecast variance

£000 £000 £000 £000

12,610 229 16,813 3051,508 (0) 2,011 (0)1,308 14 1,744 18

88 (0) 118 (0)895 (33) 1,193 (44)

63 (0) 84 (0)

131 66Practice continuing in caretaking to year end and nolonger part of T6 procurement 175 88

16,604 275 22,138 36728 (170) 38 (227)

16,632 105 22,176 140

1,501 0 2,002 (0)716 0 954 (0)

2,217 0 2,956 (0)

123 0 164 (0)343 (0) 458 (1)

30 0 40 015 3 20 4

1 0 1 (0)512 3 683 3

1,324 2 1,766 2363 2 485 2

50 0 66 (0)373 2 497 2

33 5 45 70 0 0 0

218 11 includes CHP void/subsidy charges budget 291 152,362 22 3,149 29

140 0 187 (0)105 0 140 (0)139 0 185 (0)113 (0) 150 (0)497 (0) 662 (1)

20 (0) 27 (0)



0 184 0 24563 (0) 84 (0)

0 0 0 0(320) (320) Un-utilised prior year credits (320) (320)

0 0 0 00 0 0 00 0 0 0

(237) (136) (209) (75)

21,983 (7) 29,417 96

£000 £000 £000 £00014,813 210 19,750 279

28 (170) 38 (227)131 66 175 88

1,659 (0) 2,213 (0)2,217 0 2,956 (0)

512 3 683 32,362 22 3,149 29

497 (0) 662 (1)(237) (136) (209) (75)

00

21,983 (7) 29,417 96



primary care commissioning committee , part 1 held in public … care joint... · blossom care...

Documents