Meeting Agenda ( Public Session) Primary Care Commissioning … · 2020. 7. 10. · Patient in...

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Meeting Agenda (Public Session)

Primary Care Commissioning Committee

Wednesday 15 July 2020 9:00-10:20

Zoom Meeting

Time Item Presenter Reference

09:00 Introductory Items

1. Welcome, introductions and apologies Eleri de Gilbert PCC/20/057

2. Confirmation of quoracy Eleri de Gilbert PCC/20/058

3. Declarations of interest for any item on the agenda Eleri de Gilbert PCC/20/059

4. Management of any real or perceived conflicts of interest

Eleri de Gilbert PCC/20/060

5. Questions from the public Eleri de Gilbert PCC/20/061

6. Minutes from the meeting held on 17 June 2020 Eleri de Gilbert PCC/20/062

7. Action log and matters arising from the meeting held on 17 June 2020


09:10 Contract Management and Applications

8. Orchard Medical Practice: List Closure Update Lynette Daws PCC/20/064

09:20 Items for Approval

9. Nottingham City: First Contact Physiotherapists and Care Coordinators Additional Roles

Michelle Tilling PCC/20/065

09:35 Covid-19 Update

10. Primary Care Recovery Group Terms of Reference Joe Lunn PCC/20/066

11. Covid-19 GP Practice Additional Expenses’ Joe Lunn PCC/20/067

09:45 For Assurance

12. Workforce Scoring Matrix for List Closures - Practice Data Comparison

Joe Lunn PCC/20/068

10:00 Financial Management

13. Finance Report Michael Cawley PCC/20/069

10:05 Risk Management

14. Risk Report Siân Gascoigne PCC/20/070

10:15 Closing Items

15. Any other business Eleri de Gilbert PCC/20/071

16. Key messages to escalate to the Governing Body Eleri de Gilbert PCC/20/072

Chair: Eleri de Gilbert

Enquiries to: ncccg.notts - [email protected]

Agenda

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mailto:ncccg.notts%20-%[email protected]

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17. Date of next meeting:

19/08/2020

Zoom Meeting


Confidential Motion: The Primary Care Commissioning Committee will resolve that representatives of the press and other members of the public be excluded from the remainder of this meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (Section 1[2] Public Bodies [Admission to Meetings] Act 1960)

Agenda

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Name Current position (s)

held in the CCGs

Declared

Interest

(Name of the

organisation

and nature of

business)

Nature of Interest

Fin

an

cia

l In

tere

st

No

n-f

ina

nc

ial

Pro

fes

sio

na

l

Inte

res

ts

No

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nc

ial

Pe

rso

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sts

Ind

ire

ct

Inte

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t

Da

te F

rom

:

Da

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o:

Action taken to mitigate risk

AINSWORTH, David Locality Director Mid-Notts Erewash Borough Council Lay Member of the

Remuneration Committee

01/01/2019 Present This interest will be kept under review

and specific actions determined as

required.

AINSWORTH, David Locality Director Mid-Notts Consultancy Ad hoc nurse consultancy to

provider organisations



required.

AINSWORTH, David Locality Director Mid-Notts Saxon Cross Surgery Registered Patient

-

Present This interest will be kept under review


required - as a general guide, the

individual should be able to participate in

discussions relating to this practice but AUDIS, Adrian NHS England/NHS

Improvement

Commissioning Manager

No relevant interests declared Not applicable

- -

Not applicable

BEEBE, Shaun Non-Executive Director Eastwood Primary Care Centre Family members are registered

patients

-

01/03/2020 Interest expired - no action required

BEEBE, Shaun Non-Executive Director University of Nottingham Senior manager with the

University of Nottingham

-



required.

BEEBE, Shaun Non-Executive Director Nottingham University Hospitals

NHS Trust

Patient in Ophthalmology

-



required.

BURNETT, Danni Deputy Chief Nurse NHS England and Improvement Spouse employed as Senior

Delivery and Improvement Lead



required.

BURNETT, Danni Deputy Chief Nurse Nottingham and Nottinghamshire

CCGs

Family member employed as

Head of Service Improvement

and BCF



required.

Register of Declared Interests

• As required by section 14O of the NHS Act 2006 (as amended), the CCG has made arrangements to manage conflicts and potential conflicts of interest to ensure

that decisions made by the CCG will be taken and seen to be taken without being unduly influenced by external or private interests.

• This document is extracted, for the purposes of this meeting, from the CCG’s full Register of Declared Interests (which is publically available on the CCG’s website).

This document was extracted on 02 July 2020 but has been checked against the full register prior to the meeting to ensure accuracy .

• The register is reviewed in advance of the meeting to ensure the consideration of any known interests in relation to the meeting agenda. Where necessary

(for example, where there is a direct financial interest), members may be fully excluded from participating in an item and this will include them not receiving

the paper(s) in advance of the meeting.

• Members and attendees are reminded that they can raise an interest at the beginning of, or during discussion of, an item if they realise that they do have a (potential) interest

that hasn’t already been declared.

• Expired interests (as greyed out on the register) will remain on the register for six months following the date of expiry.

Declarations of interest for any item

on the agenda

3 of 24309:00 - 10:20 via Z

oom (link sent seperately)-15/07/20


held in the CCGs

Declared

Interest

(Name of the

organisation

and nature of

business)

Nature of Interest

Fin

an

cia

l In

tere

st

No

n-f

ina

nc

ial

Pro

fes

sio

na

l

Inte

res

ts

No

n-f

ina

nc

ial

Pe

rso

na

l In

tere

sts

Ind

ire

ct

Inte

res

t

Da

te F

rom

:

Da

te T

o:


BURNETT, Danni Deputy Chief Nurse NHS England and Improvement Family member employed as

Contracts Manager



required.

BURNETT, Danni Deputy Chief Nurse NEMS Community Benefit Services

Ltd

Family member employed as

Finance Accountant



required.

BURNETT, Danni Deputy Chief Nurse Academic Health Science Network Family member employed in

Project Team



required.

BURNETT, Danni Deputy Chief Nurse Castle Healthcare Practice Registered Patient 01/07/2018 Present This interest will be kept under review




discussions relating to this practice but

be excluded from decision-making.

CALLAGHAN, Fiona Locality Director - South

Nottinghamshire

Radcliffe on Trent Health Centre Registered Patient

-







CAWLEY, Michael Operational Director of

Finance

Castle Healthcare Practice Registered Patient

-







DADGE, Lucy Chief Commissioning Officer Mid Nottinghamshire and Greater

Nottingham Lift Co (public sector)

Director 01/10/2017 Present This interest will be kept under review


required.

DADGE, Lucy Chief Commissioning Officer Pelham Homes Ltd – Housing

provider subsidiary of

Nottinghamshire Community

Housing Association



required.

DADGE, Lucy Chief Commissioning Officer 3Sixty Care Ltd – GP Federation,

Northamptonshire

Chair 01/01/2017 Present This interest will be kept under review


required.

DADGE, Lucy Chief Commissioning Officer First for Wellbeing Community

Interest Company (Health and

Wellbeing Company)



required.

DADGE, Lucy Chief Commissioning Officer Valley Road Surgery Registered Patient 19/06/1905 Present This interest will be kept under review







on the agenda

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held in the CCGs

Declared

Interest

(Name of the

organisation

and nature of

business)

Nature of Interest

Fin

an

cia

l In

tere

st

No

n-f

ina

nc

ial

Pro

fes

sio

na

l

Inte

res

ts

No

n-f

ina

nc

ial

Pe

rso

na

l In

tere

sts

Ind

ire

ct

Inte

res

t

Da

te F

rom

:

Da

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o:


DADGE, Lucy Chief Commissioning Officer Nottingham Schools Trust Chair and Trustee 01/11/2017 Present This interest will be kept under review


required.

DAWS, Lynette Head of Primary Care Rivergreen Medical Centre Family members are registered

patients

-







DE GILBERT, Eleri Non-Executive Director Middleton Lodge Surgery Individual and spouse registered

patients at this practice

-







DE GILBERT, Eleri Non-Executive Director Rise Park Practice Son and Daughter in Law

registered patients



required.

DE GILBERT, Eleri Non-Executive Director Nottingham Bench Justice of the Peace

-



required.

DE GILBERT, Eleri Non-Executive Director Sherwood and Newark Citizens

Advice Bureau

Trustee on the board 01/03/2016 07/02/2020 Interest expired - no action required

DE GILBERT, Eleri Non-Executive Director Major Oak Medical Practice,

Edwinstowe

Son, daughter in law and

grandchild registered patients

-



required.

GASCOIGNE, Sian Head of Corporate

Assurance

Nottingham University Hospitals

NHS Trust

Husband is the Integration

Manager



required.

GASCGOIGNE, Sian Head of Corporate

Assurance

Radcliffe Health Centre Patient

Participation Group

Father is a member 01/01/2019 Present This interest will be kept under review


required.

GASCGOIGNE, Sian Head of Corporate

Assurance

Nottinghamshire Healthwatch Father is a volunteer 01/01/2019 Present This interest will be kept under review


required.

GASKILL, Esther Head of Quality Intelligence Mapperley and Victoria Practice Registered Patient

-








on the agenda

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held in the CCGs

Declared

Interest

(Name of the

organisation

and nature of

business)

Nature of Interest

Fin

an

cia

l In

tere

st

No

n-f

ina

nc

ial

Pro

fes

sio

na

l

Inte

res

ts

No

n-f

ina

nc

ial

Pe

rso

na

l In

tere

sts

Ind

ire

ct

Inte

res

t

Da

te F

rom

:

Da

te T

o:


GRIFFITHS, Helen Associate Director of Primary

Care Networks

Musters Medical Practice Registered Patient 01/04/2013 Present This interest will be kept under review







Care Networks

Castle Healthcare Practice

(Rushcliffe Practice)

Spouse is GP Partner 01/10/2015 Present To be excluded from all commissioning

decisions (including procurement

activities and contract management

arrangements) relating to services that

are currently, or could be, provided by

this practice


Care Networks

Embankment Primary Care Centre Spouse is Director 01/10/2015 Present This interest will be kept under review


required.


Care Networks

NEMS Healthcare Ltd Spouse is shareholder 01/04/2013 Present This interest will be kept under review


required.


Care Networks

Partners Health LLP Spouse is a member 01/10/2015 Present This interest will be kept under review


required.


Care Networks

Principia Multi-specialty Community

Provider

Spouse is a member 01/10/2015 Present This interest will be kept under review


required.


Care Networks

Nottingham Forest Football Club Spouse is a Doctor for club 01/04/2013 Present This interest will be kept under review


required.

LUNN, Joe Interim Associate Director of

Primary Care

Kirkby Community Primary Care

Centre

Registered Patient

-







STRATTON, Dr Richard GP Representative Belvoir Health Group GP Partner 01/08/2012 Present To be excluded from all commissioning



arrangements) relating to services that

are currently, or could be, provided by

GP Practices.

STRATTON, Dr Richard GP Representative PartnersHealth LLP GP member 01/11/2015 Present To be excluded from all commissioning



arrangements) in relation to services

currently provided by Partners Health

LLP; and Services where it is believed

that Partners Health LLP could be an

interested bidder.


on the agenda

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held in the CCGs

Declared

Interest

(Name of the

organisation

and nature of

business)

Nature of Interest

Fin

an

cia

l In

tere

st

No

n-f

ina

nc

ial

Pro

fes

sio

na

l

Inte

res

ts

No

n-f

ina

nc

ial

Pe

rso

na

l In

tere

sts

Ind

ire

ct

Inte

res

t

Da

te F

rom

:

Da

te T

o:


SUNDERLAND, Sue Non-Executive Director Joint Audit Risk Assurance

Committee, Police and Crime

Commissioner (JARAC) for

Derbyshire / Derbyshire

Constabulary



required.

SUNDERLAND, Sue Non-Executive Director NHS Bassetlaw CCG Governing Body Lay Member 16/12/2015 Present This interest will be kept under review


required.

SUNDERLAND, Sue Non-Executive Director Inclusion Healthcare Social

Enterprise CIC (Leicester City)

Non-Executive Director 16/12/2015 Present This interest will be kept under review


required.

TILLING, Michelle Locality Director - City No relevant interests declared Not applicable

- -

Not applicable

TRIMBLE, Dr Ian Independent GP Advisor Occasional consultancy work for

other CCGs

Occasional consultancy work for

other CCGs



required.

TRIMBLE, Dr Ian Independent GP Advisor Unity Surgery, Mapperley Registered Patient

-







TRIMBLE, Dr Ian Independent GP Advisor National Advisory Committee for

Resource Allocation

Independent GP Advisor 01/04/2013 Present This interest will be kept under review






WRIGHT, Michael LMC Representative, CEO Practice Support Services Limited -

Nottinghamshire

Support service as for profit

subsidiary of LMC



required.

WRIGHT, Michael LMC Representative, CEO LMC Buying Groups Federation Manager 01/04/2016 Present This interest will be kept under review


required.

WRIGHT, Michael LMC Representative, CEO GP-S coaching and mentoring Support service as for profit

subsidiary of LMC



required.

WRIGHT, Michael LMC Representative, CEO Nottinghamshire GP Phoenix

Programme

Manager 01/04/2016 Present This interest will be kept under review


required.


on the agenda

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held in the CCGs

Declared

Interest

(Name of the

organisation

and nature of

business)

Nature of Interest

Fin

an

cia

l In

tere

st

No

n-f

ina

nc

ial

Pro

fes

sio

na

l

Inte

res

ts

No

n-f

ina

nc

ial

Pe

rso

na

l In

tere

sts

Ind

ire

ct

Inte

res

t

Da

te F

rom

:

Da

te T

o:


WRIGHT, Michael LMC Representative, CEO Castle Healthcare Practice Registered Patient 30/09/2016 Present This interest will be kept under review


required.

WRIGHT, Michael LMC Representative, CEO Notspar and Trent Valley Surgery

Special Allocation Schemes (violent

patient schemes)



required.


on the agenda

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Managing Conflicts of Interest at Meetings

1. A “conflict of interest” is defined as a “set of circumstances by which a reasonable person

would consider that an individual’s ability to apply judgement or act, in the context of

delivering commissioning, or assuring taxpayer funded health and care services is, or could

be, impaired or influenced by another interest they hold”.

2. An individual does not need to exploit their position or obtain an actual benefit, financial or

otherwise, for a conflict of interest to occur. In fact, a perception of wrongdoing, impaired

judgement, or undue influence can be as detrimental as any of them actually occurring. It is

important to manage these perceived conflicts in order to maintain public trust.

3. Conflicts of interest include:

Financial interests: where an individual may get direct financial benefits from the

consequences of a commissioning decision.

Non-financial professional interests: where an individual may obtain a non-financial

professional benefit from the consequences of a commissioning decision, such as

increasing their reputation or status or promoting their professional career.

Non-financial personal interests: where an individual may benefit personally in ways

which are not directly linked to their professional career and do not give rise to a direct

financial benefit.

Indirect interests: where an individual has a close association with an individual who has

a financial interest, a non-financial professional interest or a non-financial personal

interest in a commissioning decision.

The above categories are not exhaustive and each situation must be considered on a case

by case basis.

4. In advance of any meeting of the Committee, consideration will be given as to whether

conflicts of interest are likely to arise in relation to any agenda item and how they should be

managed. This may include steps to be taken prior to the meeting, such as ensuring that

supporting papers for a particular agenda item are not sent to conflicted individuals.

5. At the beginning of each formal meeting, Committee members and co-opted advisors will be

required to declare any interests that relate specifically to a particular issue under

consideration. If the existence of an interest becomes apparent during a meeting, then this

must be declared at the point at which it arises. Any such declaration will be formally

recorded in the minutes for the meeting.

Management of any real or perceived conflicts of interest


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6. The Chair of the Committee (or Deputy Chair in their absence, or where the Chair of the

Committee is conflicted) will determine how declared interests should be managed, which is

likely to involve one the following actions:

Requiring the individual to withdraw from the meeting for that part of the discussion if the

conflict could be seen as detrimental to the Committee’s decision-making arrangements.

Allowing the individual to participate in the discussion, but not the decision-making

process.

Allowing full participation in discussion and the decision-making process, as the potential

conflict is not perceived to be material or detrimental to the Committee’s decision-making

arrangements.

Management of any real or perceived conflicts of interest


NHS Nottingham and Nottinghamshire Clinical Commissioning Group

Public Session of the Primary Care Commissioning Committee

Unratified minutes of the meeting held on

17/06/2020, 9.00-10.30

Zoom Meting

Members present:

Eleri de Gilbert Non-Executive Director (Chair)

Shaun Beebe Non-Executive Director

Danielle Burnett Deputy Chief Nurse

Michael Cawley Operational Director of Finance

Lucy Dadge Chief Commissioning Officer

Helen Griffiths Associate Director of Primary Care Networks

Joe Lunn Interim Associate Director of Primary Care

Dr Richard Stratton GP Representative

Sue Sunderland Non-Executive Director

Dr Ian Trimble Independent GP Advisor

In attendance:

Adrian Audis Commissioning Manager, NHS England/Improvement GP Hub

Helen Brocklebank-Clark Corporate Governance Officer (minutes)

Fiona Callaghan Locality Director, South Nottinghamshire (item PCC 20 047)

Lynette Daws Head of Primary Care

Siân Gascoigne Head of Corporate Assurance

Esther Gaskill Head of Quality – Primary Care

Lynne Sharp Associate Director of Estates (item PCC 20 050)

Jo Simmonds Head of Corporate Governance

Michael Wright Nottinghamshire Local Medical Committee

Apologies:

None

Cumulative Record of Members’ Attendance (2020/21)

Name Possible Actual Name Possible Actual

Shaun Beebe 3 3 Joe Lunn 3 2

Michael Cawley 3 3 Dr Richard Stratton 3 3

Lucy Dadge 3 3 Sue Sunderland 3 3

Eleri de Gilbert 3 3 Dr Ian Trimble 3 3

Helen Griffiths 3 3 Danielle Burnett 3 1

Minutes from the meeting held on 17 June 2020


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Introductory Items

PCC 20 038 Welcome and Apologies

Eleri de Gilbert welcomed everyone to the public session of the Primary Care

Commissioning Committee meeting, which was being held virtually due to the Covid-19

pandemic.

No apologies had been received.

PCC 20 039 Confirmation of Quoracy

The meeting was declared quorate

PCC 20 040 Declaration of interest for any item on the shared agenda

In advance of the meeting it was identified that Dr Stratton was conflicted in relation to

item PCC 20 050 Primary Care Estates Update as he is a GP Partner at the Belvoir

Health Group.

The Chair reminded members of their responsibility to highlight any interests should

they transpire as a result of discussions during the meeting.

PCC 20 041 Management of any real or perceived conflicts of interest

It was agreed that as no decision needed to be made, Dr Richard Stratton could

participate in the discussion relating to item PCC 20 050 Primary Care Estates Update.

PCC 20 042 Questions from the public

No questions had been received.

PCC 20 043 Minutes from the meeting held on 20 May 2020

It was agreed that the minutes were an accurate record of the meeting.

PCC 20 044 Action log and matters arising from the meeting held on 20 May 2020

There were no actions outstanding; all other actions were noted as complete and there

were no matters arising.

PCC 20 045 Actions arising from the Governing Body

There were no actions outstanding.

Contract Management and Applications

PCC 20 046 Giltbrook Surgery: Boundary Change and Update on List Closure

Joe Lunn introduced the item and highlighted the following points:

a) At the February 2020 Nottingham West Clinical Commissioning Group’s Primary

Care Commissioning Committee (PCCC) it was agreed to extend the Giltbrook

Surgery list closure to a full twelve months, with three conditions:

i. Robust cleansing of the patient list;

ii. More proactive engagement with the Primary Care Network (PCN) to explore

available space and medium term solutions;



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iii. Apply to reduce the practice boundary.

b) Since February, the patient list size has begun to decrease, and the practice has

taken proactive steps to address the other conditions set by the Committee,

including submitting a temporary boundary reduction application.

c) The current boundary is historic, extending into areas of Derbyshire, Mansfield and

Ashfield and Nottingham City. Aligning the boundary with the Nottingham West PCN

footprint will enable the practice to control its list size and achieve sustainability in

the existing estate until a long term solution to the premises issue is secured.

d) The Committee is asked to approve a temporary boundary reduction for three

months to allow the practice to engage with patients and neighbouring practices and

PCNs. This would normally take place prior to submission of the boundary change

request; however it has been delayed to due to the Covid-19 pandemic.

Fiona Callaghan joined the meeting at this point.

e) During the three months, the practice cannot remove the patients currently

registered within the areas of reduction; however, it will be able to decline new

patients resident in these areas once the list is open and give them more control

over the future list size growth.

f) The practice would continue to support the nursing homes within the area of

reduction.

The following points were made in discussion:

g) Members were supportive of the boundary reduction and welcomed a robust

engagement exercise to identify and mitigate the impact on patients and

neighbouring practices and PCNs.

h) Assurance was received that there were no gaps in general practice provision

associated with this temporary boundary reduction. Furthermore, it was noted that it

would be helpful if future reports included the practice boundary overlaid on

neighbouring practice boundaries, which would be incorporated.

ACTION:

Joe Lunn to ensure future boundary change papers include the practice

boundary overlaid on neighbouring practice boundaries.

The Primary Care Commissioning Committee:

NOTED the information contained in this paper with regards to the practice list

closure.

CONSIDERED the application to reduce the practice boundary.

APROVED the application for the boundary reduction for a temporary period of three

months. This would be scheduled on the forward work programme to come back to

the Committee in September 2020.

Items for Approval

PCC 20 047 South Nottinghamshire: First Contact Physiotherapists

Fiona Callaghan was in attendance to present this item. The following points were



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highlighted:

a) This paper related to First Contact Physiotherapists within South Nottinghamshire

only as the Nottingham City requirement was still in discussion.

b) Under the Primary Care Network Contract Directed Enhanced Service (PCN DES),

funding is made available to PCNs through the Additional Roles Reimbursement

Scheme (ARRS) to recruit additional staff members across a range of specific roles.

One of these roles is First Contact Physiotherapists (FCPs).

c) FCPs are physiotherapists with enhanced skills who are able to see patients with

musculoskeletal (MSK) issues directly without needing a referral from their GP; this

is a role anticipated to be much sought after through the Covid-19 recovery phase

as numbers of people experiencing MSK issues is anticipated to increase.

d) In contrast to previous versions of the PCN DES, the most recent version, released

on 31 March 2020, limited the number of FCPs a PCN was eligible to be reimbursed

for to “one WTE per PCN where the PCN’s patients number 99,999 or less”.

However, “the commissioner may waive any limits in Table 1 where this is agreed by

the PCN, the commissioner, and the relevant Integrated Care System”.

e) The Rushcliffe, Nottingham West and Byron PCNs request that this waiver is applied

to allow them to continue with their plans to recruit up to 5.0 Whole Time Equivalent

(WTE) FCPs, 4.0 WTE FCPs and 2.0 WTE FCPs respectively, in the year 2020/21,

to meet the identified needs of their patient populations.


f) Assurance was received that each of the South Nottinghamshire PCNs had

analysed the roles they needed to meet the needs to their patients, and FCPs had

emerged as a priority area.

g) Members were supportive of the proposal, noting a similar request relating to FCPs

in Mid-Nottinghamshire was approved at the May Committee.

h) Confirmation was received that the twenty PCNs across Nottingham and

Nottinghamshire would be submitting workforce plans to NHS England/NHS

Improvement in August and October; which could be submitted to the Committee for

information, once signed off.


APPROVED the increase in number of WTE First Contact Physiotherapists eligible

to be reimbursed to the Rushcliffe PCN under the Additional Roles Reimbursement

Scheme for 2020/21 from 2.0 WTE to 5.0 WTE.


to be reimbursed to the Nottingham West PCN under the Additional Roles

Reimbursement Scheme for 2020/21 from 2.0 WTE to 4.0 WTE.


to be reimbursed to the Byron PCN under the Additional Roles Reimbursement


Fiona Callaghan left the meeting at this point.

Covid-19 Update

PCC 20 048 Primary Care Recovery Group Terms of Reference



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Joe Lunn introduced the item, highlighting the following points:

a) A Primary Care Recovery Group has been established to support primary care

through the period of restoration and recovery, and establish a ‘new normal’.

b) The Terms of Reference outline the objectives of the Recovery Group, the

membership and the reporting requirements, and is presented to the Committee for

information.


c) Discussion took place regarding the expected outputs of the Recovery Group, and it

was confirmed that restoration and recovery would be achieved through the

completion of individual streams of work, which had been formalised into a work

programme. These outputs would be articulated within the Terms of Reference and

re-submitted to the July Committee for information.

d) It was noted that the reporting requirements of the Group needed to be considered

in relation to the other cells within the CCG, some of which did not have terms of

reference as yet.


NOTED the Primary Care Recovery Group Terms of Reference and AGREED

that they would be received again at the July Committee, once the outputs of the

Group had been articulated.

PCC 20 049 Healthwatch Report

Eleri de Gilbert introduced the item and invited Lucy Dadge and Helen Griffiths to

highlight the key points:

a) Healthwatch Nottingham and Nottinghamshire has recently issued a report on the

information needs of vulnerable people during the Covid-19 pandemic. The report

details the findings of a survey undertaken (between 17 April and 4 May) to try and

understand the impact of the pandemic on vulnerable people. It had already been

considered by the Governing Body and was presented to the Primary Care

Commissioning Committee for information.

b) The results of the survey highlighted that a significant proportion of respondents did

not know if they were in the highest risk or increased risk group for Covid-19 and

demonstrated that nearly half of the respondents reported unmet information needs;

particularly around managing existing health conditions, accessing repeat

prescriptions and accessing mental health support.

c) The report makes several recommendations to both the local and national health

and care system.

d) Due to the timing of the report, there would be value in Healthwatch revisiting the

survey in relation to the differential impact of Covid-19 on the Black, Asian and

Minority Ethnic (BAME) population. This was supported by members and would be

fedback to Healthwatch.

e) Lucy and the CCG’s Joint Clinical Leaders had met with Healthwatch to understand

patients’ concerns, particularly around access to diagnostic tests for the

management of long term conditions, and provided assurance that these tests could

be accessed, just in a different way.

f) A system wide approach has been taken to supporting shielded patients, with link



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workers supporting vulnerable patients in need of additional support to access

appointments; a piece of work that has been recognised nationally.

g) As part of the Local Resilience Forum, work has taken place in conjunction with both

local authorities and the district councils to mobilise community hubs and establish a

single database of all shielded and vulnerable patients.

h) As telephone triage and online appointments become embedded, work is taking

place to consider the patient journey, and identify and support those patients unable

to access appointments remotely.

i) Effective communication, between the patient, the practice and within the

community, will be essential to ensuring patients can access face to face

appointments if they are needed.


j) Although the differential impact on the BAME population was not yet fully

understood, it was anticipated that this would inform a more focused piece of work

regarding access to services.

k) Members agreed that the report was useful, identifying key areas of learning,

particularly around the impact of new technology on patients.

ACTION:

To feedback to Healthwatch the value in revisiting the survey in relation to

the differential impact of Covid-19 on the Black, Asian and Minority Ethnic

(BAME) population.


NOTED the Healthwatch Report

For Assurance

PCC 20 050 Primary Care Estates Update

Prior to the meeting it was identified that Dr Stratton was conflicted in relation to this

item as he is a GP Partner at the Belvoir Health Group. However, as no decision is

required it was agreed that he could participate in the discussion.

Lynne Sharp presented this item and highlighted the following points:

a) The purpose of the paper is to bring members of the Committee up to date with

developments in primary care estates across the CCG.

b) Since the last update provided to the Primary Care Commissioning Committees of

the predecessor CCGs, progress on many of the estates work areas was halted in

due to the Covid-19 pandemic.

c) The estates team’s focus switched to supporting PCNs and locality teams to

establish Clinical Management Centres (CMCs) and supporting the Business

Continuity Cell to close all CCG Headquarters, apart from Standard Court, and

mobilise all staff to work from home.

d) In May 2020 the Infection Prevention and Control Standard Operating Procedure

(SOP) for Primary Care was issued. Practice compliance with the SOP would be

verified through a desktop exercise undertaken by the locality teams. Further to this,

a GP Practice COVID-19 Restoration and Recovery Phase Preparedness - Good



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Practice Checklist has been developed to help practices identify key areas for

improvement, some of which will relate to primary care estate.

e) Progress on producing the Primary Care Estates Strategy (PCES) has been delayed

due to Covid-19, however, this time has enabled each PCN to evaluate their estate

requirements in light of lessons learned.

f) The national Primary Care Data Gathering Programme was launched at the

beginning of June to gather sufficient information to ensure investment decisions

across primary and secondary care are equitable. The CCG is a pilot for this piece

of work, the outputs of which will inform the PCES.

g) All outline business cases for priority schemes identified by the predecessor CCGs

are developed sufficiently to bid for central capital whenever it becomes available,

with the exception of Strelley Health Centre. Due to changes in primary care

contracts, a new strategic case would be required to take this scheme forward.

h) A capital bid was successful for the Cotgrave Hub development: however, due to

timing issues this allocation has not been drawn down. This is close to completion

and a meeting to discuss this with the practice has been arranged.

i) The CCG requested £600k for its 20/21 allocation. This capital funding has not been

received or confirmed due to Covid-19. This is a concern as it would be a potential

funding stream for improvements to address Covid-19 compliance and is being

pursued through the Integrated Care System (ICS).

j) Certain workstreams have not progressed as anticipated due to the Covid-19

pandemic, for example, GP Debt issues; however, these will be picked up as soon

as possible.


k) Members felt that timelines would be a positive addition to the report to inform the

PCCC work programme and enable the Committee to be sighted of any revenue

implications.

l) It was confirmed that practices had been Red, Amber, Green (RAG) rated in relation

to their compliance with the Primary Care SOP, and particular issues unrelated

estates were being addressed by the locality teams.

m) The importance of ensuring the future resilience of primary care estate was

discussed, with assurance provided that a range of options were being considered,

including modular facilities and the flexibility of CMCs.

n) Assurance was provided that the full business cases will be reviewed and changes

as necessary to reflect learning from the Covid-19 pandemic response and PCN

DES.

o) It was explained that PCN workshops would provide an opportunity to engage with

PCNs around complex matters such as revenue and capital schemes.

p) Members were reminded that without capital funding, there were limited financial

resources available.

q) Members thanked Lynne for the report and asked that the outcome of the

desktop/checklist exercise be brought back to the Committee, along with the timeline

for the outline business cases.

ACTION:

Helen Brocklebank-Clark to update the forward work programme to reflect

that the outcome of the desktop/checklist exercise, along with the timeline



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for the outline business cases would come back to the Committee in the

coming months.


NOTED the update.

Lynne Sharp left the meeting at this point.

PCC 20 051 Future Primary Care Quality Assurance Monitoring and Reporting

Esther Gaskill was in attendance to present this item, highlighting the following points:

a) The purpose of this paper is to provide a proposed outline of the future primary care

quality assurance monitoring and reporting arrangements. These arrangements

incorporate lessons learned following practice closures and service disruptions; new

ways of working that have emerged as a result of the recent CCG; NHS

England/NHS Improvement restructures; and the CCG’s response to the Covid-19

pandemic.

b) Since the alignment of the CCGs in April 2019, work has successfully taken place to

implement the CCG’s Primary Care Quality Assurance and Improvement Framework

across the three localities and to ensure that a consistent approach to monitoring

primary care quality across Nottingham and Nottinghamshire has been embedded.

c) The framework comprises three dimensions; a Primary Care Quality group for each

locality, a quality dashboard with a risk matrix, and an escalation process, all of

which feed into the quarterly quality assurance report received by the Committee.

d) A development group has been established to scrutinise the quality dashboard to

verify its value as a quality improvement tool both for the CCG and general practice.

e) Over the last few years, practice closures and service disruptions have primarily

been as a result of Care Quality Commission (CQC) enforcement action and GP

retirement. Lessons learnt from these incidents have informed the quality assurance

process, and led to a close working relationship between the CQC and CCG’s

Primary Care Quality Team.

f) Reflection and learning from previous experiences has identified gaps in the

intelligence and information available to the primary care quality, primary care and

locality teams which would, if available, give a more comprehensive view of where

support may be required to prevent a sudden closure or service disruption. This

includes workforce data, complaints, patient safety incident information and

professional standards team reviews and investigations.

g) Matrix working across the primary care quality, primary care and locality teams

during the Covid-19 pandemic as a result of the incident cell working arrangements

has provided an opportunity for more collaboration and a model for future working

and alignment.

h) A series of recommendations were outlined to further strengthen the quality

assurance process moving forward, including implementation of a mechanism to

advise the Chair of the PCCC of significant emerging contractual and quality risks

and issues at the earliest possible opportunity.


i) Members thanked Esther for the helpful overview of quality assurance monitoring



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and reporting arrangements, and the steps being taken to build resilience in primary

care.

j) Members were pleased to see how learning from adverse incidents and practice

closures had influenced the monitoring arrangements and that learning was being

shared across practices.

k) Assurance was received that although the recent focus had been on practices with

an ‘inadequate’ or ‘requires improvement’ CQC rating, a more proactive approach to

analysing the dashboard indicators would enable early identification of a downward

trend in performance of well performing practices, which would be reflected in

reporting arrangements moving forward.

l) It was noted that the report reflects arrangements at a specific point in time, and will

be informed and strengthened through collaborative working and data analysis.

m) It was hoped that in time PCN Clinical Directors would be able to support the

development of local resilience plans; noting that staff resignations, particularly at

single handed practices, were an early indicator of additional support requirements.

n) Addressing the gap in workforce data was being explored, as it was recognised that

the Operational Pressures Escalation Levels (OPEL) reporting that had emerged in

response to the Covid-19 pandemic, enabled early identification of workforce issues

within primary care.

o) It was noted that although primary care demand would return to pre Covid-19 levels,

the system response would be different, with quality monitoring essential in

understanding the emerging impact on practices.


REVIEWED and ENDORSED the future primary care quality assurance

monitoring and reporting recommendations.

Financial Management

PCC 20 052 Finance Report

Michael Cawley presented this item, highlighting the following points:

a) The original CCG-wide Revenue Resource Limit (RRL) for the financial year,

including the Primary Care allocation, has been removed by NHS England/NHS

Improvement.

b) This has been replaced with a predetermined non-recurrent budget to cover an initial

revised reporting period of April to July.

c) Further to this, the CCG has been asked to report actual costs against the non-

recurrent budget and any resulting variances will be top-sliced or funded accordingly

to allow the CCG to break-even and report an on plan financial position for each

reporting period.


d) Discussion took place regarding the recording of costs related to primary care

Information Technology. It was confirmed that these were reflected within the

primary care budget, which Ian Trimble and Michael Cawley would explore in more

detail outside of the meeting.




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NOTED the contents of the Primary Care Commissioning Finance Report.

APPROVED the Primary Care Commissioning Finance Report as at May 2020.

Risk Management

PCC 20 053 Risk Report

Siân Gascoigne was in attendance to present this paper and highlighted the following

points:

a) There are four risks relating to the Committee’s responsibilities, all of which have

been reviewed by the Head of Corporate Assurance and the Interim Associate

Director of Primary Care since the last meeting.

b) Since the last meeting discussions have taken place with the CCG's Quality Team to

determine the best way forward in relation to risk RR 104 (quality in primary care) as

its narrative is felt to be too generic. It is suggested that it is archived, to be replaced

by more specific primary care quality risks with clearly defined mitigations; an

approach supported by members.

c) No new risks had been identified during the course of the meeting and no further

points were raised in discussion.


APPROVED the archiving of risk RR 104.

Closing Items

PCC 20 054 Any other business

Joe Lunn advised that all practices have been asked to confirm that they have risk

assessed their vulnerable staff groups, including BAME staff, and to identify any

specific issues and additional Personal Protective Equipment (PPE) requirements.

The outcome of this exercise will be shared with the Committee once available.

PCC 20 055 Key messages to escalate to the Governing Body

a) Approved a temporary three month boundary reduction at Giltbrook Surgery.

b) Approved the increase in number of WTE First Contact Physiotherapists eligible to

be reimbursed to the Rushcliffe PCN under the Additional Roles Reimbursement


c) Approved the increase in number of WTE First Contact Physiotherapists eligible to

be reimbursed to the Nottingham West PCN under the Additional Roles

Reimbursement Scheme for 2020/21 from 2.0 WTE to 4.0 WTE.

d) Approved the increase in number of WTE First Contact Physiotherapists eligible to

be reimbursed to the Byron PCN under the Additional Roles Reimbursement


e) Received the Healthwatch Report into the information needs of vulnerable people

during the Covid-19 pandemic, and identified value in revisiting the survey in relation

to the differential impact of Covid-19 on the Black, Asian and Minority Ethnic (BAME)

population, which would be fedback to Healthwatch.

PCC 20 056 Date of next meeting:

15/07/2020



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Zoom Meeting

Confidential Motion: The Primary Care Commissioning Committee resolved that representatives of the press

and other members of the public be excluded from the remainder of this meeting, having

regard to the confidential nature of the business to be transacted, publicity on which

would be prejudicial to the public interest (Section 1[2] Public Bodies [Admission to

Meetings] Act 1960)



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Primary Care Commissioning Committee Action Log for the meeting held on 17 June 2020

MEETING

DATE

AGENDA

REFERENCE

AGENDA ITEM ACTION LEAD DATE TO BE

COMPLETED

COMMENT

ACTIONS OUTSTANDING

No actions outstanding

ACTIONS ONGOING/NOT YET DUE

17/06/2020 PCC 20 049 Healthwatch

Report

To feedback to Healthwatch the

value in revisiting the survey in

relation to the differential impact

of Covid-19 on the Black, Asian

and Minority Ethnic (BAME)

population.

Eleri de Gilbert 15/07/2020 Eleri to provide a verbal

update at the meeting

ACTIONS COMPLETED

20/05/2020 PCC 20/032 Primary Care

Quality Report

Esther Gaskill to develop a

Hazard Log to identify potential

hazards of remote working and

identify mitigating actions before

they begin to adversely impact on

Esther

Gaskill/Danni

Burnett

15/07/2020 Hazard Log has been

drafted and is in further

development. Presented in

confidential session for

initial review.

Action log and m

atters arising from the m

eeting held on 17 June 2020

22 of 24309:00 - 10:20 via Z


of 2

MEETING

DATE

AGENDA

REFERENCE

AGENDA ITEM ACTION LEAD DATE TO BE

COMPLETED

COMMENT

patients.

17/06/2020 PCC 20 046 Giltbrook Surgery:

Boundary Change

and Update on

List Closure

Joe Lunn to ensure future

boundary change papers include

the practice boundary overlaid on

neighbouring practice

boundaries.

Joe Lunn 15/07/2020 This has been

communicated to the

primary care team and

incorporated into business

as usual arrangements.

17/06/2020 PCC 20 050 Primary Care

Estates Update

The outcome of the

desktop/checklist exercise, along

with the timeline for the outline

business cases to be scheduled

on the forward work programme.

Helen

Brocklebank-

Clark

15/07/2020 The work programme has

been updated to reflect that

the outcome of

desktop/checklist exercise

will come to the Committee

in August. The timeline for

the outline business cases

will be incorporated within

the Primary Care Estates

update in September 2020.

Action log and m

atters arising from the m

eeting held on 17 June 2020

23 of 24309:00 - 10:20 via Z


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Meeting Title: Primary Care Commissioning Committee

(Open Session)

Date: 15 July 2020

Paper Title: Orchard Medical Practice List Closure

Review

Paper Reference: PCC 20 064

Sponsor:

Presenter:

Joe Lunn, Associate Director of Primary

Care

Attachments/

Appendices:

N/A

Lynette Daws, Head of Primary Care

Purpose: Approve ☐ Endorse ☐ Review

☐ Receive/Note for:

Assurance

Information

☒

Executive Summary

Arrangements for Discharging Delegated Functions

Delegated function 4 – Decisions in relation to the commissioning, procurement and management of

primary medical services contracts

In September 2019, an application was submitted to Mansfield and Ashfield CCG’s Primary Care

Commissioning Committee for Orchard Medical Practice, in the Mansfield and Ashfield locality, to close their

list for a period of twelve months. This was approved by the Committee and the practice closed their list to

new patients as of 1 October 2019.

The purpose of this paper is to provide an update to the committee of the effect of the list closure to date.

During discussions with the practice to obtain progress they requested the reopening of their list be deferred

by 3-6 months (due to reopen 1 October 2010), as a result of COVID-19; an application has not been

submitted.

Relevant CCG priorities/objectives:

Compliance with Statutory Duties ☐ Wider system architecture development

(e.g. ICP, PCN development)

☐

Financial Management ☒ Cultural and/or Organisational

Development

☐

Performance Management ☐ Procurement and/or Contract Management ☒

Strategic Planning ☐

Conflicts of Interest:

☒ No conflict identified

Orchard Medical Practice: List Closure Update


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Completion of Impact Assessments:

Equality / Quality Impact

Assessment (EQIA)

Yes ☐ No ☐ N/A ☒ An EQIA was completed for the original paper,

this remains unchanged.

Data Protection Impact

Assessment (DPIA)

Yes ☐ No ☐ N/A ☒ Not required for this item.

Risk(s):

There are no risks identified within this paper.

Confidentiality:

☒No

Recommendation(s):

1. NOTE the information contained in the paper



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Orchard Medical Practice List Closure Review

1. Background

Orchard Medical Practice is located in the Mansfield and Ashfield locality of Nottingham and

Nottinghamshire CCG and has one of the largest list sizes of the area (weighted as of 1 June 2020 -

19,607).

In their original list closure application the practice cited significant staffing changes, which included the

early retirement of the lead GP and three further experienced GPs in their original application. The

practice anticipated that a further two GPs would also be retiring in the next two years and wanted to

plan for this to ensure the practice would be resilient for this change. At the time of the list closure

application, the practice had the following vacancies: two Salaried GPs; one Assistant Nurse

Practitioner; one Pharmacist.

2. Progress following the list closure

2.1. Recruitment

Since the list closure the practice has recruited one new salaried GP and one current salaried GP

joined the partnership in April 2020. However, another partner also retired from the practice around

this time, therefore the partnership has remained at the same position. A Nurse Practitioner was

recruited but this again was followed by the retirement of another nurse at the practice. A Pharmacy

Technician has been recruited and the practice report this position is working well.

The practice currently has GP registrars at the practice which they may consider offering salaried

positions to once they are fully qualified.

In terms of workforce, the practice still has a salaried GP vacancy and a Nurse Practitioner vacancy.

It would also help to stabilise the practice if further partners could be recruited to replace those who

left pre-list closure and for the anticipated retirements.

Updated Practice Workforce (March 2020) - Whole Time Equivalents Per Role:

Role WTE in September

2019

Current WTE as of

March 2020

Current WTE Ratio

1 : Patients

GP* 11.84 12.96 1 : 1,512

Nurse** 4.68 7.62 1 : 2,573

HCA 2.49 2.89 N/A

Administrative Staff 19.44 20.72 N/A

* Partners, salaried, GP registrars and locums

** Pharmacy technician, nurse additional session and nurse pre-retirement

2.2. GP:Patient ratio

At the time of the list closure, the GP to patient ratio was approximately 1:1,692. It is usually flagged

for concern when the GP to Patient ratio exceeds 1:2,200; the British Medical Association (BMA)

guide for GP to Patient ratio is 1:2,239. The current ratio for Orchard Medical Practice (1:1,512) is

still within the England average; in the Mansfield and Ashfield locality there are a number of practices

which exceed these figures.



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2.3. List Size Changes

The practice has seen a reduction in the number of patients registered at the practice since the list

closure.

Month List Size Month List Size

1 July 2019 (original paper) 19,893 1 October 2019 20,044

1 January 2020 19,853 1 April 2020 19,661

1 June 2020 19,607

Since the list closed on October 1, the list size has reduced by 2.18%. The smaller reduction April -

June 2020 is likely due to COVID-19 limiting movement in the population and registering elsewhere.

2.4. Impact on neighbouring practices

The closure has had a minimal impact on the list sizes of practices in Mansfield North Primary Care

Network (PCN), of which Orchard Medical Practice is a member, the highest increase in list size saw

Pleasley Surgery list grow by 82 patients (1 Oct 2019 – 1 June 2020).

There is a second PCN in Mansfield (Rosewood PCN); a number of these practices are within close

proximity to Orchard Medical practice. All but one practice has seen an increase in their list size.

Practice Name Distance from Orchard

Medical Practice

(miles)

List Size as of 1

October 2019

List Size as of 1 June

2020

Churchside Medical

Practice

1 6,499 6,714 (+215)

Forest Medical 0.9 15,656 15,971 (+315)

Roundwood Surgery 2.2 13,233 13,346 (+113)

Millview Surgery (List

closure in place until Dec 2019) 0.5 8,247 8,187 (–60)

Acorn Medical Practice 0.9 3,239 3,380 (+141)

The practices that increased their list size the most during this closure is Churchside Medical

Practice and Forest Medical, their list sizes grew by 3.3% and 2% respectively. Although the closure

of Orchard Medical Practice is likely to have contributed to the list size increases, both practice’s list

sizes have been growing for some time.

When the original list closure paper was presented, neighbouring practices raised no concerns and

were keen for patients to register with them.

2.5. COVID-19

As part of the COVID-19 response, Orchard Medical Practice has been set up as a site with a

dedicated area for seeing patients with COVID-19 symptoms. The site can be mobilised if there is a

need and it is anticipated that patients from other PCN practices would attend this site. This has

disrupted the practice’s usual clinical room availability and they feel it would be difficult to house

more clinicians, especially if there is a spike in COVID-19 cases.

The practice has requested the re-opening of the list be deferred for a period of 3-6 months, due to

the exceptional circumstances of COVID-19.



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3. Consideration of list closure extension

The practice was granted the maximum term for a list closure and the CCG have not received a formal

application for any extension.

Although the practice has cited uncertainty in the future of the COVID-19 pandemic and the effects it has

had on the list closure, it should be noted that the COVID-19 pandemic has changed ways of working for

all GP practices. More remote consultations are taking place and footfall into practices has reduced

significantly. These new ways of working should help practices manage their capacity and allow for

clinicians to work without needing additional room space. Patients may also be screened before

entering the practice, which again can limit the number of people accessing the surgery.

Overall, the GP to patient ratio is in line with the England average and is not yet a cause for concern.

Due to recruitment efforts, the practice has slightly improved their workforce numbers and has at least

prevented this from worsening.

4. Financial implications

There has been no financial impact to the CCG as a result of the list closure and no future costs are

anticipated.

5. Objective and vision of the CCG/Integrated Care System (ICS)

The ICS Primary Care plan makes reference to ensuring the resilience of the GP workforce. The list

closure has so far allowed for the practice to develop their resilience for the workforce issues they are

facing and therefore has supported this action.

6. Summary

Overall the practice seems in a stable position; although there is still some outstanding positions at the

practice this is not unusual for GP practices. The list size has reduced and the GP:Patient ratio is still

below the England average and below BMA guidance.

Twelve months is the maximum term permitted for a list closure by the Primary Medical Services Policy

and Guidance Manual. Since the practice was originally granted a twelve month closure, there is no

scope within the regulations to extend this further and the practice list should re-open as planned.

7. Recommendation

The Primary Care Commissioning Committee is asked to NOTE the information contained in the paper.



of 7

Meeting Title: Primary Care Commissioning Committees (Open Session)

Date: 15 July 2020

Paper Title: Nottingham City: First Contact Physiotherapists and Care Coordinators Additional Roles

Paper Reference: PCC/20/065

Sponsor: Lucy Dadge, Chief Commissioning Officer

Attachments/ Appendices:

A - Network Contract Directed Enhanced Service Contract specification 2020/21 – PCN Requirements and Entitlements

B - Update to the GPcontract agreement 2020/21 – 2023/24

C – ARRS Expenditure

Presenter: Michelle Tilling, Nottingham City Locality Director

Summary Purpose:

Approve ☒ Endorse ☐ Review ☐ Receive/Note for:

∑ Assurance∑ Information

☐

Executive Summary

Under the Primary Care Network (PCN) Contract Directed Enhanced Service (DES), funding is made available to PCNs through the Additional Roles Reimbursement Scheme (ARRS) to recruit additional workforce across a range of specific roles.

First Contact Physiotherapist (FCP)First Contact Physiotherapist (FCPs) are specialist physiotherapists who have developed an enhanced skillset that enables them to see patients with musculoskeletal (MSK) issues directly, without the need of a referral from the patient’s General Practitioner (GP).

The most recent version of the PCN DES, released on 31st March 2020, places a limitation on the number of First Contact Physiotherapists a PCN is eligible to be reimbursed for within the year 2020/21, whereas this has not been the in previous iterations. However the document also states that “the commissioner may waive any limits in Table 1 where this is agreed by the PCN, the commissioner, and the relevant Integrated Care System” (ref. section 6.3.4, page 35, Appendix A).

Radford & Mary Potter PCN, Nottingham City East PCN and Clifton & Meadows PCN request that this waiver is applied to allow them to continue their plans to recruit up to 2.0 Whole Time Equivalent (WTE) FCPs, 1.8 WTE FCPs and 2.0 WTE FCPs respectively, in the year 2020/21. There is no financial implication to the CCG of approving the additional numbers as funding for additional roles is provided to PCNs through the national Additional Roles Reimbursement Scheme (ARRS). Approval isrequired to allow PCNs to deviate from updated guidance.

Full workforce plans are due to be submitted by PCNs in August 2020. In lieu of this, the above mentioned PCNs have confirmed that the stipulated WTEs of FCPs fall within their individual 2020/21 ARRS budgets.

Nottingham City: First Contact Physiotherapists and Care Coordinators Additional Roles


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Bulwell & Top Valley, BACHS, Bestwood & Sherwood, City South and Unity PCNsNone of the remaining five PCNs in Nottingham City are recruiting more than 1.0 WTE First Contact Physiotherapist in 2020/21, and therefore do not require approval from the CCG to increase their reimbursable WTE through the ARRS. Two of the PCNs, BACHS and City South, are choosing not to recruit to this role at all.

Care Co-Ordinator Care co-ordinators provide extra time, capacity and expertise within Primary Care. The focus of the role should reflect local priorities, health inequalities or population health management risk stratification.

Nottingham City East PCN wishes to employ a care co-ordinator under the ARRS scheme with a sole focus on safeguarding. Safeguarding concerns create a significant workload for practices within this PCN which has high numbers of deprivation.

The most recent version of the PCN DES lists a number of key responsibilities for the role (ref. section B5.2, page 76, Appendix A). Three of which are patient facing. The safeguarding focus would deviate slightly from these responsibilities however; they would still be met indirectly by the care co-ordinatorliaising with the patients social / link workers.

The proposed role has been discussed with the Clinical Directors in Nottingham City and a further five PCNs are interested in employing a care co-ordinator with a sole focus on safeguarding.


Compliance with Statutory Duties ☐ Establishment of a Strategic Commissioner ☐

Financial Management ☐ Wider system architecture development (e.g. ICP, PCN development)

☒

Performance Management ☐ Cultural and/or Organisational Development

☐

Strategic Planning ☐ Procurement and/or Contract Management ☐




Equality / Quality Impact Assessment (EQIA)

Yes ☐ No ☐ N/A☒ Not required for this item.

Data Protection Impact Assessment (DPIA)

Yes ☐ No ☐ N/A☒ Not required for this item.

Risk(s):

First Contact Physiotherapists

1. A lack of flexibility in WTE may cause tension in the relationship between the PCN and the Strategic Commissioner;

2. A lack of flexibility in WTE will create inconsistency in PCN autonomy across Nottingham and Nottinghamshire;

3. A reduced number of WTE First Contact Physiotherapists within the PCN may result in;∑ Very little or no impact in GP resilience∑ Very little or no impact in patient satisfaction∑ Very little or no impact in reducing the prevalence of chronic musculoskeletal issues



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∑ Very little or no impact in reducing secondary care referrals into rheumatology and orthopaedic services

∑ Very little or no impact in reducing imaging requests∑ Very little or no impact in optimising surgical conversion rate∑ Increased waiting times for patients to access First Contact Physiotherapy services∑ Reduced local/neighbourhood access to First Contact Physiotherapy∑ The patient not seeing the right person, in the right place, at the right time.

Care Co-ordinators

1. A lack of flexibility in shaping the role may cause tension in the relationship between the PCN and the Strategic Commissioner;

2. A lack of flexibility in shaping the role may result in a lost opportunity to be innovative;3. A lack of flexibility in shaping the role may result in the PCN not recruiting and underutilising their ARRS

budget, effectively reducing their efficiency and capacity as a network ;4. A cohort of patients may go on unsupported increasing their risk of safeguarding and potential harm;5. Potential increase in health inequalities within the city by not being able to focus the role where it’s

needed;6. Further reduction in GP resilience.

Confidentiality:

☒No

Recommendation(s):

1. APPROVE the increase in number of WTE First Contact Physiotherapists eligible to be reimbursed to the Radford & Mary Potter PCN under the Additional Roles Reimbursement Scheme for 2020/21 from 1.0 WTE to 2.0 WTE.

2. APPROVE the increase in number of WTE First Contact Physiotherapists eligible to be reimbursed to the Nottingham City East PCN under the Additional Roles Reimbursement Scheme for 2020/21 from 1.0 WTE to 1.8 WTE.

3. APPROVE the increase in number of WTE First Contact Physiotherapists eligible to be reimbursed to the Clifton & Meadows PCN under the Additional Roles Reimbursement Scheme for 2020/21 from 1.0 WTE to 2.0 WTE.

4. APPROVE the proposed safeguarding focus for the care co-ordinator role under the Additional Roles Reimbursement Scheme for 2020/21.



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Additional Roles; Additional First Contact Physiotherapists; and Focused Care Co-ordinators -Nottingham City Primary Care Networks

Background/ ContextUnder the Primary Care Network (PCN) Contract Directed Enhanced Service (DES), funding is made available to PCNs through the Additional Roles Reimbursement Scheme (ARRS) to recruit additional workforce across a range of specific roles.

First Contact Physiotherapist (FCPs) are specialist physiotherapists who have developed an enhanced skillset that enables them to see patients with musculoskeletal (MSK) issues directly, without the need of a referral from the patient’s General Practitioner (GP).

In all previous iterations of the ARRS document there have been no limitations placed on the number of FCPs a PCN is eligible to be reimbursed for from April 2020 onwards, within the limitations of the individual PCN’s ARRS budget.

A new version of the PCN DES was released on 31st March 2020 which placed a limitation on the number of First Contact Physiotherapists a PCN is eligible to employ within the year 2020/21. The document states that a PCN may be reimbursed for;

∑ “one WTE per PCN where the PCN’s Patients number 99,999 or less” or,∑ “two WTE per PCN where the PCN’s Patients number 100,000 or over”

(ref. section 6.3.3, Table 1, page 34 - Appendix A).

The document also states that “the commissioner may waive any limits in Table 1 where this is agreed by the PCN, the commissioner, and the relevant Integrated Care System” (ref. section 6.3.4, page 35, Appendix A).

Care co-ordinators provide extra time, capacity and expertise within Primary Care. The focus of the role should reflect local priorities, health inequalities or population health management risk stratification.

The most recent version of the PCN DES lists a number of key responsibilities for the role (ref. section B5.2, page 76, Appendix A). Applying a safeguarding focus to the role would deviate slightly from these responsibilities, meeting them indirectly instead.

First Contact PhysiotherapistsRadford & Mary Potter PCN, Nottingham City East PCN and Clifton & Meadows PCN request that this waiver is applied to allow them to continue their plans to recruit up to 2.0 Whole Time Equivalent (WTE)FCPs, 1.8 WTE FCPs and 2.0 WTE FCPs respectively, in the year 2020/21.

Advice from the CCG’s Director of Procurement has confirmed that PCNs do not need to go out to tender for FCP services. There is no financial implication to the CCG of approving the additional WTE as funding for additional roles is provided to PCNs through the national Additional Roles Reimbursement Scheme (ARRS). Approval is required to allow the PCN to deviate from updated guidance.

Radford & Mary Potter PCN (registered population 49,313)This PCN demonstrates the need for an increased number of FCPs as the PCN has a significantly higher proportion (25%) of young people age 20-24 years due to the large student population in the area.The predominant mosaic groups are Group J & L (educated young people privately renting in urban neighbourhoods & single people privately renting low cost homes for the short term), making up 58% of the population. They comprise young people, most likely students and young working people in private rented accommodation. Despite prevalence of back pain in people of all ages being lower than the national average for England, sports and alcohol related injuries are likely to be higher, therefore creating a greater demand on general practice.



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Nottingham City East PCN (registered population 66,826)This PCN demonstrates the need for an increased number of FCPs as this PCN is responsible for 17% of the registered patients in Nottingham City ICP. This makes it the largest PCN in the ICP. Despite prevalence of back pain in people of all ages being lower than the national average for England, the proportion of working age adults, aged 25-64 years, is higher than the ICP. However, unemployment (% of the working age population claiming out of work benefit) is significantly worse than the England average which may be due to MSK related injuries (outside of back pain). Clifton & Meadows PCN (registered population 31,727) This PCN demonstrates the need for an increased number of FCPs as the PCN has a significantly higher prevalence of severe back pain in people of all ages than the national average for England.

Evidence of Demand – First Contact Physio City-wide pilotFirst Line Physio, provided by CityCare Partnership, ran from 1st December 2014 to 31st March 2016 across a number of practices within the city. Practices from each of the PCNs participated in the pilot.Further details are provided in the table below:

Primary Care Network Participating practices Appointments utilised

Projected demand

Radford & Mary Potter Fairfields Medical Practice 293 p/a 1,465

Nottingham City East Family Medical Centre The Windmill Practice NEMS Platform One

346 p/a 2,422

Clifton & Meadows Clifton Medical Practice John Ryle Medical Practice

336 p/a 1,680

*Based on one of the offers from a community provider 2.0 WTE FCPs would provide 1,892 appointments per year, which would be in line with demand.

The pilot was evaluated and found that at least 75% of patients referred to the First Line Physiotherapy Service can be managed successfully within primary care, predominantly within physiotherapy. Very few patients needed to be directed to their GP following their physiotherapy appointment. The most common reasons for doing so were for medical issues raised in addition to an MSK problem or to exclude a medical cause for an MSK disorder. One of the main benefits of having physiotherapists within a GP practice was that requests for analgesia, sick notes etc. were often able to be dealt with within the First Line appointment through liaison with the on-call GP, removing the need for an additional GP appointment. Patients were rarely recommended for referral to secondary care or for further investigations.

DES guidanceThe updated DES guidance published on 6th February 2020 listed the illustrative WTE of FCPs for an average PCN to be 3.5 WTE by 2023/24 (ref. table 2, page 11, Appendix B). An average PCN is considered to have approximately 50,000 registered patients. It is felt that in order to achieve this, a baseline model of 2.0 WTE is a realistic number to start to build upon and will also provide a robust enough service to create a tangible impact in the PCN.

AffordabilityFull workforce plans are due to be submitted by PCNs in August 2020 however all three PCNs have confirmed that the additional FCPs will fall entirely within their 2020/21 ARRS budgets with no use of 2019/20 underspend (Appendix C).

ARRS budgets are set to increase year on year. However, Clifton & Meadows PCN may need to utilise additional funds to maintain this level of staffing in 2021/22. Discussions are currently on-going and will be finalised by the time the PCN is required to submit their workforce intentions to 2023/24.



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Care Co-ordinatorsNottingham City East PCN wishes to employ a care co-ordinator under the ARRS scheme with a sole focus on safeguarding. Safeguarding concerns create a significant workload for practices within this PCN which serves populations in the most deprived 10% in England (City overall ranking 11th highest deprived of 317 districts across the country). Due to the population, it is feasible that there may be increased number of safeguarding concerns creating a significant workload for practices. A designated role would support PCNs to manage this workload.

A number of key responsibilities are listed in the DES, three of which are patient facing. A safeguarding focus would deviate slightly from these responsibilities however; they would still be met indirectly by the care co-ordinator liaising with the patients social / link workers (see table below). All other requirements of the role would be met by the proposal.

Care Co-ordinators Key responsibilities (as listed in the DES) Met by proposal

Support patients to utilise decision aids in preparation for a shared decision-making conversation

INDIRECTLY – Via liaison with social worker / link worker

Support people to understand their level of knowledge, skills and confidence (their “Activation” level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure


Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level


In addition to the key responsibilities the PCN is also required to ensure that the Care Coordinator(s) can discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g. abuse, domestic violence and support with mental health) with a relevant GP. The proposed role would fulfil this requirement.

This concept is not new to Primary Care. In 2015 Camden CCG decided to fund a dedicated administrator to support general practice to manage and engage in child protection cases. The role increased the percentage of written reports received for Child Protection Case Conferences (CPCC) from 54% in 2015-16 to 94% 2018-19.

ConclusionAdditional FCPs will provide the registered populations of the Radford & Mary Potter, Nottingham City East and Clifton & Meadows PCNs with considerably better access to FCP services than if the reimbursement limitations remain in place. This, in turn, will help in releasing GP time, improving patient experience, reducing referrals into secondary care, and reducing the likelihood of patients developing chronic MSK conditions.

Focusing the care co-ordinator role on safeguarding would allow the post to become a valuable asset to Nottingham City East PCN and would increase clinical capacity, improve efficiency and continuity and act as a specialist resource. As a further five PCNs are also interested in employing a care co-ordinator with a sole focus on safeguarding this would be an opportunity to create an expert resource across the city and provide peer support to each PCN. The Nottingham City GP Alliance (NCGPA) may also offer to host the role if this proposal is supported.

Recommendation The Primary Care Commissioning Committee is asked to:

1. APPROVE the request to increase the number of WTE FCPs eligible to be reimbursed to the Radford & Mary Potter PCN under the ARRS for 2020/21 from 1.0 WTE to 2.0 WTE



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2. APPROVE the request to increase the number of WTE FCPs eligible to be reimbursed to the Nottingham City East PCN under the ARRS for 2020/21 from 1.0 WTE to 1.8 WTE.

3. APPROVE the request to increase the number of WTE FCPs eligible to be reimbursed to the Clifton & Meadows PCN under the ARRS for 2020/21 from 1.0 WTE to 2.0 WTE.

4. APPROVE the request to focus the care co-ordinator role on safeguarding under the ARRS 2020/21.

Gemma MarkhamPrimary Care Network Development Manager – Nottingham City LocalityNottingham and Nottinghamshire CCG – July 2020



NHS England and NHS Improvement

Network Contract Directed Enhanced Service

Contract specification 2020/21 - PCN Requirements and Entitlements March 2020



Network Contract Directed Enhanced Service

Contract Specification 2020/21 – PCN Requirements and

Entitlements

Publishing approval number: 001681

Version number: 1

First published: 31 March 2020

Prepared by: Primary Care Strategy and NHS Contracts Group

This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. Please contact the Primary Care Strategy and NHS Contracts Group at [email protected]. Equalities and health inequalities statement "Promoting equality and addressing health inequalities are at the heart of NHS England’s values. Throughout the development of the policies and processes cited in this document, we have:

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

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



mailto:[email protected]

Contents

Network Contract Directed Enhanced Service .............................................................1

Contract Specification 2020/21 – PCN Requirements and Entitlements......................1

1. Introduction .........................................................................................................3

2. Commonly used terms ........................................................................................3

3. Relationship between the Network Contract DES and the primary medical services contract .................................................................................................5

4. Eligibility for and participation in the Network Contract DES ...............................5

5. PCN Organisational Requirements ................................................................... 16

6. Additional Roles Reimbursement Scheme ........................................................ 31

7. Service Requirements ....................................................................................... 39

8. Contract management ....................................................................................... 48

9. Network financial entitlements ........................................................................... 50

10. Monitoring ......................................................................................................... 63

Annex A - Network Contract DES Participation Form ................................................ 66

Annex B - Additional Roles Reimbursement Scheme - Minimum Role Requirements67

B.1. Clinical Pharmacist ............................................................................................ 67

B.2. Pharmacy Technicians ...................................................................................... 68

B.3. Social Prescribing Link Workers ........................................................................ 70

B.4. Health and Wellbeing Coach ............................................................................. 73

B.5. Care Coordinator ............................................................................................... 76

B.6. Physician Associates ......................................................................................... 78

B.7. First Contact Physiotherapists ........................................................................... 79

B.8. Dieticians ........................................................................................................... 81

B.9. Podiatrists ......................................................................................................... 83

B.10. Occupational Therapists .................................................................................. 84

Please be aware that all aspects of this service specification outline the requirements for this programme. As such, commissioners and practices should ensure they have read and understood all sections of this document as part of the implementation of this programme. Practices are advised that to ensure they receive payment, particular attention should be paid to the payment and validation terms. Practices will need to ensure they understand and use the designated clinical codes as required to ensure payment.



1. Introduction

1.1. The Network Contract Directed Enhanced Service (the “Network Contract

DES”) was first introduced in the Directed Enhanced Services Directions 20191.

1.2. The Network Contract DES placed obligations on practices and commissioners

and granted various entitlements to practices with effect from 1 July 2019.

1.3. An objective of the Network Contract DES in 2019 was for primary medical

services contractors to establish and develop Primary Care Networks (“PCNs”).

1.4. The Network Contract DES forms part of a long-term, larger package of general

practice contract reform originally set out in Investment and Evolution: A five-

year framework for GP contract reform to implement the NHS Long Term Plan

and subsequent updates.

1.5. It is intended that there will be a Network Contract DES each financial year until

at least 31 March 2024 with the requirements of the Network Contract DES

evolving over time.

1.6. This document sets out:

1.6.1. how commissioners must offer to primary medical services contractors the

opportunity to participate in the Network Contract DES;

1.6.2. the eligibility requirements and process for primary medical services contractors

to participate in the Network Contract DES; and

1.6.3. in relation to the Network Contract DES, the rights and obligations of:

a. primary medical services contractors that participate;

b. the PCNs of which they are members; and

c. commissioners,

for the financial year from 1 April 2020 to 31 March 2021.

1.7. This document has been agreed by NHS England and the British Medical

Association’s (BMA) General Practitioners Committee England (GPCE).

2. Commonly used terms

2.1. This document is referred to as the “Network Contract DES Specification”.

2.2. In this Network Contract DES Specification:

1 The Network Contract DES Directions can be found at

https://www.gov.uk/government/publications/nhs-primary-medical-services-directions-2013



https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf


https://www.gov.uk/government/publications/nhs-primary-medical-services-directions-2013

2.2.1. the “Network Contract DES” refers to the Network Contract DES for the

financial year commencing 1 April 2020 and ending on 31 March 2021 unless

expressly stated otherwise;

2.2.2. a “practice” refers to a primary medical services contractor;

2.2.3. a “New Practice” refers to a practice that is newly formed following the taking

effect of a new primary medical services contract;

2.2.4. the “commissioner” refers to the organisation with responsibility for contract

managing a practice and this will be either NHS England or a clinical

commissioning group (“CCG”) where the latter carries out contract

management of primary medical services contracts under delegated

arrangements with NHS England;

2.2.5. the “Network Agreement” refers to the agreement entered into by practices

(and potentially other organisations) that are members of a PCN and which

incorporates the provisions that are required to be included in a network

agreement2 in accordance with section 5.1.2.d;

2.2.6. a “Core Network Practice” of a PCN has the same meaning as in a PCN’s

Network Agreement and refers to the practices that are members of a PCN

who are responsible for delivering the requirements of the Network Contract

DES in relation to that PCN;

2.2.7. an “Previously Approved PCN” refers to a PCN that was approved in the

period commencing 1 July 2019 and ending on 31 March 2020;

2.2.8. the “Nominated Payee” refers to a practice or organisation (which must hold a

primary medical services contract) that receives payment of the applicable

financial entitlement set out in this Network Contract DES Specification;

2.2.9. the “Network Area” refers to the area of a PCN as described in section 5.1.3;

2.2.10. a “list of patients” refers to the registered list of patients in respect of a

practice that is maintained by NHS England and NHS Improvement in

accordance with that practice’s primary medical services contract;

2.2.11. the “PCN’s Patients” refers collectively to the persons on a PCN’s Core

Network Practices’ lists of patients;

2.2.12. the “practice list size” refers to the number of persons on the list of patients

of the practice;

2 The Network Agreement and Schedule can be found at

https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-network-agreement/





2.2.13. the “PCN list size” refers to the number of PCN Patients, which is the sum of

all practice list sizes of the Core Network Practices of the PCN;

3. Relationship between the Network Contract DES and

the primary medical services contract

3.1.1. Where this Network Contract DES Specification sets out a requirement or

obligation of a PCN, each Core Network Practice of a PCN is responsible for

ensuring the requirement or obligation is carried out on behalf of that PCN.

3.1.2. A practice participating in the Network Contract DES must enter into a

variation of its primary medical services contract to incorporate the provisions

of this Network Contract DES Specification.

3.1.3. The provisions of this Network Contract DES Specification therefore become

part of the practice’s primary medical services contract.

3.1.4. Where a practice chooses not to participate in the Network Contract DES, this

will not impact on the continuation of primary medical services under its

primary medical services contract.

4. Eligibility for and participation in the Network Contract

DES

4.1. Context

4.1.1. A practice wishing to participate in the Network Contract DES for the period

from 1 April 2020 to 31 March 2021 must follow the participation process set

out in this section 4.

4.1.2. A practice participating in this Network Contract DES acknowledges that it will

automatically participate in subsequent years’ Network Contract DES unless

the practice follows the opt-out process set out in section 4.13 of this Network

Contract DES Specification.

4.1.3. A commissioner must ensure that any patients of a practice that is not

participating in the Network Contract DES are covered by a PCN (for example

through commissioning a local incentive scheme). Further information on

commissioning PCN services for patients of non-participating practices is

available in the Network Contract DES Guidance.



4.2. Eligibility

4.2.1. A practice must satisfy each eligibility criteria below to be eligible to participate

in the Network Contract DES:

a. the practice must hold a primary medical services contract;

b. the practice has a registered list of patients which means that persons are

recorded in the registration system approved by NHS England as being

registered with the practice; and

c. the practice’s primary medical services contract must require the practice

to offer in-hours (essential services) primary medical services.

4.3. Participation

4.3.1. By 1 April 2020 the commissioner must indicate to each practice the method

the practice must use to provide the information necessary for that practice to

participate in the Network Contract DES. The information must be provided by

using the form set out at Annex A of this Network Contract DES Specification.

4.3.2. Where a practice wishes to participate in the Network Contract DES, one of

the situations below will apply. The practice must identify the relevant situation

and act in accordance with the appropriate section:

a. If the practice is a Core Network Practice under the Network Agreement of

a Previously Approved PCN and there have been no changes to the

following information:

i. identity of the Core Network Practices,

ii. the Nominated Payee,

iii. the Clinical Director;

iv. Network Area,

the practice must act in accordance with section 4.4;

b. If the practice is a Core Network Practice under the Network Agreement of

a Previously Approved PCN and there have been changes to the

information listed in sections a.i to a.iv above, the practice must act in

accordance with section 4.5;

c. If the practice has not previously participated in a Network Contract DES

but wishes to be a Core Network Practice of a Previously Approved PCN,

the practice must act in accordance with section 4.6;

d. If the practice is a New Practice and wishes to be a Core Network Practice

of a Previously Approved PCN, the practice must act in accordance with

section 4.7;



e. If the practice is either a New Practice or an existing practice and wishes

to be a Core Network Practice of a newly proposed PCN, the practice

must act in accordance with section 4.8; or

f. If the practice cannot identify a Previously Approved PCN or a newly

proposed PCN that is willing to allow the practice to be a Core Network

Practice under its Network Agreement, the practice must act in

accordance with section 4.9.

4.4. Previously Approved PCNs with no change

4.4.1. Where this section applies, the practice must notify the commissioner of no

change on or before 31 May 2020. Where the PCN wants to ensure there is

no interruption to payments made to the PCN as the PCN transitions to this

new Network Contract DES Specification, the Core Network Practices of that

PCN must have completed the process for participating in the Network

Contract DES prior to the next local payment deadline. Commissioners should

liaise with Core Network Practices to confirm timescales.

4.4.2. On receipt of the notification, the commissioner will consider all information

received including the extent to which the Previously Approved PCN meets the

criteria for a PCN set out in section 5.1.2 and, as soon as practicable and in

any event within one month of receipt of the notification, notify the practice

whether its participation in the Network Contract DES is confirmed.

4.4.3. Where the commissioner notifies a practice that its participation in the Network

Contract DES:

a. is not confirmed, section 4.10 applies;

b. is confirmed, section 4.11 applies.

4.5. Previously Approved PCNs with change

4.5.1. Where this section applies, the practice must notify the commissioner of the

relevant change on or before 31 May 2020. Where the PCN wants to ensure

there is no interruption to payments made to the PCN as the PCN transitions

to this new Network Contract DES Specification, the Core Network Practices

of that PCN must have completed the process for participating in the Network

Contract DES prior to the next local payment deadline. Core Network

Practices should liaise with the commissioner to confirm timescales.

4.5.2. The practice must include in the notification:

a. the change that has occurred;

b. the reasons for the change.



4.5.3. The practice must promptly provide to the commissioner any information the

commissioner requests in relation to the change.

4.5.4. Where the commissioner is satisfied that it has all required and necessary

information, the commissioner will consider all information received including

the extent to which the Previously Approved PCN meets the criteria for a PCN

set out in section 5.1.2 and, as soon as practicable and in any event within

one month of receipt of the notification, notify the practice whether its

participation in the Network Contract DES is confirmed.

4.5.5. Where the commissioner consents to a change in the details of the Previously

Approved PCN, the commissioner must complete the PCN ODS Change

Instruction Notice3, to indicate any changes to a PCN’s membership and/or

Nominated Payee. The commissioner must submit the notice by the last

working day on or before the 14th day of the month for the change to take

effect by the end of that month. The commissioner must ensure that the latest

it submits the notice by 12 June 2020.


Contract DES:



4.6. Previously non-participating practice joining a Previously Approved

PCN

4.6.1. Where this section applies, the practice must provide the following information

to the commissioner on or before 31 May 2020:

a. confirmation that the practice has signed an updated version of the PCN’s

Network Agreement;

b. confirmation that the practice is listed as a Core Network Practice in the

PCN’s Network Agreement;

c. confirmation that the practice agrees that payments under the Network

Contract DES are made to the PCN’s Nominated Payee;

d. confirmation that the practice will have in place patient record sharing

arrangements (as clinically required) and data sharing arrangements of the

PCN, in line with data protection legislation and patient opt-out

preferences, prior to the start of any service delivery under the Network

Contract DES.

3 The PCN ODS Change Instruction Notice is available here.



https://digital.nhs.uk/services/organisation-data-service/services-provided-by-the-organisation-data-service/organisation-data-service-forms#primary-care-networks

4.6.2. Where the commissioner is satisfied that it has all relevant and necessary



set out in section 5.1.2 and, as soon as practicable and in any event within

one month of receipt of the notification, notify the practice whether its

participation in the Network Contract DES is confirmed.

4.6.3. Where, as a result of the commissioner’s decision, there is a change in the

details of the Previously Approved PCN, the commissioner must complete the

PCN ODS Change Instruction Notice4, to indicate any changes to a PCN’s

membership and/or Nominated Payee. The commissioner must submit the

notice by the last working day on or before the 14th day of the month for the

change to take effect by the end of that month. The commissioner must

ensure that the latest it submits the notice is by 12 June 2020.


Contract DES:



4.7. New Practice joining a Previously Approved PCN

4.7.1. Where this section applies, the New Practice must provide the information set

out in sections 4.6.1.a to 4.6.1.d to the commissioner.

4.7.2. A New Practice may provide the information to the commissioner at any time

during the financial year.




set out in section 5.1.2 and, as soon as practicable, notify the practice whether

its participation in the Network Contract DES is confirmed.


details of the Previously Approved PCN, the commissioner must complete the

PCN ODS Change Instruction Notice5, to indicate any changes to a PCN’s

membership and/or Nominated Payee. The commissioner must submit the

notice by the last working day on or before the 14th day of a month for the

change to take effect by the end of that month.

4 The PCN ODS Change Instruction Notice is available here. 5 The PCN ODS Change Instruction Notice is available here.






Contract DES:



4.8. New Practice or existing practice forms a new PCN

4.8.1. Where this section applies, the practice must provide the following information

to the commissioner on or before 31 May 2020:

a. the names and ODS codes6 of the proposed PCN’s Core Network

Practices7;

b. the number of the PCN’s Patients as at 1 January 20208;

c. a map clearly marking the geographical area covered by the Network Area

of the proposed PCN;

d. an initial Network Agreement – this requires completion of the proposed

Core Network Practices’ details in the front end of the Network Agreement

and in Schedule 1, details of the Network Area, the Clinical Director and

Nominated Payee (additional information in Schedule 1 relating to PCN

meetings and decision-making may also be submitted but it is recognised

that this may not have been fully agreed at the point of submission to the

commissioner);

e. the Nominated Payee9 and details of the relevant bank account that will

receive funding on behalf of the PCN; and

f. the identity of the accountable Clinical Director.

4.8.2. The information must be provided by using the form set out at Annex A of this

Network Contract DES Specification.

4.8.3. The practice must promptly provide to the commissioner any further

information the commissioner requests in relation to the proposed PCN.

4.8.4. Where the commissioner is satisfied that it has all required and necessary


the extent to which the proposed PCN meets the criteria for a PCN set out in

section 5.1.2 and, as soon as practicable and in any event within one month of

6 https://digital.nhs.uk/services/organisation-data-service 7 This may be a single super practice. 8 This can be obtained by aggregating the number of persons on the lists of patients for all Core

Network Practices as recorded in the registration system approved by NHS England. 9 Payment nomination would only apply where there is more than one primary medical care contractor in

the PCN.



https://digital.nhs.uk/services/organisation-data-service

receipt of the notification, notify the practice whether its participation in the

Network Contract DES is confirmed and whether the proposed PCN is

approved.

4.8.5. Where the commissioner approves the PCN, the commissioner must complete

the PCN ODS Change Instruction Notice10 to indicate the details of the PCN.

The commissioners must submit the notice by the last working day on or

before the 14th day of the month for the change to take effect by the end of

that month. The commissioner must ensure that the latest it submits the notice

by 12 June 2020. The commissioner must also indicate to the PCN and its

Core Network Practices when they are required to commence delivery of the

Network Contract DES and the date payments will be made, taking into

account local payment arrangements.


Contract DES:



4.9. PCNs unwilling to accept a practice

4.9.1. Where this section applies, the practice must notify the commissioner by 31

May 2020 that no Previously Approved PCN or proposed PCN is willing to

enable the practice to be a Core Network Practice of the PCN.

4.9.2. On receipt of the notification, the commissioner will liaise with the relevant

LMC to facilitate discussions between the practice wishing to sign-up to the

Network Contract DES and the appropriate PCN(s) taking all reasonable steps

to reach agreement on the terms for the inclusion of the practice in a PCN.

4.9.3. Where the commissioner determines that there is no agreement on the terms

for the inclusion of the practice in a PCN, the commissioner may require a

PCN to include the practice as a Core Network Practice of that PCN.

4.9.4. Where the commissioner is minded to require a PCN to include the practice as

a Core Network Practice of that PCN, the commissioner must engage with the

relevant LMC and, when making its determination, have regards to the views

of the LMC. The commissioner acknowledges that the Core Network Practices

of the PCN may already have submitted information and had their participation

in the Network Contract DES confirmed at the point the commissioner is

minded to require the PCN to include the practice as a Core Network Practice.

If the commissioner requires a PCN to include the practice, the commissioner





will consider this a change to the details of the PCN and consider any

consequences of inclusion on the PCN and its Core Network Practices.

4.9.5. Where the commissioner requires a PCN to include the practice as a Core

Network Practice of that PCN pursuant to section 4.9.3:

a. the commissioner must inform that PCN on or before 30 June 2020;

b. the commissioner must inform any other PCN with whom the

commissioner has been liaising with pursuant to section 4.9.2 of its

determination; and

c. each practice in the PCN to which the practice has been allocated will, as

soon as practicable, and in any event within 30 days, after the

commissioner informs them of its decision, take the necessary steps to

enable the practice to become a Core Network Practice of the PCN

including, but not limited, to varying the Network Agreement to include the

practice.

4.9.6. As soon as practicable after the PCN has taken the necessary steps pursuant

to section 4.9.5.c, the practice joining the PCN must provide the following

information to the commissioner:

a. confirmation that the practice has signed an updated version of the PCN’s

Network Agreement;

b. confirmation that the practice is listed as a Core Network Practice in the

PCN’s Network Agreement;

c. confirmation that the practice agrees that payments under the Network

Contract DES are made to the PCN’s Nominated Payee;

d. confirmation that the practice will have in place patient record sharing

arrangements (as clinically required) and data sharing arrangements of the

PCN, in line with data protection legislation and patient opt-out

preferences11, prior to the start of any service delivery under the Network

Contract DES.


information, the commissioner will as soon as practicable but in any event

within five working days, taking into account the information that has been

provided and the fact that the commissioner has required the PCN to include

11 https://digital.nhs.uk/about-nhs-digital/our-work/keeping-patient-data-safe/how-we-look-after-your-

health-and-care-information/your-information-choices/opting-out-of-sharing-your-confidential-patient-information



https://digital.nhs.uk/about-nhs-digital/our-work/keeping-patient-data-safe/how-we-look-after-your-health-and-care-information/your-information-choices/opting-out-of-sharing-your-confidential-patient-information



the practice in the PCN, notify the practice whether its participation in the

Network Contract DES is confirmed.


details of the PCN, the commissioner must complete the PCN ODS Change

Instruction Notice12. The commissioner must submit the notice by the last

working day on or before the 14th day of the month for the change to take

effect by the end of that month.


Contract DES:



4.10. Participation not confirmed


Contract DES is not confirmed:

a. the commissioner will explain to the practice the reasons for its decision;

b. the commissioner, the practice and the relevant PCN if applicable must

make every reasonable effort to communicate and co-operate with each

other, and with the local LMC if relevant, with a view to enabling the

commissioner to confirm the practice’s participation in the Network

Contract DES as soon as practicable;

c. if no agreement is reached after a reasonable timescale, the commissioner

or the practice may refer the matter to the local NHS England team.

4.10.2. Where a local LMC is involved in the matter, the commissioner must work with

the local LMC to support PCN development, addressing where appropriate

issues that arise and seeking to maintain 100 per cent geographical coverage

of PCNs.

4.10.3. If the commissioner notifies the practice that its participation in the Network

Contract DES is confirmed, section 4.11 applies;

4.11. Confirmation of participation

4.11.1. Where a commissioner has confirmed a practice’s participation in the Network

Contract DES, the practice must, as soon as practicable:





a. enter into a written variation of its primary medical services contract with

the commissioner that incorporates the provisions of this Network Contract

DES Specification;

b. if the practice has been provided with access to the Calculating Quality

Reporting Service (“CQRS”), indicate via CQRS that it is participating in

the Network Contract DES; and

c. ensure the PCN’s Network Agreement reflects the arrangements for

delivery of the Network Contract DES.

4.12. Auto-enrolment in the subsequent Network Contract DES or in-year

variation

4.12.1. A practice participating in this Network Contract DES acknowledges that it will

automatically participate in:

a. the subsequent Network Contract DES (which means the Network

Contract DES commencing on 1 April 2021); and

b. any variation to the Network Contract DES Specification that is to take

effect prior to 31 March 2021,

unless it chooses not to continue to participate in the Network Contract DES in

accordance with section 4.13.

4.12.2. The PCN acknowledges that to automatically participate in the subsequent

Network Contract DES and the associated specification or the varied Network

Contract DES Specification (as relevant), this particular Network Contract DES

Specification must end on either 31 March 2021 or, where the Network

Contract DES Specification has been varied, the date determined in

accordance with section 4.13, to be replaced with the new specification.

Subject to section 4.12.3 therefore, where a practice participates in the

Network Contract DES, the practice and the commissioner agree that

immediately after the 31 March 2021 or the date determined in accordance

with section 4.13, as relevant, provided that the practice’s participation has not

ceased at an earlier date:

a. this Network Contract DES Specification will cease to have effect; and

b. the practice’s primary medical services contract will be deemed to have

been varied to remove the incorporation of this Network Contract DES

Specification.

4.12.3. Unless expressly stated otherwise or by necessary implication, no term of this

Network Contract DES Specification shall survive beyond 31 March 2021 or

earlier termination (as relevant).



4.13. Opting out of auto-enrolment in the subsequent Network Contract

DES and opting out of the Network Contract DES where there is an

in-year variation

4.13.1. A Core Network Practice of a PCN may choose not to participate in:

a. the subsequent Network Contract DES (which means the Network

Contract DES commencing on 1 April 2021); or

b. the Network Contract DES where there is any variation to the Network

Contract DES Specification that is to take effect prior to 31 March 2021,

in which case that Core Network Practice must notify the commissioner within

one calendar month of the publication by NHS England and NHS Improvement

of the specification for the subsequent Network Contract DES or the varied

Network Contract DES Specification (as relevant).

4.13.2. The PCN, of which the practice providing notice under section 4.13.1 was a

Core Network Practice, must act in accordance with any provisions set out in

the specification for the subsequent Network Contract DES or the varied

Network Contract DES Specification that relate to changes to the PCN.

4.13.3. For the avoidance of doubt, a practice choosing not to participate in the

subsequent Network Contract DES or any variation is required to act in

accordance with this Network Contract DES Specification until 31 March 2021

unless section 4.14 applies.

4.14. Ending participation in this Network Contract DES

4.14.1. A practice participating in the Network Contract DES acknowledges that it will

participate in the Network Contract DES until 31 March 2021 unless:

a. the practice chooses to end its participation in this Network Contract DES

by notifying the commissioner prior to 31 May 2020, in which case section

4.14.2 applies;

b. the practice provides notice under section 4.13.1 that it no longer wishes

to participate in the Network Contract DES where there is any variation to

the Network Contract DES Specification that is to take effect prior to the 31

March 2021, in which case section 4.14.2 applies; or

c. any of the following events occur:

i. expiry or termination of the Core Network Practice’s primary medical

services contract, in which case section 5.13 applies;

ii. there has been an irreparable breakdown in relationship or an

expulsion, in which case section 5.14 applies;



iii. the commissioner consents to a merger or split of the Core Network

Practice, in which case section 5.15 applies; or

iv. the commissioner determines that the Core Network Practices’

participation in the Network Contract DES should cease in accordance

with section 8.

4.14.2. Where a practice notifies the commissioner:

a. prior to 31 May 2020 that it chooses to cease its participation in the

Network Contract DES; or

b. that it no longer wishes to participate in the Network Contract DES where

there is any variation to the Network Contract DES Specification that is to

take effect prior to 31 March 2021,

the same process applies as where there is a change in the Core Network

Practice members due to expiry or termination of a Core Network Practice’s

primary medical services contract (and the applicable sections are sections

5.13.1.b to 5.13.4.c).

5. PCN Organisational Requirements

5.1. Definition and criteria for a PCN

5.1.1. A PCN can be broadly defined as a practice or practices (and possibly other

providers13) serving an identified Network Area with a minimum population of

30,000 people.

5.1.2. The criteria for a PCN is:

a. that the PCN has an identified Network Area that complies with the

requirements set out in section 5.1.3;

b. that the PCN list size as at 1 January 2020 is between 30,000 and 50,000

except that:

i. in exceptional circumstances, a commissioner may waive the 30,000

minimum PCN list size requirement where a PCN serves a natural

community which has a low population density across a large rural and

remote area; and

ii. a commissioner may waive the 50,000 maximum PCN list size

requirement where it is satisfied that it is appropriate to do so. In such

13 Examples of other providers - community (including community pharmacy, dentistry, optometry),

voluntary, secondary care providers, social care - and GP providers who are not participating in the Network Contract DES.



circumstances, the commissioner may require the Core Network

Practices of the PCN to organise the PCN operationally into smaller

neighbourhood teams that cover population sizes between 30,000 to

50,000 and the Core Network Practices will comply with such

requirement. For the avoidance of doubt, the PCN will still be required

to have one Nominated Payee.

iii. that there is more than one Core Network Practice in the PCN except

that there may only be one Core Network Practice if the commissioner

is satisfied that this is appropriate having regard to all relevant factors.

Where a PCN has only one Core Network Practice, the PCN must

work with other providers as set out in section 5.7.1 to achieve the

optimal benefits of PCN working.

c. that the PCN has a Nominated Payee which must hold a primary medical

services contract;

d. that the PCN has in place a Network Agreement signed by all PCNs

members, that incorporates the mandatory provisions set out in the

national template network agreement1415.

e. that the PCN has at all times an accountable Clinical Director;

f. that the PCN has in place appropriate arrangements for patient record

sharing in line with data protection legislation honouring patient opt-out

preferences1617.

5.1.3. The Network Area must:

a. satisfy the commissioner that the Network Area is sustainable for the

future, taking account of how services are delivered by wider members of

the PCN beyond the practices and with a view to the evolution of PCNs;

b. align with a footprint which would best support delivery of services to

patients in the context of the relevant Integrated Care System (ICS) or

Sustainability and Transformation Partnership (STP) strategy;

c. cover a boundary that makes sense to:

14 Where PCNs decide to seek advice related to the Network Agreement, these costs will not be

covered under the Network Contract DES nor by commissioners at a local level. 15 The Network Agreement template has been agreed between NHS England and GPC. The Network

Agreement template can be found at https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-network-agreement/

16 https://digital.nhs.uk/about-nhs-digital/our-work/keeping-patient-data-safe/how-we-look-after-your-health-and-care-information/your-information-choices/opting-out-of-sharing-your-confidential-patient-information

17 A template data controller/data processer agreement and a template data controller/data controller agreement can be found at https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-data-templates/








https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-data-templates/


i. the Core Network Practices of the PCN;

ii. other community-based providers which configure their teams

accordingly; and

iii. the local community;

d. cover a geographically contiguous area;

e. not cross CCG, STP or ICS boundaries except where:

i. a Core Network Practice’s boundary or branch surgery crosses the

relevant boundaries; or

ii. the Core Network Practices are situated in different CCGs.

5.1.4. Where a practice has one or more branch surgeries in different PCNs, the

practice must ensure that it will be a Core Network Practice of only one PCN

and a non-core member of the other PCN(s) within which the relevant branch

surgeries are situated. The practice acknowledges that its list of patients will

be associated with the PCN of which the practice is a Core Network Practice.

5.1.5. Where a PCN’s Core Network Practices are situated within different CCG

areas, the relevant commissioners must agree which commissioner will be the

‘lead’ for the PCN and identified as such within the PCN ODS reference data

and subsequently within the relevant GP IT systems for payment processing.

The identified lead commissioner will make payments to the relevant

Nominated Payee in relation to the Network Contract DES. The lead

commissioner and any other relevant commissioner must reconcile any

funding allocation discrepancies between themselves and not via national GP

payment systems.

5.2. General PCN organisational requirements

5.2.1. A PCN must ensure it remains compliant with the criteria of a PCN set out in

section 5.1.2 at all times.

5.2.2. A PCN must ensure its Network Agreement reflects the requirements of this


5.2.3. Where required by data protection legislation, a PCN must ensure each

member of the PCN has in place appropriate data sharing arrangements and,

if required, data processor arrangements18, that are compliant with data

protection legislation to:

18 Optional data sharing agreement and data processing agreement can be found at





a. support the delivery of extended hours access service requirement from 1

April 2020; and

b. support the delivery of all other service requirements set out in this

Network Contract DES prior to the provision of these services to patients.

5.2.4. A Previously Approved PCN must ensure that there is no interruption in

provision of services in the transition from the previous year’s Network

Contract DES to this Network Contract DES. For the avoidance of doubt, this

requires a Previously Approved PCN to:

a. provide the Extended Hours Access service under this Network Contract

DES Specification from 1 April 2020; and

b. to take such steps as are necessary to provide the service requirements

under this Network Contract DES Specification other than the Extended

Hours Access service in the timescales set out in this Network Contract

DES Specification.

5.2.5. The PCN acknowledges that confirmation of the Core Network Practices’

participation in this Network Contract DES may not be received until after 1

April 2020. The PCN acknowledges that it must act in accordance with section

5.2.4 but the PCN acknowledges that section 9 sets out backdating of certain

elements of the financial entitlements.

5.2.6. A commissioner and a PCN must not vary this Network Contract DES

Specification. For the avoidance of doubt, the commissioner must not increase

or reduce the requirements of the financial entitlements set out in this Network


5.2.7. Where a commissioner commissions local services from the PCN that are

supplemental to the Network Contract DES (referred to in this Network

Contract DES Specification as “Supplementary Network Services”)19, the

arrangements for such local Supplementary Network Services must not be

included in a varied version of this Network Contract DES Specification and

should instead be contained in a separate local incentive scheme.

5.3. PCN Clinical Director

5.3.1. A PCN must have in place a Clinical Director who:

a. is accountable to the PCN members;

19 Supplementary Network Services would be services commissioned locally, under separate

arrangements and with additional resource, building on the foundation of the Network Contract DES. Further information regarding commissioning local services can be found in the Network Contract DES Guidance.



https://www.england.nhs.uk/publication/des-guidance-2020-21/


b. provides leadership for the PCN’s strategic plans, working with PCN

members to improve the quality and effectiveness of its delivery of the

Network Contract DES;

c. is a direct and integral component of the overall Network Contract DES;

d. is a practicing clinician from within the PCN’s Core Network Practices;

e. is able to undertake the responsibilities of the role and represent the

PCN’s collective interests;

f. works collaboratively with Clinical Directors from other PCNs within the

ICS/STP area, playing a critical role in shaping and supporting their

ICS/STP, helping to ensure full engagement of primary care in developing

and implementing local system plans;

5.3.2. A PCN must ensure its Clinical Director has overall responsibility for the

following key requirements20:

a. strategic and clinical leadership for the PCN, developing and implementing

strategic plans, leading and supporting quality improvement and

performance across Core Network Practices (including professional

leadership of the Quality and Outcomes Framework Quality Improvement

activity across the PCN). The Clinical Director is not solely responsible for

the operational delivery of services - this is a collective responsibility of the

PCN;

b. strategic leadership for workforce development, through assessment of

clinical skill-mix and development of a PCN workforce strategy;

c. completing the workforce planning template and agree, on behalf of the

PCN, the estimate as referred to in section 6.5;

d. supporting PCN implementation of agreed service changes and pathways

and work closely with Core Network Practices and the commissioner and

other PCNs to develop, support and deliver local improvement

programmes aligned to national priorities;

e. developing local initiatives that enable delivery of the PCN’s agenda,

working with commissioners and other networks to reflect local needs and

ensuring initiatives are coordinated;

f. developing relationships and work closely with other Clinical Directors,

clinical leaders of other primary care, health and social care providers,

local commissioners and LMCs;

20 This section sets out the high-level minimum responsibilities of the Clinical Director. The detailed

requirements will vary according to the characteristics of the PCN, including its maturity and local context and should be set out in the PCN’s Network Agreement.



g. facilitating participation by practices that are members of the PCN in

research studies and act as a link between the PCN and local primary care

research networks and research institutions; and

h. representing the PCN at CCG-level clinical meetings and the ICS/STP,

contributing to the strategy and wider work of the ICS/STP.

5.3.3. A PCN must manage any conflicts of interest. A PCN must ensure that its

Clinical Director takes a lead role in developing the PCN’s conflict of interest

arrangements, taking account of what is in the best interests of the PCN and

its patients.

5.3.4. A PCN’s appointment of a Clinical Director must follow a selection process

either via appointment, election or both details of which must be included in

Schedule 1 of the Network Agreement.

5.4. Data and analytics

5.4.1. A PCN must share non-clinical data between its members in certain

circumstances. The data to be shared is the data required to:

a. support understanding and analysis of the population’s needs;

b. support service delivery in line with local commissioner objectives; and

c. support compliance with the requirements of this Network Contract DES

specification.

5.4.2. A PCN must determine appropriate timeframes for sharing of this data.

5.4.3. Where the functionality is available, a PCN should ensure that clinical data

sharing for service delivery uses read/write access, so that a GP from any

practice can refer, order tests and prescribe electronically and maintain a

contemporaneous record for every patient.

5.4.4. A PCN must:

a. benchmark and identify opportunities for improvement;

b. identify variation in access, service delivery or gaps in population groups

with highest needs; and

c. review capacity and demand management across the PCN, including

sharing appointment data for the PCN to action (this could be achieved

through using the GP workload tool or other similar tools), and the PCN



must monitor, share and aggregate relevant data21 across the Core

Network Practices to enable it to carry out these requirements.

5.4.5. A commissioner and the wider system may support PCNs in the analysis of

data.

5.4.6. Core Network Practices of a PCN must use the relevant SNOMED codes to

support data collections for the indicators related to the Network Contract DES

some of which will be included in the Network Dashboard22.

5.5. Patient engagement

5.5.1. A PCN must act in accordance with the requirements relating to patient

engagement under the PCN’s Core Network Practice’s primary medical

services contracts by:

a. engaging, liaising and communicating with the PCN’s Patients in the most

appropriate way;

b. informing and/or involving them in developing new services and changes

related to service delivery; and

c. engaging with a range of communities, including ‘seldom heard’ groups.

5.5.2. A PCN must provide reasonable support and assistance to the commissioner

in the performance of its duties23 to engage patients in the provision of and/or

reconfiguration of services where applicable to the PCN’s Patients.

5.6. Sub-contracting arrangements

5.6.1. Where a PCN (or any one or more of its members which are practices) is

considering sub-contracting arrangements related to the provision of services

under the Network Contract DES, the PCN must have due regard to the

requirements set out in the statutory regulations or directions that underpin

each Core Network Practices’ primary medical services contracts in relation to

sub-contracting, which will also apply to any arrangements to sub-contract

services under the Network Contract DES.

5.6.2. A PCN acknowledges that its members that are practices may be required

under their primary medical services contract to notify the commissioner, in

writing, of their intention to sub-contract as soon as reasonably practicable and

21 Data sources include workload data, population data, appointment data, cost data, outcome data and

patient experience data (e.g. friends and family test, GP patient survey). 22 The Network Dashboard will be introduced during 2020/21. It will include key PCN metrics to support

population health management, including prevention, urgent and anticipatory care, prescribing and hospital use.

23 Section 14Z2 of the 2006 NHS Act.



before the date on which the sub-contracting arrangement is intended to

begin.

5.6.3. A PCN (and its members that are practices) must make available on request

from the commissioner any information relating to sub-contracting

arrangements and reporting information relating to either the delivery of

network services or the engagement of PCN staff, for which reimbursement is

being claimed under the Network Contract DES.

5.6.4. Notwithstanding any provision to the contrary of a PCN Core Network

Practices’ primary medical services contract, a Core Network Practice may

sub-contract any of its rights or duties under the Network Contract DES in

relation to non-clinical matters provided that the Core Network Practice obtains

prior written approval from the commissioner (such approval to not be

unreasonably withheld or delayed).

5.6.5. Where a Core Network Practice of a PCN has sub-contracted a non-clinical

matter that relates to the Network Contract DES, the sub-contract may allow

the sub-contractor to sub-contract the non-clinical matter provided that the

Core Network Practice obtains prior written approval from the commissioner

(and such approval will not be unreasonably withheld or delayed).

5.7. Collaboration with non-GP providers

5.7.1. A PCN must agree with local community services providers, mental health

providers and community pharmacy providers how they will work together.

5.7.2. A PCN must ensure that compliance with this requirement is evidenced

through setting out in Schedule 7 of the Network Agreement:

a. the specifics of how, where required by this Network Contract DES

Specification or otherwise deemed appropriate, the service requirements

will be delivered through integrated working arrangements between the

PCN and other providers; and

b. how providers will work together, including agreed communication

channels, agreed representatives, and how any joint decisions will be

taken.

5.7.3. A PCN must detail the arrangements with its local community services

provider(s) in Schedule 7 of the Network Agreement by 30 September 2020.

The commissioner will use reasonable endeavours to facilitate the agreement

of arrangements between the local community services provider(s) and the

PCN.



5.7.4. A PCN must detail its arrangements with community mental health providers,

and community pharmacy (via the community pharmacy nominated Pharmacy

PCN Lead) in Schedule 7 of the Network Agreement by 31 March 2021.

5.8. Changes to a PCN

5.8.1. A PCN acknowledges that:

a. it was approved; and

b. its Core Network Practices’ participation in the Network Contract DES was

confirmed,

on the basis of the information provided to the commissioner.

5.8.2. Where a PCN is minded to change that information, it must act in accordance

with the appropriate section of this Network Contract DES Specification.

5.9. Clinical Director change

5.9.1. Where a PCN wishes to change the identity of its clinical director, it is required

to notify the commissioner of the identity of the new clinical director as soon as

reasonably practicable following the change.

5.10. Nominated Payee change

5.10.1. A PCN must obtain the prior written consent of the commissioner to any

change in the identity of its Nominated Payee.

5.10.2. The PCN must provide to the commissioner the identity of the organisation of

the proposed Nominated Payee and provide such information as required by

the commissioner to enable the commissioner to determine whether the

proposed Nominated Payee meets the requirement of section 5.1.2.c.

5.10.3. Where the commissioner is satisfied that the proposed Nominated Payee

meets the requirement of section 5.1.2.c:

a. it shall provide its written consent to the PCN; and

b. complete the PCN ODS Change Instruction Notice24.

5.10.4. The commissioner must also ensure this information aligns to the information

contained within the relevant GP payment systems.

5.10.5. The change will take effect on the first day of the month following the month in

which the commissioner gave consent and completed the PCN ODS Change

24 The PCN ODS Change Instruction Notice is available here. The commissioner must submit the notice

by the end of the last working day on or before the 14th day the month for the change to take effect by the end of that month.




Instruction Notice provided that the commissioner submitted the notice by the

last working day on or before the 14th day of that month. If submission was

later in the month, the change will take effect on the first day of the month

following the subsequent month.

5.11. Change in non-Core Network Practice members

5.11.1. Where a PCN changes its non-Core Network Practices members it is not

required to notify the commissioner or obtain the commissioner’s prior written

consent, but it is required to ensure that its Network Agreement reflects the

change of members.

5.12. Change in Core Network Practice members

5.12.1. A PCN acknowledges that a practice participating in the Network Contract

DES cannot end its participation in the Network Contract DES except as set

out in section 4.14. The process for changing Core Network Practice members

is separate from the process of a practice ending its participation in the

Network Contract DES but there may be situations in which a change is a

result of a practice ending its participation.

5.12.2. Once a PCN has been approved in line with the process set out in this

Network Contract DES Specification, changes to Core Network Practices of

the PCN will only be allowed in the exceptional circumstances set out in

sections 5.13 to 5.16.

5.12.3. Where a PCN requests consent for a change to its Core Network Practices

members due to one of the exceptional circumstances set out in sections 5.13

to 5.16, the PCN will act in accordance with the process set out in the relevant

section. A PCN must obtain the prior written consent of the commissioner to

any changes of its Core Network Practice members.

5.12.4. A commissioner must, as part of its consideration of the proposed change,

ensure that the PCN will at all times satisfy the criteria of a PCN set out in

section 5.1.

5.12.5. A PCN seeking to change its Core Network Practices members must provide

to the commissioner details of its view of the impact (if any) of the change on

the PCN’s baseline for the Additional Roles Reimbursement Sum25. As part of

its consideration of the proposed change, the commissioner will seek to agree

with the PCN the change (if any) to the PCN’s baseline for the Additional

Roles Reimbursement Sum.

25 Refer to section 6.2 for details of baselines.



5.12.6. A PCN must promptly provide any information required by the commissioner in

relation to the change in Core Network Practice membership.

5.12.7. The commissioner will record a PCN’s Core Network Practices members via

NHS Digital’s Organisation Data Service (ODS). Where the commissioner

consents to a change, the commissioner must, before the end of the month in

which it gives consent, complete the PCN ODS Change Instruction Notice26.

The commissioner must submit the notice by the last working day on or before

the 14th day of the month for the change to take effect by the end of that

month. The commissioner must also ensure this information aligns to the

information contained within the relevant GP payment systems.

5.12.8. The change will take effect on the first day of the month following the month in

which the commissioner gives consent and completes the PCN ODS Change

Instruction Notice27 provided that the commissioner submits the notice by the

last working day on or before the 14th day of that month. If submission was

later in the month, the change will take effect on the first day of the month

following the subsequent month.

5.12.9. The PCN must ensure the Network Agreement is updated as soon as

reasonably practicable following the change taking effect.

5.13. Change in Core Network Practice membership due to contract

expiry/termination

5.13.1. Where the primary medical services contract of a Core Network Practice of a

PCN expires or terminates for any reason prior to 31 March 2021, then that

Core Network Practice’s participation in the Network Contract DES will cease

from the date of expiry/termination. In such circumstances:

a. the Core Network Practices of a PCN must, as soon as they are aware of

the possibility of a practice no longer being a Core Network Practice of the

PCN, notify the commissioner.

b. The commissioner will consider the matter, including holding discussions

with all practices within the PCN.

c. The commissioner will consider the consequences of the practice no

longer being a Core Network Practice of the PCN. This will include:

i. the likely consequences for the registered patients of the practice

when that GP practice is no longer a Core Network Practice of the

PCN – i.e. whether a new primary medical services contract will be




https://digital.nhs.uk/services/organisation-data-service/primary-care-networks---publication-of-organisational-data-service-ods-codes



entered into which takes over the former practice’s list of patients,

whether the list of patients of the previous practice are dispersed

between existing practices in the area or any other likely

consequences;

ii. the impact of any consequences on the financial entitlements set out

in this Network Contract DES Specification including consideration of

the fact that for payments based on practice list size or PCN list size,

the consequence of a practice no longer being a Core Network

Practice of a PCN could result in a reduction in the level of payments

made to a PCN; and

iii. any other relevant matters.

5.13.2. The commissioner will, depending on the likely consequences and following

any discussion with the LMC, determine the outcome of such matters including

any changes to the information of the PCN such as changes to the Network

Area and/or level of payments due to the PCN under this Network Contract

DES specification.

5.13.3. The commissioner may, depending on the likely consequences and at its

discretion, determine that where there is a significant influx of new patients

registering with a Core Network Practice of a PCN, it is appropriate for

payments that are based on practice list size or PCN list size to be based on

practice list size or PCN list size as at a date that is more recent than 1

January 2020.

5.13.4. From the date of the expiry or termination of the relevant practice’s primary

medical services contract:

a. the practice will no longer participate in the Network Contract DES;

b. the practice will no longer be considered a Core Network Practice of the

PCN;

c. the PCN must remove that practice from the Network Agreement with

effect from that date; and

d. the commissioner must complete and submit the PCN ODS Change

Instruction Notice28.





5.14. Change in Core Network Practice membership due to an irreparable

breakdown in relationships or expulsion

5.14.1. Where there is an irreparable breakdown in relationships in respect of a Core

Network Practice within a PCN such that the other members of the PCN are

minded to expel the Core Network Practice from the PCN, the PCN must first

notify the commissioner.

5.14.2. The commissioner will consider the matter, including holding discussions with

all practices within the PCN.

5.14.3. The commissioner will consider the consequences of the practice being

expelled from the PCN. This will include:

a. the likely consequences for the registered patients of the practice of that

practice being expelled the PCN, i.e. whether that practice can join

another PCN;

b. the impact of any consequences on the financial entitlements of the

Network Contract DES of the PCN which the practice would be expelled

from and that of any PCN the practice may seek to join. It is acknowledged

that for payments based on practice list size or PCN list size, the

consequence of a practice being expelled from a PCN is likely to be a

reduction in the level of payments made to a PCN;

c. the viability of the PCN including reference to the criteria of a PCN set out

in section 5.1.2; and

d. any other relevant matters.

5.14.4. The commissioner will, having regard to the likely consequences and any

discussion with the LMC, determine the outcome of such matters including

whether it consents to any changes to the information of any affected PCN

including but not limited to changes to the Core Network Practices, Network

Area, Nominated Payee and/or level of payments.

5.14.5. Where, following the process set out in this Network Contract DES

Specification, a Core Network Practice is expelled from a PCN, then, from the

date the practice leaves the PCN:

a. the practice will no longer be considered a Core Network Practice of the

PCN;

b. the PCN must remove that practice from the Network Agreement with

effect from that date; and



c. the commissioner must complete and submit the PCN ODS Change

Instruction Notice29.

5.15. Change in Core Network Practice membership due to merger/split

5.15.1. Where:

a. two or more Core Network Practices intend to merge and the resulting

single practice intends to be a Core Network Practice of the same PCN; or

b. two or more practices intend to be formed from the split of a single Core

Network Practice and the resulting practices intend to be Core Network

Practices of the same PCN,

the PCN acknowledges that the prior written consent of the commissioner is

required for both the merger/split and any resulting changes to the information

of the PCN.

5.15.2. The commissioner will consider the application for merger or split and, as part

of that consideration, will consider the consequences (if any) on the practice’s

or practices’ membership of the PCN.

5.15.3. The commissioner may require any New Practice formed from a merger/split

to provide the information set out in sections 4.6.1.a to 4.6.1.d before

indicating to the New Practice whether its participation in the Network Contract

DES is confirmed.

5.15.4. Where the commissioner consents to the type of change set out in section

5.15.1 the commissioner acknowledges that, for the purposes of this Network

Contract DES, payments due under the Network Contract DES will continue to

be made in accordance with this Network Contract DES Specification.

5.15.5. Where the commissioner consents to the type of change set out in section

5.15.1, the commissioner must, before the end of the month in which it gives

consent, complete the PCN ODS Change Instruction Notice30. The

commissioner must submit the notice by the last working day on or before the

14th day of the month for the change to take effect by the end of that month.

The commissioner must also ensure this information aligns to the information

contained within the relevant GP payment systems.

5.15.6. Where:

a. two or more Core Network Practices of a PCN intend to merge and the

resulting single practice does not intend to be a Core Network Practice of

the same PCN; or






b. two or more practices intend to be formed from the split of a single Core

Network Practice and either one or both of the resulting practices do not

intend to be Core Network Practices of the same PCN,

the PCN and the practices acknowledge that the prior written consent of the

commissioner is required for both the merger/split and any resulting changes

to the information of the PCN and any other related PCN.

5.15.7. The commissioner will consider the application for merger or split and, as part

of that consideration, will consider the consequences on the practice’s or

practices’ membership of the PCN or other PCNs.

5.15.8. The commissioner’s consideration of the consequences of any merger/split on

PCN membership will include:

a. the likely consequences for the registered patients of the practice(s);

b. the impact of any consequences on a PCN’s financial entitlements due

under this Network Contract DES Specification given that the

consequence of a practice leaving a PCN is likely to be a reduction in the

level of payments made to the PCN;

c. whether, if consent for the change was provided, any relevant PCN would

satisfy the criteria for a PCN set out in section 5.1.2; and

d. any other relevant matters.

5.15.9. Where a Core Network Practice is subject to a split or a merger and:

a. the application of sections 5.15.1 to 5.15.8 in respect of splits or mergers

would, in the reasonable opinion of the commissioner, lead to an

inequitable result; or

b. the circumstances of the split or merger are such that sections 5.15.1 to

5.15.8 cannot be applied,

the commissioner will consider the resulting effect on the PCN as part of its

consideration of the application for merger/split and make a determination on

both matters.

5.15.10. Where the commissioner consents to any changes to the details of a PCN as

a result of sections 5.15.8 or 5.15.9, the commissioner must complete the

PCN ODS Change Instruction Notice31. The commissioner must submit the

notice by the last working day on or before the 14th day of the month for the

change to take effect by the end of that month. The commissioner must also

ensure this information aligns to the information contained within the relevant

GP payment systems.





5.16. Change in Core Network Practice membership due to New Practice

joining

5.16.1. Where a New Practice wishes to join a Previously Approved PCN, section 4.7

applies.

5.16.2. Where a commissioner has confirmed the New Practice’s participation in the

Network Contract DES, the PCN must ensure that its Network Agreement

reflects the arrangements for delivery of the Network Contract DES.

6. Additional Roles Reimbursement Scheme

6.1. General

6.1.1. A PCN is entitled to funding as part of the Network Contract DES to support

the recruitment of new additional staff to deliver health services.

6.1.2. The new additional staff recruited by a PCN are referred to in this Network

Contract DES Specification as “Additional Roles” and this element of the

Network Contract DES is referred to as the “Additional Roles

Reimbursement Scheme”.

6.2. Principle of additionality

6.2.1. To receive the associated funding, a PCN must show that the staff delivering

health services for whom funding is requested, i.e. the Additional Roles,

comply with the principle of “additionality”. Sections 6.2.2 to 6.2.11 below set

out how additionality is measured.

6.2.2. Additionality will be measured on a baseline of staff supporting a GP practice

as taken at 31 March 2019 against six of the reimbursable staff roles – clinical

pharmacists, social prescribing link workers, first contact physiotherapists,

physician associates, pharmacy technicians and paramedics. Two baselines

were established32 during 2019 as follows:

a. A PCN baseline declared by the Core Network Practices of the PCN and

agreed with the commissioner. It is comprised of the actual whole time

equivalent (WTE) staff across these six reimbursable roles and funded by

general practice as at 31 March 2019. The PCN baseline will be fixed until

31 March 2024.

32 See Network Contract DES: Additional Roles Reimbursement Scheme Guidance 2019/20 for further

information.



https://www.england.nhs.uk/wp-content/uploads/2019/12/network-contract-des-additional-roles-reimbursement-scheme-guidance-december2019.pdf

b. A Clinical Commissioning Group (CCG) baseline declared by the CCG. It

is comprised of the whole time equivalent (WTE) patient facing or first

contact time of staff across the six reimbursable roles deployed to support

general practice or primary medical care services - either in a specific

practice or in the wider community - funded33 by the CCG as at 31 March

2019 (regardless of whether funded due to direct CCG employment or

through a contract). Any administration, travel, triage or other time directly

related to patient care is included in the WTE. The commissioner is

required to maintain funding for these baseline posts and will be subject to

audit to ensure the funding is maintained.

6.2.3. Subject to section 6.2.4 below, a PCN’s Core Network Practices are required

to maintain the declared PCN baseline in order to meet the additionality rules

under the Network Contract DES Additional Roles Reimbursement Scheme. In

the event the PCN baseline reduces (meaning a vacancy arises in a Core

Network Practices’ baseline WTE) during the period 1 April 2020 to 31 March

2024, then the PCN will be subject to an equivalent WTE reduction in

workforce funding under the Network Contract DES Additional Roles

Reimbursement Scheme. The equivalent WTE reduction will be applicable

from three months after the date at which the vacancy arose, resulting in a

PCN baseline reduction, subject to the post not having been filled within this

period and in accordance with section 9.

6.2.4. With the agreement of the commissioner, which will not be unreasonably

withheld, a PCN will be able to substitute between clinical pharmacists, first

contact physiotherapists and physician associates within the PCN baseline.

Where agreement to a substitution has taken place, the PCN will not be

subject to an equivalent WTE reduction in workforce funding under the

Network Contract DES Additional Roles Reimbursement Scheme.

6.2.5. A PCN is required to demonstrate that claims being made are for new

additional staff roles beyond this baseline (including in future years,

replacement as a result of staff turnover). The commissioner must be assured

that claims meet the additionality principles above.

6.2.6. A PCN baseline will not be established for health and wellbeing coaches, care

coordinators, dieticians, podiatrists or occupational therapists. While the PCN

baseline will not include these five roles, the additionality principles will still

apply as per the additionality principles above. For the avoidance of doubt, this

means that a PCN acknowledges that where it claims reimbursement in

respect of these five roles, the PCN is confirming that:

33 The six reimbursable roles funded include those directly employed by the CCG.



a. the reimbursement is for additional staff engaged or employed since 31

March 2019; and

b. the reimbursement is not being used to subsidise practice-funded roles

that existed as at 31 March 2019.

6.2.7. A failure to submit information or the provision of inaccurate workforce

information is a breach of the Network Contract DES Specification and may

result in commissioners withholding reimbursement pending further enquires

in accordance with section 9.10. reimbursement claims will be subject to

validation and any suspicion that deliberate attempts have been made to

subvert the additionality principles will result in a referral for investigation as

potential fraud.

6.2.8. Staff employed or engaged via a sub-contract within the reimbursable roles

after 31 March 2019 (i.e. above the baseline set) will be eligible for

reimbursement under the Network Contract DES, if those staff are employed

or engaged to deliver services across the PCN and if the PCN meets the

requirements set out in this Network Contract DES specification.

6.2.9. Clinical pharmacists previously employed via the national Clinical Pharmacist

in General Practice Scheme or those clinical pharmacists or pharmacy

technicians employed via the Medicines Optimisation in Care Homes Scheme

(“MOCH”)34 transferred to become PCN staff will be exempt from the

additionality principles.

a. For this exception to apply to clinical pharmacists previously employed via

the national Clinical Pharmacist in General Practice Scheme the employee

must have been in post on 31 March 2019 and been transferred to

become PCN staff by 31 March 2020 in line with the requirements set out

in this Network Contract DES Specification35.

6.2.10. For all clinical pharmacists and pharmacy technicians employed under the

MOCH Scheme, transfer must take place by no later than 31 March 2021

under the relevant requirements for clinical pharmacists or pharmacy

technicians within this Network Contract DES Specification. PCNs will be

required to support any pharmacists who transfer from the MOCH Scheme

prior to 31 March 2021 to complete their training. Where the transfer is agreed

before 31 March 2021 then PCNs will be expected to make operational use of

the pharmacist’s experience in relation to Care Homes as outlined in the

Network Contract DES Guidance. Any MOCH pharmacy technicians

transferred will count towards a PCN’s eligible limit as outlined in Table 1 in

34 This will include some pharmacy technicians currently funded by CCGs. 35 Full details on the transfer arrangements for clinical pharmacists is available in the 2019/20 Network

Contract DES Guidance.



https://www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/cp-gp/

https://www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/cp-gp/

https://www.england.nhs.uk/primary-care/pharmacy/medicines-optimisation-in-care-homes/

https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/

https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/

section 6.3.3. Where MOCH pharmacists do not transfer before 31 March

2021, the commissioner is required to align the work objectives of the CCG

commissioned MOCH team to that of the Enhanced Health in Care Homes

service requirements outlined in this Network Contract DES Specification.

6.2.11. The Additional Roles may be employed by a member of the PCN, or another

body (e.g. GP Federation, voluntary sector provider, Local Authority or Trust).

If the PCN chooses to commission the health services provided by the

Additional Roles from another body, outside of the PCN, which therefore

employs the staff, this does not change the general position that the PCN and

its Core Network Practices are responsible for ensuring that the requirements

of the Network Contract DES are delivered. The employer remains responsible

for all costs (including taxes and where applicable VAT) and liabilities relating

to the employment of staff or sub-contracting of services. A PCN should set

out within the Network Agreement if and how any costs and liabilities will be

shared.

6.3. Additional Roles Reimbursement Sum

6.3.1. A PCN must act in accordance with the requirements set out in this section 6

in respect of the Additional Roles and the arrangements in section 9 to receive

reimbursement for employing or engaging the Additional Roles from within a

maximum allocated sum. This sum is referred to in this Network Contract DES

Specification as the “Additional Roles Reimbursement Sum”.

6.3.2. From within the allocated Additional Roles Reimbursement Sum, a PCN may

claim reimbursement for staff across ten eligible roles in accordance with the

terms set out in this section 6.3, section 9 and Table 1.

6.3.3. A PCN may employ or engage any one or more of the roles set out in Table 1

below subject to any limits on the number of any specific role.

Table 1: Workforce roles eligible for reimbursement under the Network

Contract DES with applicable limits

Roles Limit on number eligible for reimbursement

Clinical Pharmacists No limit

Pharmacy Technicians One individual pharmacy technician per PCN

where the PCN’s Patients number 99,999 or

less.



Roles Limit on number eligible for reimbursement

Two individual pharmacy technicians per PCN

where the PCN’s Patients number 100,000 or

over.

Social Prescribing Link

Workers

No limit

Health and Wellbeing

Coaches

No limit

Care Co-ordinators No limit

Physician Associates No limit

First Contact

Physiotherapists

One WTE per PCN where the PCN’s Patients

number 99,999 or less.

Two WTE per PCN where the PCN’s Patients

number 100,000 or over.

Dieticians No limit

Podiatrists No limit

Occupational Therapists No limit

6.3.4. The commissioner may waive any limits in Table 1 where this is agreed by the

PCN, the commissioner, and the relevant Integrated Care System (ICS).

6.4. Additional Role requirements

6.4.1. To ensure satisfactory provision of health services, a PCN must comply with

the following requirements in relation to any Additional Roles:

a. Additional Roles employed or engaged via a sub-contract must:

i. be embedded within the PCN’s Core Network Practices and be fully

integrated within the multi-disciplinary team delivering healthcare

services to patients;

ii. have access to other healthcare professionals, electronic ‘live’ and

paper-based record systems of the PCN’s Core Network Practices, as

well as access to admin/office support and training and development

as appropriate; and



iii. have access to appropriate clinical supervision and administrative

support.

b. Liaising with any employing organisation if relevant, the PCN must

consider the appropriateness of, and if considered appropriate, the PCN

must carry out, a review and appraisal process for Additional Roles

whether they are employed directly by the PCN or a PCN member or

engaged via a sub-contract.

c. The PCN must ensure that Additional Roles comply with the minimum role

requirements set out in Annex B of this Network Contract DES

Specification to be eligible for the Additional Roles Reimbursement Sum. A

PCN may build upon the requirements set out in Annex B of this Network

Contract DES Specification in relation to any Additional Role job

description.

d. The PCN must ensure the PCN’s approach to deploying the Additional

Roles is set out in the Network Agreement.

6.4.2. A PCN must inform the commissioner as soon as reasonably practicable

where any change to its Additional Roles arrangements will have an impact on

the payments being claimed (for example changes in WTE or new starters).

6.4.3. A PCN must record information on its Additional Roles, whether those

Additional Roles are employed by the PCN itself or by another body, in the

National Workforce Reporting Service (“NWRS”) in line with the existing or

updated requirements for general practice staff.

6.4.4. The commissioner must complete and return the six-monthly workforce report

to [email protected].

6.5. PCN Additional Roles planning and redistribution of Additional Roles

Reimbursement Scheme funding

6.5.1. A PCN must complete and return to the commissioner a workforce plan, using

the agreed national workforce planning template38, providing details of its

recruitment plans for 2020/21 by 31 August 2020 and indicative intentions

through to 2023/24 by 31 October 2020.

36 Further information is available in the Network Contract DES Guidance. 37 Further information is available in the Network Contract DES Guidance. 38 The workforce planning template is available at https://www.england.nhs.uk/publication/pcn-

workforce-planning-template-2020-21/






https://www.england.nhs.uk/publication/pcn-workforce-planning-template-2020-21/

https://www.england.nhs.uk/publication/pcn-workforce-planning-template-2020-21/

6.5.2. The commissioner must explore, and must endeavour to procure that the local

ICS explores, different ways of supporting the PCN to implement the

workforce plan through:

a. offering CCG or ICS staff support to the PCN to help with coordinating and

undertaking recruitment exercises;

b. offering collective or batch recruitment across PCNs;

c. brokering arrangements to support full-time direct employment of staff by

community partners, or to support rotational working across acute and

community providers; and

d. ensuring the NHS workforce plans for the local system are helpful in

supporting PCN’s workforce plan.

6.5.3. The commissioner must:

a. have shared with the PCN and relevant LMCs; and

b. have agreed with the PCN,

by 30 September 2020 an estimation of the amount of financial entitlements in

relation to the PCN under the Additional Roles Reimbursement Scheme that

the PCN is unlikely to claim by 31 March 2021. This amount is referred to in

this Network Contract DES Specification as the “Unclaimed Funding”.

6.5.4. The commissioner must base its estimate of the Unclaimed Funding on the

PCN’s workforce planning information that is returned to the commissioner by

the 31 August 2020.

6.5.5. Where the PCN agrees the estimate, the PCN acknowledges that the PCN will

no longer have the right to claim the Unclaimed Funding and the

commissioner may give other PCNs within the commissioner’s boundary the

opportunity to bid for the Unclaimed Funding.

6.5.6. Where a commissioner provides the opportunity to PCNs within the

commissioner’s boundary to bid for any PCN’s Unclaimed Funding, the

commissioner will indicate when and how PCNs may bid.

6.5.7. A PCN acknowledges that if it bids for Unclaimed Funding and is successful,

the Unclaimed Funding allocated to the PCN must be used for the purpose of

recruiting further Additional Roles in accordance with this Network Contract

DES Specification. The PCN and the commissioner acknowledge that any

payment of the Unclaimed Funding to the PCN is in addition to the PCN’s

allocated Additional Roles Reimbursement Sum.

6.5.8. Where there are one or more bids for the Unclaimed Funding, the

commissioner will assess the bids in accordance with the following criteria:



a. evidence that a bidding PCN has a recruitment process ready to begin for

the Additional Roles to which the Unclaimed Funding relates;

b. evidence that a bidding PCN has the resources and capability to

undertake further recruitment; and

c. whether a bidding PCN is a PCN which:

i. had previously indicated in the workforce planning information that it

was unlikely to claim its full financial entitlement but considers it is now

in a position to recruit; and

ii. evidences that it is able to meet sections 6.5.8.a and 6.5.8.b

d. whether a bidding PCN currently has staff on paid leave e.g. parental

leave or sickness leave;

e. evidence that a PCN is in an area of higher deprivation39; and

f. any other factor that the commissioner, acting reasonably, considers is

relevant to its decision.

6.5.9. A bidding PCN acknowledges that:

a. the above criteria are in descending order of preference. For the

avoidance of doubt, this means that bids satisfying criteria at the top of the

list will be preferred over bids that only satisfy criteria further down the list;

and

b. the commissioner will give preference to a bid which satisfies the criteria in

section 6.5.8.c. over all other bids.

6.5.10. The commissioner will notify each PCN of the outcome of its consideration and

indicate to any successful bidding PCN the level of funding allocated to the

successful bidding PCN.

6.5.11. Notwithstanding that any payments of Unclaimed Funding are not part of the

PCN’s allocated Additional Roles Reimbursement Sum and is in addition to

the PCN’s allocated Additional Roles Reimbursement Sum, payment of the

Unclaimed Funding will be made on the same basis as payments of the PCN’s

Additional Roles Reimbursement Sum.

6.5.12. A successful bidding PCN acknowledges that any additional funding allocated

to the PCN only relates to the period from the date the PCN was notified that it

was successful to 31 March 2021 and that there is no right for the PCN to

39 Defined by the Indices of Deprivation (IoD), based on seven different domains or facets of deprivation

– (1) income deprivation, (2) employment deprivation, (3) education, skills and training deprivation, (4) health deprivation and disability, (5) crime, (6) barriers to housing and services and (7) living environment deprivation. See https://www.gov.uk/government/collections/english-indices-of-deprivation and https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019



https://www.gov.uk/government/collections/english-indices-of-deprivation

https://www.gov.uk/government/collections/english-indices-of-deprivation

https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019

require a commissioner to continue paying the additional funding after 31

March 2021.

6.5.13. The commissioner will be responsible for monitoring any Additional Roles

Reimbursement Scheme funding redistribution. Where there are repeated

occurrences of redistribution from and/or to particular PCNs, the commissioner

will be responsible for reviewing this in conjunction with the relevant PCNs

and, where appropriate, the LMC and ICS, and take appropriate supportive

actions.

7. Service Requirements

7.1. Extended Hours Access

7.1.1. A PCN must provide extended hours access in the form of additional clinical

appointments in accordance with this Network Contract DES Specification

regardless of whether any practices within the PCN are providing any CCG

commissioned extended access services in 2020/21 (which are referred to in

this Network Contract DES Specification as “CCG Extended Access

Services”).

7.1.2. Where a commissioner is not satisfied that a PCN is delivering extended hours

access in accordance with the requirements of this Network Contract DES

specification then the commissioner may take action as set out in section 8. If

a commissioner determines to withhold payment40, the amount withheld will

be an appropriate proportion of the extended hours access payment and the

Core PCN funding payment.

7.1.3. To provide extended hours access, a PCN must provide additional clinical

appointments that satisfy all the requirements set out below:

a. are available to all registered patients within the PCN:

b. may be for emergency, same day or pre-booked appointments;

c. are with a healthcare professional or another person employed or

engaged by the PCN to assist that healthcare professional in the provision

of health services;

d. are held at times outside of the hours that the PCN Core Network

Practices’ primary medical services contracts41 require appointments to be

40 Payment withheld in this context would be an appropriate proportion of the payments in relation to

both extended hours access and Core PCN funding payments. 41 For practices with PMS and APMS arrangements, the additional clinical appointments provided in

accordance with this Extended Hours Access requirement do not apply to any hours covered by core



provided otherwise than under the Network Contract DES. For the

avoidance of doubt, if a Core Network Practice was required under a

General Medical Services (“GMS”) contract to provide core services at its

premises until 6:30pm, the additional clinical appointments under this

Extended Hours Access requirement could be provided after 6:30pm. If,

however, another Core Network Practice in the PCN provided core

services at its premises until 8pm, then:

i. any additional clinical appointments provided after 6:30pm but before

8pm must not be provided at the later closing practice’s premises (as

these would not be additional hours appointments) but could be

provided at the other practice’s premises; and

ii. a proportion of the additional clinical appointments must be provided

after 8pm;

e. are demonstrably in addition to any appointments provided by the PCN’s

practices under the CCG Extended Access Services;

f. are held at times having taken into account the PCN’s patient’s expressed

preferences, based on available data at practice or PCN level and

evidenced by patient engagement;

g. equate to a minimum of 30 minutes per 1,000 registered patients per

week, calculated using the following formula:

additional minutes* = the PCN list size** ÷ 1000 × 30

*convert to hours and minutes and round, either up or down, to the

nearest quarter hour

**this is the total number of person on the lists of patients of all Core

Network Practices of the PCN as at 1 January 2020

h. are provided in continuous periods of at least 30 minutes;

i. are provided on the same days and times each week with sickness and

leave of those who usually provide such appointments covered by the

PCN; and

j. may be provided face to face, by telephone, by video or by online

consultation provided that the PCN ensures a reasonable number of

hours set out in the practice’s primary medical services contracts. A PCN will be required to take consideration of this when agreeing the Extended Hours Access offer to the PCN Contractor Registered Population. For practices with GMS arrangements, core hours are from 08:00 to 18:30.



appointments are available for face-to-face consultations where

appropriate.

7.1.4. A PCN must set out how the extended hours access appointments will be

delivered in the Network Agreement.

7.1.5. A PCN must ensure that all practices in the PCN member actively engage in

planning of the provision of the extended hours access requirements and

acknowledges that nothing in this Network Contract DES Specification require

an individual clinician or practice within the PCN to deliver a particular share of

the appointments. The exact number of extended hours access appointments

delivered from each member practice premises will be for the PCN to

determine subject to complying with the minimum additional minutes set out in

section 7.1.3.g.

7.1.6. A PCN’s Core Network Practices must ensure that their registered patients are

aware of the availability of extended hours access appointments, including any

change to published availability, through promotion and publication of the days

and times of these appointment through multiple routes. This may include the

NHS Choices website, the practice leaflet, the practice website, on a waiting

room poster, by writing to patients and active offers by staff booking

appointments.

7.1.7. Where a PCN cancels any extended hours access appointments or where

appointments cannot be offered on the usual days and times (for example, but

not limited to, due to a bank holiday falling on the usual day), the PCN must

make up the cancelled time by offering additional appointments within a two-

week period. For the avoidance of doubt, any rescheduled appointments

offered in a subsequent week are in addition to the minimum minutes that

must be offered for that week as set out in section 7.1.3.g. The PCN must

ensure that all patients within the PCN are notified of the cancelled and

rescheduled appointments.

7.1.8. A commissioner must publicise information to help patients to identify which

practices are offering appointments at given times.

7.1.9. Core Network Practices of a PCN must inform patients of any changes to the

days and time at which extended hours access appointments are offered,

providing reasonable notice to patients.

7.1.10. If any Core Network Practice of a PCN is providing out of hours services to its

own list of patients, the PCN must, as part of the Extended Hours Access

service provision offer routine extended hours access appointments in addition

to the out of hours service.

7.1.11. A PCN must ensure that:



a. no Core Network Practice of the PCN will be closed for half a day on a

weekly basis, except where a Core Network Practice has prior written

approval from the commissioner; and

b. the PCN’s Patients are able to access essential services, which meet the

reasonable needs of patients during core hours, from their own practice or

from any sub-contractor.

7.1.12. For the avoidance of doubt, unless a practice has prior written approval from

the commissioner, all PCN Core Network Practices will not close for half a day

on a weekly basis.

7.1.13. The term “prior written approval” in section 7.1.11.a means an explicit

agreement between the practice and the commissioner that specifically

includes written approval to close for half a day on a weekly basis for the

purposes of the Network Contract DES Specification. The agreement must

take the form of either:

a. a new agreement which expressly states that:

i. it is pursuant to the Network Contract DES Specification; and

ii. it will expire no later than 31 March 2021; or

b. an existing agreement with the commissioner to close for half a day on a

weekly basis, which, instead of referring to the Network Contract DES,

explicitly references the GP Extended Hours Access Scheme Directed

Enhanced Service which came to an end on 30 June 2019. For the

purposes of the Network Contract DES, existing agreements will be

considered to expire no later than 31 March 2021.

7.1.14. Where a Core Network Practice does not have prior written approval to close

for half a day on a weekly basis, a Core Network Practice that previously

closed for half a day on a weekly basis will need to either:

a. be open for that half a day in the same way that it is open on other days of

the week, or

b. have in place appropriate sub-contracting arrangements for the time the

practice is closed - in line with Schedule 3, Part 5 para 44 (10) and (11) of

the GMS Regulations42 or Schedule 2, Part 5 para 43 (5) and (6) of the

PMS Regulations43, as applicable - so that patients continue to have

43 National Health Service (Personal Medical Services Agreements) Regulations 2015



access to essential services which meet their reasonable44 needs during

core hours.

7.2. Structured Medication Review and Medicines Optimisation

7.2.1. From the 1 October 2020, a PCN is required to:

a. use appropriate tools to identify and prioritise the PCN’s Patients who

would benefit from a structured medication review (referred to in this

Network Contract DES Specification as a “SMR”), which must include

patients:

i. in care homes45;

ii. with complex and problematic polypharmacy, specifically those on 10

or more medications;

iii. on medicines commonly associated with medication errors46;

iv. with severe frailty47, who are particularly isolated or housebound

patients, or who have had recent hospital admissions and/or falls; and

v. using potentially addictive pain management medication;

b. offer and deliver a volume of SMRs determined and limited by the PCN’s

clinical pharmacist capacity, and the PCN must demonstrate reasonable

ongoing efforts to maximise that capacity;

c. ensure invitations for SMRs provided to patients explain the benefits of,

and what to expect from SMRs;

d. ensure that only appropriately trained clinicians working within their sphere

of competence undertake SMRs. The PCN must also ensure that these

professionals undertaking SMRs have a prescribing qualification and

44 NHS England’s guidance is that it includes for example: the ability to book and cancel appointments,

collect prescriptions, access urgent appointments/advice as clinically necessary, the ability to attend a pre-bookable appointment.

45 Patients in a ‘care home’ are those resident in services registered by CQC as care home services with nursing (CHN) and care home services without nursing (CHS).

46 See NHS Business Services Authority (2019) Medication Safety Indicators Specification: https://www.nhsbsa.nhs.uk/sites/default/files/2019-08/Medication%20Safety%20-%20Indicators%20Specification%20%28Aug19%29.pdf This document sets out 20 indicators that have been developed to help reduce medications errors and promote safer use of medicines. The ‘denominator’ section for each of the indicators lists medicines commonly associated with prescribing errors, which PCNs should use to help identify individuals to invite for a SMR.

47 Based on the validation of the eFI, on average around 3 per cent of over 65s will be identified as potentially living with severe frailty. However, in some practices this number may be significantly higher. Severe frailty is defined as a person having an eFI score of >0.36. https://www.england.nhs.uk/ourwork/clinical-policy/older-people/frailty/efi/



https://www.nhsbsa.nhs.uk/sites/default/files/2019-08/Medication%20Safety%20-%20Indicators%20Specification%20%28Aug19%29.pdf


https://www.england.nhs.uk/ourwork/clinical-policy/older-people/frailty/efi/

advanced assessment and history taking skills, or be enrolled in a current

training pathway to develop this qualification and skills;

e. clearly record all SMRs within GP IT systems;

f. actively work with its CCG in order to optimise the quality of local

prescribing of:

i. antimicrobial medicines;

ii. medicines which can cause dependency;

iii. metered dose inhalers, where a lower carbon device may be

appropriate; and

iv. nationally identified medicines of low priority;48

g. work with community pharmacies to connect patients appropriately to the

New Medicines Service which supports adherence to newly prescribed

medicines; and

h. in complying with this section 7.2, have due regard to NHS England and

NHS Improvement guidance on Structured Medication Reviews and

Medicines Optimisation.

7.3. Enhanced Health in Care Homes

7.3.1. By 31 July 2020, a PCN is required to:

a. have agreed with the commissioner the care homes for which the PCN will

have responsibility (referred to as the “PCN’s Aligned Care Homes” in

this Network Contract DES Specification). The commissioner will hold

ongoing responsibility for ensuring that care homes within their

geographical area are aligned to a single PCN and may, acting

reasonably, allocate a care home to a PCN if agreement cannot be

reached. Where the commissioner allocates a care home to a PCN, that

PCN must deliver the Enhanced Health in Care Homes service

requirements in respect of that care home in accordance with this Network

Contract DES Specification;

b. have in place with local partners (including community services providers)

a simple plan about how the Enhanced Health in Care Homes service

requirements set out in this Network Contract DES Specification will

operate;

48 See the Recommendation (section 5, pp.14-39) of ‘Items which should not routinely be prescribed in

primary care’ https://www.england.nhs.uk/wp-content/uploads/2019/08/items-which-should-not-routinely-be-prescribed-in-primary-care-v2.1.pdf



https://www.england.nhs.uk/wp-content/uploads/2019/08/items-which-should-not-routinely-be-prescribed-in-primary-care-v2.1.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/08/items-which-should-not-routinely-be-prescribed-in-primary-care-v2.1.pdf

c. support people entering, or already resident in the PCN’s Aligned Care

Home, to register with a practice in the aligned PCN if this is not already

the case; and

d. ensure a lead GP (or GPs) with responsibility for these Enhanced Health

in Care Homes service requirements is agreed for each of the PCN’s

Aligned Care Homes.

7.3.2. By 30 September 2020, a PCN must:

a. work with community service providers (whose contracts will describe their

responsibility in this respect) and other relevant partners to establish and

coordinate a multidisciplinary team (“MDT”) to deliver these Enhanced

Health in Care Homes service requirements; and

b. have established arrangements for the MDT to enable the development of

personalised care and support plans with people living in the PCN’s

Aligned Care Homes.

7.3.3. As soon as is practicable, and by no later than 31 March 2021, a PCN must

establish protocols between the care home and with system partners for

information sharing, shared care planning, use of shared care records, and

clear clinical governance.

7.3.4. From 1 October 2020, a PCN must:

a. deliver a weekly ‘home round’ for the PCN’s Patients who are living in the

PCN’s Aligned Care Home(s). In providing the weekly home round a PCN:

i. must prioritise residents for review according to need based on MDT

clinical judgement and care home advice (a PCN is not required to

deliver a weekly review for all residents);

ii. must have consistency of staff in the MDT, save in exceptional

circumstances;

iii. must include appropriate and consistent medical input from a GP or

geriatrician, with the frequency and form of this input determined on

the basis of clinical judgement; and

iv. may use digital technology to support the weekly home round and

facilitate the medical input;

b. using the MDT arrangements referred to in section 7.3.2 develop and

refresh as required a personalised care and support plan with the PCN’s

Patients who are resident in the PCN’s Aligned Care Home(s). A PCN

must:



i. aim for the plan to be developed and agreed with each new patient

within seven working days of admission to the home and within seven

working days of readmission following a hospital episode (unless there

is good reason for a different timescale);

ii. develop plans with the patient and/or their carer;

iii. base plans on the principles and domains of a Comprehensive

Geriatric Assessment49 including assessment of the physical,

psychological, functional, social and environmental needs of the

patient including end of life care needs where appropriate;

iv. draw, where practicable, on existing assessments that have taken

place outside of the home and reflecting their goals; and

v. make all reasonable efforts to support delivery of the plan;

c. identify and/or engage in locally organised shared learning opportunities

as appropriate and as capacity allows; and

d. support with a patient’s discharge from hospital and transfers of care

between settings, including giving due regard to NICE Guideline 2750.

7.3.5. For the purposes of this section 7.3, a ‘care home’ is defined as a CQC-

registered care home service, with or without nursing.51

7.4. Early Cancer Diagnosis

7.4.1. From 1 October 2020, a PCN is required to:

a. review referral practice for suspected cancers, including recurrent cancers.

To fulfil this requirement, a PCN must:

i. review the quality of the PCN’s Core Network Practices’ referrals for

suspected cancer, against the recommendations of NICE Guideline

1252 and make use of:

a. clinical decision support tools;

b. practice-level data to explore local patterns in presentation and

diagnosis of cancer; and

49 https://www.bgs.org.uk/sites/default/files/content/resources/files/2019-03-12/CGA%20Toolkit%20for%20Primary%20Care%20Practitioners_0.pdf 50 https://www.nice.org.uk/guidance/ng27 51 See https://www.cqc.org.uk/guidance-providers/regulations-enforcement/service-types for further

information on the definition of care home services for this purpose. A monthly directory of registered care home services that meet these categories is available at https://www.cqc.org.uk/about-us/transparency/using-cqc-data

52 https://www.nice.org.uk/guidance/ng12



https://www.bgs.org.uk/sites/default/files/content/resources/files/2019-03-12/CGA%20Toolkit%20for%20Primary%20Care%20Practitioners_0.pdf

https://www.bgs.org.uk/sites/default/files/content/resources/files/2019-03-12/CGA%20Toolkit%20for%20Primary%20Care%20Practitioners_0.pdf

https://www.nice.org.uk/guidance/ng27

https://www.cqc.org.uk/guidance-providers/regulations-enforcement/service-types

https://www.cqc.org.uk/about-us/transparency/using-cqc-data

https://www.cqc.org.uk/about-us/transparency/using-cqc-data

https://www.nice.org.uk/guidance/ng12

c. where available the Rapid Diagnostic Centre pathway for people

with serious but non-specific symptoms53;

ii. build on current practice to ensure a consistent approach to monitoring

patients who have been referred urgently with suspected cancer or for

further investigations to exclude the possibility of cancer (‘safety

netting’), in line with NICE Guideline 12; and

iii. ensure that all patients are signposted to or receive information on

their referral including why they are being referred, the importance of

attending appointments and where they can access further support;

b. contribute to improving local uptake of National Cancer Screening

Programmes. To fulfil this requirement, a PCN must:

i. work with local system partners – including the Public Health

Commissioning team and Cancer Alliance – to agree the PCN’s

contribution to local efforts to improve uptake which should build on

any existing actions across the PCN’s Core Network Practices and

must include at least one specific action to engage with a group with

low-participation locally; and

ii. provide the contribution agreed pursuant to section 7.4.1.b.i within

timescales agreed with local system partners; and

c. establish a community of practice between practice-level clinical staff to

support delivery of the requirements set out in sections 7.4.1.a to 7.4.1.b.

A PCN must, through the community of practice:

i. conduct peer to peer learning events that look at data and trends in

diagnosis across the PCN, including cases where patients presented

repeatedly before referral and late diagnoses; and

ii. engage with local system partners, including Patient Participation

Groups, secondary care, the relevant Cancer Alliance, and Public

Health Commissioning teams.

7.5. Social Prescribing Service

7.5.1. A PCN must provide the PCN’s Patients with access to a social prescribing

service.

7.5.2. To comply with this, a PCN may:

53 Further detail on the RDC vision and strategy is available here: https://www.england.nhs.uk/wp-

content/uploads/2019/07/rdc-vision-and-1920-implementation-specification.pdf. Assessment pathways for specific cancers are published here: https://www.england.nhs.uk/publication/rapid-cancer-diagnostic-and-assessment-pathways/



https://www.england.nhs.uk/wp-content/uploads/2019/07/rdc-vision-and-1920-implementation-specification.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/07/rdc-vision-and-1920-implementation-specification.pdf

https://www.england.nhs.uk/publication/rapid-cancer-diagnostic-and-assessment-pathways/

a. directly employ Social Prescribing Link Workers; or

b. sub-contract provision of the service to another provider.

in accordance with this Network Contract DES Specification.

7.5.3. Where a PCN directly employs Social Prescribing Link Workers to provide the

service, the PCN will be considered to have provided the service where the

PCN’s Social Prescribing Link Workers comply with the provisions of

paragraph 3 of Annex B of this Network Contract DES Specification.

7.5.4. Where a PCN sub-contracts provision of the service to another provider, the

PCN will be considered to have provided the service where the persons

employed or engaged by the sub-contracted provider to deliver the service

comply with the provisions of paragraph 3 of Annex B of this Network Contract

DES Specification. Where this applies, references to the Social Prescribing

Link Worker or Workers in paragraph 3 of Annex B are to be read as

references to the persons employed or engaged by the sub-contracted

provider to deliver the service.

8. Contract management

8.1. General

8.1.1. Section 3 of this Network Contract DES Specification states that each Core

Network Practice of a PCN is responsible for ensuring that a requirement or

obligation of a PCN as set out in this Network Contract DES Specification is

carried out on behalf of that PCN.

8.1.2. A PCN acknowledges that, where a requirement or obligation of a PCN is not

carried out, each Core Network Contract will be in breach of this Network


8.1.3. A PCN further acknowledges that as the provisions of this Network Contract

DES Specification are part of a Core Network Practice’s primary medical

services contract, the commissioner is able to take any action set out in the

relevant primary medical services contracts in relation to a breach of this


8.1.4. Where a breach of this Network Contract DES Specification occurs, a

commissioner may require a PCN to work with the commissioner to compile

and agree a collaborative action plan setting out actions to address non-

delivery and timescales for those actions. The commissioner and the PCN will

make all reasonable efforts to agree the action plan.

8.1.5. It is not expected that commissioners will need to resort to contract

management processes such as issuing of breach or remedial notices due to



the support options available across the system and the action plan

development process as described in section 8.1.4.

8.1.6. The commissioner acknowledges that the action plan is intended to be a first

step towards remedying the breach. If:

a. the commissioner, acting reasonably, determines that an action plan is not

appropriate;

b. an action plan cannot be agreed within a reasonable timescale; or

c. a breach is not remedied by an action plan,

the commissioner may take any appropriate action set out in the Core Network

Practice’s primary medical services contracts in relation to the breach. This

may include issue of a breach or remedial notice, withholding of payments or

termination.

8.1.7. A PCN (and each Core Network Practice in the PCN) acknowledge that:

a. the legislation underpinning GMS and PMS arrangements include

references to “Contract Sanctions” and “Agreement Sanctions”

respectively which enable the commissioner, in certain circumstances, to

terminate certain obligations under the primary medical services contracts;

and

b. in the unlikely event that a breach cannot be resolved by the application of

the provisions of this Network Contract DES Specification and the contract

management provisions of the primary medical services contract, the

commissioner is able to rely on the Contract Sanctions or Agreement

Sanctions, as relevant, to terminate a Core Network Practice’s

participation in the Network Contract DES while the rest of the obligations

in the primary medical services contract are not terminated;

c. if the commissioner is minded to terminate Core Network Practices’

participation in the Network Contract DES, it must act in accordance with

section 5.13 as if references to the Core Network Practice’s primary

medical services contract terminating are references to the Core Network

Practice’s participation in the Network Contract DES terminating; and

d. where a PCN’s members include a Core Network Practice which holds an

APMS contract, the commissioner must consider if there are

corresponding rights in the APMS contract for the commissioner to

partially terminate the APMS contract to terminate only the provisions

relating to the Network Contract DES. The commissioner acknowledges

that if such rights are not included, the need to deal with all PCN Core

Network Practices in a similar way may mean that the commissioner is not



be able to terminate the PCN’s Core Network Practices’ participation in the

Network Contract DES.

9. Network financial entitlements

9.1. General

9.1.1. A practice participating in the Network Contract DES acknowledges that

payments made under the Network Contract DES are dependent on the Core

Network Practices of a PCN working together to deliver the requirements of

this Network Contract DES.

9.1.2. A PCN acknowledges that confirmation of participation in the Network

Contract DES may not occur until June 2020 but that this Network Contract

DES Specification sets out certain elements of the Network financial

entitlements that will, provided any required criteria or conditions are satisfied,

be backdated to April 2020. Any such backdating is set out in the relevant

sections of this section 9.

9.1.3. Where information relating to a new proposed PCN is submitted to the

commissioner between 1 April 2020 and 31 March 2021, the commissioner

will, where a PCN is approved, indicate when payments of the financial

entitlements will be made.

9.1.4. Where the financial entitlements refers to a payment being based on practice

list size or PCN list size, the relevant figure will be taken from the registration

system (approved by NHS England) as at 1 January 2020 or a later date if the

commissioner, in its absolute discretion, considers that a PCN has

satisfactorily evidenced that there has been a large fluctuation in its Core

Network Practice’s lists of patients such that the figure derived from the later

date is more appropriate.

9.1.5. The commissioner must ensure that payments due to a PCN set out in this

Network Contract DES are made into the bank account of the Nominated

Payee. For the avoidance of doubt, the Network Participation Payment is not a

payment due to a PCN as it is payable directly to a Core Network Practice.

The PCN must inform the commissioner of the relevant payment details of its

Nominated Payee. The PCN will include in the Network Agreement the details

of arrangements with the Nominated Payee and may indicate the basis on

which the Nominated Payee receives the payments on behalf of the other

practices, e.g. as an agent or trustee.

9.1.6. A PCN and its commissioner acknowledge that:



a. payments made in accordance with this Network Contract DES

Specification are not payments for specific services and instead are made

in consideration of the PCN delivering the requirements of this Network

Contract DES Specification; and

b. the calculation of the payments in accordance with this Network Contract

DES Specification are split into separate elements which are listed in more

detail in sections 9.3 to 9.10.

9.1.7. Where an ODS Change Instruction Notice needs to be submitted prior to a

payment being made, the payment will be made by the end of the month in

which the notice was submitted provided the notice was submitted before the

end of the last working day on or before the 14th day of that month. If

submitted after the end of the last working day on or before the 14th day of the

month, payment will be made at the end of the following month. The exact

date of payment is subject to local payment arrangements.

9.1.8. If a practice is allocated to a PCN in accordance with section 4.9, an

adjustment will be made to reflect that practice’s patient list in the calculation

of a payment due to the PCN. The adjustment will only apply to payments that

are made once the ODS Change Instruction Notice has been submitted in

accordance with the timescales in section 9.1.7, which, for the avoidance of

doubt, will only occur after the commissioner has confirmed the practice’s

participation in the Network Contract DES in accordance with section 4.9.7.

9.1.9. The adjustment referred to in section 9.1.8 which is to be made to reflect the

practice’s patient list in the calculation of a payment due to the PCN is as

follows:

a. The relevant payment will be recalculated with the relevant measure of the

practice’s patient list included;

b. The amount recalculated will be divided into 12 (or six for the PCN Support

Payment) equal monthly instalments; and

c. Each monthly payment to the PCN, made after the ODS Change

Instruction Notice has been submitted in accordance with the timescales in

section 9.1.7, will be an amount equal to the recalculated monthly

instalment; and

d. For the avoidance of doubt, there will be no adjustment to the previous

monthly payments that have already been paid to the PCN.

9.2. Administrative provisions relating to payment

9.2.1. Payments under the Network Contract DES are to be treated for accounting

and superannuation purposes as gross income of the PCN’s Core Network



Practices, in the financial year. Where payments are made to the Nominated

Payee, how the income is apportioned for accounting and superannuation

purposes will depend on the arrangements for the distribution of payments

between the Core Network Practices, as set out in the Network Agreement.

Core Network Practices are responsible for ensuring that their arrangements

are appropriate.

9.2.2. Payments made in accordance with this Network Contract DES Specification

may be changed when there is any change to a PCN, including, but not limited

to, where there is a change to the Core Network Practices members.

9.2.3. A PCN (and its Core Network Practices) is required to adhere to current

financial probity standards that are in place across the NHS, ensuring that the

deployment of resources would stand up to wider scrutiny as an efficient and

effective use of NHS funding.

9.2.4. The commissioner will be responsible for post payment verification. This may

include auditing claims of the PCN (and a Core Network Practice in relation to

the Network Participation Payment) to ensure that they meet the requirements

of the Network Contract DES. Where required, PCNs and/or a Core Network

Practice as relevant will provide to the commissioner in a timely manner all

relevant information and assistance to support assessment of compliance with

the requirements of this service and expenditure against the Network Contract

DES.

9.2.5. Payments pursuant to the Network Contract DES, or any part thereof, are only

payable if a PCN or a Core Network Practice if relevant satisfies the following

conditions:

a. the PCN or Core Network Practice as relevant makes available to the

commissioner any information under the Network Contract DES, which the

commissioner requests and the PCN or Core Network Practice as relevant

either has or could be reasonably expected to obtain;

b. the PCN or Core Network Practice as relevant makes any returns required

of it (whether computerised or otherwise) to the payment system or CQRS

and does so promptly and fully; and

c. all information supplied pursuant to or in accordance with this section 9

must be accurate.

9.2.6. If a commissioner makes a payment under the Network Contract DES and:

a. the recipient was not entitled to receive all or part thereof, whether

because it did not meet the conditions for the payment or because the

payment was calculated incorrectly (including where a payment on

account overestimates the amount that is to fall due); or



b. the commissioner was entitled to withhold all or part of the payment

because of a breach of a condition attached to the payment, but is unable

to do so because the money has already been paid,

then the commissioner is entitled to repayment of all or part of the money paid.

The commissioner may, in this circumstance, recover the money paid by

deducting an equivalent amount from any payment payable to the PCN (or if

the payment relates to payments of the Network Participation, from any

payment to the relevant Core Network Practice), and where no such deduction

can be made, it is a condition of the payments made under the Network

Contract DES that the PCN54 or relevant Core Network Practice as relevant

must pay to the commissioner that equivalent amount.

9.2.7. Where the commissioner is entitled under the Network Contract DES to

withhold all or part of a payment because of a breach of a payment condition

and the commissioner does so or recovers the money by deducting an

equivalent amount from another payment in accordance with this section 9, it

may, where it sees fit to do so, reimburse the PCN or relevant Core Network

Practice as relevant the amount withheld or recovered, if the breach is cured.

9.3. Network Participation Payment

9.3.1. Each practice that:

a. is eligible to participate in this Network Contract DES;

b. has submitted information for confirmation of participation in accordance

with section 4;

c. has been confirmed as participating in the Network Contract DES as a

Core Network Practice of a PCN; and

d. commits to being active members of their PCN as it evolves over the

coming years,

will be eligible for a Network Participation Payment (“NPP”) with effect from 1

April 2020 to support practice engagement.

9.3.2. For the avoidance of doubt:

a. the NPP payment is only made in respect of a PCN of which the practice is

a Core Network Practice; and

54 The PCN must agree how it would deal with such a circumstance so as not to disadvantage the

Nominated Payee. Where required, the commissioner may consider withholding the SFE payment in accordance with the provisions of the SFE.



b. the NPP payment is paid directly to a Core Network Practice and not the

PCN’s Nominated Payee.

9.3.3. For practices to whom the SFE applies, the NPP will be paid in accordance

with the SFE and is not a financial entitlement pursuant to this Network


9.3.4. For practices to whom the SFE does not apply, it is a requirement of this

Network Contract DES that the commissioner ensures that a payment is made

in respect of those practices that equates to the NPP that would have been

made to the practice if the SFE applied to that practice.

9.3.5. The NPP for the period 1 April 2020 to 31 March 2021 is calculated as £1.761

multiplied by the practice’s “weighted patient population” where weighted

patient population means the practice’s Contractor Registered Population (as

calculated in accordance with the SFE regardless of whether the SFE applies

to that practice) as at 1 January 2020 and as adjusted by the Global Sum

Allocation Formula set out in Part 1 of Annex B of the SFE.

9.3.6. Subject to sections 9.3.7 and 9.3.8, the amount calculated as the NPP is

payable in 12 equal monthly instalments and the commissioner must arrange

for the relevant payment to be made to a Core Network Practice no later than

the last day of the month following the month in which the payment applied

and taking into account local payment arrangements.

9.3.7. The commissioner will make the first payment of the relevant NPP amount to a

Core Network Practice of a Previously Approved PCN no later than the end of

the month following the month in which the participation of all Core Network

Practices of that PCN has been confirmed subject to section 9.1.7 and local

payment arrangements. Where the first payment is paid after April 2020, the

first payment will include payment of instalments backdated to April 2020.

9.3.8. Where a new proposed PCN is approved after 1 April 2020, the Core Network

Practices of that PCN acknowledges that the NPP will be calculated as set out

in section 9.3.4 and split into 12 monthly instalments but the PCN’s Core

Network Practices will only be entitled to receive the monthly instalments for

the months they deliver the service requirements of the Network Contract

DES. As indicated in section 4.8 the commissioner will, when the PCN is

approved, indicate to the PCN the relevant service delivery commencement

date and payment dates.

9.3.9. A Core Network Practice will no longer be eligible to receive the NPP if under

exceptional circumstances it leaves the PCN after 31 May 2020. The change

will take effect from the month following the month in which the Core Network

Practice leaves the PCN.



9.4. Clinical Director Payment

9.4.1. A PCN is entitled to a population-based payment to facilitate the delivery of the

requirements of the Clinical Director role.

9.4.2. The clinical director payment for the period 1 April 2020 to 31 March 2021 is

calculated using a baseline equivalent of 0.25 WTE (1 WTE is £139,469 in

2020/21) per 50,000 PCN Patients (as at 1 January 2020)55. This equates to a

payment of £0.72256 per registered patient per annum (which equates to

£0.060 per patient per month).

9.4.3. Subject to sections 9.4.4 and 9.4.5, the amount calculated as the clinical

director payment is payable in 12 equal monthly instalments and the

commissioner must arrange for payment to be made no later than the last day

of the month in which the payment applies and taking into account local

payment arrangements.

9.4.4. The commissioner will make the first payment of the relevant clinical director

payment amount to a Previously Approved PCN no later than the end of the

month in which the participation of all Core Network Practices of that PCN has

been confirmed subject to section 9.1.7 and local payment arrangements.

Where the first payment is paid after April 2020, the first payment will include

payment of instalments backdated to April 2020.

9.4.5. Where a new proposed PCN is approved after 1 April 2020, the PCN

acknowledges that the clinical director payment will be calculated as set out in

section 9.4.2 and split into 12 monthly instalments but the PCN will only be

entitled to receive the monthly instalments for the months it delivers the

service requirements of the Network Contract DES. As indicated in section 4.8

the commissioner will indicate to the PCN the relevant service delivery

commencement date and payment dates when the PCN is approved.

9.5. Core PCN funding

9.5.1. A PCN is entitled to a payment of Core PCN Funding for use by the PCN as it

sees fit.

9.5.2. The Core PCN Funding for the period 1 April 2020 to 31 March 2021 is

calculated as £1.50 multiplied by the PCN list size (equating to £0.125 per

patient per month).

55 https://digital.nhs.uk/services/organisation-data-service 56 The additional 6 per cent employer’s superannuation will be met centrally.



https://digital.nhs.uk/services/organisation-data-service

9.5.3. Subject to sections 9.5.4 and 9.5.5, the amount calculated as the Core PCN

Funding is payable in 12 equal monthly instalments and the commissioner

must arrange for payment to be made no later than the last day of the month

in which the payment applies and taking into account local payment

arrangements.

9.5.4. The commissioner will make the first payment of the relevant Core PCN

Funding amount to an Approved PCN no later than the end of the month in

which the participation of all Core Network Practices of that PCN has been

confirmed subject to section 9.1.7 and local payment arrangements. Where

the first payment is paid after April 2020, the first payment will include payment

of instalments backdated to April 2020.


acknowledges that the Core PCN Funding will be calculated as set out in

section 9.5.2 and split into 12 monthly instalments but the PCN will only be





9.5.6. The Commissioner must provide the Core PCN Funding from its CCG core

allocations57 as per the NHS Operational Planning and Contracting Guidance

2020/2158.

9.6. Extended hours access payment

9.6.1. A PCN is entitled to a payment to facilitate the delivery of the requirements of

the Extended Hours Access service requirement.

9.6.2. The extended hours access payment for the period 1 April 2020 to 31 March

2021 is calculated as £1.45 multiplied by the PCN list size (equating to £0.121

per patient per month).

9.6.3. Subject to sections 9.6.4 and 9.6.5, the amount calculated as the extended

hours access payment is payable in 12 equal monthly instalments and the




9.6.4. The commissioner will make the first payment of the relevant extended hours

access payment amount to an Approved PCN no later than the end of the

month in which the participation of all Core Network Practices of that PCN has

57 Rather than specific primary medical care allocations. 58 https://www.england.nhs.uk/publication/nhs-operational-planning-and-contracting-guidance-2020-21/



https://www.england.nhs.uk/operational-planning-and-contracting/

https://www.england.nhs.uk/operational-planning-and-contracting/

https://www.england.nhs.uk/publication/nhs-operational-planning-and-contracting-guidance-2020-21/

been confirmed subject to section 9.1.7 and local payment arrangements.

Where the first payment is paid after April 2020, the first payment will include

payment of instalments backdated to April 2020.


acknowledges that the extended hours access payment will be calculated as

set out in section 9.6.2 and split into 12 monthly instalments but the PCN will

only be entitled to receive the monthly instalments for the months it delivers

the service requirements of the Network Contract DES. As indicated in section

4.8 the commissioner will indicate to the PCN the relevant service delivery


9.7. Care home premium

9.7.1. A PCN is entitled to a payment to facilitate delivery of services to patients in

care homes.

9.7.2. The payment is calculated on the basis of £60 per bed for the period 1 August

2020 to 31 March 2021. The number of beds will be based on Care Quality

Commission (CQC) data on beds within services that are registered as care

home services with nursing (CHN) and care home services without nursing

(CHS) in England59.

9.7.3. The commissioner must arrange for payment to be made to the PCN on a

monthly basis from 1 August 2020 at a rate of £7.50 per bed per month for the

period 1 August 2020 to 31 March 2021 based on the number of relevant beds

in the PCN’s Aligned Care Homes.

9.7.4. Subject to sections 9.7.5 to 9.7.7 the amount calculated as the care home

premium payment is payable in eight equal monthly instalments and the




9.7.5. Where a new proposed PCN is approved after 1 August 2020, the PCN

acknowledges that the care home premium payment will be calculated as set

out in section 9.7.3 and split into eight monthly instalments but the PCN will

only be entitled to receive the monthly instalments for the months it delivers

the service requirements60 of the Network Contract DES. As indicated in

59 See https://www.cqc.org.uk/guidance-providers/regulations-enforcement/service-types for further

information on the definition of care home services for this purpose. 60 Monthly payments will be paid in full regardless of whether the new proposed PCN was established

mid-month.




section 4.8 the commissioner will indicate to the PCN the relevant service

delivery commencement date and payment dates when the PCN is approved.

9.7.6. The commissioner must ensure that the number of beds on which payment is

based is updated on a monthly basis in line with the CQC Care Directory61.

9.7.7. Payment will only be made where the commissioner is satisfied that the PCN

or its Core Network Practices have comprehensively coded care home

residents using appropriate clinical codes as follows and as set out in section

10:

a. 160734000 – Lives in a nursing home; and

b. 394923006 – Live in a residential home.

9.8. PCN Support Payment

9.8.1. A PCN is entitled to the PCN Support Payment for the period 1 April 2020 to

30 September 2020. This payment is calculated as £0.27 multiplied by the

PCNs “weighted patient population” where weighted patient population

means the PCN’s Core Network Practice’s Contractor Registered Population

(as calculated in accordance with the SFE regardless of whether the SFE

applies to that practice) as at 1 January 2020 and as adjusted by the Global

Sum Allocation Formula set out in Part 1 of Annex B of the SFE. This equates

to £0.045 per weighted patient per month.

9.8.2. Subject to sections 9.8.3 and 9.8.4, the amount calculated as the PCN

Support Payment is payable in six equal monthly instalments and the




9.8.3. The commissioner will make the first payment of the relevant PCN Support

Payment amount to an Approved PCN no later than the end of the month in

which the participation of all Core Network Practices of that PCN has been

confirmed subject to section 9.1.7 and local payment arrangements. Where

the first payment is paid after April 2020, the first payment will include payment

of instalments backdated to April 2020.


acknowledges that the PCN Support Payment will be calculated as set out in

section 9.8.1 and split into six monthly instalments but the PCN will only be



61 See https://www.cqc.org.uk/guidance-providers/regulations-enforcement/service-types for further

information on the definition of care home services for this purpose.



https://protect-eu.mimecast.com/s/AhPCCy8yKumgLjytQEbKz?domain=cqc.org.uk



9.9. Additional funding from October 2020

9.9.1. A PCN and the commissioner acknowledge that:

a. additional funding will be made available to practices in the six months

prior to 31 March 2021;

b. to receive the funding, a PCN may be required to carry out certain actions

or activities;

c. NHS England and NHS Improvement will publish in a separate document

prior to 1 October 2020 details of the level of funding, how to claim the

funding and any actions or activities required to be eligible for the funding

which will be agreed with the BMA’s GPCE;

d. Where a PCN is required to carry out certain actions or activities to receive

the funding and a PCN carries out those actions or activities, then the

terms of the document published by NHS England and Improvement

relating to those actions or activity and associated arrangements for

funding will apply for the period specified in that document;

e. Where a PCN does not carry out those actions or activities then the PCN

will not be entitled to the funding and the terms of the document published

by NHS England and NHS Improvement will not apply; and

f. The existing provisions of this Network Contract DES Specification will not

change as a result of the additional funding and therefore section 4.13.1.b

will not apply in respect of the additional funding.

9.10. Workforce

9.10.1. Subject to sections 9.10.4 to 9.10.8, a PCN is entitled to claim 100 per cent

reimbursement of the aggregate WTE actual62 salary (including employer on-

costs63) up to the maximum amount per role as outlined in Table 2 and within

that PCN’s overall Additional Roles Reimbursement Sum, for the delivery of

health services.

9.10.2. A PCN’s Additional Roles Reimbursement Sum equates to £7.131 per PCN

weighted list size as at 1 January 2020. The explanation of PCN’s weighted

62 If relevant the percentage will be appropriately apportioned to PCN related activity. 63 This does not include the additional 6 per cent employer contributions.



list size and the calculation used to determine a PCN’s Additional Roles

Reimbursement Sum is set out in the Network Contract DES Guidance.

9.10.3. A PCN must use the mandatory claim form64, or subsequent electronic

replacement, to submit the monthly workforce claim.

9.10.4. The following conditions apply to any claim made pursuant to section 9.10.1:

a. The commissioner will arrange for payment to be made on a monthly basis

in arrears following the start of employment of the relevant Additional Role

or engagement via a service sub-contract. The commissioner will only

make payments following the start of the employment or engagement.

b. The Nominated Payee must in accordance with local payment

arrangements submit a claim for the reimbursement of the cost relating to

the previous month.

c. The commissioner must make payments no later than the last day of the

month following the month to which the payment relates and taking into

account local payment arrangements (for example, a payment relating to

April 2020 is to be made on or by the end May 2020).

d. The claim must relate to reimbursement of costs referred to in section

9.10.1 from within the ten roles covered by the Additional Roles

Reimbursement Scheme in accordance with section 6.

e. A PCN must demonstrate that claims being made are for additional staff

roles beyond the baseline (including in future years, replacement as a

result of staff turnover) as set out in this Network Contract DES

Specification. The commissioner will be required to ensure the claims

meet the ‘additionality rules’ set out in section 6.

f. A PCN (and Core Network Practices) not adhering to the additionality rules

and principles will not be eligible for workforce reimbursement under this

Network Contract DES Specification and could be subject to the recovery

of funds and referral for investigation of fraud.

g. The commissioner will carry out audit appropriately and a PCN must co-

operate fully in providing the relevant information. Failure by a PCN to

provide the requested information will enable the commissioner to withhold

or reclaim reimbursements.

h. A PCN must ensure that clinical pharmacists and pharmacy technicians,

reimbursed under the national Medicines Optimisation in Care Homes

64 The claim form available at https://www.england.nhs.uk/publication/des-additional-roles-

reimbursement-scheme-claim-form-2020-21/. Further information regarding the electronic replacement is available in the Network Contract DES Guidance 2020/21.




https://www.england.nhs.uk/publication/des-additional-roles-reimbursement-scheme-claim-form-2020-21/

https://www.england.nhs.uk/publication/des-additional-roles-reimbursement-scheme-claim-form-2020-21/


Scheme and that have been transferred65 so that they receive funding

under the Network Contract DES, meet the terms set out in this Network

Contract DES Specification. The PCN must ensure that the clinical

pharmacist or pharmacy technician work across the PCN and carry out the

relevant duties pursuant to section 6 in the delivery of health services.

i. The commissioner will make any payments due under this section 9.10 to

the Nominated Payee.

9.10.5. For the purposes of this section 9.10, “WTE” is defined as 37.5 hours in line

with Agenda for Change (AfC) terms, but this may vary for non-AfC posts.

Where AfC does not apply, a PCN should calculate the relevant WTE

according to the normal full-time hours for that role in the employing

organisation with reimbursement being made on a pro-rata basis accordingly.

9.10.6. If the workforce delivering the health services is employed by a non-PCN

body, the contribution will be the relevant percentage of the actual WTE

equivalent salary and employer on-costs costs, that have been appropriately

apportioned to PCN-related activity.

9.10.7. In addition to the reimbursement of 100 per cent of actual WTE equivalent

salary and employer on costs (pension and national insurance contributions),

where a PCN does not employ a Social Prescriber Link Worker and sub-

contracts the delivery of the social prescribing service, a PCN may claim a

contribution towards additional costs charged by the sub-contracted provider

for the provision of the social prescribing service. A PCN may claim a

contribution of up to £200 per month (£2,400 per year) for each whole WTE

that the sub-contracted provider has appropriately apportioned to PCN-related

activity provided that:

a. a claim for the contribution towards additional costs charged by the sub-

contracted provider must not exceed £200 in respect of any month; and

b. the total annual amount claimed by the PCN in respect of the social

prescribing element in respect of each WTE does not exceed the

maximum reimbursable amount set out in Table 2. For the avoidance of

doubt, the contribution towards additional costs charged by the sub-

contracted provider is included when considering whether the total annual

amount is within the maximum reimbursable amount.

65 Information regarding the transition arrangements is available in the Network Contract DES guidance.





Table 2: Maximum reimbursement amounts per role for 2020/21

Role

AfC band

Annual maximum reimbursable amount per role66

£

Clinical pharmacist 7-8a 55,670

Pharmacy technician 5 35,389

Social prescribing link worker Up to 5 35,389

Health and wellbeing coach Up to 5 35,389

Care coordinator 4 29,135

Physician associate 7 53,724

First contact physiotherapist 7-8a 55,670

Dietician 7 53,724

Podiatrist 7 53,724

Occupational therapist 7 53,724

9.10.8. A PCN will only be eligible for payment where all of the following requirements

have been met:

a. For workforce related claims, the PCN has met the requirements as set

out in section 6 for the relevant roles against which payment is being

claimed.

66 The maximum reimbursable amount is the sum of (a) the weighted average salary for the specified

AfC band plus (b) associated employer on-costs. These amounts do not include any recruitment and reimbursement premiums that PCNs may choose to offer. If applicable, the on-costs will be revised to take account of any pending change in employer pension contributions. The maximum reimbursement amount in subsequent years will be confirmed in line with applicable AfC rates.



b. The employing organisation (whether this is a PCN member or a third

party) continues to employ the individual(s) for whom payments are being

claimed and the PCN continues to have access to those individual(s);

c. The PCN makes available to commissioners any information under the

Network Contract DES, which the commissioner needs and the PCN either

has or can be reasonably expected to obtain in order to establish that the

PCN has fulfilled the requirements of the Network Contract DES

Specification;

d. The PCN makes any returns required of it and does so promptly and fully;

and

e. All information supplied pursuant to or in accordance with this Network

Contract DES Specification is complete and accurate.

10. Monitoring

10.1. The commissioner will monitor services and calculate payments under the

Network Contract DES using CQRS and/or NHAIS or any subsequent

replacement system.

10.2. A PCN’s Core Network Practices will be required to manually input data into

CQRS, until General Practice Extraction Service (“GPES”) (or any

subsequent replacement system) is available to conduct electronic data

collections. The data input67 will be in relation to both management and

payment counts.

10.3. Details as to when automated collections will be available to support this

Network Contract DES will be communicated via NHS Digital68.

10.4. A PCN’s Core Network Practices will be required to use the relevant

SNOMED codes, as published in the supporting Business Rules on the NHS

Digital website (http://www.hscic.gov.uk/qofesextractspecs) to record:

Activity to be coded Code type69

Available from70

Patient Activation Measure (PAM) completed Existing Apr 2020

67 For information on how to manually enter data into CQRS, see NHS Digital’s website 68 https://digital.nhs.uk/search/publicationStatus/false?area=data&sort=date 69 Those codes indicated as being ‘new’ have either been requested or are being requested and will be

available in clinical systems in due course. 70 Proposed availability but may be subject to change.



http://www.hscic.gov.uk/qofesextractspecs

https://digital.nhs.uk/search/publicationStatus/false?area=data&sort=date

Patients whose care has been discussed as part of shared decision-making

Existing Apr 2020

Workforce

Referrals to social prescribing services (carried over from 2019/20).

Existing Oct 2019

Patients who have declined a referral to a social prescribing service (carried over from 2019/20).

Existing Oct 2019

Medication reviews by clinical pharmacists (carried over from 2019/20).

Existing Oct 2019

Consultations by clinical pharmacists (carried over from 2019/20).

Existing Oct 2019

Care home visits by a clinical pharmacist (carried over from 2019/20).

Existing Oct 2019

Consultations by a First Contact Physiotherapist. New Oct 2020

Consultations by a Physician Associate New Oct2020

Consultations by a Health and Wellbeing Coach New Apr 2021

Consultations by a Care Coordinator New Apr 2021

Consultations by a Dietician Existing Apr 2020

Consultations by an Occupational Therapist Existing Apr 2020

Consultations by a Podiatrist Existing Apr 2020

Consultations by a Pharmacy Technician Existing Apr 2020

Structured Medication Reviews

Delivery of structured medication reviews. New Oct 2020

Enhanced Health in Care Homes

Patients living in a residential home or nursing home Existing Apr 2020

Patients living temporarily in a residential home or nursing home.

New Oct 2020

Delivery of personalised care and support plans New Oct 2020

Reviews of personalised care and support plans New Oct 2020



Falls risk assessments for patients recorded as living in a residential home or nursing home

Existing Apr 2020

Patients with acute confusion recorded as living in a residential home or nursing home

Existing Apr 2020

Delirium assessments for patients experiencing acute confusion, who are recorded as living in a residential home or nursing home

Existing Apr 2020

Psychosocial assessments for patients recorded as living in a residential or nursing home

Existing Apr 2020

Supporting Early Cancer Diagnosis

Patients placed on an urgent referral pathway for suspected cancer

Existing Apr 2020

Delivery of safety netting for patients on urgent referral pathway for suspected cancer

New Oct 2020

Investment and Impact Fund (IIF)

Patients on the learning disability register Existing Apr 2020

Learning disability annual health checks for patients on the learning disability register

Existing Apr 2020

Seasonal flu vaccinations for patients aged 65+ Existing Apr 2020

Patients referred to social prescribing Existing Apr 2020

10.5. A PCN’s Core Network Practices must ensure the coding of care home

residence is accurately recorded on a continuous basis.

10.6. The SNOMED codes outlined in section 10.4 will be used as the basis for the

GPES data collection, which will allow CQRS to calculate aggregated

numbers to support the management information counts. Core Network

Practices must use the relevant codes, outlined above, within their clinical

systems as only those included in this document and the supporting

Business Rules will be acceptable to allow CQRS calculations. A PCN’s Core

Network Practices will therefore need to ensure that they use the relevant

codes and if necessary, re-code patients.



Annex A - Network Contract DES Participation Form

The Network Contract DES Participation Form is available at https://www.england.nhs.uk/publication/des-participation-form-2020-21/.



https://www.england.nhs.uk/publication/des-participation-form-2020-21/

Annex B - Additional Roles Reimbursement Scheme -

Minimum Role Requirements

B.1. Clinical Pharmacist

B1.1. Where a PCN employs or engages a Clinical Pharmacist under the Additional

Roles Reimbursement Scheme, the PCN must ensure that the Clinical

Pharmacist is enrolled in, or has qualified from, an approved 18-month training

pathway or equivalent that equips the Clinical Pharmacist to:

a. be able to practice and prescribe safely and effectively in a primary care

setting (for example, the CPPE Clinical Pharmacist training pathways71,72);

and

b. deliver the key responsibilities outlined in section B1.2.

B1.2. Where a PCN employs or engages one or more Clinical Pharmacists under

the Additional Roles Reimbursement Scheme, the PCN must ensure that each

Clinical Pharmacist has the following key responsibilities in relation to

delivering health services:

a. work as part of a multi-disciplinary team in a patient facing role to clinically

assess and treat patients using their expert knowledge of medicines for

specific disease areas;

b. be a prescriber, or completing training to become prescribers, and work

with and alongside the general practice team;

c. be responsible for the care management of patients with chronic diseases

and undertake clinical medication reviews to proactively manage people

with complex polypharmacy, especially the elderly, people in care homes,

those with multiple co-morbidities (in particular frailty, COPD and asthma)

and people with learning disabilities or autism (through STOMP – Stop

Over Medication Programme);

d. provide specialist expertise in the use of medicines whilst helping to

address both the public health and social care needs of patients at the

PCN’s practice(s) and to help in tackling inequalities;

e. provide leadership on person-centred medicines optimisation (including

ensuring prescribers in the practice conserve antibiotics in line with local

antimicrobial stewardship guidance) and quality improvement, whilst

71 https://www.cppe.ac.uk/career/clinical-pharmacists-in-general-practice-education#navTop 72 https://www.cppe.ac.uk/wizard/files/general-practice/clinical-pharmacists-in-general-practice-

education-brochure.pdf



https://www.cppe.ac.uk/career/clinical-pharmacists-in-general-practice-education#navTop

https://www.cppe.ac.uk/wizard/files/general-practice/clinical-pharmacists-in-general-practice-education-brochure.pdf

https://www.cppe.ac.uk/wizard/files/general-practice/clinical-pharmacists-in-general-practice-education-brochure.pdf

contributing to the quality and outcomes framework and enhanced

services;

f. through structured medication reviews, support patients to take their

medications to get the best from them, reduce waste and promote self-

care;

g. have a leadership role in supporting further integration of general practice

with the wider healthcare teams (including community and hospital

pharmacy) to help improve patient outcomes, ensure better access to

healthcare and help manage general practice workload;

h. develop relationships and work closely with other pharmacy professionals

across PCNs and the wider health and social care system;

i. take a central role in the clinical aspects of shared care protocols, clinical

research with medicines, liaison with specialist pharmacists (including

mental health and reduction of inappropriate antipsychotic use in people

with learning difficulties), liaison with community pharmacists and

anticoagulation; and

j. be part of a professional clinical network and have access to appropriate

clinical supervision. Appropriate clinical supervision means:

i. each clinical pharmacist must receive a minimum of one supervision

session per month by a senior clinical pharmacist73;

ii. the senior clinical pharmacist must receive a minimum of one

supervision session every three months by a GP clinical supervisor;

iii. each clinical pharmacist will have access to an assigned GP clinical

supervisor for support and development; and

iv. a ratio of one senior clinical pharmacist to no more than five junior

clinical pharmacists, with appropriate peer support and supervision in

place.

B.2. Pharmacy Technicians

B2.1. Where a PCN employs or engages a Pharmacy Technician under the

Additional Roles Reimbursement Scheme, the PCN must ensure that the

Pharmacy Technician:

a. is registered with the General Pharmaceutical Council (GPhC);

73 This does not need to be a senior clinical pharmacist within the PCN but could be part of a wider local

network, including from secondary care or another PCN.



b. meets the specific qualification and training requirements as specified by

the GPhC criteria74 to register as a Pharmacy Technician;

c. enrolled in, undertaking or qualified from, an approved training pathway.

For example, the Primary Care Pharmacy Educational Pathway (PCPEP)

or Medicines Optimisation in Care Homes (MOCH); and

d. is working under appropriate clinical supervision to ensure safe, effective

and efficient use of medicines

in order to deliver the key responsibilities outlined in section B2.2.

B2.2. Where a PCN employs or engages one or more Pharmacy Technicians under


Pharmacy Technician has the following key clinical, and technical and

administrative responsibilities, in delivering health services:

B2.2.1. Clinical responsibilities of the Pharmacy Technician:

a. undertake patient facing and patient supporting roles to ensure effective

medicines use, through shared-decision making conversations with

patients;

b. carry out medicines optimisation tasks including effective medicine

administration (e.g. checking inhaler technique), supporting medication

reviews, and medicines reconciliation. Where required, utilise consultation

skills to work in partnership with patients to ensure they use their

medicines effectively;

c. support, as determined by the PCN, medication reviews and medicines

reconciliation for new care home patients and synchronising medicines for

patient transfers between care settings and linking with local community

pharmacists.

d. provide specialist expertise, where competent, to address both the public

health and social care needs of patients, including lifestyle advice, service

information, and help in tackling local health inequalities;

e. take a central role in the clinical aspects of shared care protocols and

liaising with specialist pharmacists for more complex patients;

f. support initiatives for antimicrobial stewardship to reduce inappropriate

antibiotic prescribing;

74 The training requirements for Pharmacy Technicians are currently in transition and further information

is available on the General Pharmaceutical Council (GPhC) website. This information will provide the specific criteria to register as a pharmacy technician – see https://www.pharmacyregulation.org/i-am-pharmacy-technician



https://www.pharmacyregulation.org/i-am-pharmacy-technician

https://www.pharmacyregulation.org/i-am-pharmacy-technician

g. assist in the delivery of medicines optimisation and management incentive

schemes and patient safety audits;

h. support the implementation of national prescribing policies and guidance

within GP practices, care homes and other primary care settings. This will

be achieved through undertaking clinical audits (e.g. use of antibiotics),

supporting quality improvement measures and contributing to the Quality

and Outcomes Framework and enhanced services;

B2.2.2. Technical and Administrative responsibilities of the Pharmacy Technician:

a. work with the PCN multi-disciplinary team to ensure efficient medicines

optimisation, including implementing efficient ordering and return

processes, and reducing wastage;

b. supervise practice reception teams in sorting and streaming general

prescription requests, so as to allow GPs and clinical pharmacists to

review the more clinically complex requests;

c. provide leadership for medicines optimisation systems across PCNs,

supporting practices with a range of services to get the best value from

medicines by encouraging and implementing Electronic Prescriptions, safe

repeat prescribing systems, and timely monitoring and management of

high-risk medicines;

d. provide training and support on the legal, safe and secure handling of

medicines, including the implementation of the Electronic Prescription

Service (EPS); and

e. develop relationships with other pharmacy technicians, pharmacists and

members of the multi-disciplinary team to support integration of the

pharmacy team across health and social care including primary care,

community pharmacy, secondary care, and mental health.

B.3. Social Prescribing Link Workers

B3.1. A PCN must provide to the PCN’s patients access to a social prescribing

service. To comply with this, a PCN may:

a. directly employ Social Prescribing Link Workers; or

b. sub-contract provision of the service to another provider

in accordance with this Network Contract DES Specification.

B3.2. Where a PCN employs or engages a Social Prescribing Link Worker under the


Social Prescribing Link Worker:



a. has completed the NHS England and NHS Improvement online learning

programme75

b. is enrolled in, undertaking or qualified from appropriate training as set out

by the Personalised Care Institute76; and

c. attends the peer support networks run by NHS England and NHS

Improvement at ICS and/or STP level;


B3.3. Where a PCN employs or engages one or more Social Prescribing Link

Workers under the Additional Roles Reimbursement Scheme or sub-contracts

provision of the social prescribing service to another provider, the PCN must

ensure that each Social Prescribing Link Worker providing the service has the

following key responsibilities in delivering the service to patients:

a. as members of the PCN’s team of health professionals, take referrals from

the PCN’s Core Network Practices and from a wide range of agencies77 to

support the health and wellbeing of patients;

b. assess how far a patient’s health and wellbeing needs can be met by

services and other opportunities available in the community;

c. co-produce a simple personalised care and support plan to address the

patient’s health and wellbeing needs by introducing or reconnecting

people to community groups and statutory services, including weight

management support and signposting where appropriate and it matters to

the person;

d. evaluate how far the actions in the care and support plan are meeting the

patient’s health and wellbeing needs78;

e. provide personalised support to patients, their families and carers to take

control of their health and wellbeing, live independently, improve their

health outcomes and maintain a healthy lifestyle;

f. develop trusting relationships by giving people time and focus on ‘what

matters to them’;

75 https://www.e-lfh.org.uk/programmes/social-prescribing/ 76 https://www.england.nhs.uk/personalisedcare/supporting-health-and-care-staff-to-deliver-

personalised-care/personalised-care-institute/ 77 These agencies include but are not limited to: the PCN’s members, pharmacies, multi-disciplinary

teams, hospital discharge teams, allied health professionals, fire service, police, job centres, social care services, housing associations and voluntary, community and social enterprise (VCSE) organisations.

78 Including considering if the persons needs are met (for example, reasonable adjustments, interpreter etc).



https://www.e-lfh.org.uk/programmes/social-prescribing/

https://www.england.nhs.uk/personalisedcare/supporting-health-and-care-staff-to-deliver-personalised-care/personalised-care-institute/

g. take a holistic approach, based on the patient’s priorities and the wider

determinants of health;

h. explore and support access to a personal health budget where

appropriate;

i. manage and prioritise their own caseload, in accordance with the health

and wellbeing needs of their population; and

j. where required and as appropriate, refer patients back to other health

professionals within the PCN.

B3.4. A PCN’s Core Network Practices must identify a first point of contact for

general advice and support and (if different) a GP to provide supervision for

the Social Prescribing Link Worker(s). This could be provided by one or more

named individuals within the PCN.

B3.5. A PCN will ensure the Social Prescribing Link Worker(s) can discuss patient

related concerns and be supported to follow appropriate safeguarding

procedures (e.g. abuse, domestic violence and support with mental health)

with a relevant GP.

B3.6. A PCN must ensure referrals to the Social Prescribing Link Worker(s) are

recorded within GP clinical systems using the new national SNOMED codes

(see section 6.4.1 and 10).

B3.7. Where a PCN employs or engages one or more Social Prescribing Link

Workers under the Additional Roles Reimbursement Scheme or sub-contracts

provision of the social prescribing service to another provider, the PCN must

ensure that each Social Prescribing Link Worker has the following key wider

responsibilities:

a. draw on and increase the strength and capacity of local communities,

enabling local Voluntary, Community and Social Enterprise (VCSE)

organisations and community groups to receive social prescribing referrals

from the Social Prescribing Link Worker;

b. work collaboratively with all local partners to contribute towards supporting

the local VCSE organisations and community groups to become

sustainable and that community assets are nurtured, through sharing

intelligence regarding any gaps or problems identified in local provision

with commissioners and local authorities;

c. have a role in educating non-clinical and clinical staff within the PCN

through verbal or written advice or guidance on what other services are

available within the community and how and when patients can access

them;



B3.8. A PCN must be satisfied that organisations and groups to whom the Social

Prescribing Link Workers(s) directs patients:

a. have basic safeguarding processes in place for vulnerable individuals; and

d. provide opportunities for the patient to develop friendships and a sense of

belonging, as well as to build knowledge, skills and confidence.

B3.9. A PCN must ensure that all staff working in practices that are members of the

PCN are aware of the identity of the Social Prescribing Link Worker(s) and the

process for referrals.

B3.10. A PCN must work in partnership with commissioners, social prescribing

schemes, Local Authorities and voluntary sector leaders to create a shared

plan for social prescribing which must include how the organisations will build

on existing schemes and work collaboratively to recruit additional social

prescribing link workers to embed one in every PCN and direct referrals to the

voluntary sector.

B.4. Health and Wellbeing Coach

B4.1. Where a PCN employs or engages a Health and Wellbeing Coach under the


Health and Wellbeing Coach:

a. is enrolled in, undertaking or qualified from appropriate health coaching

training covering topics outlined in the NHS England and NHS

Improvement Implementation and Quality Summary Guide79, with the

training delivered by a training organisation listed by the Personalised

Care Institute80;

b. adheres to a code of ethics and conduct in line with the NHS England and

NHS Improvement Health coaching Implementation and Quality Summary

Guide;

c. has formal individual and group coaching supervision which must come

from a suitably qualified or experienced individual; and

d. working closely in partnership with the Social Prescribing Link Worker(s) or

social prescribing service provider to identify and work alongside people

who may need additional support, but are not yet ready to benefit fully

from social prescribing

79 https://www.england.nhs.uk/publication/health-coaching-summary-guide-and-technical-annexes/ 80 https://www.england.nhs.uk/personalisedcare/supporting-health-and-care-staff-to-deliver-

personalised-care/personalised-care-institute/



https://www.england.nhs.uk/publication/health-coaching-summary-guide-and-technical-annexes/




B4.2. Where a PCN employs or engages one or more Health and Wellbeing

Coaches under the Additional Roles Reimbursement Scheme, the PCN must

ensure that each Health and Wellbeing Coach has the following key

responsibilities, in delivering health services:

a. manage and prioritise a caseload, in accordance with the health and

wellbeing needs of their population through taking an approach that is

non-judgemental, based on strong communication and negotiation skills,

while considering the whole person when addressing existing issues.

Where required and as appropriate, the Health and Wellbeing Coach will

refer people back to other health professionals within the PCN;

b. utilise existing IT and MDT channels to screen patients, with an aim to

identify those that would benefit most from health coaching;

c. provide personalised support to individuals, their families, and carers to

support them to be active participants in their own healthcare; empowering

them to manage their own health and wellbeing and live independently

through:

d. coaching and motivating patients through multiple sessions to identify their

needs, set goals, and supporting patients to achieve their personalised

health and care plan objectives;

e. providing interventions such as self-management education and peer

support;

f. supporting patients to establish and attain goals that are important to the

patient;

g. supporting personal choice and positive risk taking while ensuring that

patients understand the accountability of their own actions and decisions,

thus encouraging the proactive prevention of further illnesses;

h. working in partnership with the social prescribing service to connect

patients to community-based activities which support them to take

increased control of their health and wellbeing;

i. increasing patient motivation to self-manage and adopt healthy

behaviours;

j. work with patients with lower activation scores to understand their level of

knowledge, skills and confidence (their “Activation” level), when engaging

with their health and well-being and subsequently supporting them in

shared decision-making conversations;

k. utilise health coaching skills to support people with lower levels of

activation to develop the knowledge, skills, and confidence to manage



their health and wellbeing, whilst increasing their ability to access and

utilise community support offers; and

l. explore and support patient access to a personal health budget, where

appropriate, for their care and support.

B4.3. The following sets out the key wider responsibilities of Health and Wellbeing

Coaches:

a. develop collaborative relationships and work in partnership with health,

social care, and community and voluntary sector providers and multi-

disciplinary teams to holistically support patients’ wider health and well-

being, public health, and contributing to the reduction of health

inequalities;

b. provide education and specialist expertise to PCN staff, supporting them to

improve their skills and understanding of personalised care, behavioural

approaches and ensuring consistency in the follow up of people’s goals

with MDT input; and

c. raise awareness within the PCN of shared-decision making and decision

support tools.

B4.4. A PCN must be satisfied that organisations and groups to whom its Health and

Wellbeing Coach(es) directs patients:


b. provide opportunities for the patient to develop friendships and a sense of




the PCN’s Health and Wellbeing Coach(es). This could be provided by one or

more named individuals within the PCN. The Health and Wellbeing Coach

must have access to regular supervision from a health coaching mentor. In

addition to this, formal and individual group coaching supervision must come

from a suitably qualified or experienced health coaching supervisor.

B4.6. A PCN will ensure the PCN’s Health and Wellbeing Coach(es) can discuss

patient related concerns and be supported to follow appropriate safeguarding

procedures (e.g. abuse, domestic violence and support with mental health)

with a relevant GP.


PCN are aware of the identity of the PCN’s Health and Wellbeing Coach(es).



B.5. Care Coordinator

B5.1. Where a PCN employs or engages a Care Coordinator under the Additional

Roles Reimbursement Scheme, the PCN must ensure that the Care

Coordinator:

a. is enrolled in, undertaking or qualified from appropriate training as set out

by the Personalised Care Institute81; and

b. works closely and in partnership with the Social Prescribing Link Worker(s)

or social prescribing service provider and Health and Wellbeing

Coach(es),


B5.2. Where a PCN employs or engages one or more Care Coordinators under the

Additional Roles Reimbursement Scheme, the PCN must ensure that each

Care Coordinator has the following key responsibilities, in delivering health

services:

a. utilise population health intelligence to proactively identify and work with a

cohort of patients to deliver personalised care;

b. support patients to utilise decision aids in preparation for a shared

decision-making conversation;

c. holistically bring together all of a person’s identified care and support

needs, and explore options to meet these within a single personalised

care and support plan (PCSP), in line with PCSP best practice, based on

what matters to the person;

d. help people to manage their needs through answering queries, making

and managing appointments, and ensuring that people have good quality

written or verbal information to help them make choices about their care;

e. support people to take up training and employment, and to access

appropriate benefits where eligible;

f. support people to understand their level of knowledge, skills and

confidence (their “Activation” level) when engaging with their health and

wellbeing, including through the use of the Patient Activation Measure;

g. assist people to access self-management education courses, peer support

or interventions that support them in their health and wellbeing and

increase their activation level;

81 https://www.england.nhs.uk/personalisedcare/supporting-health-and-care-staff-to-deliver-

personalised-care/personalised-care-institute/





h. explore and assist people to access personal health budgets where

appropriate;

i. provide coordination and navigation for people and their carers across

health and care services, working closely with social prescribing link

workers, health and wellbeing coaches, and other primary care

professionals; and

j. support the coordination and delivery of MDTs within the PCN.

B5.3. The following sets out the key wider responsibilities of Care Coordinators:

a. work with the GPs and other primary care professionals within the PCN to

identify and manage a caseload of patients, and where required and as

appropriate, refer people back to other health professionals within the

PCN;

b. raise awareness within the PCN of shared-decision making and decision

support tools; and

c. raise awareness of how to identify patients who may benefit from shared

decision making and support PCN staff and patients to be more prepared

to have shared decision-making conversations.

B5.4. A PCN must be satisfied that organisations and groups to whom its Care

Coordinator directs patients:


b. provide opportunities for the patient to develop friendships and a sense of




the PCN’s Care Coordinator(s). This could be provided by one or more named

individuals within the PCN.

B5.6. A PCN will ensure the PCN’s Care Coordinator(s) can discuss patient related

concerns and be supported to follow appropriate safeguarding procedures

(e.g. abuse, domestic violence and support with mental health) with a relevant

GP.


PCN are aware of the identity of the PCN’s Care Coordinator(s).



B.6. Physician Associates

B6.1. Where a PCN employs or engages a Physician Associate under the Additional

Roles Reimbursement Scheme, the PCN must ensure that the Physician

Associate:

a. has completed a post-graduate physician associate course (either PG

Diploma or MSc);

b. has maintained professional registration with the Faculty of Physician

Associates and/or the General Medical council following implementation of

statutory regulation, working within the latest code of professional conduct

(CIPD); and

c. has passed the UK Physician Associate (PA) National Re-Certification

Exam, which needs to be retaken every six years;

d. participates in continuing professional development opportunities by

keeping up to date with evidence-based knowledge and competence in all

aspects of their role, meeting clinical governance guidelines for continuing

professional development (CPD), and

e. is working under supervision of a doctor as part of the medical team,


B6.2. Where a PCN employs or engages one or more Physician Associates under


Physician Associate has the following key responsibilities, in delivering health

services:

a. provide first point of contact care for patients presenting with

undifferentiated, undiagnosed problems by utilising history-taking, physical

examinations and clinical decision-making skills to establish a working

diagnosis and management plan in partnership with the patient (and their

carers where applicable);

b. support the management of patient’s conditions through offering

specialised clinics following appropriate training including (but not limited

to) family planning, baby checks, COPD, asthma, diabetes, and

anticoagulation;

c. provide health/disease promotion and prevention advice, alongside

analysing and actioning diagnostic test results;

d. develop integrated patient-centred care through appropriate wording with

the wider primary care multi-disciplinary team and social care networks;



e. utilise clinical guidelines and promote evidence-based practice and

partake in clinical audits, significant event reviews and other research and

analysis tasks;

f. participate in duty rotas; undertaking face-to-face, telephone, and online

consultations for emergency or routine problems as determined by the

PCN, including management of patients with long-term conditions;

g. undertake home visits when required; and

h. develop and agree a personal development plan (PDP) utilising a

reflective approach to practice, operating under appropriate clinical

supervision.

B6.3. A PCN’s Core Network practices must identify a suitable named GP

supervisor for each physician associate, to enable them to work under

appropriate clinical supervision.

B.7. First Contact Physiotherapists

B7.1. Where a PCN employs or engages a First Contact Physiotherapist under the

Additional Roles Reimbursement Scheme, the PCN must ensure that the First

Contact Physiotherapist:

a. has completed an undergraduate degree in physiotherapy;

b. is registered with the Health and Care Professional Council;

c. holds the relevant public liability insurance;

d. has a Masters Level qualification or the equivalent specialist knowledge,

skills and experience;

e. can demonstrate working at Level 7 capability in MSK related areas of

practice or equivalent (such as advanced assessment diagnosis and

treatment);

f. can demonstrate ability to operate at an advanced level of practice,


B7.2. Where a PCN employs or engages one or more First Contact Physiotherapist

under the Additional Roles Reimbursement Scheme, the PCN must ensure

that each First Contact Physiotherapist has the following key responsibilities,

in delivering health services:

a. work independently, without day to day supervision, to assess, diagnose,

triage, and manage patients, taking responsibility for prioritising and

managing a caseload of the PCN’s Registered Patients;



b. receive patients who self-refer (where systems permit) or from a clinical

professional within the PCN, and where required refer to other health

professionals within the PCN;

c. work as part of a multi-disciplinary team in a patient facing role, using their

expert knowledge of movement and function issues, to create stronger

links for wider services through clinical leadership, teaching and

evaluation;

d. develop integrated and tailored care programmes in partnership with

patients, providing a range of first line treatment options including self-

management, referral to rehabilitation focussed services and social

prescribing;

e. make use of their full scope of practice, developing skills relating to

independent prescribing, injection therapy and investigation to make

professional judgements and decisions in unpredictable situations,

including when provided with incomplete or contradictory information. They

will take responsibility for making and justifying these decisions;

f. manage complex interactions, including working with patients with

psychosocial and mental health needs, referring onwards as required and

including social prescribing when appropriate;

g. communicate effectively with patients, and their carers where applicable,

complex and sensitive information regarding diagnoses, pathology,

prognosis and treatment choices supporting personalised care;

h. implement all aspects of effective clinical governance for own practice,

including undertaking regular audit and evaluation, supervision and

training;

i. develop integrated and tailored care programmes in partnership with

patients through:

i. effective shared decision-making with a range of first line management

options (appropriate for a patient’s level of activation);

ii. assessing levels of Patient Activation to support a patient’s own level

of knowledge, skills and confidence to self-manage their conditions,

ensuring they are able to evaluate and improve the effectiveness of

self-management interventions, particularly for those at low levels of

activation;

iii. agreeing with patient’s appropriate support for self-management

through referral to rehabilitation focussed services and wider social

prescribing as appropriate; and



iv. designing and implementing plans that facilitate behavioural change,

optimise patient’s physical activity and mobility, support fulfilment of

personal goals and independence, and reduce the need for

pharmacological interventions;

j. request and progress investigations (such as x-rays and blood tests) and

referrals to facilitate the diagnosis and choice of treatment regime

including, considering the limitations of these investigations, interpret and

act on results and feedback to aid patients’ diagnoses and management

plans; and

k. be accountable for decisions and actions via Health and Care Professions

Council (HCPC) registration, supported by a professional culture of peer

networking/review and engagement in evidence-based practice.

B7.3. The following sets out the key wider responsibilities of First Contact

Physiotherapists:

a. work across the multi-disciplinary team to create and evaluate effective

and streamlined clinical pathways and services;

b. provide leadership and support on MSK clinical and service development

across the PCN, alongside learning opportunities for the whole multi-

disciplinary team within primary care;

c. develop relationships and a collaborative working approach across the

PCN, supporting the integration of pathways in primary care;

d. encourage collaborative working across the wider health economy and be

a key contributor to supporting the development of physiotherapy clinical

services across the PCN;

e. liaising with secondary and community care services, and secondary and

community MSK services where required, using local social and

community interventions as required to support the management of

patients within the PCN; and

f. support regional and national research and audit programmes to evaluate

and improve the effectiveness of the First Contact Practitioner (FCP)

programme. This will include communicating outcomes and integrating

findings into own and wider service practice and pathway development.

B.8. Dieticians

B8.1. Where a PCN employs or engages a Dietician under the Additional Roles

Reimbursement Scheme, the PCN must ensure that the Dietician:



a. has a BSc or pre-reg MSc in Dietetics under a training programme

approved by the British Dietetic Association (BDA);

b. is a registered member of the Health and Care Professionals Council

(HCPC);

c. is able to operate at an advanced level of practice; and

d. has access to appropriate clinical supervision and an appropriate named

individual in the PCN to provide general advice and support on a day to

day basis,


B8.2. Where a PCN employs or engages one or more Dieticians under the


Dietician has the following key responsibilities, in delivering health services:

a. provide specialist nutrition and diet advice to patients, their carers, and

healthcare professionals through treatment, education plans, and

prescriptions;

b. educate patients with diet-related disorders on how they can improve their

health and prevent disease by adopting healthier eating and drinking

habits;

c. provide dietary support to patients of all ages (from early-life to end-of-life

care) in a variety of settings including nurseries, patient homes and care

homes;

d. work as part of a multi-disciplinary team to gain patient’s cooperation and

understanding in following recommended dietary treatments;

e. develop, implement and evaluate a seamless nutrition support service

across the PCN, working with community and secondary care where

appropriate, and aimed at continuously improving standards of patient

care and wider multi-disciplinary team working;

f. work with clinicians, multi-disciplinary team colleagues and external

agencies to ensure the smooth transition of patients discharged from

hospital back into primary care, so that they can continue their diet plan;

g. make recommendations to PCN staff regarding changes to medications for

the nutritional management of patients, based on interpretation of

biochemical, physiological, and dietary requirements; and

h. implement all aspects of effective clinical governance for own practice,

including undertaking regular audit and evaluation, supervision and

training.



B8.3. The following sets out the key wider responsibilities of Dieticians:

a. undertake a range of administrative tasks such as ensuring stock levels

are maintained and securely stored, and equipment is kept in good

working order; and

b. ensure delivery of best practice in clinical practice, caseload management,

education, research, and audit, to achieve corporate PCN and local

population objectives.

B.9. Podiatrists

B9.1. Where a PCN employs or engages a Podiatrist under the Additional Roles

Reimbursement Scheme, the PCN must ensure that the Podiatrist:

a. has a BSc or pre-reg MSc in Podiatry under a training programme

approved by the College of Podiatry;


(HCPC);




day basis,


B9.2. Where a PCN employs or engages one or more Podiatrists under the


Podiatrist has the following key responsibilities, in delivering health services:

a. work as part of a PCN’s multi-disciplinary team to clinically assess, treat,

and manage a caseload of patients of all ages with lower limb conditions

and foot pathologies, using their expert knowledge of podiatry for specific

conditions and topics;

b. utilise and provide guidance to patients on equipment such as surgical

instruments, dressings, treatment tables and orthotics;

c. prescribe, produce, and fit orthotics and other aids and appliances;

d. provide specialist treatment and support for high-risk patient groups such

as the elderly and those with increased risk of amputation;

e. support patients through the use of therapeutic and surgical techniques to

treat foot and lower leg issues (e.g. carrying out nail and soft tissue

surgery using local anaesthetic);

f. deliver foot health education to patients;



g. implement all aspects of effective clinical governance for their own

practice, including undertaking regular audit and evaluation, supervision,

and training;

h. liaise with PCN multi-disciplinary team, community and secondary care

staff, and named clinicians to arrange further investigations and onward

referrals;

i. communicate outcomes and integrate findings into their own and wider

service practice and pathway development; and

j. develop, implement and evaluate a seamless podiatry support service

across the PCN, working with community and secondary care where

appropriate, and aimed at continuously improving standards of patient

care and wider multi-disciplinary team working.


a. undertake continued professional development to understand the

mechanics of the body in order to preserve, restore, and develop

movement for patients;

b. provide leadership and support on podiatry clinical service development

across the PCN, alongside learning opportunities for the whole multi-

disciplinary team within primary care;

c. provide education and specialist expertise to PCN staff, raising awareness

of good practice in good foot health;

d. ensure delivery of best practice in clinical practice, caseload management,


population objectives; and

e. undertake a range of administrative tasks such as ensuring stock levels

are maintained and securely stored, and equipment is kept in good

working order.

B.10. Occupational Therapists

B10.1. Where a PCN employs or engages an Occupational Therapist under the


Occupational Therapist:

a. has a BSc in or pre-reg MSc in Occupational Therapy under a training

programme approved by the Royal College of Occupational Therapists;


(HCPC);






day basis,


B10.2. Where a PCN employs or engages one or more Occupational Therapists

under the Additional Roles Reimbursement Scheme, the PCN must ensure

that each Occupational Therapist has the following key responsibilities, in

delivering health services:

a. assess, plan, implement, and evaluate treatment plans, with an aim to

increase patients’ productivity and self-care;

b. work with patients through a shared-decision making approach to plan

realistic, outcomes-focused goals;

c. undertake both verbal and non-verbal communication methods to address

the needs of patients that have communication difficulties;

d. work in partnership with multi-disciplinary team colleagues,

physiotherapists and social workers, alongside the patients' families,

teachers, carers, and employers in treatment planning to aid rehabilitation;

e. where appropriate, support the development of discharge and contingency

plans with relevant professionals to arrange on-going care in residential,

care home, hospital, and community settings;

f. periodically review, evaluate and change rehabilitation programmes to

rebuild lost skills and restore confidence;

g. as required, advise on home, school, and workplace environmental

alterations, such as adjustments for wheelchair access, technological

needs, and ergonomic support;

h. advise patients, and their families or carers, on specialist equipment and

organisations that can help with daily activities;

i. help patients to adapt to and manage their physical and mental health

long-term conditions, through the teaching of coping strategies; and

j. develop, implement and evaluate a seamless occupational therapy

support service across the PCN, working with community and secondary

care where appropriate, and aimed at continuously improving standards of

patient care and wider multi-disciplinary team working.


a. provide education and specialist expertise to PCN staff, raising awareness

of good practice occupational therapy techniques; and



b. ensure delivery of best practice in clinical practice, caseload management,


population objectives.



Update to the GP contract agreement 2020/21 - 2023/24 6 February 2020



2

Contents

Introduction and summary ....................................................................... 3

1. Enhancing the Additional Roles Reimbursement Scheme ............... 7

2. More doctors in general practice .................................................... 18

3. Releasing time to care ................................................................... 23

4. Improving access for patients ........................................................ 25

5. Reforming arrangements for vaccinations and immunisations ....... 28

6. Updating the Quality and Outcomes Framework (QOF) ................. 35

7. Delivering PCN service specifications ............................................ 40

8. Introducing the Investment and Impact Fund ................................. 47

9. Network arrangements ................................................................... 50

Publishing approval number: 001201 Version number: 1 First published: February 2020 Prepared by: Primary Care Strategy and NHS Contracts Group



3

Introduction and summary

This agreement document updates and enhances the existing five-year GP contract agreement Investment and Evolution1, which stands unless otherwise amended in this update document.

Jointly developed by the British Medical Association (BMA) General Practitioners Committee England (GPC) and NHS England and NHS Improvement, the revised deal has been confirmed by Government.

Enhancing the Additional Roles Reimbursement Scheme

1. More roles are now added to the Scheme from April 2020, at the request ofPrimary Care Network (PCN) Clinical Directors. PCNs can now choose torecruit from the following roles within the Scheme, in addition to thosepreviously agreed, to make up the workforce they need: pharmacy technicians,care co-ordinators, health coaches, dietitians, podiatrists and occupationaltherapists. Mental health professionals will be added from April 2021 followingcurrent pilots. Some further flexibility is included in the operation of the‘additionality’ rules.

2. 6,000 extra staff are funded by Government, through additional investment –committed in the Government’s election manifesto – for NHS England and NHSImprovement of £150m/£300m/£300m/£300m between 2020/21 and 2023/24,expanding the Scheme to 26,000. Reimbursement now increases from thecurrent 70% to 100% for all 26,000 roles. Essential for achieving the 26,000target, the move to 100% reimbursement frees up the existing £1.50/head tocontribute to management support for PCNs. Funding entitlements increasefrom £257m to £430m in 2020/21 and, in 2023/24, from £891m to £1,412m.

3. For the average PCN in 2020/212, that means around 7 Full Time Equivalent(FTE) staff, through an average reimbursement pot of £344,000. This rises to20 FTE staff and an average reimbursement pot of £1.13 million in 2023/24. Aready reckoner will be published on the NHS England and NHS Improvementwebsite. Assurances made under this deal mean PCNs can recruit fully, withoutworry about the theoretical risk of future employment liability and redundancycosts. PCNs are encouraged to take immediate action to recruit, with additionalsupport from their Clinical Commissioning Group (CCG), e.g. throughcollective/batch recruitment exercises, supporting joint or rotational roles with

1 NHS England and the BMA (2019) Investment and evolution: a five year framework for GP contract reform to deliver the NHS Long Term Plan. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf2 For the purposes of this document, references to the ‘average’ or ‘typical’ PCN have been derived by taking national funding entitlements (and associated potential workforce roles) and dividing by 1,250 PCNs. The figures for an individual PCN will vary, depending on its size and population characteristics.




4

other community providers. Adding 26,000 extra staff in the PCN additional roles scheme now becomes a first order priority for the whole NHS.

More doctors working in general practice

4. The Government is conducting an urgent review of pensions to seek to solvethe taper problem. Extra Government investment funds new GP trainingrecruitment and retention measures. GP trainee numbers increase from 3,500to 4,000 a year from 2021. 24 months of the 36 month training period will bespent in general practice, from 2022. Together with the increase in trainees, thischange will contribute over half of the 6,000 extra doctors working in generalpractice. The Targeted Enhanced Recruitment Scheme (TERs) will beexpanded: from 276 places now, to 500 in 2021, and 800 in 2022, encouragingGP trainees to work in under-doctored areas.

5. A two-year Fellowship in General Practice will now be offered as a guaranteedright to all GP trainees on completion of their training. It will automatically beoffered as part of signing up to GP training. Our shared goal is to achieve asclose to 100% participation as possible. The Fellowship programme will also beextended to newly qualified nurses. A new national Mentors Scheme will offerhighly experienced GPs the opportunity to mentor GPs, in return for a minimumtime commitment. To boost the GP partnership model, from April 2020, the Newto Partnership Payment guarantees first-time partners a £20,000 one offpayment, plus £3,000 funding for business training. The Induction andRefresher Scheme will be expanded and enhanced to provide more support toGPs returning to general practice, including those with childcare or other caringresponsibilities. A new Locum Support Scheme will provide greater support tolocum GPs, in return for a minimum time contribution. Enhanced sharedparental leave is introduced. A core offer for staff has been developed tosupport good employment practices.

Releasing time to care

6. The Government is committed to reviewing Cross-Government Bureaucracy inGeneral Practice. NHS England and NHS Improvement will developcomplementary proposals to reduce administrative burdens. The digitisation ofLloyd George records starts in 2020.

Improving access for patients

7. More people working in general practice will help achieve 50 million moreappointments in general practice. An improved appointments dataset will beintroduced in 2020, alongside a new, as close to real-time as possible, measureof patient experience. At least £30m of the £150m PCN Investment and ImpactFund in 2021/22 will support improved access for patients, rising to at least£100m of the £300m Fund in 2023/24. A new GP Access Improvement



5

Programme will identify and spread proven methods of improving access including cutting waiting times for routine appointments. Every PCN and practice will be offering a core digital service offer to all its patients from April 2021.

Reforming payment arrangements for vaccinations and immunisations 8. The findings of the vaccinations and immunisations review will be implemented

over the next two years3. The payment model will be overhauled to support improved vaccination coverage. Vaccinations and immunisations will become an essential service in 2020. New contractual core standards will be introduced. Item of service payments will be introduced and standardised across all routine programmes over the next two years. This will begin with Measles Mumps and Rubella (MMR) in 2020/21 and extend to other vaccines from April 2021. New incentive payments will be introduced to maximise population coverage as part of QOF, replacing the current Childhood Immunisation Directed Enhanced Service (DES).

Updating the Quality and Outcomes Framework 9. The asthma, Chronic Obstructive Pulmonary Disease (COPD) and heart failure

domains have been overhauled, with 97 points recycled into 11 more clinically appropriate indicators. £10m of additional funding will support a new indicator on non-diabetic hyperglycaemia worth 18 points. This brings the total number of available QOF points to 567. In 2020/21, the quality improvement modules are Learning Disabilities and Supporting Early Cancer Diagnosis.

10. Maternity medical services become an essential service with a universal 6-8 week post-natal check for new mothers, backed by £12m of additional funding. From 2020/21, we will also introduce a new non-contractual requirement for GPs to offer to refer people with obesity into weight management services, where this is clinically appropriate and where commissioned services exist.

Delivering PCN service specifications 11. The Structured Medication Review and Medicines Optimisation, Enhanced

Health in Care Homes and Supporting Early Cancer Diagnosis service specifications have now been significantly improved in the light of consultation responses. Agreed by GPC England and NHS England and included in chapter 7, they will be introduced in 2020/21. Delivery of Structured Medication Reviews is linked to available pharmacist capacity. Medical input into the care homes service is specified as needing to be appropriate and consistent. In recognition

3 NHS England and NHS Improvement (2019) Interim findings of the Vaccinations and Immunisations Review – September 2019. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/10/interim-findings-of-the-vaccinations-and-immunisations-review-2019.pdf



https://www.england.nhs.uk/wp-content/uploads/2019/10/interim-findings-of-the-vaccinations-and-immunisations-review-2019.pdf


6

of the differential extra workload, a new care home premium payment worth £120 per bed per year will be introduced when the service goes live from 30 September 2020. Every care home will be supported by a single PCN with a named GP or GP team. By 31 July a delivery plan for the new service will be agreed with community provider partners. From 2021/22, at least one third of the PCN Investment and Impact Fund will support effective delivery against the service specifications. The remaining four service specifications – CVD diagnosis and prevention, tackling inequalities, personalised care and anticipatory care - will be introduced in 2021/22, following negotiation with GPC England. From April 2020 every PCN will be offering a social prescribing service. Where the Network Contract DES delivers services that were previously funded locally, that investment must be reinvested by the CCG into primary medical care.

Introducing the Investment and Impact Fund (IIF) 12. The Fund rewards PCNs for delivering objectives set out in the NHS Long Term

Plan and GP contract agreement. It will operate in a similar way to QOF. Eight indicators are included in 2020/21, relating to seasonal flu vaccination, health checks for people with a learning disability, social prescribing referrals, and prescribing. The Fund will be worth £40.5m in 2020/21, increasing to £150m in 2021/22, £225m in 2022/23 and £300m in 2023/24.

The over-riding priority in 2020/21 for both the NHS and the profession is to expand the size of the general practice workforce by making full use of the investment guaranteed under this agreement. The improvements to the additional roles scheme, with 100% reimbursement for 26,000 staff, show unequivocal backing for the PCN model. The new recruitment and retention measures are intended to increase the number of doctors working in general practice, and the partnership model will be boosted by the new incentive for first time partners. More people are needed, to alleviate workforce and workload pressures and ensure general practice is sustainable and can thrive, delivering new and better services and improved access for patients.

DR RICHARD VAUTREY IAN DODGE GPC ENGLAND CHAIR NHS ENGLAND NEGOTIATING TEAM CHAIR



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1. Enhancing the Additional Roles ReimbursementScheme

1.1 Expanding the workforce is the top priority for primary care, foundational to all other goals. Far more people are needed to boost capacity, for three reasons:

• to alleviate workload pressures on existing staff, and thereby ensure primarycare is sustainable and can thrive;

• to improve patient experience of access, cut waiting times and meet theGovernment’s commitment to provide 50 million more appointments withingeneral practice; and

• to improve the quality of care and implement NHS Long Term Plan goals4,including the integration of care as set out in the January 2019 five-year GPcontract deal5.

1.2 Under this agreement, an array of significant additional measures will now be introduced, in order to secure two new national workforce targets: 26,000 extra staff under the Additional Roles Reimbursement Scheme, and 6,000 extra doctors working in General Practice. These commitments now become first order priorities for the entire NHS. Their attainment is the main means of securing the 50 million more appointments and further sustaining general practice.

Adding more roles

1.3 The Additional Roles Reimbursement Scheme was established in 2019 with the advent of Primary Care Networks (PCNs). Inclusion of a role within the Scheme is subject to satisfying three criteria:

• sufficient expected available supply nationwide;

• demand from general practice for the roles; and

• it must be operationally feasible to guarantee the roles are additional tothose that are already in place, and so avoid the risk of funding for existingprimary care staff being diverted into the newly funded posts with no netincrease in capacity.

1.4 Initially, five roles met these three criteria: clinical pharmacists and social prescribing link workers in 2019/20; physician associates and first contact

4 NHS England (2019) The NHS Long Term Plan. Available from: https://www.longtermplan.nhs.uk/online-version/ 5 NHS England and the BMA (2019) Investment and evolution: a five year framework for GP contract reform to deliver the NHS Long Term Plan. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf



https://www.longtermplan.nhs.uk/online-version/


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physiotherapists from 2020/21; and community paramedics from 2021/22. The Government is committed to bringing forward secondary legislation to regulate physician associates as soon as parliamentary time allows. That will enable autonomous working and open up the possibility of independent prescribing in the future, and so maximise the potential to relieve workload from GPs and other staff.

1.5 PCNs want more flexibility. Consistent with the three criteria, the scope of the Additional Roles Reimbursement Scheme extends into six more roles, taking the total number for 2020/21 from four to ten:

• Pharmacy technicians, as envisaged in the five-year deal. Working withHealth Education England (HEE), NHS England and NHS Improvement iscommitted to an increase in the numbers of pharmacy technician trainees.For 2020/21 and 2021/22 only, in recognition of workforce supplyconstraints, the default expectation is that PCNs will not recruit more thanone additional individual pharmacy technician under the Scheme, or two inthose PCNs with a population of over 100,000 patients. This limitation isunnecessary where CCG agreement, on behalf of the local system, confirmsthat local supply constraints are not an issue and will be reviewed for2022/23;

• New roles for both health and wellbeing coaches and care co-ordinators.These can be distinct roles from the social prescribing link worker role. Insome parts of the NHS, health coaching, care navigation and co-ordination,and social prescribing are combined; it is up to PCNs to determine as longas the minimum requirements for at least one of the roles are met. All threeroles can support patients to lead healthier lives including achieving andmaintaining a healthy weight. The health coaching roles will be set at up toan indicative Agenda for Change band 5 and care co-ordinator at up to band4. The roles must be additional;

• Occupational therapists, dietitians, and podiatrists, permitted at anindicative Agenda for Change band 7. Their inclusion in the scheme is at thedirect request of a number of PCN Clinical Directors. This flexibility does notconstitute an expectation that PCNs must now deliver services morenormally performed by community health providers and does not change thecontractual requirements of GMS; and

• Community paramedics, due to be introduced to the Scheme from April2021, will be reimbursed up to an indicative Agenda for Change band 7 rate,increased from the planned Agenda for Change band 6.

1.6 In addition to these six, mental health practitioner roles – including Improving Access to Psychological Therapy (IAPT) practitioners - will also be included in the Scheme from April 2021. The exact arrangements will be informed by the work of twelve sites across England piloting integrated models



9

of primary and community mental health care and wider engagement. The Network Contract Directed Enhanced Service (DES) will include requirements on the individual to work in collaboration with community mental health providers and/or IAPT providers.

1.7 We will also explore whether or not it is feasible to include Advanced Nurse Practitioners in the scheme, bearing in mind supply constraints and the critical need for additionality beyond the significant numbers who are already working in primary care.

1.8 It is important to note that medicines optimisation in care homes (MOCH) clinical pharmacists and pharmacy technicians must be transferred into the Scheme at the point at which they have completed their training. The last date at which this transfer can happen is set at 31 March 2021. Where the roles were counted in the 31 March 2019 staffing baseline, they form an exemption from the calculation of additionality. Aside from this specific exemption, together with the existing exemption for clinical pharmacists transferring to PCNs from the Clinical Pharmacists in General Practice scheme, reimbursement is only for those roles which are demonstrably additional to the 31 March 2019 baseline agreed by CCGs and PCNs. Baseline data for pharmacy technicians was collected as part of the original exercise to baseline the five original ARRS roles.

TABLE 1: 2020/21 MAXIMUM ANNUAL REIMBURSEMENT RATES Role AfC band Maximum reimbursable

amount over 12 months (with on costs)

Clinical pharmacist 7-8A 55,670 Social prescribing link worker Up to 5 35,389 First contact physiotherapist 7-8A 55,670 Physician associate 7 53,724 Pharmacy technician 5 35,389 Community paramedic 7 N/A – reimbursement

available from 2021/22 Occupational therapists 7 53,724 Dietitians 7 53,724 Chiropodists / podiatrists 7 53,724 Health and wellbeing coach Up to 5 35,389 Care co-ordinator 4 29,135 Mental health practitioners TBC (from

2021/22) TBC (from 2021/22)



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More operational flexibility

1.9 Whilst PCNs recognise the necessity of the additionality rules to ensure net capacity expansion, aspects of their operation have been criticised as needlessly restrictive.

1.10 Voluntary sector partners are often best placed to provide social prescribing services. The original rules could make this difficult and partway through 2019 they were amended. When engaging this service from a third party, PCNs can pay and reclaim a contribution of £2,400 for additional costs – beyond salary and on-costs, but within the maximum reimbursable amount – for each service equivalent of one annual whole time equivalent social prescribing link worker.

1.11 Until now, the additionality calculation has operated on a role-by-role basis. From 1 April 2020, PCNs may substitute between clinical pharmacists, first contact physiotherapists and physician associates within their practice-funded baseline, with the agreement of their commissioner which will not be unreasonably withheld. This will help prevent the operation of the Additional Roles Reimbursement Scheme from inadvertently ossifying the service delivery model.

1.12 Under the current rules, where there is an unexpected short-term vacancy in a practice-funded role counted within the Additional Roles Reimbursement Scheme baseline, this would automatically lead to a commensurate reduction in claims by the PCN for an additional such role. We have heard that this can create challenges in the relationships and financial flows between individual practices and the network in which they operate. A three-month ‘grace period’ will now operate for vacancies in these practice-funded baseline roles, from the point at which the role becomes vacant, before the commensurate reduction in Scheme funding is applied. It does not of course apply to vacancies in roles funded under the Scheme.

1.13 Other than pharmacy technicians, for whom a baseline was established in March 2019, the five further roles now added to the scheme in 2020/21 are employed in tiny numbers in primary care. A further baseline exercise would not be proportionate. When so declared by PCNs they will be deemed to be additional.

Extra Government investment in 6,000 more staff

1.14 For the main purpose of improving access and cutting waiting times in surgeries, through providing greater support to general practices, extra Government investment is funding 6,000 extra staff through the Scheme at 100% reimbursement. The Government will now increase NHS England’s revenue budget by £150m/£300m/£300m/£300m between 2020/21-2023/24. Under this agreement, that funding is now added to the Scheme, so that it funds



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26,000 rather than 20,000 staff. The funding is deliberately front-loaded in order to maximise impact by the end of the five-year contract deal.

1.15 It is up to each PCN to decide the distribution of roles required, limited only by differentially available supply of different roles in different parts of the country. Table 2 provides what is purely an illustrative example, and is not an expectation of how a typical PCN will actually recruit. That will depend on the make-up of their existing workforce and local population needs, and will only become clear through the new bottom-up planning process (described below) and actual recruitment exercises.

TABLE 2: ILLUSTRATIVE DISTRIBUTION OF ROLES FOR AN AVERAGE PCN BY 2023/24, BASED ON EXPECTED NATIONAL SUPPLY

100% reimbursement

1.16 From April 2020, all roles will be reimbursed at 100% of actual salary plus defined on-costs, up to the maximum reimbursable amounts. For 2020/21 these are set out in Table 1. This enhancement is intended to:

• accelerate the pace of recruitment, by providing total certainty of full funding.100% reimbursement is a necessary corollary of 26,000 extra staffbecoming a first order national delivery commitment for the Government andthe NHS, as opposed to an optional funding arrangement;

• respond to one of the major criticisms raised through the engagementexercise on the draft service specifications, that the 30% reimbursementcontribution from practices could adversely impact on existing practiceservices. It also means that increases in total practice income and otherstreams such as the new Impact and Investment Fund can more readily bedeployed to support increases in GP and practice nurse numbers;

• free up much needed management and transformational support for ClinicalDirectors. We have heard that the £1.50/head support for PCNs – worth£72,000 annually for an average PCN – has been deployed to contribute tothe 30% funding of additional roles. Instead it can now be used as neededfor development and transformation support. It equates to a full-time band

Role Illustrative FTE Clinical pharmacists 6 Pharmacy technicians 2 First contact physiotherapists 3.5 Physician associates 2.5 Social prescribing link workers/health and wellbeing coaches/care co-ordinators

5

Paramedics and other AHPs 2 Total 21



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8A, and increasing the contribution to Clinical Director time by almost 50%. We encourage Clinical Directors to use the funding to ensure sufficient support as rapidly as possible; and

• demonstrate unequivocal and long-term backing for PCNs.

1.17 Taken together, the extra 6,000 staff and 100% reimbursement constitute a

step-change in funding guaranteed in the Scheme: TABLE 3: GUARANTEED INVESTMENT IN THE SCHEME

(£ millions) 20/21 21/22 22/23 23/24 Original funding 257 415 634 891

Additional funding 173 331 393 521

Revised total 430 746 1,027 1,412 1.18 As set out in the Additional Roles Reimbursement Scheme guidance6, from

April 2020/21, each PCN will be allocated a single combined maximum sum under the Scheme. The sum will be based upon its weighted population share. The weighting takes account of the relative costs and workload associated with service delivery, including deprivation and health inequalities, age profile and deprivation. To ensure consistency and fairness in allocations, the basis for weighting is the same as for the practice global sum. A ready reckoner will be made available for PCNs.

TABLE 4: AVERAGE PCN ADDITIONAL ROLES REIMBURSEMENT SUM7

(£000s) 20/21 21/22 22/23 23/24 Original funding 206 332 507 713 Revised total 344 597 821 1,130

Addressing worries about accrued employment liabilities

1.19 The Network Contract DES is an extension of the existing practice contract. The

Scheme gives general practice the choice to hire additional staff under its direct control, to be part of the PCN team and is a major boost to the independent contractor model. Nonetheless, some networks and practices have naturally been worried about the risk of taking on big additional employment liabilities.

6NHS England (2019) Network Contract Directed Enhanced Service: Additional Roles Reimbursement Scheme Guidance. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/12/network-contract-des-additional-roles-reimbursement-scheme-guidance-december2019.pdf 7 Calculation based on 1250 PCNs






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1.20 Three measures address this concern:

• For those PCNs who do not wish to employ extra staff directly, weencourage them to engage their community-based partners, who canemploy staff on their behalf. CCGs can help broker these arrangements;

• Under this agreement, we can confirm that the level of reimbursementalready drawn down to support new staff employed by a PCN will nowbe guaranteed during this GP contract period with their ongoingparticipation in the Network Contract DES, and these staff will be treatedas part of the core general practice cost base beyond 2023/24 when weconsider future GP contract funding, like the practice global sum; and

• Furthermore, should all the practices which comprise a PCN everdecide in future to hand back the DES, the commissioner must arrangetimely alternative provision for the same services from anotherprovider, e.g. another PCN or an NHS community provider. In thiscircumstance the law regarding transfer of staff would apply asnormal. The commissioner will approach the appointment of the newprovider on the basis that, unless there are exceptional circumstances not todo so, (1) relevant staff will transfer from the outgoing practice(s) to thereplacement(s), (2) the TUPE Regulations will apply to that transfer and (3)transferring staff will be treated no less favourably than if the TUPERegulations had applied.

Making full use of funding

1.21 GPC England and NHS England and NHS Improvement are clear that the additional roles funding should be fully used each year, rather than lost to general practice. This means taking action as soon as possible (including in the remainder of this financial year), aided by a clear and simple workforce planning process, with explicit support from CCGs and systems. We encourage all PCNs to spend time now to think through their longer-term recruitment plans, aided by the extra certainty provided by this deal document, as well as firming up their intentions for 2020/21.

1.22 As part of the DES, all PCNs will be expected to seek to utilise 100% of their available funding. CCGs will be placed under a corresponding duty to support their PCNs in doing so. A CCG-wide plan to use the available Additional Roles Reimbursement Scheme budget will be developed every year, jointly with Clinical Directors and LMCs. Community partners should also be fully engaged.



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1.23 NHS Digital will increase the frequency and timeliness of its workforce reporting so that data on additional roles recruitment are available monthly with less of a time lag before publication. The monthly data will be able to be disaggregated by PCN, CCG and system. We anticipate this will be in place by spring 2020.

PCN intentions

1.24 A simple workforce planning template will be developed and agreed with

GPC England shortly, for PCNs to share their intentions. By this means, rather than anything more onerous, PCNs will be asked to indicate the number of each additional reimbursable roles to which they realistically intend to recruit and by when, so they spend their funding every year. This should include firm initial intentions for 2020/21, with indicative intentions for the remaining years of the contract through to 2023/24. This will help understand demand as well as which PCNs want and need most assistance. PCNs will be free to change these plans at any stage and at the same time keep their CCG and local primary care training hub informed.

System support for PCNs

1.25 CCGs and systems are expected to explore different ways of supporting PCNs.

These should include, but not be limited to:

• the immediate offer of support from their own staff to help with co-ordinating and running recruitment exercises;

• the offer of collective/batch recruitment across PCNs. Where groups of PCNs wish to advertise vacancies collectively, CCGs or Integrated Care Systems (ICSs) will be tasked with supporting this;

• brokering arrangements to support full-time direct employment of staff by community partners, or to support rotational working across acute, community and (in time) mental health trusts, as well as community pharmacy. We are seeing increasing examples of rotational working across the country and we strongly endorse this approach. It can help build more rewarding careers, support collaboration and secure extra capacity more quickly; and

• ensuring that NHS workforce plans for the local system are as helpful as possible in meeting PCN intentions.



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Redistribution of funding as fallback

1.26 If a CCG judges there still remains a likelihood of significant unspent entitlement, even after inviting community partners to propose joint or rotational posts, the CCG will be expected to share funding across PCNs. It is neither desirable nor expected that redistribution will be necessary on a widespread basis, but it is better than the alternative of funding being lost to general practice.

1.27 Each CCG will need to estimate the likely level of unclaimed entitlements under the Additional Roles Reimbursement scheme and share this with their PCNs and the LMC by the end of July 2020.

1.28 If a PCN and a CCG agree that a PCN is unlikely to use its year’s full allocation,

this funding may then be made available to other PCNs within that CCG area to bid for to enable them to undertake additional recruitment. CCGs will be required to assess bids from PCNs for additional funding, in line with high-level national criteria. These criteria will include:

• evidence that a PCN has a recruitment process ready to begin and is well-placed to undertake further recruitment;

• if yes to the above, has the PCN had a share of their allocation held by the CCG for re-allocation but then found themselves able to recruit (if yes, priority will be given to such bids);

• in conjunction with the above, consideration of whether or not a PCN currently has staff on paid leave e.g. parental or sickness;

• evidence that a PCN is in an area of high deprivation; and

• CCG discretion for other factors to consider.

1.29 Any reallocation would be on a one-off basis for the remainder of the financial

year. The increase in PCN allocations from year to year would cover the additional funding required for any PCNs who have been able to undertake additional recruitment. We envisage that this exercise will be repeated by CCGs at the end of October, based on discussions with PCNs during the first half of the year. CCGs will monitor on a year-to-year basis any redistribution which has taken place. Where there are repeated occurrences of redistribution from and/or to particular PCNs, particularly where this risks creating or worsening health inequalities, this will be reviewed on a local basis by the CCG and relevant PCNs, discussed with the LMC and, where appropriate, the ICS, and appropriate supportive actions taken.



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1.30 The additional roles workforce planning timetable is no later than as set out in table 5. The June and July dates are backstops, and NHS England and the BMA warmly encourage those PCNs and CCGs that are able to go faster to do so.

TABLE 5: 2020/21 ADDITIONAL ROLES WORKFORCE PLANNING TIMETABLE

Improving employment practices 1.31 We have agreed a new Core NHS Offer statement for staff delivering primary

medical services. This will be published in due course.

1.32 During 2020/21 we will review and agree changes in the following areas to be delivered within existing resources:

• the minimum sickness and parental leave provisions all staff in primary care should be able to expect;

• childcare support;

• occupational health provision, aligned to wider NHS England and NHS Improvement work; and

• tackling the gender pay gap in general practice.

1.33 We are committed to agreeing arrangements that will allow practices to make a

more generous offer of Enhanced Shared Parental Leave to employed GPs, starting as soon as possible in 2020/21.

Task Date PCN discusses and works out its intentions From now

Each PCN seeks to accelerate recruitment exercises that are being planned, supported by CCG staff if requested

From now

Each PCN submits its intentions to its CCG By no later than 30 June 2020

Each CCG confirms an effective local plan. This must be agreed with PCN Clinical Directors, before being shared with Regions

By no later than 31 July 2020

Regional engagement and support Early June 2020 onwards

CCGs declare amount for in-year redistribution to other PCNs

By end July and again in October 2020



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Ensuring sufficient space for additional staff 1.34 Sufficient building space is required to support the staff expansion. Where

existing practice premises are insufficient, PCNs will be encouraged to engage now with their community provider partners to agree any necessary short-term actions. Together they should also start developing a fully joint vision of fit-for purpose future estate. We will work together to make the best use of any new capital funding available to primary care to support general practice and the PCN model.



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2. More doctors in general practice

2.1 The NHS needs as many doctors working in general practice as it can get. Important recruitment and retention measures were started by the GP Forward View8. The headcount numbers of doctors working in primary care has grown by over 4,300 since September 2015. But this only equates to an increase of 433 GPs in full time equivalent terms as more GPs choose to leave the workforce early, or work on a more part-time basis in response to workload pressures9. Without further urgent investment and action now, the numbers of FTE doctors working in general practice is likely to remain static or grow only marginally – by fewer than a thousand in five years’ time.

New investment to achieve 6,000 extra doctors 2.2 The Government is committed to funding Health Education England to increase

the number of GP trainee places to 4,000. The Government is also now increasing NHS England and NHS Improvement’s revenue budget by £94m/£117m/£114m/£103m for the four-year period 2020/21-2023/24 for the specific purpose of supporting a raft of additional recruitment and retention schemes aimed at GPs which are now set out in this agreement document and have been developed with a range of stakeholders including the Royal College of GPs and Health Education England. Designed as an interlocking package, these schemes build on existing local good practice, or expand the offer already available through nationally-led schemes, to support GPs at different points of their career pathway.

2.3 Taken together, these actions are intended to enable the NHS to meet the Government’s target of increasing the number of extra doctors working in primary care by 6,000. The potential for further measures will be kept under consideration.

Solving pension issues 2.4 In 2019/20, NHS England and NHS Improvement has established a scheme

which will mitigate the impact of the annual allowance and support GPs to offer additional time to the NHS over this winter. The government has agreed urgently to review the pensions annual allowance taper problem.

8 NHS England (2016) General Practice forward View. Available from: https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf 9 NHS Digital (2019). General Practice Workforce 30 September 2019. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/final-30-september-2019



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

https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/final-30-september-2019


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More GP trainees spending more of their time in general practice 2.5 More new GPs are now being trained in England than ever before, but we still

have a structural imbalance between the number of GPs and the number of other medics. Since 1948, the number of GPs has doubled, whereas the number of hospital doctors has risen tenfold, with significant increases occurring this past decade.

2.6 In 2019, 3,540 doctors entered GP specialty training against a target of 3,250, and a further 3,500 places are now being offered10. From 2021, HEE will increase the number of GP training places to 4,000 a year.

2.7 A significant proportion of the extra GP trainees are likely to be international medical graduates. From 2020/21, all international medical graduates entering general practice training will be offered a fixed five-year NHS contract. This will include three years training and a new two-year fellowship programme (see below).

2.8 The GP training model will also undergo significant reform, as proposed

by the Royal College of GPs. Out of their three-year training programme, GP trainees currently spend around half of this working in a hospital setting. From 2022, to support better training for GPs, and a more balanced distribution of trainee capacity across the NHS, the proportion of time that GP trainees spend in general practice during their training will rise from 18 months to 24 months.

2.9 Taken together these two changes to training will secure over 3,000 of the extra

6,000 doctors working in general practice. Alongside pre-existing plans, the array of additional measures is intended to help secure the remainder. Working with the Government, RCGP, BMA and local systems, NHS England and NHS Improvement will keep open the precise mix of investment in the different schemes below according to what is proving most effective.

More trainees in under-doctored areas 2.10 The Targeted Enhanced Recruitment Scheme (TERS) has proved highly

successful in attracting GP trainees to the most under-doctored areas, with a fill rate of close to 100% last year and oversubscription in many parts of the country. It provides a one-off financial incentive of £20k to the trainee and also encourages them to settle in these communities. 276 places are currently being offered as part of 2019 recruitment round. Backed by extra manifesto investment, NHS England and NHS Improvement will work with HEE to increase the number of TERS places offered to at least 500 by 2021, and at least 800 by 2022.

10 The General Practice (GP) National Recruitment Office (2019). Available here: https://gprecruitment.hee.nhs.uk/resource-bank/recruitment-figures



https://gprecruitment.hee.nhs.uk/resource-bank/recruitment-figures

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Two-year Fellowship Programme for all newly qualified GPs and nurses 2.11 Over the past year, NHS England and NHS Improvement has worked with the

profession and local health systems to design and pilot a new two-year primary care Fellowship Programme for newly qualified doctors and nurses entering general practice. Fellows will get guaranteed funded mentorship, funded continuing professional development (CPD) opportunities of one session per week, and rotational placements within or across PCNs to develop their experience and support their transition into the workforce in a local area.

2.12 The fellowship is intended to create a ‘glide path’ from being a trainee through to an ongoing employment relationship. By 2021, every newly qualified GP coming out of training will have the guaranteed opportunity to benefit from enhanced support through the scheme, through becoming an employee of a named practice, or a PCN. From 2021, all new entrants to GP trainee training will automatically be enrolled in the programme as part of signing up to the training programme and then be expected to enter the fellowship programme on qualification. The shared intention of NHS England and NHS Improvement, the BMA and RCGP is for as close to 100% of newly qualified GP trainees to enter the fellowship programme.

2.13 To provide a major boost to general practice nursing, the Fellowship

Programme will also be open to newly qualified nurses. New to Partnership Payment 2.14 As an extension of the practice contract, the PCN contract represents major

investment in the GP partnership model. Partnerships and in particular the number of GP partners will be given a further boost by the New to Partnership Payment. This new national scheme is primarily designed to attract early to mid-career GPs into partnership opportunities.

2.15 From 1 April 2020, new partners will benefit from £3,000 of business

training allowance and a guaranteed one-off payment of £20,000 for a full-time GP (calculated on a 37.5 hours a week basis) to support their establishment as a new partner. Initially a loan, we envisage that it will automatically convert to a permanent payment after an expected minimum number of years (for example, five) as a partner. With on-costs, and business training costs, the relevant practice would claim reimbursement of £25,500. We would require assurance from the practice that the pro-rata payment and associated business training allowance had been paid to the partner within a maximum time period.

2.16 The national scheme will be available to all GPs who have never before been

partners and are offered partnerships. It will be open to other professional groups (e.g. nurses and pharmacists). Detailed guidance on its operation will be



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published following ongoing engagement with the profession and wider stakeholders. The scheme is expected to evolve in the light of experience. Its initial phase is likely to run for two or three years.

Locum Support Scheme 2.17 Groups of PCNs will be directly supported to create an offer to GPs who want to

continue to work on a locum basis. As well as helping to meet demand at practice and PCN level through additional sessions, locum GPs will benefit from greater peer support and networking opportunities. Each locum GP engaged through the Locum Support Scheme will also receive a funded session of CPD per month in exchange for a minimum contribution of sessions per week to the group of PCNs. In 2020/21, implementation will be supported by ICS/STPs and LMCs, working closely with training hubs and local PCNs. Full coverage will be established as soon as possible during the year. NHS England and NHS Improvement aims to support at least 500 GPs through Locum Support Schemes in their first year of operation.

National GP Retention Scheme 2.18 The GP Retention Scheme provides a package of financial and educational

support and acts as a safety net to help GPs remain in clinical practice where they cannot undertake a regular part-time role, and might otherwise leave the profession. Statistics indicate 480 GPs were being supported on the scheme as at 30 September 2019, an increase of over 300 GPs since September 201511. During 2020, NHS England and NHS Improvement will work with the RCGP, BMA and local systems to consider if changes to the scheme, for example increasing the number of sessions participants can provide, would provide a sufficiently worthwhile impact.

Return to Practice 2.19 Through the existing Induction and Refresher Scheme, GPs who may have left

practice (for example, to undertake extended maternity leave or due to a career break) are encouraged to return. The Scheme will be expanded and enhanced during 2020/21 to provide more support for GPs with caring responsibilities.

2.20 The cost of childcare acts as a disincentive to many parents considering returning to a career in general practice through this scheme. From April 2020, GPs on the Induction and Refresher Scheme with children aged under 11 will be able to claim up to £2,000 towards the cost of childcare for each child whilst on the scheme (or £1,000 for those on the Portfolio Route due to

11 NHS Digital (2019). General Practice Workforce 30 September 2019. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/final-30-september-2019





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the shorter length of their placements). GPs will be eligible for this support until 1 September after each child’s 11th birthday.

Supporting Mentors Scheme 2.21 A new national scheme will offer highly experienced GPs the opportunity to

mentor newly qualified GPs entering the workforce through the Fellowship Programme. Training will be provided to all mentors and practices will be reimbursed to release these GPs to do a session per week to undertake mentoring activity provided the GP is delivering at least three other clinical sessions in addition to the mentoring session. We expect this offer to be attractive to GPs nearing the end of their careers.

2.22 Implementation of the national offer will be led by ICSs/STPs, working closely

with training hubs, and based on national guidance. This will allow some flexibility to build on existing local good practice. Schemes will be established from April 2020, with nationwide coverage as soon as possible during 2020/21. We will plan to support around 450 GPs through this scheme in its first year of operation.



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3. Releasing time to care

3.1 By reducing unnecessary bureaucracy, more time can be released to care. The Government will instigate a swift and full Review of Cross-Government Bureaucracy in General Practice with the BMA. This will consider what actions the Government could take to reduce the bureaucratic burden on GPs and other health practitioners within general practice in order to free up valuable time. The review will conclude in 2020 and its recommendations will be agreed with the BMA and other partners.

3.2 In parallel, NHS England and NHS Improvement will review, with GPC England, RCGP and wider stakeholders:

• mandatory training requirements;

• how to reduce the time associated with the annual appraisal process, learning from the East of England pilots;

• how to make revalidation simpler for GPs, particularly those approaching retirement age and beyond;

• how to reduce the burden associated with annual coding requirements for patients with long-term conditions;

• how to remove unnecessary barriers for patient self-referral;

• how to improve the e-Referral and electronic prescribing systems, consistent with the outpatient reform programme;

• operation of the performers list; and

• how best to take more effective action to implement the NHS Standard Contract requirements intended to reduce the extent to which other NHS providers generate avoidable extra GP workload.

3.3 Work is already underway to progress the digitisation of paper ‘Lloyd

George’ Records. Subject to the piloting, publication of national guidance and ongoing work with the Joint General Practitioners Information Technology Committee (JGPITC), the implementation process could start from April 2020. This nationally funded programme will also help free up physical space within practices for additional staff. We will look at how third-party redaction software could be made available to general practice as a matter of course to further support practices to deliver full historic online access to records for their patients.



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3.4 The newly established NHS Community Pharmacist Consultation Service will also relieve pressure on GP practices12. This went live in October 2019 and has so far taken over 150,000 referrals which would otherwise have been made to a GP. Subject to the successful evaluation of ongoing pilots, the service will be expanded, with referrals from other settings during 2020/21.

3.5 The Time for Care programme has delivered a range of service improvement

interventions in the past four years to improve productivity in General Practice and enhance resilience13. NHS England and NHS Improvement will seek to build on its progress and increase impact as part of a single dedicated access improvement programme.

12 NHS England (2019) Advanced Service Specification - NHS Community Pharmacist Consultation Service. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/10/advanced-service-specification-nhs-pharmacist-consultation-service.pdf 13 NHS England (2019). Releasing time for care. Available from: https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/releasing-time/



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4. Improving access for patients

50 million more appointments

4.1 The additional Government investment in primary care capacity under this agreement is for the purpose of improving patients’ experience of accessing primary care and cutting waiting times. Progress towards delivering the extra 50 million appointments as soon as possible will be driven mainly by increasing staff numbers.

4.2 Initial actions arising from NHS England’s review of access to General Practice have now been agreed and are set out below. The review will complete in 2020, to inform contract discussions in 2020/21.

Better data

4.3 An improved appointments dataset will be introduced in 2020 as part of the practice contract. The details will be agreed as soon as possible between NHS England and NHS Improvement and the BMA. This will provide more comprehensive, granular, frequent and timely information. It will help practices understand their current relative position on how long patients are waiting to access services, the type of care they are receiving, and which professional is providing it. The date in 2020/21 when practices are required to use the dataset and provide quality data will depend on the timing of IT system changes during the course of the year. By March 2021, the dataset will be fully comprehensive, covering all practices without exception.

4.4 As agreed in the five-year deal, a new, as close to real time as possible and transparent measure of patient experience will be designed and tested in 2020, for nationwide introduction by no later than 1 April 2021. The details will be agreed as soon as possible between NHS England and NHS Improvement and the BMA.

Access Improvement Programme

4.5 NHS England and NHS Improvement will establish a major new GP Access Improvement Programme in early 2020. Working with PCNs, the programme will:

• identify best operational management methods proven to improve bookingexperience, reducing waiting times for both urgent and routineappointments, and moderating demand growth for A&E attendances;

• in Q3 and Q4 of 2020/21, seek to apply these methods supportively forpractices/PCNs whose patients are experiencing the longest routine waits;

• incorporate the existing work on Time for Care;



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• consider appropriately how to ensure continuity of care is supported and thecontinuing need to reduce health inequalities; and

• seek to learn from the mixed previous experiences of setting accessstandards in primary care.

4.6 Progress against the new patient reported experience metric will be supported by the new PCN Investment and Impact Fund in 2021/22, when at least £30m of the £150m Fund will be directed at improving access. However, we intend to introduce the measure as early as possible across all practices in England during 2020/21, and to begin incentivising performance against it at the equivalent rate of £30m/annum pro-rata. The work of the Access Improvement Programme will inform how at least at a third of funding under the Investment and Impact Fund can best directly support better experience and reductions in waiting times. This amounts to at least £75m in 2022/23 and at least £100m in 2023/24.

Digital-first services

4.7 Every PCN and practice will be offering a core digital service offer to all its patients from April 2021. This will be delivered through a new national supplier framework and other support activity, alongside improvements to IT infrastructure, more online services for patients and using digital tools to increase flexibility in how staff work and care for patients. This will be backed by additional STP/ICS support. Digital delivery can offer flexible working for GPs, and contribute to securing the additional 6,000 doctors working in general practice.

Extended hours

4.8 As agreed and set out in Investment and Evolution14, from April 2021 the funding currently in the Network Contract DES for extended hours access together with the wider CCG commissioned extended access service will fund a single, combined access offer as an integral part of the Network Contract DES. A nationally consistent offer will be developed and discussed with GPC England and patient groups, reflecting what works best in existing local schemes. In the meantime, we encourage PCNs and practices to work with their CCGs to enable more flex between existing in-hours and extended hours capacity, so that the latter is better used, for example for vaccinations, annual reviews of patients with long term conditions and screening appointments.

14 NHS England and the BMA (2019) Investment and evolution: a five year framework for GP contract reform to deliver the NHS Long Term Plan. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf




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Fuller join-up with urgent care services

4.9 NHS England and NHS Improvement will develop and then consult on options for creating a newly expanded role for PCNs in joining up and running urgent care in the community, as an option rather than an obligation. This would enable better integration of primary care with urgent care and increase their ability in being able to moderate increases in A&E demand.



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5. Reforming arrangements for vaccinations andimmunisations

5.1 During 2019, NHS England and NHS Improvement undertook the most significant review of vaccination and immunisation payment mechanisms since 1990. Overseen by an advisory group, with representation from GPC England, Pharmaceutical Services Negotiating Committee (PSNC), RCGP, NICE, Public Health England (PHE) and Royal College of Nursing (RCN), an interim report was published in October 201915.

Review conclusions

5.2 General practice plays an invaluable role in the delivery of vaccination services, especially for children. But that the current payment system is far from optimal. It:

• is unnecessarily complicated, with wide variations in payment rates andapproaches for different vaccines, and indeed different patients receivingthe same vaccine;

• results in limited practice oversight of their current performance. Thiscompares unfavourably with the Quality and Outcomes Framework (QOF),where practices are usually fully aware of their current and anticipatedperformance; and

• is outdated as it does not align with levels of coverage required forpopulation protection, and the incentive structure could be redesigned toimprove impact. The contract does not reflect known best practice in thedelivery of vaccination services, such as consistent call/recall and flexibleappointment availability16.

5.3 The reforms we have agreed have been devised to address these weaknesses. They will provide a more effective set of incentives to increase vaccine coverage and improve population outcomes, by giving practices confidence that more vaccinations lead to higher payments, and by giving timely performance data to act upon. The reforms also represent an investment in vaccination and immunisation services from the existing and agreed total contract resources of at least £30m by 2021/22.

15 NHS England and NHS Improvement (2019) Interim findings of the Vaccinations and Immunisations Review – September 2019. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/10/interim-findings-of-the-vaccinations-and-immunisations-review-2019.pdf 16 NHS England and NHS Improvement (2019) Interim findings of the Vaccinations and Immunisations Review – September 2019. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/10/interim-findings-of-the-vaccinations-and-immunisations-review-2019.pdf







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Global sum payment and new core standards

5.4 Vaccinations and immunisation becomes an essential service which should be available to the whole practice population, rather than an additional service. All practices will be expected to offer all routine, pre and post-exposure vaccinations and NHS travel vaccinations to their registered eligible population, as the overwhelming majority already do.

5.5 The global sum that practices receive will be protected, in line with the five-year agreement. This is worth £164.5m in 2020/21. It will continue to cover NHS travel vaccinations and pre/post prophylaxis vaccinations. As now, significant outbreak management is not included in the global sum. We continue to expect commissioners to take the lead on response, working with practices and providing funding where necessary (for example if the vaccine does not already accrue payment).

5.6 New contractual core standards have been agreed for the provision of vaccination and immunisation services to address both the historical differences in practices’ approaches to the organisation and delivery of these services and the opportunities of new technology.

5.7 We have defined five core components. These core components are:

• All practices will have a named lead for vaccination services who takesresponsibility for ensuring that:

o the core standards and contractual requirements described in thispaper are met and that opportunities for vaccination are maximised;

o appropriate liaison with others within and outwith the PCN, includingNHS England and NHS Improvement public health commissioningteams and embedded PHE Screening and Immunisation Leads, ChildHealth Information Systems (CHIS) and Local Authority Public Healthcolleagues (who work with their Health visitor and school nursingteams).

• Practices should ensure the availability of sufficient trained staff andconvenient, timely appointments to cover 100% of their eligiblepopulation. Appointments should be available at a range of times acrossthe working week, including using the PCN extended hours service onevenings and weekends. Additionally, appointments should be bookableonline and over time be integrated with other digital developments such asthe eRed Book and the NHS App;

• Practices should ensure their call/recall and opportunistic offers arebeing made in line with national standards. These will be defined insupporting guidance for each vaccination programme and over time will beupdated to reflect use of the most effective technology. Some areas already



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use text-based reminders, and all practices must move towards this as soon as the infrastructure is in place. CCGs should ensure that there is access to sufficient text message capacity. Call/recall will be delivered by practices themselves as a default or may be delivered by the local CHIS on their behalf;

• Practices should participate in agreed national catch-up campaigns.For 2020/21, this will be a continuation of the MMR catch-up in 10/11 yearolds. There will no longer be an Item of Service (IoS) fee linked to thecall/recall activity. Practices will instead be eligible for an IoS fee for eachvaccine delivered;

• Practices should adhere to defined standards for record keeping andreporting of coverage data for contract monitoring and payment purposesand for population coverage monitoring.

5.8 We will work with the BMA to update, on the basis of expert advice, the current limited list of pre/post exposure vaccines set out in contractual arrangements. This will reflect reflect current practice and the indication for these modified to be more reflective of their clinical indication. This update will:

• provide greater clarity of the reasonable expectations of general practice inthese circumstances;

• thereby remove the current administrative burden of determiningresponsibility for the provision of these vaccines; and

• also improve the timeliness of patient care.

5.9 Further guidance will clarify the division of responsibilities between general practice, commissioners and public health in relation to pre/post-exposure prophylaxis. This will be differentiated from outbreak management which will continue to be a responsibility of commissioners and would normally accrue additional funding (unless this relates to a vaccine which already accrues an IoS payment).



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A standard Item of Service (IoS) fee

5.10 We will standardise the IoS fees for the delivery of each dose of all routine and annual vaccines at £10.06, fixed for the remaining three years of this contract deal. This will also apply to routine vaccines which are given outside of the routine schedule where clinically indicated from 2021/22. For 2020/21 the IoS payment will apply to all Measles, Mumps and Rubella (MMR) vaccines, with rollout the following year to the following childhood vaccines:

• Diphtheria, tetanus, poliomyelitis, pertussis, haemophilus influenza type B(HiB) and hepatis B (6-in-1);

• Rotavirus;• Pneumococcal conjugate vaccine (PCV);• Meningococcal B Infant;• Haemophilus influenza type B and Meningitis C (HiB/MenC).

Incentive payments

5.11 From 2021 there will be incentive payments for achieving specified levels of population coverage for vaccinations which benefit from a herd immunity effect or which are policy priorities, for example MMR. For routine schedule vaccinations this incentive will operate at practice level and form part of a new QOF domain. The new QOF domain will reward incremental improvements in performance, unlike the current dual threshold-based approach of the Childhood Immunisation DES, which does not offer many practices a real opportunity to gain.

5.12 Achievement will be measured in a more timely way, more closely aligned to the routine vaccination schedule than the current DES payment. All investment currently committed to routine vaccination that is not redistributed into IoS payments, will be used to fund this new routine vaccination QOF domain which we expect to have a value of at least £40m. We will work with clinical leads and experts from the BMA, PHE and other partners over the coming months to optimise the design of this new domain. We anticipate that the thresholds for MMR and the 6-in-one vaccine will be set at ~90%+, with points allocated to maximise the incentive and minimise negative redistributive effects.

5.13 PCNs, as the vehicle for collaboration between GP practices and community pharmacy, are ideally placed to take the lead on improving flu vaccine coverage. Additional general practice incentives for flu, beyond the IoS, will therefore ultimately be channelled through the PCN Investment and Impact Fund. This will start in 2020/21 with an indicator worth £8m for flu vaccination coverage in over 65s. We expect there to be an aligned incentive for community pharmacy in the Pharmacy Quality Scheme (PQS).



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5.14 During 2020/21 we will review the existing QOF indicators incentivising flu vaccination for specified at risk groups, worth around £20m, and consolidate an updated set of indicators within the IIF for 2021/22. The QOF points which are freed up through this exercise will be redistributed into the new routine immunisation domain, or other public health indicators, meaning practice level investment will be protected. The redistribution of points will be discussed and agreed with GPC England in the next round of negotiations for April 2021.

Repayment for lower coverage

5.15 In the current system, practices achieving a combined coverage of less than 70% earn nothing from the Childhood Immunisation DES. This does not fairly reflect that every additional vaccination for a child has value. In general, the movement to an IoS payment means that practices will be rewarded for the extra work of an additional vaccine. However, unless addressed directly, another effect of moving to IoS would be an increase in payments to practices with lower (less than 80%) population coverage at the expense of higher performers. Therefore, we have agreed that we will recoup a portion of the IOS paid from practices with lower coverage. Where practices are not achieving a minimum of 79% coverage on the routine childhood vaccines (MMR, 6-in-1, rotavirus, PCV, Men B, Hib, Men C) then a repayment of a proportion of earnings will be triggered according to the following formula: value of the IoS fee x 50% of eligible cohort size. It is anticipated that this calculation will be made on an annual basis using data extracted directly from practice clinical systems. The detailed methodology will be published later in the year once agreed between NHS England and NHS Improvement and GPC England and applied to practice payments from April 2021 onwards.

5.16 We have balanced the payment reforms such that all practices, apart from a very small number of the lowest performers, will gain from the new arrangements. This is because they earn the full £10.06 IOS for every patient vaccinated after the first 50% of their eligible population. Previously no payments would have applied below 70% coverage for MMR and the 6-in-1 vaccine, and in other childhood vaccines a lower payment generally applied.

5.17 A baseline calculation of achievement on all the vaccines listed above will be completed in 2020/21 and the repayment arrangements will commence in April 2021. This means that practices have 1 year to prepare for the introduction of the scheme. As a result, practices with low MMR coverage will receive a one-year boost in funding from the new MMR IoS fee which we expect to be fully reinvested in improving coverage rates. It would be a huge success if in 2021/22 we require no practice repayments, because all practices are achieving 80% coverage.



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5.18 A practice may very occasionally demonstrate extenuating circumstances, and therefore be exempt from the repayment. In this situation the practice would need to demonstrate that the core contractual requirements had all been met and that they had made appropriate efforts to improve the vaccination rate before a commissioner could consider it.

5.19 We are in the process of planning the implementation with NHS Digital and will provide further detail in 2020. We anticipate that practices will be paid an aspiration payment on a monthly basis with a final balancing payment at year end which reflects actual achievement and any repayments, in a similar manner to QOF payments. This best protects practice cash flow, whilst avoiding the need for practices to factor in the risk of managing a full repayment at year end. Vaccines not included in this repayment scheme will be paid on an IoS basis of £10.06 throughout the year. From 2021/22 we intend that all vaccine payments will be made via CQRS using an automated data extraction.

Two-year transition plan

5.20 These changes to vaccination and immunisation payments are the most significant for 30 years and require much work to implement. We will phase this over two years, to ensure that the process runs smoothly and that practices are supported with the change. In year one, starting in April 2020 we will:

• introduce the clearer core contractual requirements described in 5.7 and expect all practices to enact these;

• introduce an IoS payment for MMR 1 and 2 at £10.06. Achievement in 2020/21 will provide the baseline figures for the repayment scheme being introduced in 2021/22; and

• introduce an incentive worth £8m into the IIF for networks to improve seasonal flu vaccine coverage for the over 65 age group, in collaboration with community pharmacies.

5.21 This IoS payment will be funded largely from the planned rise in practice contract funding with the remainder coming from a marginal reduction to the value of the current Childhood Immunisation DES. This will bring a needed focus to improving MMR population coverage next year. We will not make changes to the vaccination incentives within QOF in year one, but will use the time to undertake collaborative design work on a new QOF domain for routine vaccinations.



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5.22 In year two, 2021/22, we will:

• expand the application of the IoS of £10.06, and associated repaymentsystem, to all outstanding routine vaccinations;

• introduce the new QOF domain for routine vaccinations worth at least£40m;

• restructure and consolidate all flu incentives at network level through theIIF in a set of indicators worth £30m; and

• retire the existing Childhood Immunisation DES from April 2021, in order tocomplete the expansion of the IoS and the new QOF domain.



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6. Updating the Quality and Outcomes Framework (QOF)

6.1 Further improvements have been agreed to the Quality and Outcomes Framework in 2020/21, in line with the findings of the 2018 QOF Review17. QOF implementation guidance will be published by the end of March 2020. Associated changes to the Statement of Financial Entitlements will made for 1 April 2020. Further details of the indicator changes are set out in annex B.

Indicator changes from April 2020

6.2 QOF currently comprises 559 points. We have agreed to recycle 97 points

into 11 more clinically appropriate indicators. NHS England is also investing an additional £10m into QOF bringing the total points available to 567 from 2020/21.

6.3 From 2020/21, we will introduce a number of improvements to the asthma, COPD and heart failure domains as follows:

Asthma domain

• Practices will be required to establish and maintain a register of patients aged 6 years and over with a diagnosis of asthma, in line with NICE guidance;

• Practices will be expected to use a minimum of two diagnostic tests to confirm an asthma diagnosis. These tests should be performed up to 3 months before any date of diagnosis and up to 6 months after this date;

• The content of the asthma review has been amended to incorporate aspects of care positively associated with better patient outcomes and self-management;

• Practices will be required to record smoking exposure in children and young people under the age of 19 years.

COPD domain

• Entry to the COPD register will be determined by the presence of a clinical diagnosis plus a record of post bronchodilator spirometry FEV1/FVC ratio below 0.7 recorded between 3 months before or 6 months after diagnosis in diagnoses made on or after 1 April 2020;

17 NHS England (2018) Report of the Review of the Quality and Outcomes Framework in England. Available from: https://www.england.nhs.uk/wp-content/uploads/2018/07/quality-outcome-framework-report-of-the-review.pdf



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• The annual review will include a requirement to record the number ofexacerbations in order to help guide future management and potentiallyavoidable emergency admissions.

Heart Failure domain

• Any new diagnosis of heart failure should be confirmed by anechocardiogram or specialist assessment between 3 months before or 6months after diagnosis;

• There will be changes to the denominator for treatment with beta-blockers;

• An annual review indicator has been agreed to provide a focus uponfunctional assessment and the up-titration of medication to addresssymptoms.

6.4 A new indicator will be introduced to incentivise practices to offer an annual HbA1c test in people known to have non-diabetic hyperglycaemia. The aim of this test is to support early identification of those who would have gone on to develop Type 2 diabetes. This indicator will be worth 18 points. It will be supported through both new investment and the retirement of the current CVD-PP001 indicator18.

New Quality Improvement modules

6.5 We introduced in 2019/20 a new Quality Improvement domain worth 74 points. In year one, this comprised two modules: Prescribing Safety and End of Life Care. Whilst these modules will change in 2020/21, we encourage practices to continue to consolidate and mainstream the successful improvements made.

6.6 In 2020/21, the modules will focus on improving care of people with a learning disability and supporting early cancer diagnosis. These modules have been developed by the RCGP in collaboration with NICE and the Health Foundation.

18 CVD-PP001: In those patients with a new diagnosis of hypertension aged 30 or over and who have not attained the age of 75, recorded between the preceding 1 April to 31 March (excluding those with pre-existing CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an assessment tool agreed with the NHS CB) of ≥20% in the preceding 12 months: the percentage who are currently treated with statins.



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6.7 The aims of the Early Cancer Diagnosis module are to:

• improve participation in the national breast, cervical and bowel cancerdetection and screening programmes; and

• improve referral and safety netting practices for patients suspected of havingcancer. It has been developed to support the roll out of the PCN earlycancer diagnosis service specification. The full module can be read here:https://www.england.nhs.uk/gp/investment/gp-contract/.

6.8 The Care of People with a Learning Disability module builds upon the work published earlier this year to improve the identification of people with a learning disability in general practice. It aims to promote increased uptake of annual health checks, optimisation of medication in line with STOMP, identification and recording of reasonable adjustments and the patient engagement with community resources through social prescribing to maintain health and well-being. The full module can be read here: https://www.england.nhs.uk/gp/investment/gp-contract/

Payment thresholds

6.9 Payment thresholds for new indicators are based upon NICE recommendations and knowledge of practice performance, for example, as a result of previous activity. The points and payment thresholds for unchanged indicators will be held at 2019/20 levels for a further year, pending a full review of the threshold setting methodology in 2020. Payment thresholds for new and revised indicators are detailed in annex B.

Further development of QOF

6.10 The changes described represent the next step in implementing the recommendations of the QOF Review. NHS England and NHS Improvement and GPC England have agreed to an ongoing programme of indicator review in key priority areas, including mental health in 2020/21.

6.11 The following further QI modules are in development: (i) CVD prevention and detection, (ii) shared decision making, (iii) anxiety and depression, (iv) anti-microbial resistance including antibiotic prescribing, (v) wider primary prevention and (vi) preventing prescription drug dependency. An evaluation of the QI domain is currently underway, which will inform its further development in subsequent years.



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Obesity

6.12 The Government has pledged to empower people with lifestyle related conditions such as obesity to lead healthier lives. Global obesity rates have tripled since 1975, and the UK ranks among the worst in Europe19, but recent research shows that referrals into weight management services can have a significant impact on population health20.

6.13 From 2020/21, we will introduce a new non-contractual requirement for GPs to offer to refer people with obesity into weight management services, where this is clinically appropriate and where commissioned services exist. Local Authorities are the main commissioners of weight management services under their public health responsibilities, but NHS England will seek to commission additional weight management services for those who are both obese and living with either type 2 diabetes or hypertension in areas with the greatest unmet need from 2021/22 onwards.

6.14 As those plans develop over the next year, and as such approaches are further piloted and expanded for other cohorts, we will explore the utility and timing of an incentive in QOF to ensure that patients are appropriately offered a referral to weight management services once commissioned and we can be sure they exist universally and in sufficient volume across England.

Maternity Services

6.15 We have agreed a number of improvements to maternity medical services. From 2020/21:

• all practices will be required to deliver a maternal check at 6-8 weeks afterbirth (live and stillbirth), as an additional appointment to that for the 6-8 weekbaby check (see below);

• the Maternity Medical Services additional service will become an essentialservice;

• the child health surveillance additional service will also become an essentialservice; and

• we will revise the contract’s current definition of the “postnatal period” from 2to 8 weeks, to bring it in line with NICE guidance on best practice, along withthe needs of women following birth21.

19 Organisation for Economic Cooperation and Development (2017) Obesity Update 2017. Available from: http://www.oecd.org/health/obesity-update.htm 20 Aveyard, P. et al. (2016) Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial. The Lancet 2016; 388: 2492-500. Retrieved from: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2816%2931893-1 21 National Institute for Health and Care Excellence (2015) Postnatal care up to 8 weeks after birth. Available from: https://www.nice.org.uk/guidance/CG37



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6.16 NICE recommends a 6-8 week check for mothers to ‘ensure that the woman's

physical, emotional and social wellbeing is reviewed’ (NICE Clinical Guideline 37 on post-natal care) 22. The GP contract currently makes provisions for a new-born infant physical examination at 6 weeks as part of the additional service for child health surveillance, but there is no specific contractual requirement for practices to review the mother’s health. Recent research suggests that many practices already offer a postnatal check for new mothers, but not all23. We want to make this a consistent offer for all mothers. Therefore from 2020/21, we will introduce a new requirement for GPs to offer a 6-8 week postnatal check for new mothers, as an additional appointment to that for the baby. An additional £12m has been invested through global sum to support all practices to deliver this.

6.17 In line with NICE guidance, the maternal check should focus on:

• a review of the mother’s mental health and general wellbeing, using open questioning;

• the return to physical health following childbirth, and early identification of pelvic health issues;

• family planning and contraception options; and

• any conditions that existed before or arise during pregnancy that require on-going management, such as gestational diabetes.

22 National Institute for Health and Care Excellence (2015) Postnatal care up to 8 weeks after birth. Available from: https://www.nice.org.uk/guidance/CG37 23 The research was conducted by the NIHR Policy Research Unit in Maternal and Neonatal Health and Care which is based at the National Perinatal Epidemiology Unit, University of Oxford.




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7. Delivering PCN service specifications

7.1 Chapter 6 of the five-year GP contract deal document described the agreement to introduce five service specifications to the Network Contract DES from 2020/21, with a further two following in 2021/2224.

7.2 Drafts were developed through a process of engagement, including input from expert working groups comprising representation from patients, working GPs and other clinicians, voluntary sector organisations (such as Cancer Research UK, Macmillan, and Age UK), NHS Providers Community Network, Local Government Association, commissioners, Royal College of General Practitioners, Public Health England and the British Medical Association. NHS England and NHS Improvement took the unprecedented step of publishing those for engagement prior to negotiating them with GPC England so that there was an opportunity to shape the proposals.

7.3 This generated a high and unambiguous level of concern, particularly but not solely from general practice. NHS England published a summary of the feedback on 30 January25.

7.4 The major concerns raised included:

• the workforce and workload implications of the initial drafts;

• the resources to support the work;

• the level of specificity; and

• the implied performance management approach.

7.5 We have agreed a significantly revised approach:

• Final requirements for three of the service specifications for 2020/21have been rewritten. They are radically shorter at three pages in total, andalso respond to the detailed feedback. They replace the previous draft andare set out below;

• Quality improvement and high achievement against the servicespecifications will be supported by metrics in the network dashboard and

24 NHS England and the BMA (2019) Investment and evolution: a five year framework for GP contract reform to deliver the NHS Long Term Plan. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf 25 NHS England and NHS Improvement (2020) Network Contract DES – Engagement on Draft Outline Service Specifications Summary report. Available from: https://www.england.nhs.uk/wp-content/uploads/2020/01/2020-01-30-pcn-services-engagement-report.pdf




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direct incentivisation through the national Investment and Impact Fund. The dashboard will include data and indicators relating to the seven PCN service specifications to support local quality improvement, as well as wider information on population health and prevention, workforce, access and hospital use. From 2021/22 onwards, at least a third of IIF funding will directly support achievement of service specification-related indicators (£50m/£75m/£100m). This will recognise PCN efforts in the successful delivery of the specifications:

• Two of the five service specifications – Anticipatory Care andPersonalised Care - are deferred until 2021/22. These – and the CVDDiagnosis and Prevention, and Tackling Health Inequalities specifications -will now be reworked and negotiated with GPC England in a similar mannerto the three finalised service specifications prior to their introduction in2021/22. In place of the Personalised Care specification in 2020/21, eachPCN must provide access to a social prescribing service in 2020/21,drawing on the workforce funded under the Network Contract DES;

• We have clarified explicitly that the volume of SMRs undertaken will bedetermined and limited by the clinical pharmacist capacity of the PCN;

• The proposed requirement for fortnightly face to face medical input tothe care homes is replaced with a requirement for medical input to be‘appropriate and consistent’ but with the frequency and form of thismedical input to be based on local clinical judgement by the PCN;

• A new ‘Care Home Premium’ will provide an additional and specificcontribution, responding to concerns about care home distributionbetween PCNs. PCNs will be entitled to a recurrent £120 per bed peryear, based on CQC data on registered care home beds in England (latestfigure: 457,110 beds), which will be payable on or after 31 July once CCGshave (a) agreed the allocation of care homes to PCNs, and (b) agreed thatPCNs have appropriately and comprehensively coded residents in carehomes using the SNOMED codes available for this. Given that the corerequirements of the 2020/21 Enhanced Health in Care Homes servicespecification do not come into effect until 30 September 2020, this funding ison a half-year (£60 per bed) basis in the first year;

• Where a LES/LIS already exists for a service that is duplicated by theDES requirements, no decommissioning of that service by the CCGshould take place until the DES requirements commence. For the carehomes service, for example this will be 1 October 2020. Where therequirements in an existing LES/LIS exceed those in the DES,commissioners must, engaging with PCNs and LMCs and takingaccount of the PCN employment liabilities directly linked to delivery ofthe LES/LIS, consider maintaining this higher level of service provision



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to their patients, alongside an appropriate portion of existing funding additional to the entitlements of the national contract. And all funding previously invested by CCGs in LES/LIS arrangements which are now delivered through the DES must be reinvested within primary medical care. LMCs should be engaged on reinvestment proposals and provided with an annual report – drawn from CCG annual accounts – of how the CCG has used its primary medical care funding allocation; and

• PCNs do not carry contractual responsibility for any failure by community service providers to deliver their part of the service, and vice versa.



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Structured Medication Review and Medicines Optimisation

In delivering these requirements, PCNs must have due regard to separate guidance.

26 See NHS Business Services Authority (2019) Medication Safety -Indicators Specification. Available from: https://www.nhsbsa.nhs.uk/sites/default/files/2019-08/Medication%20Safety%20-%20Indicators%20Specification%20%28Aug19%29.pdf. This experimental analysis links prescribing data to admissions data at a national level and outlines a number of prescribing situations that have resulted in harm or hospitalisation. A set of 20 indicators have been developed to help reduce medications errors and promote safer use of medicines. 27 Based on the validation of the eFI, on average around 3% of over 65s will be identified as potentially living with severe frailty. However, in some practices this number may be significantly higher. Severe frailty is defined as a person having an eFI score of >0.36. https://www.england.nhs.uk/ourwork/clinical-policy/older-people/frailty/efi/

From 1 April 2020, each PCN will: 1 Use appropriate tools to identify and prioritise patients who would benefit from

a Structured Medication Review, which will include those:

• in care homes;

• with complex and problematic polypharmacy, specifically those on 10 or more medications;

• on medicines commonly associated with medication errors26;

• with severe frailty27, who are particularly isolated or housebound patients, or who have had recent hospital admissions and/or falls; and

• using potentially addictive pain management medication.

2 Offer and deliver a volume of SMRs determined and limited by PCN clinical pharmacist capacity, demonstrating all reasonable on-going efforts to maximise that capacity.

3 Ensure invitations to patients explain the benefits and what to expect.

4 Ensure that only appropriately trained clinicians working within their sphere of competence undertake SMRs. These professionals will need to have a prescribing qualification and advanced assessment and history taking skills, or be enrolled in a current training pathway to develop this qualification and skills.

5 Clearly record all SMRs within GPIT systems.

6 Actively work with their CCG to optimise quality of prescribing of (a) antimicrobial medicines, (b) medicines which can cause dependency, (c) metered dose inhalers, where a low carbon alternative may be appropriate and (d) nationally identified medicines of low priority.

7 Work with community pharmacies to connect patients appropriately to the New Medicines Service which supports adherence to newly prescribed medicines.








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Enhanced Health in Care Homes Each PCN will: 1 By 31 July 2020, agree the care homes for which it has responsibility with its

CCG, and have agreed a simple plan about how the service will operate with local partners (including community services providers). People entering the care home should be supported to re-register with the aligned PCN.

2 By 31 July 2020, ensure a lead GP or GPs with responsibility for this service is agreed for each aligned care home

3 By 30 September 2020, work with community service providers (whose contracts will describe their joint responsibility in this respect) and other relevant partners to establish and coordinate a multidisciplinary team (MDT) to deliver this service.

4 As soon as is practicable, and by no later than 31 March 2021, establish protocols between the care home and with system partners for information sharing, shared care planning, use of shared care records and clear clinical governance.

5 From 30 September 2020, deliver a weekly ‘home round’ for people living in the care home(s) who are registered with practices in the PCN. The home round must:

• prioritise residents for review according to need based on MDT clinicaljudgement and care home advice (this is not intended to be a weeklyreview for all residents);

• have consistency of staff in the MDT, save in exceptional circumstances;and

• include appropriate and consistent medical input from a GP or geriatrician,with the frequency and form of this input determined on the basis ofclinical judgement.

Digital technology may support the weekly home round and facilitate the medical input.

6 By 30 September 2020 have established arrangements for the MDT to develop and refresh as required a personalised care and support plan with people living in care homes. Through these arrangements, the MDT will:

• aim for the plan to be developed and agreed with each new resident withinseven working days of admission to the home and within seven workingdays of readmission following a hospital episode (unless there is goodreason for a different timescale);

• develop plans with the person and/or their carer;

• base plans on the principles and domains of a Comprehensive GeriatricAssessment including assessment of the physical, psychological,functional, social and environmental needs of the person including end oflife care needs where appropriate;



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For the purposes of these requirements, a ‘care home’ is defined as a CQC-registered care home service, with or without nursing.28 Good practice guidance will be developed to support PCNs in delivery of these requirements.

Supporting Early Cancer Diagnosis

From 1 April 2020, and building in a manageable way on the quality improvement activity on early cancer diagnosis set out in QOF, PCNs will take reasonable steps to improve rates of early cancer diagnosis for their registered population, in line with the NHS Long Term Plan ambition to increase the proportion of people who are diagnosed at stage 1 and 2 and supported by wider action by others in the healthcare system.

28 Care Quality Commission. Service Types. Available from https://www.cqc.org.uk/guidance-providers/regulations-enforcement/service-types

• draw, where practicable, on existing assessments that have taken placeoutside of the home and reflecting their goals; and

• make all reasonable efforts to support delivery of the plan.

7 From 30 September 2020, identify and/or engage in locally organised shared learning opportunities as appropriate and capacity allows.

8 From 30 September 2020, support discharge from hospital and transfers of care between settings, including giving due regard to NICE Guideline 27.

Each PCN will: 1 Review referral practice for suspected cancers, including recurrent cancers.

This will be done by:

• enabling and supporting practices to review the quality of their referralsfor suspected cancer, in line with NICE Guideline 12. This should makeuse of: Clinical Decision Support Tools; practice-level data to explorelocal patterns in presentation, and diagnosis of cancer; and, the newRapid Diagnostic Centre pathway for people with serious but non-specificsymptoms where available; and

• building on current practice to ensure a consistent approach to monitoringpatients who have been referred urgently with suspected cancer or forfurther investigations to exclude the possibility of cancer (‘safety netting’),in line with NICE Guideline 12.

• ensuring that all patients are signposted to or receive information on theirreferral including why they are being referred, the importance of attendingappointments and where they can access further support.

2 Contribute to improving local uptake of National Cancer Screening Programmes by:




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Good practice guidance will be developed to support PCNs in delivery of these requirements.

working with local system partners – including the Public Health Commissioning team and Cancer Alliance – to agree the PCN contribution to local efforts to improve uptake. This should build on any existing actions across practices and include at least one specific action to engage with a group with low-participation locally.

3 Support delivery of 1) and 2) through a community of practice between practice-level clinical staff that will:

• support constituent practices to conduct peer to peer learning events thatlook at data and trends in diagnosis across a Network, including caseswhere patients presented repeatedly before referral and late diagnoses.

• support engagement with local system partners, including PatientParticipation Groups, secondary care, the relevant Cancer Alliance andPublic Health Commissioning teams.



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8. Introducing the Investment and Impact Fund

8.1 The Investment and Impact Fund (IIF) will be introduced as part of the Network Contract DES in 2020/21, with PCNs rewarded for delivering objectives set out in the NHS Long Term Plan and the five-year agreement document29.

8.2 At least £30m of the £150m IIF for 2021/22 will reward better access, rising in 2023/24 to at least £100m of the £300m. From 2021/22 onwards an expected £30m will support implementation of the vaccinations and immunisation changes, and at least a third of IIF funding will be directly linked to indicators related to service specifications. In light of revisions to plans for the service specifications, in 2020/21 the IIF will be worth £40.5m with the rest of the original £75m reinvested within the wider GP contract package to support three new commitments set out in this document: postnatal checks, diabetes QOF points, and the care homes premium.

8.3 As described previously, monies earned from the Fund must be used for workforce expansion and services in primary care. Each PCN will need to agree with their CCG how they intend to reinvest monies earned. This can take the form of a simple reinvestment commitment.

Design principles

8.4 The IIF will operate in a similar way to the QOF:

• It will be a points-based system. The IIF will contain domains relating tothe NHS ‘triple aim’ (prevention and tackling health inequalities; providinghigh quality care; and creating a sustainable NHS). In turn it will containareas described by individual performance indicators, the number of whichwill grow during the scheme’s expansion. Each indicator will be allocated acertain number of points, with the number of points indicating the relativeallocation of funds. The number of points allocated to each indicator will besubject to annual revision, with clear expiry dates for each indicator. EachIIF point will be worth a defined amount of money, details of which will be setout in the Network Contract DES. Payments will be proportional to pointsearned, with an adjustment for list size and (where relevant) prevalence;

• It will have aspiration payments from 2021/22. Funds earned via the IIFwill be paid partly through aspiration payments. The aspiration payment willneed to be approved by the PCN’s aligned CCG before any funds aredisbursed. Any adjustment to payments necessary due to a gap between





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aspiration and attainment will take place once annual attainment is calculated at the end of the financial year; and

• It will fairly reward performance based on national priorities. Indicatorswill reward PCNs for attainment in relation to national goals. They will bestructured very similarly to QOF, albeit with calculation of attainment andpayment at the network rather than practice level. Each indicator will have alower performance threshold below which no payment is made, and anupper performance threshold above which no payment is made. There willbe a sliding scale relating attainment to reward for performance between thelower and upper thresholds. Upper performance thresholds for achievementhave been defined taking into account national targets, LTP commitments,and expert clinical advice; lower thresholds are typically based on the 40th

centile of 2018/19 performance for each indicator (with the exception ofseasonal flu vaccination for over 65s where a bespoke lower threshold of70% coverage has been agreed, social prescribing referrals which arebased on expectations of the capacity available to PCNs, and low priorityprescribing). These thresholds have been set to strike an appropriatebalance between rewarding good performance, and ensuring that allnetworks are able to access some IIF funds. Where indicators have alifespan of multiple years, thresholds will be subject to annual review.

Network Dashboard

8.5 A new Network Dashboard from April 2020 will include key metrics to allow every PCN to see the benefits it is achieving for its local community and patients. It will include indicators on performance against the IIF, by PCN and constituent practice. It will also include data and indicators relating to the seven PCN service specifications to support local quality improvement, as well as wider information on population health and prevention, workforce, access and hospital use. The dashboard will be available to all PCNs, and help identify areas of opportunity to reduce variations within and across PCNs and improve services for patients. The dashboard will evolve during 2020/21.



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TABLE 6: 2020/21 IIF INDICATORS AND THRESHOLDS

Indicator Indicator value (£m)

Indicative value for average PCN

Upper Threshold

Lower Threshold

Percentage of patients aged 65+ who received a seasonal flu vaccination (1 September-31 March)

8 £6,400 77% 70%

Percentage of patients on the LD register who received an LD health check

6.25 £5,000 80% 49%

Number of patients referred to social prescribing per 1000

6.25 £5,000 8 referrals per 1000 population

4 referrals per 1000 population

Gastro-protective prescribing - Percentage of patientsprescribed a non-steroidalanti-inflammatory drugwithout a gastro protective(age 65+)

6.2530 £5,000 30% 43%

Gastro-protective prescribing - Percentage of patientsprescribed an oralanticoagulant and anti-platelet without a gastro-protective (age 18+)

25% 40%

Gastro-protective prescribing - Percentage of patientsprescribed aspirin andanother anti-platelet without agastro-protective (age 18+)

25% 42%

Metered Dose Inhaler prescriptions as a percentage of all inhaler prescriptions (excluding salbutamol)

6.25 £5,000 45% 53%

Spend per patient on 20 of the 25 medicines on the national list of items that should not routinely be prescribed in primary care

7.5 £6,000 PCN spending goal

60% above PCN spending goal

30 The £6.25 million available to incentivise increased gastro-protective prescribing will be divided proportionately to the size of the target groups (i.e. the denominators) for each of these three indicators.



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9. Network arrangements

Network Contract DES registration

9.1 Over 99% of practices across England are currently signed up to the Network Contract DES. The improvements to the contract agreement mean that PCNs can have certainty and confidence to develop.

9.2 PCN membership should be seen as a long-term decision. Frequently changing membership threatens the agreements which PCNs have strived to make, including on how services will be delivered, how workforce will be employed, how payments will operate and how liabilities will be shared.

9.3 NHS England and GPC England will support PCNs to have stable membership through the introduction in 2021/22 of auto-enrolment for existing practices and PCNs, combined with an annual one-month window in which practices will be able to opt-out of the Network Contract DES, or opt-in if they are not currently participating. Sign-up and opt-out will only be allowed outside the window in exceptional circumstances, at the discretion of the commissioner. This will also help to reduce those instances where an agreed PCN later becomes unviable due to one of its member practices choosing to serve notice on the DES mid-year, particularly where this has left the PCN below the necessary 30,000 population.

9.4 In 2020/21, commissioners will reconfirm with practices that they are continuing to participate in the DES on the basis of existing PCN footprints. Practices are strongly encouraged to confirm participation before local payment deadlines in April, to ensure there is no interruption in their PCN-related income. Practices may subsequently opt out of the DES, and will be able to serve the required one month’s notice up until 31 May. Practices will also have until 31 May 2020 to sign up to the DES. Sign-up and opt-out after 31 May will only be allowed in exceptional circumstances, at the discretion of the commissioner.

9.5 To ensure that the whole of England benefits from the investment and service improvements that PCNs offer, CCGs must ensure 100% population coverage of PCNs. Existing practices have guaranteed preferential rights. But where they choose to opt-out, arrangements for alternative provision of core GMS with network services will automatically apply.

Equal opportunity to join a PCN

9.6 Every practice has the right to sign up to the Network Contract DES and join a PCN. It is voluntary. In unusual circumstances, we have seen practices wanting to sign up to the Network Contract DES but unable to find a PCN to join. Such occurrences will become rare over time as PCN membership stabilises. But



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where it does occur, it does not deliver the best outcome for patients or for practices.

9.7 Where agreement between a practice that wishes to sign up to the Network Contract DES and a PCN is difficult to secure, CCGs, with their LMC, will, as has been the case this year, support the parties involved through mediation to come to agreement on the practice joining the PCN. We will introduce from April 2020 the ability for CCGs, in the unlikely circumstances that agreement cannot be secured through the mediation process, to assign such a practice to a PCN. This will require the CCG to work closely with the LMC on the decision given its sensitivity.

The Network Agreement

9.8 The Network Agreement documents the collaboration between all constituents of the PCN. Like the partnership agreement of a GP practice, it sets out the arrangements and responsibilities of each member. Investment and Evolution committed to amending the Network Contract DES from 2020/21 to include collaboration with non-GP providers as a requirement, and that the Network Agreement will be the formal basis for working with other non-GP providers and community-based organisations31. We expect that in many cases PCNs are already collaborating with local non-GP providers and have agreements in place about what this looks like. Cementing these relationships further, from April 2020, in order to deliver the requirements of the Network Contract DES, PCNs will need to agree with their local Community Services provider(s), community mental health provider(s), and Community Pharmacies how they will work together.

9.9 This will be supported by a requirement in the Network Contract DES for each PCN to outline in Schedule 7 of the Network Agreement the details of the collaboration agreement reached with its Community Services provider(s) and Community Pharmacy, particularly where this is necessary to deliver the DES service specifications. PCNs will need to work with community providers to deliver a consistent plan for service delivery across an area, for example in relation to delivery of the Care Homes service specification. Requirements in relation to delivering service specifications will be part of community services contracts from April 2020, as will an obligation to configure according to PCN footprints. There will also be a specific need for mental health providers to agree arrangements with PCNs for delivering integrated care across PCN footprints by April 2021.





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Annex A: List of 2020/21 contractual requirements and non-contractual agreements

2020/21 Contractual requirements

Additional Services

1. From October 2020, maternity medical services and child health surveillancewill no longer be Additional Services but will become part of Essential Services.There will be no opt-out or reduction of global sum as a result.

2. As a component of Essential Services, GPs must provide all necessarymaternity medical services to female patients whose pregnancy has terminatedas a result of miscarriage or abortion. Where a GP has a conscientiousobjection to providing treatment required following an abortion, the GP mayrefer the patient to another GP in the practice who does not have an objectionor where there is no such GP then they must sub-contract all or part ofmaternity medical services to another GP.

3. The Regulations will also be amended to revise the definition of the “postnatalperiod” from 2 to 8 weeks, to bring it in line with other guidance on bestpractice, along with the needs of women following birth.

Appointments data

4. From 2020, all general practices and primary care networks in England will berequired to participate in NHS Digital's 'Appointments in General Practice' datacollection. Providers will also be required to support improvements to the dataquality of this collection by:

• mapping each appointment slot type to the most appropriate 'nationalcategory', once the national category capability has been switched on bytheir system supplier.

• taking additional action to improve the data quality as required byforthcoming guidance, which will be agreed with the BMA and may require achange to the Regulations; and

• implementation support will be available for providers to draw upon during2020-21, with an expectation that these actions will be completed by 1October 2020, subject to availability of necessary system supplier capability.

The date in 2020/21 when practices are required to use the dataset and provide quality data will depend on the timing of IT system changes during the course of the year. By March 2021, the dataset will be fully comprehensive, covering all practices without exception



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5. As agreed in the five-year deal, a new, as close to real-time as possible and transparent measure of patient experience will be designed and tested in 2020, for nationwide introduction by no later than 1 April 2021. Practices will be required to participate in this.

Digital 6. From April 2020:

• GP practices should no longer use facsimile machines for either NHS or patient communications where there is a secure electronic alternative;

• GP practices must offer all patients online access to all prospective data on their patient record unless exceptional circumstances apply. This will not affect the right of any patients registered from October 2019 until the new Regulations come into force to online access to their prospective record from their date of registration. In addition, GP practices will make online access to the full historic digital record available to patients on request. We will look at how third-party redaction software could be made available to general practice as a matter of course to further support practices deliver full historic online access to records for their patients; and

• GP practices will need to have an up-to date and informative online presence, with key information being available as standardised metadata for other platforms to use.

The Regulations will be updated in April 2020 to incorporate these changes.

List cleansing 7. From October 2020, there will be a new requirement in the GP contract for

practices to support NHS England to fulfil its statutory duties to maintain an accurate and up-to-date list of patients. The change will make it clear that this will only oblige practices to undertake activity that is reasonable.

MHRA CAS alert system

8. Since October 2019, practices have been contractually required to register a

practice email address with the MHRA CAS alert system and monitor the email account to act on CAS alerts where appropriate; notify the MHRA if the email address changes to ensure MHRA distribution list is updated; and register a mobile phone number (or several) to MHRA CAS to be used only as an emergency back up to email for text alerts when email systems are down. In the interests of patient safety and business continuity, guidance in relation to this requirement will be amended to clarify that ‘practice’ email address means a generic email rather than an individual account.



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Patient assignment

9. From October 2020, there will be a change to the arrangements for patientswhose relationship with their practice has broken down, and who need to bereassigned to another practice. Currently, such patients can only be assigned toa practice in whose catchment area they live. With ever larger practices andcatchment areas, increasingly that has limited the choice of a new practice.With this change, the new practice can be anywhere in the CCG where thepatient lives. NHS E/I will produce guidance for commissioners emphasisingthat in making such assignments contractors should not be mandated toprovide home visits outside their practice area so it may be necessary toregister such patients as an out-of-area registered patient.

10. The Regulations will be amended to clarify commissioners’ powers andresponsibilities to assign patients whose practice has closed to a new GPpractice, in discussion with that practice.

Pay transparency

11. From October 2020, the Regulations will be amended to require contractors andsub-contractors to submit self-declarations annually if their NHS superannuableearnings are over £150,000 per annum – starting with 2019/20 income. Thisthreshold will rise each year in line with predicted Consumer Price Index (CPI)rises:

19/20 20/21 21/22 22/23 23/24 Threshold £150k £153k £156k £159k £163k

12. Salaried GPs and locums will also be expected to declare NHS earnings over£150,000 per annum along with:

• company directors, employees and others engaged through companiescontracted or sub-contracted to provide primary medical services, howsoeverremunerated; and

• any other person employed, engaged contracted or sub-contracted -howsoever remunerated - by any of the above or any other party to provideNHS-funded primary medical services.

13. For the purposes of pay transparency, NHS earnings will be defined initially asGP pensionable income32 although the scope may be broadened in futureyears. The self-declaration process will be aligned with the pensions return tominimise burden and potential costs for practices.



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14. 2019/20 NHS earnings of over £150,000 will need to be declared in February2021. Individuals with total NHS earnings above £150,000 per annum will belisted by name and earnings bands in a national publication.

15. Further guidance will be published later this year on the process.

16. In 2020/21, NHS England and NHS Improvement will also look to arrange forthe publication of anonymous data on the NHS earnings of all GPs, along withtheir whole time equivalent status.

6-8 week postnatal checks for new mothers

17. From October 2020, the Regulations will be amended to include a newrequirement for GPs to offer a maternal check at 6-8 weeks after birth, as anadditional appointment to that for the baby. This should be provided for both liveand still births. In line with NICE guidance, the maternal check should focus on:

• a review of the mother’s mental health and general wellbeing, using openquestioning;

• the return to physical health following childbirth, and early identification ofpelvic health issues;

• family planning and contraception options; and

• any conditions that existed before or arise during pregnancy that require on-going management, such as gestational diabetes.

18. Following a birth, the maternity unit will write to the mother’s practice notifyingthem of the outcome, along with any issues of relevance for futuremanagement. At this time, the GP practice should arrange an appointment forthe mother at 6-8 weeks, as is already done for the baby check.

19. Scheduling this check ‘back to back’ with the baby check would reducetravelling burden on parents, and having mother and baby together aids insightinto bonding and interaction. However, mothers may opt for these appointmentsto be separate.

20. Additional funding has been added to the core practice contract to supportpractices to deliver the requirements.



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Quality and Outcomes Framework changes

21. See Chapter 6 and Annex B for further details of the QOF changes from April2020.

Recruitment and Retention initiatives

22. The SFE will be updated where required to support delivery of the recruitmentand retention schemes outlined in Chapter 2.

Removal of patients who are violent from the practice list

23. From October 2020, an existing requirement in the GMS Regulations relating tothe removal of patients who are violent from the practice list will be updated.The Regulations currently enable a contractor to remove a patient from their listif they become aware the patient has previously been removed from anotherGP practice list for committing or threatening an act of violence. The changewill clarify that patients should not be removed from the GP practice list if,having been previously removed from a GP practice list and entered into aSpecial Allocation Scheme for violent patients, they have subsequently beendischarged for reintegration into mainstream primary care.

Removal of patients who live outside of the practice catchment area

24. From October 2020, when a patient is removed from a practice list becausethey have moved outside of the practice catchment area, once the contractornotifies the commissioner of that removal, the patient will continue to beregistered with the practice for 30 days (or until they register with anotherpractice, whichever is sooner) but the contractor will not be required to providehome visits during that period. This strikes an appropriate balance, in ensuringpatients have continuous access to primary medical care while not requiringcontractors to provide home visits at a distance from their practice. Patientsrequiring a home visit during this 30-day period will be advised either to registerwith a new local GP practice, or access the services commissioned locally forout-of-area registered patients.

Service requirements and associated data under the Network Contract DES

25. New service specifications under the Network Contract DES will be introducedas described in Chapter 7. Metrics are associated with the forthcoming servicespecifications to support local quality improvement initiatives and, in somecases, achievement of the IIF. The Network Contract DES will also containspecific requirements, agreed with GPC England, to improve data quality for themetrics associated with the service specifications and to ensure appropriate useof related clinical codes to be introduced during 2020/21.



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Sub-contracting under the Network Contract DES

26. Restrictions on sub-contracting of clinical services under GMS and PMSarrangements are impacting on the ability of PCNs to enter into agreementswith other organisations to support the delivery of the Network Contract DES.An example is where a practice sub-contracts a requirement of the NetworkContract DES to another organisation. From October 2020, to support PCNs todeliver the requirements of the Network Contract DES, amendments to GMSand PMS arrangements will be made to make clear that onward sub-contractingof clinical matters will be allowed but only in relation to the Network ContractDES and where permission of the commissioner is granted.

Termination right

27. From October 2020, commissioners will be able to terminate a GMS contract ifthe contractor has already had its Care Quality Commission (CQC) registrationpermanently cancelled. In these circumstances the contractor can no longerprovide primary medical services, and a termination right will make it easier forcommissioners to arrange a new GP for the contractor’s former registeredpatients.

Vaccinations and Immunisations

28. See Chapter 5.

Workforce data

29. Workforce data reported by practices via the National Workforce ReportingSystem (NWRS) is vital to understanding workforce pressures in primary care,and supporting effective workforce planning. We propose to introduce a newcontractual requirement for practice updates to the NWRS to be made on amonthly basis as a minimum (currently quarterly). We will also continue to workwith NHS Digital and wider stakeholders to strengthen the reporting and toolsmade available to practices and PCNs from this data to support their workforceplanning activity.



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Premises Costs Directions

30. We have agreed a number of changes to the Premises Costs Directions toallow commissioners to make larger investments in GP practices in a moreflexible way and seek to provide contractors with reassurance about theirpremises liabilities. The new Directions also deliver some significantly improvedterms for contractors, as well as technical updates:

• we have removed a long-standing restriction on commissioner contributionto premises improvements. Commissioners can now award improvementgrants funding up to 100% of project value. Grant values have beenincreased, and abatement and guaranteed use periods have beenreduced;

• we have agreed a number of measures to support contractors who maywish to retire but cannot find a successor partner from within the practice(“last partner standing”); and

• in addition, the new Directions mean:

o commissioners will reimburse VAT on rent payments;

o commissioners will reimburse Stamp Duty Land Tax (SDLT) onacquiring land or premises;

o rent reviews will not require contractors to undertake their ownvaluation;

o rent reviews will not lead to varying lease terms;

o fewer restrictions around grants to assign or surrender a lease;

o more formalised arrangements for third-party use of premises, withprotections for the contractor and reimbursement of legal expenses;

o improved provisions for minimum standards reviews;

o reimbursement of Business Improvement District (BID) levies; and

o rights to reclaim overpayments made after the Directions are published.



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2020/21 Non-contractual changes

Improved employment practices

31. We have agreed a new Core NHS Offer statement for staff delivering primarymedical services. This will be published in due course.

32. During 2020/21 we will review and agree changes in the following areas to bedelivered within existing resources:

• the minimum sickness and parental leave provisions all staff in primary careshould be able to expect;

• childcare support;

• occupational health provision, aligned to wider NHS England and NHSImprovement work; and

• tackling the gender pay gap in general practice.

33. We are committed to agreeing arrangements that will allow practices to make amore generous offer of Enhanced Shared Parental Leave to employed GPs,starting as soon as possible in 2020/21.

De-registration of Crown Servants overseas and their dependents

34. NHS England and NHS Improvement, the BMA, DHSC and the Foreign andCommonwealth Office (FCO) have agreed a programme of work to improvearrangements for Crown Servants overseas and their dependents in 2020/21, toensure this cohort of patients have good continuity of care and access tosecondary care services.

Domestic violence letters

35. Legal aid letters for victims of domestic violence will be considered as part ofthe 2020/21 Review of Cross-Government bureaucracy in general practice. TheBMA will write to GPs to recommend that, while the review is taking place, theydo not charge victims of domestic violence for the completion and signing oflegal aid letters.

Obesity and referrals to weight management services

36. From 2020/21, we will introduce a new non-contractual requirement for GPs tooffer to refer people with obesity into weight management services, where thisis clinically appropriate and where these services exist.



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Reducing the carbon impact of inhalers 37. The NHS has committed to reducing the carbon impact of inhalers used in the

treatment of respiratory conditions by 50%. These impacts are described in the 2019 BTS/SIGN Asthma guidelines and by NICE in its 2019 Shared Decision Aid on Asthma. All inhaler prescriptions, Structured Medication Reviews or planned Asthma Reviews taking place in primary care should consider moving or facilitating patients to lower carbon options where it is clinically appropriate to do so.



Annex B: QOF indicator changes

Table 1: New and amended indicator wording agreed for 2020/21 - asthma

Current 19/20 indicator wording Agreed new wording in 20/21 Points Payment thresholds

AST001. The contractor establishes and maintains a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months

AST005. The contractor establishes and maintains a register of patients with asthma aged 6 years or over, excluding patients with asthma who have been prescribed no asthma related drugs in the preceding 12 months (based on NM165)

4 NA

AST002. The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months before or any time after diagnosis (NM101)

AST006. The percentage of patients with asthma on the register from 1 April 2020 with either:

1) a record of spirometry and one other objectivetest (FeNO or reversibility or variability) between3 months before or 6 months after diagnosis; or

2) if newly registered in the preceding 12 monthswith a diagnosis of asthma recorded on orafter 1 April 2020 but no record of objectivetests being performed at the date ofregistration, with a record of spirometry andone other objective test (FeNO or reversibilityor variability) recorded within 6 months ofregistration. (based on NM166)

15 45-80%

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AST003. The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using the 3 RCP questions (NM23)

AST007. The percentage of patients with asthma on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using a validated asthma control questionnaire, a recording of the number of exacerbations, an assessment of inhaler technique and a written personalised action plan (based on NM167)

20 45-70%

AST004. The percentage of patients with asthma aged 14 or over and who have not attained the age of 20, on the register, in whom there is a record of smoking status in the preceding 12 months (NM102)

AST008. The percentage of patients with asthma on the register aged 19 or under, in whom there is a record of either personal smoking status or exposure to second-hand smoke in the preceding 12 months (based on NM168)

6 45-80%

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Table 2: New and amended indicator wording agreed for 2020/21: COPD Current 19/20 indicator wording Agreed new wording in 20/21 Points Payment

thresholds COPD001. The contractor establishes and maintains a register of patients with COPD

COPD009. The contractor establishes and maintains a register of:

1. Patients with a clinical diagnosis of COPD before 1April 2020 and

2. Patients with a clinical diagnosis of COPD on or after1 April 2020 whose diagnosis has been confirmed by aquality assured post bronchodilator spirometryFEV1/FVC ratio below 0.7 between 3 months before or6 months after diagnosis (or if newly registered in thepreceding 12 months a record of an FEV1/FVC ratiobelow 0.7 recorded within 6 months of registration);and

3. Patients with a clinical diagnosis of COPD on orafter 1 April 2020 who are unable to undertakespirometry (based on NM169)

8 NA

COPD002. The percentage of patients with COPD (diagnosed on or after 1 April 2011) in whom the diagnosis has been confirmed by post bronchodilator spirometry between 3 months before and 12 months after entering on to the register (NM103)

COPD003. The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 12 months (NM104)

COPD010. The percentage of patients with COPD on the register, who have had a review in the preceding 12 months, including a record of the number of exacerbations and an assessment of breathlessness using the Medical Research Council dyspnoea scale (NM170)

9 50-90%

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Table 3: New and amended indicator wording agreed for 2020/21 - Heart Failure

Current 19/20 indicator wording Agreed new wording in 20/21 Points Payment thresholds

HF002. The percentage of patients with a diagnosis of heart failure (diagnosed on or after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment 3 months before or 12 months after entering on to the register (NM116)

HF005. The percentage of patients with a diagnosis of heart failure after 1 April 2020 which has been confirmed by:

1. an echocardiogram or by specialist assessmentbetween 3 months before or 6 months afterentering on to the register; or

2. if newly registered in the preceding 12 months,with a record of an echocardiogram or a specialistassessment within 6 months of the date ofregistration. (based on NM71)

6 50-90%

HF003. In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, the percentage of patients who are currently treated with an ACE-I or ARB (NM89)

HF003. The percentage of patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, who are currently treated with an ACE-I or ARB (NM172)

6 60-92%

HF004. In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction who are currently treated with an ACE-I or ARB, the percentage of patients who are additionally currently treated with a beta-blocker licensed for heart failure. (NM90)

HF006. The percentage of patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, who are currently treated with a beta-blocker licensed for heart failure (NM173)

6 60-92%

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City: F

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N/A HF007. The percentage of patients with heart failure on the register, who had a review in the preceding 12 months, including an assessment of functional capacity and a review of medication to ensure medicines optimisation at maximum tolerated doses (based on NM174)

7 50-90%

Table 4: new indicator wording for 2020/21: non-diabetic hyperglycaemia

Agreed indicator wording Points Payment thresholds

The percentage of patients with non-diabetic hyperglycaemia who have had an HbA1c or FPG test in the preceding 12 months

18 50-90%

Changes to INLIQ

There will be no changes to the INLIQ extraction in 2020/21.

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Annex Bi: QOF Quality Improvement

The two topics areas agreed for 2020/21 are Early Cancer Diagnosis and Care of People with a Learning Disability.

Early cancer diagnosis QI005. The contractor can demonstrate continuous quality improvement activity focussed upon early cancer diagnosis as specified in the QOF guidance QI006. The contractor has participated in network activity to regularly share activity as specified in the QOF guidance. This would usually include participating in a minimum of two peer review meetings

Learning disabilities QI007. The contractor can demonstrate continuous quality improvement activity focussed upon learning disabilities as specified in the QOF guidance QI008. The contractor has participated in network activity to regularly share activity as specified in the QOF guidance. This would usually include participating in a minimum of two peer review meetings

Copies of the modules can be found: https://www.england.nhs.uk/gp/investment/gp-contract/





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Annex C: Network contract DES Workforce Role Descriptions and Outputs

The Network Contract DES Additional Roles Reimbursement Scheme has been expanded to include pharmacy technicians, two new personalised care roles, and three allied health professional (AHP) roles, in addition to first contact social prescribing link workers, physiotherapists, physician associates, and paramedics. The six new roles will be:

• health and wellbeing coaches

• care coordinators

• podiatrists

• dieticians

• occupational therapists

• pharmacy technicians

These roles have been identified and chosen due to the benefits they would bring to primary care in terms of supporting capacity and patient care, as well as the further development of multi-disciplinary teams within the community. This annex below provides information on the core role requirements for the new roles that will be reimbursable under the Network Contract DES Additional Roles Reimbursement Scheme from April 2020 and April 2021 respectively. It does not provide a comprehensive list, and PCNs must determine the job descriptions for their staff ensuring they reflect the core requirements and enable delivery of the service requirements set out in the Network Contract DES Specification.

Clinical Pharmacists and Social Prescribing Link Workers were included within the scheme from July 2019. Information relating to these two roles is included in the 2019/20 Network Contract DES Specification33. This specification will be updated in March 2020 to cover the period 1 April 2020 to 31 March 2021.

1. Workforce roles beginning from April 2020

There will be three personalised care roles based in primary care: social prescribing link workers, health and wellbeing coaches and care coordinators. These roles form a single resource for GPs and other primary care professionals to provide an all-encompassing approach to personalised care across PCNs.

The role outline for social prescribing link workers will be updated to reflect some minor additions and training requirements will include the following:

33 https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-des-specification-2019-20/



https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-des-specification-2019-20/

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• Completing the NHSE/I Health Education England online learning programme athttps://www.e-lfh.org.uk/programmes/social-prescribing/

• Attend the peer support networks run by NHSE/I at ICS/STP level.

• Acquire basic health coaching training and have an introduction to PersonalHealth Budgets (PHBs).

i. Health and wellbeing coaches

Description of role/core responsibilities

• Up to indicative Agenda for Change band 5

Health and wellbeing coaches predominately use health coaching skills to support people with lower levels of patient activation to develop the knowledge, skills, and confidence to manage their health and wellbeing, whilst increasing their ability to access and utilise community support offers. They may also provide access to self-management education, peer support, and social prescribing.

Health and wellbeing coaches will take an approach that considers the whole person in addressing existing issues and encourages proactive prevention of new and existing illnesses. They will take an approach that is non-judgemental, based on strong communication and negotiation skills, that supports personal choice and positive risk taking, that addresses potential consequences, and ensures patients understand the accountability of their own decisions.

Health and wellbeing coaches will:

a. Coach and motivate patients through multiple sessions to identify their needs, setgoals, and support them to implement their personalised health and care plan.

b. Provide personalised support to individuals, their families and carers to ensurethat they are active participants in their own healthcare; empowering them to takemore control in manging their own health and wellbeing, to live independently,and improve their health outcomes through:

• providing interventions such as self-management education and peersupport; and

• supporting people to establish and attain goals set by the person basedon what is important to them, building on goals that are important to theindividual; and

• working with the social prescribing service to connect them tocommunity-based activities which support their health and wellbeing.



https://www.e-lfh.org.uk/programmes/social-prescribing/

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c. Provide support to local community groups and work with other health, socialcare and voluntary sector providers to support the patients’ health and well-beingholistically.

d. Ensure that fellow PCN staff are made aware of health coaching and socialprescribing services and support colleagues to improve their skills andunderstanding of personalised care, behavioural approaches, and ensuringconsistency in the follow up of people’s goals where an MDT is involved.

e. Raise awareness within the PCN of shared decision making and decision supporttools and supporting people in shared decision-making conversations.

f. Work with people with lower activation to understand their level of knowledge,skills and confidence (their “Activation” level) when engaging with their healthand wellbeing.

g. Explore and support access to a personal health budget, where appropriate, fortheir care and support.

h. Utilise existing IT and MDT channels to screen patients, with an aim to identifythose that would benefit from health coaching

Training requirements

• The Personalised Care Institute (live from April 2020) will set out what training isavailable and expected for Health coaching link workers.

• Health coaching link workers will be required to be trained in health coaching inline with the NHS England and NHS Improvement summary guide (documentcurrently in development, and subject to discussion with GPC England). This islikely to include understanding the basics of social prescribing, plus 4-day healthcoaching training with regular supervision from health coaching mentor.



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ii. Care Coordinators


• Agenda for Change band 4

Care coordinators provide extra time, capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They will work closely with the GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed. They focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health management risk stratification.

Key role requirements

Care coordinators will:

a. Proactively identify and work with a cohort of people to support their personalisedcare requirements, using the available decision support aids.

b. Bring together all of a person’s identified care and support needs, and exploretheir options to meet these into a single personalised care and support plan, inline with PCSP best practice.

c. Help people to manage their needs, answering their queries and supporting themto make appointments.

d. Support people to take up training and employment, and to access appropriatebenefits where eligible.

e. Raise awareness of shared decision making and decision support tools, andassist people to be more prepared to have a shared decision makingconversation.

f. Ensure that people have good quality information to help them make choicesabout their care,

g. Support people to understand their level of knowledge, skills and confidence(their “Activation” level) when engaging with their health and wellbeing, includingthrough use of the Patient Activation Measure.

h. Assist people to access self-management education courses, peer support orinterventions that support them in their health and wellbeing.

i. Explore and assist people to access personal health budgets where appropriate.

j. Provide coordination and navigation for people and their carers across healthand care services, alongside working closely with social prescribing link workers,health and wellbeing coaches and other primary care roles.

k. Support the coordination and delivery of MDTs within PCNs.



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• The Personalised Care Institute (live from April 2020) will set out what training isavailable and expected for Care Coordinators.

iii. First Contact Physiotherapists


• Indicative Agenda for Change band 7-8a

First contact physiotherapists operate at an advanced level of clinical practice, with skills to assess, diagnose, treat and manage musculoskeletal (MSK) problems and undifferentiated conditions. This will involve seeing patients, without prior referral from their GP, to establish a rapid and accurate diagnosis and management plan, thus streamlining pathways of care. They work independently in clinical practice and do not require day to day supervision. Patients can either self-refer or be referred by the network’s members.

The following sets out the key role responsibilities for first contact physiotherapists:

a. They will work as part of a multi-disciplinary team in a patient facing role, usingtheir expert knowledge of Musculoskeletal (MSK) issues, to create stronger linksfor wider MSK services through clinical leadership, teaching and evaluation skills.

b. They will assess, diagnose, triage and manage patients, taking responsibility forthe management of a complex caseload etc

c. They will receive patients who self-refer (where systems permit) or from a clinicalprofessional within the network.

d. First contact physiotherapists will progress and request investigations (such as x-rays and blood tests) and referrals to facilitate diagnosis and choice of treatmentregime, understanding the limitations of investigations, interpret and act onresults and feedback to aid diagnosis and the management plans of patients.

e. They will develop integrated and tailored care programmes in partnership withpatients and provide a range of first line treatment options, including self-management and referral to rehabilitation focussed services and socialprescribing provision. These programmes will facilitate behavioural change,optimise patients’ physical activity and mobility, support fulfilment of personalgoals and independence and reduce the need for pharmacological interventions.

f. They will develop relationships and a collaborative working approach across thePCN supporting the integration of pathways in primary care.

g. They will develop and make use of their full scope of practice, including skillsrelating to independent prescribing, injection therapy and investigation.



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h. They will provide learning opportunities for the whole multi-professional teamwithin primary care, as determined by the PCN. They will also work across themulti-disciplinary team to develop and evaluate more effective and streamlinedclinical pathways and services.

i. They will liaise with secondary care MSK services, community care MSKservices and local social and community interventions as required, to support themanagement of patients in primary care.

j. Using their professional judgement, they will take responsibility for making andjustifying decisions in unpredictable situations, including in the context ofincomplete/contradictory information.

k. They will manage complex interactions, including working with patients withpsychosocial and mental health needs, referring to social prescribing whenappropriate.

l. Communicate effectively and appropriately, with patients and carers, complexand sensitive information regarding diagnosis, pathology, prognosis andtreatment choices supporting personalised care.

m. Implement all aspects of effective clinical governance for own practice, includingundertaking regular audit and evaluation, supervision and training.

n. They will be accountable for decisions and actions via Health and CareProfessions Council (HCPC) registration, supported by a professional culture ofpeer networking/review and engagement in evidence-based practice.

o. Encourage collaborative working across the health economy and be a keycontributor to the primary care networks providing leadership and support onMSK clinical and service development across the network

p. Support regional and national research and audit programmes to evaluate andimprove the effectiveness of the FCP programme. This will includecommunicating outcomes and integrating findings into own and wider servicepractice and pathway development.

q. First contact physiotherapists will develop integrated and tailored careprogrammes in partnership with patients through:

• effective shared decision making with a range of first line management options(appropriate for the person’s level of activation);

• assessing levels of Patient Activation to confirm levels of knowledge, skills andconfidence to self-manage and to evaluate and improve the effectiveness ofself-management support interventions, particularly for those at low levels ofactivation; and

• agreeing appropriate support for self-management through referral torehabilitation focussed services and social prescribing provision. Theseprogrammes will facilitate behavioural change, optimise patient’s physicalactivity and mobility, support fulfilment of personal goals and independenceand reduce the need for pharmacological interventions



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In order to qualify as a first contact physiotherapist working across a primary care network, the individual will need to have:

• completed an undergraduate degree in physiotherapy;

• be registered with the Health and Care Professions Council;

• be a member of the CSP or appropriate professional body;

• a Masters Level qualification or equivalent specialist musculoskeletalknowledge, skills and experience;

• completed Level 7 Modules in MSK related areas of practice (advancedassessment / diagnosis / treatment); and

• Hold credentials in imaging i.e. diagnostic or procedural.



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iv. Podiatrists


• Indicative Agenda for Change band 7

Podiatrists are healthcare professionals that have been trained to diagnose and treat foot and lower limb conditions. Podiatrists provide assessment, evaluation and foot care for a wide range of patients, which range from low-risk to long-term acute conditions. Many patients fall into high risk categories such as those with diabetes, rheumatism, cerebral palsy, peripheral arterial disease and peripheral nerve damage.


a. Provide treatments for patients of all ages whilst autonomously managing achanging caseload as part of the PCN’s MDT team.

b. Assess and diagnose lower limb conditions and foot pathologies, commencemanagement plans, deliver foot health education to patients and colleagues.

c. Liaise with PCN colleagues, community and secondary care staff, and namedclinicians to arrange further investigations and onward referrals.

d. Use and provide guidance on a range of equipment including surgicalinstruments, dressings, treatment tables, and orthotics.

e. Provide treatment for high-risk patient groups such as the elderly and those withincreased risk of amputation.

f. Use therapeutic and surgical techniques to treat foot and lower leg issues (e.g.carrying out nail and soft tissue surgery using local anaesthetic).

g. Prescribe, produce, and fit orthotics and other aids and appliances.

h. Undertake continued professional development to understand the mechanics ofthe body in order to preserve, restore and develop movement for patients.

i. Undertake a range of administrative tasks such as ensuring stock levels aremaintained and securely stored, and equipment is kept in good working order.

Entry requirements and training

• BSc in Podiatry under an approved training programme• Registered member of Health and Care Professions Council (HCPC)



https://www.healthcareers.nhs.uk/glossary#HCPC

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v. Dieticians



Dieticians are healthcare professionals that diagnose and treat diet and nutritional problems, both at an individual patient and wider public health level. Working in a variety of settings with patients of all ages, dieticians support changes to food intake to address diabetes, food allergies, coeliac disease and metabolic diseases. Dietitians also translate public health and scientific research on food, health and disease into practical guidance to enable people to make appropriate lifestyle and food choices.


a. Provide specialist nutrition and diet advice to patients, their carers and healthcareprofessionals through treatment and education plans and prescriptions.

b. Educate patients with diet-related disorders on how they can improve their healthand prevent disease by adopting healthier eating and drinking habits.

c. Make recommendations to PCN staff regarding changes to medications for thenutritional management of patients, based on interpretation of biochemical,physiological, and dietary requirements.

d. Provide dietary support to patients of all ages (from early-life to end-of-life care)in a variety of settings including nurseries, patient homes, and care homes.

e. Work as part of a multidisciplinary team to gain patients’ cooperation andunderstanding in following recommended dietary treatments.

f. Develop, implement and evaluate a seamless nutrition support service that isaimed at continuously improving standards of patient care and wider MDTworking.

g. Work with clinicians, MDT colleagues, and external agencies to ensure thesmooth transition of patients discharged from hospital back into primary care, sothat they can continue their diet plan.

h. Ensure best-practice in clinical practice, caseload management, education,research and audit, to achieve corporate PCN and local population objectives.

i. Undertake a range of administrative tasks such as ensuring stock levels aremaintained and securely stored, and equipment is kept in good working order.


• BSc pre-reg MSc in Dietetics under an approved training programme

• Registered member of Health and Care Professions Council (HCPC)




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vi. Occupational therapists



Occupational therapists (OTs) support people of all ages with problems resulting from physical, mental, social, or developmental difficulties. OTs provide interventions that help people find ways to continue with everyday activities that are important to them. This could involve learning new ways to do things, or making changes to their environment to make things easier. As patients’ needs are so varied, OTs must take a holistic approach to each individual patient; managing physical, social, psychological, and environmental needs alongside good clinical practice.


a. Assess, plan, implement and evaluate treatment plans, with an aim to increasepatients’ productivity and self-care.

b. Work with patients through a shared-decision making approach to plan realistic,outcomes-focused goals.

c. Undertake both verbal and non-verbal communication methods to address theneeds of patients that have communication difficulties.

d. Involve MDT colleagues, physiotherapists, social workers, alongside patients'families, teachers, carers and employers in treatment planning, to aidrehabilitation.

e. Where appropriate, support the development of discharge and contingency planswith relevant professionals to arrange on-going care in residential, care home,hospital, and community settings.

f. Periodically review, evaluate, and change rehabilitation programmes to rebuildlost skills and restore confidence.

g. Where appropriate, advise on home, school, and workplace environmentalalterations, such as adjustments for wheelchair access, technological needs, andergonomic support.

h. Teach coping strategies and support adaptation to manage long term conditionsfor physical and mental health.

i. Advise on specialist equipment and organisations to help with daily activities.

Entry requirements and training

• BSc or pre reg MSc in Occupational Therapy under an approved trainingprogramme

• Registered member of Health and Care Professions Council (HCPC)




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vii. Physician Associates


• Indicative Agenda for Change Band 7

A physician associate (PA) is a trained healthcare professional who works directly under the supervision of a doctor as part of the medical team. They are usually generalists with broad medical knowledge but can develop expertise/specialisms in a particular field.

The responsibilities of the role include direct patient contact through assessment, examination, investigation, diagnosis and treatment. Physician associates will have a key role in supporting delivery of Network Contract DES Services.

The following sets out the key role responsibilities for a physician associate:

a. Physician associates will provide first point of contact care for patients presentingwith undifferentiated, undiagnosed problems utilising history-taking, physicalexaminations and clinical decision-making skills to establish a working diagnosisand management plan in partnership with the patient (and their carers whereapplicable).

b. They will also review, analysis and action diagnostic test results.

c. They will deliver integrated patient centred-care through appropriate working withthe wider primary care multi-disciplinary team and social care networks.

d. They will undertake face-to-face, telephone and online consultations foremergency or routine problems, as determined by the PCN, includingmanagement of patient’s with long-term conditions. Where required by the PCN,physician associates can offer specialised clinics following appropriate trainingincluding (but not limited to) family planning, baby checks, COPD, asthma,diabetes and anticoagulation.

e. They will undertake home visits and participate in duty rotas.

f. Physician associates will provide health/disease promotion and preventionadvice to patients.

g. Physician associates will utilise clinical guidelines and promote evidence-basedpractice and partake in clinical audits, significant event reviews and otherresearch and analysis tasks.

h. Through participating in continuing professional development opportunitiesPhysician associates will keep up to date with evidence-based knowledge andcompetence in all aspects of their role, meeting clinical governance guidelines forcontinuing professional development (CPD).



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All physician associates will develop and agree a personal development plan (PDP) utilising a reflective approach to practice. They will operate under appropriate clinical supervision, with the PCN member practice’s identifying a suitable named GP supervisor for each physician associate. The GP supervisor is not required to be physically present but must be readily available for consultation.


• PAs will be required to undertake the UK PA National Re-Certification Examevery six years and maintain professional registration working within the latestcode of professional conduct (CIPD).



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viii. Pharmacy Technicians



Pharmacy technicians play an important role, complementing clinical pharmacists, community pharmacists and other members of the PCN multi-disciplinary team. Pharmacy technicians are different to clinical pharmacists as they are not able to prescribe or make clinical decisions, instead working under supervision to ensure effective and efficient use of medicines.

Pharmacy technicians’ core role responsibilities will cover clinical, and technical and administrative categories. The following sets out the key role responsibilities for pharmacy technicians:

Clinical:

a. Undertaking patient facing and patient supporting roles to ensure effectivemedicines use, through shared decision-making conversations with patients.

b. Carrying out medicines optimisation tasks including effective medicineadministration (e.g. checking inhaler technique), supporting medication reviewsand medicines reconciliation. Where required, utilise consultation skills to work inpartnership with patients to ensure they use their medicines effectively.

c. As determined by the PCN, supporting medication reviews and medicinesreconciliation for new care home patients and synchronising medicines forpatient transfers between care settings, linking with local communitypharmacists, and referring to the pharmacist for structured medication reviews.

d. Providing specialist expertise, where competent, to address both the publichealth and social care needs of patients, including lifestyle advice, serviceinformation, and help in tackling local health inequalities.

e. Taking a central role in the clinical aspects of shared care protocols and liaisingwith specialist pharmacists for more complex patients.

f. Supporting initiatives for antimicrobial stewardship to reduce inappropriateantibiotic prescribing.

Technical and Administrative:

g. Working with the PCN multi-disciplinary team to ensure efficient medicinesoptimisation, including implementing efficient ordering and return processes andreducing wastage.



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h. Providing training and support on the legal, safe and secure handling ofmedicines, including the implementation of the Electronic Prescription Service(EPS).

i. Developing relationships with other pharmacy technicians, pharmacists andmembers of the multi-disciplinary team to support integration of the pharmacyteam across health and social care including primary care, community pharmacy,secondary care and mental health.

j. Supervising practice reception teams in sorting and streaming generalprescription requests, so as to allow GPs and clinical pharmacists to review themore clinically complex requests.

The role will also require pharmacy technicians to support the implementation of national prescribing policies and guidance within GP practices, care homes and other primary care settings. This will be achieved through undertaking clinical audits (e.g. use of antibiotics), supporting quality improvement measures and contributing to the Quality and Outcomes Framework and enhanced services. In addition, pharmacy technicians will assist in the delivery of medicines optimisation incentive schemes (e.g. medicines switches) and patient safety audits.


Pharmacy technicians are registered healthcare professionals, who have been undertaking clinical and technical roles in hospitals, community and primary care. Their initial 2-year training is mandated by the General Pharmaceutical Council (GPhC), which specifies criteria to register as a pharmacy technician and this covers the education, training and experience requirements.

The new curriculum for pre-registration trainee pharmacy technicians is being tested with placements in general practice through the Pharmacy Integration Fund (PhF).

Eligibility for reimbursement under the Network Contract DES and proposals for reimbursement

All pharmacy technicians must have completed or be enrolled in, be undertaking or be prepared to start an approved 18-month training pathway (e.g. Primary care pharmacy educational pathway (PCPEP) or Medicines Optimisation in Care Homes (MOCH)). Pharmacy technicians must be registered with the General Pharmaceutical Council. Entry to the PCPEP programme will include the option for an accreditation of Prior Learning (APEL) process.



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2. Workforce roles beginning from April 2021

i. Paramedics – Advanced Paramedic Practitioners



Advanced paramedic practitioners work autonomously within the community, using their enhanced clinical assessment and treatment skills, to provide first point of contact for patients presenting with undifferentiated, undiagnosed problems relating to minor illness or injury, abdominal pains, chest pains and headaches. They are health professionals who practice at an advanced level having the capability to make sound judgements in the absence of full information and to manage varying degrees of risk when there are complex, competing or ambiguous information or uncertainty.

The following sets out the key role responsibilities for advanced paramedic practitioners:

a. They will assess and triage patients, including same day triage, and asappropriate provide definitive treatment or make necessary referrals to othermembers of the primary care team.

b. They will advise patients on general healthcare and promote self-managementwhere appropriate, including signposting patients to other community or voluntaryservices.

c. They will be able to:

• perform specialist health checks and reviews;

• perform and interpret ECGs;

• perform investigatory procedures as required, and;

• undertake the collection of pathological specimens including intravenousblood samples, swabs etc.

• perform investigatory procedures needed by patients and those requested bythe GPs

d. They will support the delivery of anticipatory care plans and lead certaincommunity services (e.g. monitoring blood pressure and diabetes risk of elderlypatients living in sheltered housing)

e. They will provide an alternative model to urgent and same day home visits for thenetwork and undertake clinical audits

f. The will communicate at all levels across organisations ensuring that aneffective, patient centred service is delivered

g. They will communicate proactively and effectively with all colleagues across themulti-disciplinary team, attending and contributing to meetings as required



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h. They will maintain accurate and contemporaneous health records appropriate tothe consultation, ensuring accurate completion of all necessary documentationassociated with patient health care and registration with the practice

i. Prescribe/issue medications as appropriate following policy, patient groupdirectives, NICE (national) and local clinical guidelines and local care pathways

j. Enhance own performance through continuous professional development,imparting own knowledge and behaviours to meet the needs of the service.


• In order to qualify as an advanced paramedic practitioner working across aprimary care network, the individual will need to have a relevant Masters degree– Framework for Higher Education Qualification (FHEQ) Level 7 or ScottishCredit and Qualifications Framework (SCOF) Level 11.



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Glossary of Terms

A&E Accident and Emergency AfC Agenda for Change AHP Allied Health Professional APEL Accreditation of Prior Learning BID Business Improvement District BMA British Medical Association BTS British Thoracic Society CAS alert Central Alerting System CCG Clinical Commissioning Group CHIS Child Health Information Systems COPD Chronic Obstructive Pulmonary Disease CPD Continuing Professional Development CPI Consumer Price Index CQRS Calculating Quality Reporting Service CSP Chartered Society of Physiotherapy CVD Cardiovascular Disease DES Directed Enhanced Service DHSC Department of Health and Social Care EPS Electronic Prescription Service FCO Foreign and Commonwealth Office FeNO Fractional Exhaled Nitric Oxide FEV1 Forced Expiratory Volume FHEQ Framework for Higher Education Qualification FVC Forced Vital Capacity GMS General Medical Services GP General Practitioner GPC (England) General Practitioners Committee in England GPSoC GP System of Choice HCPC Health and Care Professional Council HEE Health Education England Hib Haemophilus influenza type B IAPT Increasing Access to Psychological Therapies IIF Investment and Impact Fund IoS Item of Service HPV Human Papilloma Virus ICS Integrated Care System LD Learning Disability LES Local Enhanced Service LIS Local Incentive Scheme LMC Local Medical Committee LTP Long Term Plan MDT Multidisciplinary Team MHRA Medicines and Healthcare products

Regulatory Agency



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MMR Measles, Mumps, and Rubella MOCH Medicines Optimisation in Care Homes MSK Musculoskeletal NHS National Health Service NICE National Institute for Health and Care

Excellence

NWRS National Workforce Reporting System ONS Office for National Statistics OT Occupational Therapist PCN Primary Care Network PCPEP Primary Care Pharmacy Educational Pathway PCV Pneumococcal Conjugate Vaccine PDP Personal Development Plan PHB Personal Health Budget PHE Public Health England PMS Personal Medical Services PQS Pharmacy Quality Scheme PSNC Pharmaceutical Services Negotiating

Committee

QI Quality improvement QOF Quality and Outcomes Framework RCGP Royal College of General Practitioners RCN Royal College of Nursing SCOF Scottish Credit and Qualifications Framework SDLT Stamp Duty Land Tax SFE Statement of Financial Entitlements SIGN Scottish Intercollege Guidelines Network SMR Structured Medication Review SNOMED Systematised Nomenclature of Medicine STOMP STP

Stopping Over Medication of people with a learning disability, autism or both with psychotropic medicines Sustainability and Transformation Partnership

TERS Targeted Enhanced Recruitment Scheme TUPE Transfer of Undertakings (Protection of

Employment)

WTE Whole Time Equivalent



85

Reference List Aveyard, P. et al. (2016) Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial. The Lancet 2016; 388: 2492-500. Retrieved from: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2816%2931893-1 NHS Business Services Authority (2019) Medication Safety -Indicators Specification. Available from: https://www.nhsbsa.nhs.uk/sites/default/files/2019-08/Medication%20Safety%20-%20Indicators%20Specification%20%28Aug19%29.pdf Care Quality Commission. Service Types. Available from: https://www.cqc.org.uk/guidance-providers/regulations-enforcement/service-types NHS Digital (2019). General Practice Workforce 30 September 2019. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/final-30-september-2019 NHS Digital (2018) Historical workforce statistics in lead-up to NHS70. Available from: https://digital.nhs.uk/news-and-events/latest-news/workforce-factsheet The General Practice (GP) National Recruitment Office (2019). Available here: https://gprecruitment.hee.nhs.uk/resource-bank/recruitment-figures National Institute for Health and Care Excellence (2015) Postnatal care up to 8 weeks after birth. Available from: https://www.nice.org.uk/guidance/CG37 NHS England (2019) Advanced Service Specification - NHS Community Pharmacist Consultation Service. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/10/advanced-service-specification-nhs-pharmacist-consultation-service.pdf NHS England (2016) General Practice forward View. Available from: https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf NHS England and NHS Improvement (2019) Interim findings of the Vaccinations and Immunisations Review – September 2019. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/10/interim-findings-of-the-vaccinations-and-immunisations-review-2019.pdf NHS England and the BMA (2019) Investment and evolution: A five year framework for GP contract reform. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf NHS England (2019) Network Contract Directed Enhanced Service: Additional Roles Reimbursement Scheme Guidance. Available from: https://www.england.nhs.uk/wp-









https://digital.nhs.uk/news-and-events/latest-news/workforce-factsheet

https://gprecruitment.hee.nhs.uk/resource-bank/recruitment-figures


https://www.england.nhs.uk/wp-content/uploads/2019/10/advanced-service-specification-nhs-pharmacist-consultation-service.pdf



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






86

content/uploads/2019/12/network-contract-des-additional-roles-reimbursement-scheme-guidance-december2019.pdf

NHS England (2020) Network Contract DES Engagement on Draft Outline Service Specifications Summary Report. Available from: https://www.england.nhs.uk/wp-content/uploads/2020/01/2020-01-30-pcn-services-engagement-report.pdf

NHS England (2019) The NHS Long Term Plan. Available from: https://www.longtermplan.nhs.uk/online-version/

NHS England (2019). Releasing time for care. Available from: https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/releasing-time/

NHS England (2018) Report of the Review of the Quality and Outcomes Framework in England. Available from: https://www.england.nhs.uk/wp-content/uploads/2018/07/quality-outcome-framework-report-of-the-review.pdf

Organisation for Economic Cooperation and Development (2017) Obesity Update 2017. Available from: http://www.oecd.org/health/obesity-update.htm







https://www.longtermplan.nhs.uk/online-version/

https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/releasing-time/



http://www.oecd.org/health/obesity-update.htm

Criteria for registration as a

pharmacy technician in Great

Britain September 2019



The text of this document (but not the logo and branding) may be reproduced free of charge in any

format or medium, as long as it is reproduced accurately and not in a misleading context. This

material must be acknowledged as General Pharmaceutical Council copyright and the document

title specified. If we have quoted third party material, you must get permission from the copyright

holder.

Contact us at [email protected] if you would like a copy of the

document in another format (for example, in larger type or in a different language).

© General Pharmaceutical Council 2019




Contents About the GPhC .................................................................................................................... 4

Who we are .........................................................................................................................................4

What we do .........................................................................................................................................4

About this document ........................................................................................................... 5

Routes to registration as a pharmacy technician in Great Britain ................................. 6

Route 1: Criteria for initial registration for UK- and non-EEA-trained pharmacy technicians 6

Route 2: Criteria for initial registration for EEA-trained pharmacy technicians (excluding

UK-trained pharmacy technicians) .................................................................................................9

Route 3: Criteria for returning to registration as a pharmacy technician .............................. 10



Effective from September 2019

4 Criteria for registration as a pharmacy technician in Great Britain

About the GPhC Who we are

We regulate pharmacists, pharmacy technicians

and pharmacies in Great Britain.

We work to assure and improve standards of

care for people using pharmacy services.

What we do

Our role is to protect the public and give them

assurance that they will receive safe and

effective care when using pharmacy services.

We set standards for pharmacy professionals

and pharmacies to enter and remain on our

register.

We ask pharmacy professionals and pharmacies

for evidence that they are continuing to meet

our standards, and this includes inspecting

pharmacies.

We act to protect the public and to uphold

public confidence in pharmacy if there are

concerns about a pharmacy professional or

pharmacy on our register.

Through our work we help to promote

professionalism, support continuous

improvement and assure the quality and safety

of pharmacy.



Criteria for registration as a pharmacy technician in Great Britain 5

About this documentThis document sets out the qualifications and

work experience requirements for registration

as a pharmacy technician in Great Britain. There

are three routes to registration:

1. Initial registration by UK- and non-EEA

trained pharmacy technicians1.

2. Initial registration by EEA-trained/registered

pharmacy technicians (excluding UK-trained

pharmacy technicians)2.

3. Returning to registration as a pharmacy

technician.

As well as education and training requirements,

the registration process also includes checks on:

• health

• character

• knowledge of English language, and

• identity

You can find further information about how

to apply to join our register in the application

forms and guidance notes on how to apply for

registration as a pharmacy technician in Great

Britain.

1 Persons who do not possess rights under

Directive 2005/36/EC (as amended by Directive

2013/55/EU) or EC Treaty rights.

2 Persons who possess rights under Directive

2005/36/EC (as amended by Directive

2013/55/EU) or EC Treaty rights.



https://www.pharmacyregulation.org/registration/registering-pharmacy-technician

https://www.pharmacyregulation.org/registration/registering-pharmacy-technician



Routes to registration as a pharmacy technician in Great Britain Route 1: Criteria for initial registration for UK- and non-EEA-trained

pharmacy technicians

Overview

1.1 This route applies to applicants who trained in the United Kingdom (UK) or outside the

European Economic Area (EEA) and are making their initial application for registration as a

pharmacy technician in Great Britain (GB) on or after 1 September 2019. Such applicants must

have completed:

• the integrated, or linked, knowledge and competence qualification(s)3 4as set out on the

GPhC website; and

• a minimum of two years’ work-based experience in the UK set out in paragraphs 1.5-1.7

or by meeting the alternative requirements set out in section in paragraphs 1.8-1.12

1.2 Applicants must apply for registration as a pharmacy technician within five calendar years of

commencement on a recognised course, or within two years of completing the last

recognised course, whichever is sooner. Extenuating circumstances will be considered where

there are legitimate, documented grounds for exceeding these timeframes.

Qualifications

1.3 A list of all eligible qualifications can be found on the GPhC’s website.

1.4 There are no exceptions to the qualification requirement for registration as a pharmacy

technician. All UK and non-EEA applicants must have completed both competency-based and

knowledge-based qualifications whilst completing work-based experience in the UK.

Work-based experience

1.5 Applicants must provide evidence they have completed a minimum of two years’ relevant

work‐based experience in the UK under the supervision, direction or guidance of a pharmacist

or pharmacy technician to whom the applicant was directly accountable for not less than 14

3 ‘Qualifications’ in this document means qualifications listed in national qualifications frameworks

and other courses accredited by the GPhC which deliver the learning outcomes in Standards for the

initial education and training of pharmacy technicians (GPhC, 2017). 4 Pharmacy technician apprentice trainees in England must pass the apprenticeship end point

assessment (EPA) in order to apply to register as a pharmacy technician.




hours per week. A pre‐registration trainee pharmacy technician must commence or register

for the required qualifications (set out on the Approved pharmacy technician courses page

in the ‘Education’ section of the GPhC website) within three months of commencing

contracted, relevant work experience.

1.6 Within the two-year period of training and work experience a minimum of 1260 hours of work

experience must be undertaken under the supervision, direction or guidance of a pharmacist

or pharmacy technician to whom the applicant is directly accountable, excluding sickness

absence, maternity or paternity leave and holidays. A minimum of 315 hours of work

experience under the supervision, direction or guidance of a pharmacist or pharmacy

technician to whom the applicant is directly accountable must be undertaken in each of the

two years.

1.7 In certain circumstances (for example, prolonged serious ill health or maternity or paternity

leave) an extension of the two-year qualifying period of work experience may be granted on

application to the registrar if supported by cogent and sufficient evidence. The registrar has

the discretion to grant such an extension up to a maximum of one year.

Exceptions related to the work-based experience requirement

Non-EEA applicants

1.8 The two years’ relevant work-based experience requirement described above may be reduced

in the case of applicants wishing to register as a pharmacy technician who already hold non-

EEA pharmacist or pharmacy technician qualifications.

1.9 These applicants must have completed relevant qualifications whilst working in the UK under

the supervision, direction or guidance of a pharmacist or pharmacy technician to whom the

applicant was directly accountable for no less than 14 hours per week.

1.10 In addition to the relevant qualification(s), applicants must provide evidence of:

• their non-EEA pharmacist or pharmacy technician qualification which entitles them to

practise as a pharmacist or pharmacy technician in their original country of qualification;

and

• being registered or otherwise eligible to practise as a pharmacist or pharmacy technician

in their country of qualification.

Pharmacist pre-registration training

1.11 A period of pharmacist preregistration training in the UK, the Channel Islands or the Isle of

Man that can be validated by the GPhC and has been completed within two years of

commencing a recognised pharmacy technician training course may be offset against the

work experience requirements for registration.





1.12 The time limits for completing registration still apply. Applicants must apply for registration as

a pharmacy technician within five calendar years of commencement of the validated period of

pre-registration training or within two years of completing the last recognised qualification

whichever is sooner. This may only be included if it is within five calendar years of the date of

application for registration.

Transitional provisions

1.13 Qualifications leading to registration as a pharmacy technician accredited or recognised prior

to 1 September 2019 remain accredited or recognised until the listed expiry date. Trainees

registered on them currently may continue to study on them until the listed expiry date and,

on successful completion, can use them as part of an application for initial registration as a

pharmacy technician.

1.14 These qualifications can be found on the Approved pharmacy technician courses page in

the ‘Education’ section of the GPhC website.




Route 2: Criteria for initial registration for EEA-trained pharmacy

technicians (excluding UK-trained pharmacy technicians)

2.1 Applicants will have rights under Directive 2005/36/EC (as amended by Directive 2013/55/EU)

or EC Treaty rights if:

• they hold a pharmacy qualification gained outside an EEA member state that entitled

them to practise as a pharmacist or pharmacy technician in their country of

qualification, and subsequently that qualification has been recognised by an EEA

member state and they have been permitted to work as a pharmacy technician in that

EEA member state; or

• they hold a pharmacy technician qualification from another EEA member state. The EEA

member state of qualification may either regulate the profession of pharmacy

technician or if the profession of pharmacy technician is not regulated in that Member

State, the education and training to obtain the qualification is regulated.

• if neither the profession of pharmacy technician nor the education and training is

regulated in the EEA member state of qualification then in addition to the pharmacy

technician qualification they must also have completed one-year of full‐time

professional experience as a pharmacy technician, or an equivalent period on a part‐

time basis, during the previous 10 years.

2.2 An application for registration under Route 2 (EEA) will be subject to scrutiny and evaluation.

This is a comparative assessment of the applicant’s qualification and work experience against

the GB requirements for registration. The applicant may be required to complete an

adaptation period not exceeding three years or pass an aptitude test where either:

• the training the applicant has received covers substantially different matters from those

covered by the GPhC-recognised pharmacy technician qualification(s); or

• the pharmacy technician profession in GB comprises one or more professional activities

which are not part of the pharmacy technician profession in the applicant’s home

member state, and those professional activities require specific training which the

applicant has not covered in their home member state.





Route 3: Criteria for returning to registration as a pharmacy technician

3.1 This applies to applicants who had been previously registered with the Royal Pharmaceutical

Society of Great Britain or the GPhC, regardless of their initial route to registration.

3.2 Applicants wishing to return to registration must submit a portfolio of evidence

demonstrating their professional competence against the scope of practice they propose to

practise within once registered. Applications will be evaluated and assessed to determine

their professional competence.



General Pharmaceutical Council @TheGPHC

25 Canada Square, London E14 5LQ TheGPHC

F 020 3713 8000 /company/general-pharmaceutical-council

E [email protected] www.pharmacyregulation.org



https://twitter.com/TheGPhC

https://www.facebook.com/TheGPhC

https://www.linkedin.com/company/general-pharmaceutical-council


https://www.pharmacyregulation.org/

Appendix C – ARRS Expenditure

Radford & Mary Potter PCN

Nottingham City East PCN

Clifton & Meadows PCN

Monthly spend

Role Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

Clinical Pharmacist £4,639.17 £4,639.17 £4,639.17 £4,639.17 £4,639.17 £4,639.17 £4,639.17 £4,639.17 £4,639.17 £4,639.17 £4,639.17 £4,639.17

SP Link Worker £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08

First Contact Physio £0.00 £0.00 £0.00 £0.00 £9,278.33 £9,278.33 £9,278.33 £9,278.33 £9,278.33 £9,278.33 £9,278.33 £9,278.33

Physician Associate £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

Pharmacy Technician £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

Dietitian £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

Podiatrist/Chiropodist £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

H&WB Coach £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

Care Co-ordinator £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

Monthly total £7,588.25 £7,588.25 £7,588.25 £7,588.25 £16,866.58 £16,866.58 £16,866.58 £16,866.58 £16,866.58 £16,866.58 £16,866.58 £16,866.58

Running total £7,588.25 £15,176.50 £22,764.75 £30,353.00 £47,219.58 £64,086.16 £80,952.74 £97,819.32 £114,685.90 £131,552.48 £148,419.06 £165,285.32

Total PCN ARRS budget: £324,113.22

Total Forecast spend: £165,285.64

Cost

Monthly spend



SP Link Worker £2,949.08 £2,949.08 £2,949.08 £2,949.08 £5,898.17 £5,898.17 £5,898.17 £5,898.17 £5,898.17 £5,898.17 £5,898.17 £5,898.17




Dietitian £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00


H&WB Coach £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

Care Co-ordinator £0.00 £0.00 £0.00 £0.00 £2,429.50 £2,429.50 £2,429.50 £2,429.50 £2,429.50 £2,429.50 £2,429.50 £2,429.50

Monthly total £7,588.25 £7,588.25 £7,588.25 £7,588.25 £29,667.84 £29,667.84 £29,667.84 £29,667.84 £29,667.84 £29,667.84 £29,667.84 £29,667.84

Running total £7,588.25 £15,176.50 £22,764.75 £30,353.00 £60,020.84 £89,688.68 £119,356.52 £149,024.36 £178,692.20 £208,360.04 £238,027.88 £267,695.72



Cost

Monthly spend



SP Link Worker £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08 £2,949.08




Dietitian £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00


H&WB Coach £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

Care Co-ordinator £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

Monthly total £7,588.25 £7,588.25 £12,227.38 £12,227.38 £21,505.68 £21,505.68 £21,505.68 £21,505.68 £21,505.68 £21,505.68 £21,505.68 £21,505.68

Running total £7,588.25 £15,176.50 £27,403.88 £39,631.26 £61,136.94 £82,642.62 £104,148.30 £125,653.98 £147,159.66 £168,665.34 £190,171.02 £211,676.70



Cost



of 2

Meeting Title: Primary Care Commissioning Committee (Open Session)

Date: 15 July 2020

Paper Title: Primary Care Recovery Group – Terms of Reference


Sponsor:

Presenter:

Lucy Dadge, Chief Commissioning Officer Attachments/ Appendices:

Terms of Reference

Joe Lunn, Associate Director of Primary Care

Purpose: Approve ☐ Endorse ☐ Review ☐ Receive/Note for:


☒

Executive Summary


Delegated function 2 – Planning the provider landscape

Delegated function 4 – Decisions in relation to the commissioning, procurement and management of primary medical services contracts

The Primary Care Recovery Group Terms of Reference (TOR) were presented to the committee in June 2020.

The committee suggested the TOR were updated to formalise that outputs from the Primary Care Recovery Group would be delivered by completion of individual work streams as part of the groups work programme and reports outputs/delivery against these on a Workplan.

The committee also asked that reporting requirements for other CCG cells be considered especially where other Cells did not yet have TOR in place.

A further change has been made to reflect that the group now meets weekly.

The committee is asked to NOTE the updated Terms of Reference for the Primary Care Recovery Group


Compliance with Statutory Duties ☐ Wider system architecture development (e.g. ICP, PCN development)

☐

Financial Management ☐ Cultural and/or Organisational Development

☐

Performance Management ☐ Procurement and/or Contract Management ☐

Strategic Planning ☒

Primary Care Recovery Group Terms of Reference


of 2





Yes ☐ No ☒ N/A☐ Not required for this item.


Yes ☐ No ☒ N/A☐ Not required for this item.

Risk(s):

No risks identified.

Confidentiality:

☒No

Recommendation(s):

1. NOTE the updated Primary Care Recovery Group Terms of Reference



V02.030 Page 1 of 3TOR – 328 JulyMay 2020

Review due 328 OctoberAugust 2020 (3 months)

COVID-19 Primary Care Recovery Group Terms of Reference

Purpose1. To ensure the recovery and restoration of General Practice from COVID 19 in line with local and

national guidance.

2. To provide a focal point for the planning, review and recommendation of primary care serviceproposals – commissioner and provider – to ensure all positive transformational changes as a result of COVID 19 can be retained where safety is not compromised and economic value for money can be demonstrated.

3. To rapidly consider and critically evaluate any opportunities for primary care transformation,development and improvement to ensure a sustainable and effective general practice services continue to be delivered. Work programme to be delivered through completion of individual workstreams by the group, outputs and delivery captured for reporting purposes on the Workplan.

4. To identify issues and constraints that may affect the routine operation of primary care services during the recovery phase providing possible mitigations and solutions to help resolve, developing proposals for decision making in line with governance requirements.

5. To work with CCG business analysts to ensure data available for the wider system is shared with Primary Care to facilitate a wider understanding of the impact on general practice demand and use for modelling workload/impacts.

6. To understand the impact of the Standard Operating Procedure (SOP) for Primary Care and the implications this will have on individual practice, PCN, ICP and CCG – giving due regard to the impact of IPC and Zoning of premises and staff.

7. To ensure resilience in general practice is maintained – practice level Business Continuity Plans to ensure buddying arrangements are robust and escalation triggers are clear for when/if Clinical Management Centres (CMCs) to be stood up and down in response to the recovery stage.

8. To ensure that primary care communication and engagement with patients locally is timely, systematic, coordinated, and in line with national guidance.

9. To identify potential areas for service change/transformation providing fully worked up business case for consideration. To include those service changes/transformation programmes required to ensure safe and sustained functioning of the primary care estate, inputting to recommendations for prioritisation of primary care capital.

10. To continue to work collaboratively with other cells both within the CCG and wider as part of the LRF response to recovery from COVID 19 and returning to business as usual (the new normal),understanding the impact on general practice as a result of recovery in other parts of the health and social care system

11. Ensure all primary care service change proposals are clearly identified accordingly including required duration/permanency

∑ emergency response previously – to be retained as part of the new business as usual approach(changes implemented during COVID 19 to be retained).

∑ emergency response previously - to cease – to be stopped as primary care returns back to the new business as usual.

∑ recovery action (short/medium term) – understanding the implications of areas paused/impacted by COVID 19 and the workload implications of routine service increasing.





∑ understanding funding - where available CCG Allocations (Delegated Budget/GPFV), repurposing funding, or is investment needed.

12. To understand the potential financial impact of the recovery of services due to COVID 19 on primary care and provide recommendations for the effective deployment of resources.

Decision-making arrangements / Governance∑ All proposals developed by the Primary Care Recovery Group will be subject to consideration and/or

approval through the appropriate the CCG governance arrangements includingQuality and Performance Committee if appropriate;

o Primary Care Commissioning Committee for matters governed by the Delegation agreement and in consideration of the strategic development of primary care.

o Governing Body – should the scheme of delegation require referral of decisions from Primary Care Commissioning Committee for approval.

Membership∑ CCG Clinical Leads/Co-Chairs to Chair ∑ Independent GP Advisor (Deputy Chair)∑ Associate Director of Primary Care∑ Clinical Lead representation as required (including, CCG Governing Body GPs, PCCC GP members,

ICS Medical Director, , 2 x CDA Clinicians) –∑ Locality Directors x 3∑ Associate Director of Primary Care Networks∑ Associate Director of Estates∑ Head of Quality Primary Care∑ Operational Director of Finance∑ Communications lead∑ Chief Commissioning Officer

Officers to attend as required∑ Primary Care/Locality Team representatives as required∑ Data Analysts∑ GPIT Team∑ Commissioning leads urgent care, elective care, community and mental health co-opted as required∑ PCCC lay members co-opted as required

Meeting Requirements∑ The group will meet twice weekly – to be flexed as required

ReportingThe Primary Care Recovery & Restoration Group will report to:

∑ Primary Care Commissioning Committee – decision-making for delegated commissioning/core GP contracts

∑ HETCG Recovery Cell – for awareness/alignment of transformational changes in primary care.∑ Capacity cell – for awareness/alignment in consideration of overall system capacity requirements∑ Quality cell – for advice and guidance in respect of all clinical quality and IPC requirements∑ Executive Team – via Service Change cell, in consideration of investment requirements that fall

outside the scope/remit of the delegates commissioning/core GP contracts.∑ Other CCG Cells – as required when Terms of Reference are in place and links to Primary Care are

identified





Interface with the ICS Primary Care Programme Board

Key Links for information sharing, reporting & general communication∑ CCG Executive Team∑ Primary Care Incident Management Group ∑ Primary Care Networks & Clinical Directors∑ ICS/ICPs



of 5


Date: 15 July 2020

Paper Title: Overview of GP Practice Additional

Expenses in Relation to COVID-19. Paper Reference: PCC 20 067

Sponsor:

Presenter:



N/A




Assurance

Information

☒

Executive Summary

This paper is in line with delegated function 3; Management of the delegated funds.

This paper provides an overview of the COVID-19 additional expense claims for May 2020. This is a further

update to the previous papers which were presented to the Committee meetings held on 22 April 2020 and

20 May 2020 which detailed the cost of claims submitted in March and April respectively.



☐

Financial Management ☒ Cultural and/or Organisational Development

☐










Risk(s):

There are no risks identified with this paper.

Confidentiality:

☒No

Recommendation(s):

Covid-19 GP Practice Additional Expenses’


of 5

1. NOTE the information for assurance purposes.



of 5

GP Practice Additional Expenses due to COVID 19 Pressures

Background

Since the COVID-19 outbreak, additional pressures and costs have been placed on General Practice in order

for them to respond to the needs of patients whilst maintaining a safe environment for their staff and patients.

On the 3 April 2020, a message was distributed to practices via TeamNet, outlining a process for which

practices could claim back additional expenses from the CCG in relation to costs incurred due to COVID-19.

Practice managers were also emailed on the 6th April 2020 to ensure the message was received by all.

Practices can claim for additional expense incurred due to COVID-19 pressures such as; staff overtime costs,

locum support for ill or self-isolating GPs, additional Personal Protective Equipment (PPE) or additional cleaning

items. However, in order to be accepted under the reimbursement arrangement, the costs have to be additional

to the practice’s regular orders and outgoings and items must be appropriate and necessary in dealing with the

COVID-19 outbreak.

The CCG is currently supporting additional costs as a result of COVID-19 at risk. The CCG will seek to reclaim

expenditure from NHS England but need to be able to evidence and demonstrate to NHS England that all costs

are appropriate and will satisfy their processes.

Overview of Claims Submitted in May

Practices were asked to submit their May expenses by 12 June 2020 in order to receive timely payment. Only

claims which related to the months of March, April and May would be accepted for this submission and

practices are required to submit backing rationale and evidence of the spend with their claim. An on-going

review of previously withheld claims originally submitted in March and April is also taking place, allowing

payment of these claims once appropriate information is received.

Summary of May Claims:

103 practices submitted claims

The total cost of the claims submitted was £539,277.91; this is a reduction on the previous month’s claim

From this total £419,068.34 has been approved for payment

An additional £10,126.42 worth of equipment claims has also been approved for payment this month. These

items were submitted in March and April but were not deemed payable at the time due to the need for

further information from practices

From the total of approved claims, £33,865.58 relates to March claims. These were claims originally

withheld from payment, the further evidence and information required for payment has now been supplied.

The figure also includes a small amount of late submission claims. The total sum of paid March claims now

stands at £175,996.63



of 5

From the total of approved claims, £247,721.89 relates to April claims. These were claims originally

withheld from payment, the further evidence and information required for payment has now been supplied.

The figure also includes a number of late submission claims. The total sum of paid April claims now stands

at £713,520.78

Claims were withheld from payment due to the following reasons:

o No backing evidence of spend was provided

o Practices did not submit forms correctly

o Practices did not provide appropriate rationale for the claim

o The CCG are awaiting further supporting evidence to allow a review of clinical need for appropriate

medical equipment to be undertaken

o Following clinical review the item may or may not be deemed as appropriate or necessary in relation

to COVID-19

Total Spend Breakdown of claims paid in May

A breakdown of the spend in each claim category is listed below:

Area of Spend Cost

Cleaning Resources £11,948.83

Equipment Costs (including the additional costs noted previously) £40,665.58

Estates Costs £0

Laundry Costs £27

PPE £31,656.39

Postage Costs £2,935.86

Printing/Stationary £674.12

Scrubs £4,156.68

Telephony Charges £6,032.12

Admin Staffing (Including Practice Manager Time) £97,813.23

GP Partner and Salaried Staffing £91,611.29

Nursing Staff Costs £19,790.25

GP Locum Costs £96,618.28

Cleaning Staff (Additional Expense) £3,543.07

COVID Expenses - Other £21,722.06

(N.B this table is based on the categorisation of items by individual practices).

Future submission and payment dates are as follows:

June 2020 Claim - Submit by 3 July - Paid by 24 Jul



of 5

Summary

The total amount approved for payment so far for May 2020 COVID-19 expenses is £429,194.76.

Due to receipt of additional information, evidence and new claims, a further £281,587.47 of the total approved

figure is from claims dated March and April.

On-going contact is taking place with practices where deductions from their original claims were made. If

practices are able to provide further information and evidence, deeming the claim payable, they will be

considered for future payment in July 2020.

The maximum payable for this month’s claims would be £539,277.91.

Recommendation

1. NOTE the information for assurance purposes.



of 4

Meeting Title: Primary Care Commissioning Committee

(Open Session)

Date: 15 July 2020

Paper Title: Workforce Scoring Matrix for List Closures

– Practice Data Comparison


Sponsor:

Presenter:


Care

Attachments/

Appendices:


Care



Assurance

Information

☒

Executive Summary


Delegated function 4 – Decisions in relation to the commissioning, procurement and management of

primary medical services contracts.

The PCCC approved the inclusion of General Practice Workforce Data in future papers where workforce

challenges have been highlighted by a practice. This paper uses this data to revisit three list closure

applications submitted in 2019.


Compliance with Statutory Duties ☒ Wider system architecture development

(e.g. ICP, PCN development)

☐

Financial Management ☐ Cultural and/or Organisational

Development

☐

Performance Management ☐ Procurement and/or Contract Management ☒





Equality / Quality Impact

Assessment (EQIA)


Data Protection Impact

Assessment (DPIA)


Workforce Scoring Matrix for List Closures - Practice Data Comparison


of 4

Risk(s):

No risks are identified within the paper

Confidentiality:

☒No

Recommendation(s):

1. RECEIVE the revised comparison of the workforce data for three list closure applications



of 4

Workforce Scoring Matrix for List Closures

1. Introduction

A paper was presented to the Primary Care Commissioning Committee (PCCC) on 20 May 2020, this

paper included reference to the National Workforce Reporting System (NWRS), used to collate

workforce data for Nottingham and Nottinghamshire practices. The practices submit a General Practice

Workforce Data return via the National Workforce Reporting System; this is published on a quarterly

basis on the NHS Digital website.

The PCCC supported the use of this data as evidence of practice workforce challenges for future list

closure applications etc. A communication has been sent to Nottingham and Nottinghamshire practices

to emphasise the importance of submitting accurate details of their current workforce on the National

Workforce Reporting System. This also explained how the data will be used for future PCCC papers.

The purpose of this paper is to revisit three previous list closure decisions using the General Practice

Workforce Data returns against the workforce measures referenced in each of the list closure

applications.

2. General Practice Workforce Data compared for List Closure Applications

The table below compares the General Practice Workforce Data:

a) Submitted prior to the list closure application

b) Referenced in the list closure application

c) Submitted for period ending 31 March 2020

Practice A is located in Nottingham City, Practice B is located in Mid-Nottinghamshire and Practice C is

located in South Nottinghamshire.

a) Workforce data

submitted prior

to the list closure

application

b) Workforce data

referenced in

list closure

application

c) Workforce data

submitted for

period ending

31st March 2020

Practice A requested a list closure in November 2019. The workforce data submitted prior to the list closure

is dated September 2019. The data referenced in the list closure application is as of 1st October 2019.

List Size (Raw) 4,457 4,457 4,482

GP WTE (excl. Registrars and Locums) 1.73 1.99 2.17

GP: Patient Ratio 1 : 2,576 1 : 2,240 1 : 2,065

Practice B requested a list closure in September 2019. The workforce data submitted prior to the list

closure is dated June 2019. The data referenced in the list closure application is as of 1st July 2019.

List Size (Raw) 19,879 19,893 19,668


GP: Patient Ratio 1 : 1,847 1 : 1,680 1 : 1,828

Practice C requested a list closure in September 2019. The workforce data submitted prior to the list



of 4

closure is dated June 2019. The data referenced in the list closure application is as of 1st July 2019.

List Size (Raw) 5,057 5,056 4,968


GP: Patient Ratio 1 : 2,467 1 : 2,014 1 : 1,813

The comparison between the data submitted prior to the list closure and the data referenced in the list

closure application for each practice differs slightly. All practices show an improvement in Whole Time

Equivalent (WTE) figures and as a result the GP/ Patient ratio shows a reduction.

All three practice list closure applications submitted to PCCC showed an acceptable GP WTE, based on

the British Medical Association (BMA) guide to clinical contacts on known parameters for an average list

size of 1 WTE GP to 2,239 patients. The applications did factor other challenges, for example, capacity

of the premises anticipated changes in workforce, list size growth.

Practice A re-opened the practice list on the 1st June 2020. The practice recruited a new GP that joined

the contract on the 16 April 2020. The increased GP workforce should be reflected in the May 2020

return that will be available on the NHS Digital website in August 2020.

Practice B is due to re-open the practice list on 1 October 2020. The latest GP WTE reported on the

workforce data is the same figure submitted in June 2019.

Practice C is due to re-open the practice list on the 20 September 2020. The practice requested a list

closure due to the limited availably of clinical rooms and with the growing list size is impacting on the

current workforce.

3. Conclusion

In conclusion, the accuracy of the data submitted by the practices across Nottingham and

Nottinghamshire is varied and has been inaccurate for some practices. The Primary Care

Commissioning Team is currently developing further local guidance that will be shared with practices to

encourage accurate returns to be submitted on the National Workforce Reporting System (NWRS)

portal.

The comparison does show that whilst in some cases the GP/patient ratio wasn’t always the primary

reason for the list closure application, the decision to approve the list closure took the workforce position

into account along with other challenges. The comparison shows that the practice workforce has

improved, practice A has already re-opened the patient list and both practice B and C will re-open their

lists in October and September respectively.

4. Recommendation

The Primary Care Commissioning Committee is asked to RECEIVE the revised comparison of the

workforce data for three list closure applications



of 4


Date: 15 July 2020

Paper Title: Finance Report at Month Three Paper Reference: PCC 20 069

Sponsor:

Presenter:

Michael Cawley – Operational Director of Finance


Month Three Finance Report Enclosed

Michael Cawley – Operational Director of Finance



Assurance

Information

☒

Executive Summary

This Primary Care Commissioning (PCCC) Finance Report is written in the context of a revised financial regime implemented by NHS England/Improvement (NHSEI) given the current COVID-19 pandemic and resulting crisis.

This has resulted in a revised PCCC budget of £47.45m for months 1-4, further details of how this has been arrived at can be found in the introductory section of the Finance Report.

The CCG is reporting a breakeven position for Primary Care Commissioning based on the assumption of allocation being provided by NHSEI, as noted in the main body of the report.



☐

Financial Management ☒ Cultural and/or Organisational Development

☐










Finance Report


of 4

Risk(s):

At this point the £2.9m required allocation has not yet been reviewed and actioned by the NHSEI team.

Confidentiality:

☒No

Recommendation(s):

1. NOTE the contents of the Primary Care Commissioning Finance Report.

2. APPROVE the Primary Care Commissioning Finance Report as at June 2020.

Finance Report


of 4

Primary Care Commissioning Committee – Finance Report – June 2020

NHS Nottingham & Nottinghamshire CCG

Introduction

This Primary Care Commissioning (PCCC) finance report is written in the context of a revised financial regime

implemented by NHS England/Improvement (NHSEI) given the current COVID-19 pandemic and resulting

crisis.

The original CCG wide Revenue Resource Limit (RRL) for the financial year, including the PCC allocation, has

been removed by NHSEI. This has been replaced with a non recurrent budget to cover an initial revised

reporting period, months one to four. NHSEI have calculated this budget primarily by reference to 2019/20

outturn (further detail is given in the public Governing Body Finance Report for month two). NHSEI have then

informed CCGs to report actual costs against this budget and any resulting variances will be top-sliced or

funded accordingly to allow the CCG to break-even and report an on plan financial position for each reporting

period.

The CCG wide, and also the PCC specific, budget set by NHSEI for the period has been assessed by the

CCG finance team to be below our expected costs, so the CCG will expect to overspend initially and require

an additional allocation adjustment. The key reason why the CCG expects the NHSEI initial budget to be

below requirements is because the 2019/20 outturn position included a number of non recurrent benefits and

income in 2019/20 (which enabled the CCG to deliver its financial duties) that NHSEI budget setting

methodology then assumes are recurrent/on-going. As this is not the case, the budget is therefore under-

stated.

For PCC, NHSEI have set a budget of £47.45 million for the four month period, whereas the expected budget

requirement calculated by the CCG finance team is £50.49 million. This gives an anticipated budget shortfall of

£3.04 million for the 4 month period, and £2.28 million for the month three year to date (YTD) reporting period.

The CCG budgeting approach has been to set budgets, on a service by service basis, to match our expected /

required budget and to hold the difference between this and the NHSEI budget (ie., the funding gap and thus

expected overspend) on a separate reserves line.

The financial position, including the budget as describing above, and the month three actual costs, with a

forecast for the four month initial reporting period is set out below:

The financial position below shows the overall position for NHS Nottingham and Nottinghamshire CCG.

Co-Commissioning Category

YTD

Budget

(£m)

YTD

Actual

(£m)

YTD

Variance

(£m)

4 Mths

Budget

(£m)

FOT

Actual

(£m)

FOT

Variance

(£m)

Dispensing/Prescribing Drs 0.48 0.39 0.09 0.64 0.50 0.15

Enhanced Services 1.09 0.84 0.25 1.45 1.12 0.33

General Practice – APMS 1.80 2.05 (0.25) 2.40 2.48 (0.08)

General Practice – GMS 17.12 17.18 (0.06) 22.83 22.95 (0.12)

General Practice – PMS 6.27 6.33 (0.06) 8.37 8.37 (0.01)

Other GP Services 0.30 0.47 (0.17) 0.40 1.15 (0.75)

Other Premises costs 0.77 0.82 (0.05) 1.02 1.08 (0.06)

Premises Cost Reimbursement 4.02 3.93 0.09 5.36 5.15 0.21

Primary Care Networks 2.80 3.29 (0.49) 3.73 4.21 (0.48)

QOF 3.22 3.22 0.00 4.29 4.29 (0.00)

Subtotal 37.87 38.52 (0.65) 50.49 51.30 (0.81)

NHSEI Budget Balancing Line (2.28) 0.00 (2.28) (3.04) 0.00 (3.04)

Subtotal 35.59 38.52 (2.94) 47.45 51.30 (3.85)

Anticipated NHSEI Budget Adj 2.94 0.00 2.94 3.85 0.00 3.85

Grand Total 38.52 38.52 0.00 51.30 51.30 0.00

Finance Report


of 4

Year to Date

The year to date financial position for the CCG is showing a year to date overspend position of £2.94 million.

Due to the current situation regarding the Coronavirus Pandemic, NHSEI made a decision to determine the

level of budgets that feature within our General Ledger for months one to four (April – July).

This has resulted in a negative budget being required described as ‘NHSEI Budget Balancing’ line and this

identifies the variation to what budget should feature as part of the Primary Care Commissioning position

against the value determined by NHSEI. This is showing a overspend position on this line of £2.28m of the

overall position of £2.94m overspend.

It is anticipated that NHSEI will provide an allocation in order to show a breakeven position and this can be

seen on the line ‘Anticipated NHSEI Budget Adj’ line.

The main drivers of the remaining £0.65m overspend are:

Enhanced Services – There are underspends relating to both Minor Surgery and Learning

Disability Healthchecks, following a review in month three this has increased in relation Minor

Surgery, by basing estimates on what has been claimed so far in the year as well as what was

claimed in 19/20.

Primary Care Network (PCN) – The overspend position here relates to the Additional Roles

commitments from 2019/20 that were agreed to be made available in 2020/21.

General Practice – APMS – There has been a considerable increase in the Caretaking fees that

were expected in relation to 2019/20, this is where the Caretaking contracts that we currently have

are reimbursed on a ‘full cost recovery’ basis so the provider does not have a financial loss from

running those practices totalling £0.28m. There are also agreed Caretaking fees for 2020/21 and

these total £0.15m. Thus meaning the total increase within this area is £0.43m.

Other GP Services – There have been a number of claims received in respect of Locums covering

Maternity leave.

Premises Cost Reimbursement – The main cause of the underspend is the accounting for the

reimbursement of Business Rates as part of the GL Hearn Exercise. This has reduced from month

two due to increases in the rental values from DV reviews.

It is important note that any costs relating to the claims for Covid-19 expenditure do not form part of the figures

presented above as part of Co-Commissioning budgets.

This expenditure is presented as part of the CCG Core Primary Care budgets and at month three currently

totals £1.778m.

Forecast

The forecast consolidated position represents the anticipated breakeven position at month three and showing

the allocation that is required by NHSEI. The key drivers to this position are the factors noted above.

Recommendation

The Primary Care Commissioning Committee is asked to NOTE and APPROVE the contents of the Finance

Report as at June 2020.

Finance Report


of 2


Date: 15 July 2020

Paper Title: Risk Report Paper Reference:

PCC 20 070

Sponsor: N/A Attachments/ Appendices:

Risk Report

Risk Register (Extract) - Appendix A

Presenter: Siân Gascoigne, Head of Corporate Assurance

Summary Purpose:

Approve ☐ Endorse ☐ Review ☐ Receive/Note for:


☒

Executive Summary

The purpose of this paper is to present the Primary Care Commissioning Committee with risks relating to the Committee’s responsibilities. The paper provides assurance that primary care risks are being systematically captured across the Nottingham and Nottinghamshire CCG and sufficient mitigating actions are in place and being actively progressed.


Compliance with Statutory Duties ☒ Wider system architecture development (e.g. ICP, PCN development)

☐

Financial Management ☐ Cultural and/or Organisational Development ☐







Yes ☐ No ☐ N/A☒ None required for this paper.


Yes ☐ No ☐ N/A☒ None required for this paper.

Risk(s):

Report contains all risks from the CCG’s Corporate Risk Register which fall under the remit of the PrimaryCare Commissioning Committee.

Risk Report


of 2

Confidentiality:

☒No

Recommendation(s):

1. COMMENT on the risks shown within the paper (including the high/red risk) and those at Appendix A; and

2. HIGHLIGHT any risks identified during the course of the meeting for inclusion within the Corporate Risk Register.

Risk Report


1

Primary Care Commissioning Committee

Monthly Risk Report

1. Introduction

The purpose of this paper is to present the Primary Care Commissioning Committee with risks relating

to the Committee’s responsibilities. It provides assurance that primary care risks are being

systematically captured across the Nottingham and Nottinghamshire CCG and sufficient mitigating

actions are in place and being actively progressed.

2. Risk Profile

There are currently five risks relating to the

Committee’s responsibilities (as detailed in

Appendix A). This is an increase in one risk

since the last meeting.

Since the last meeting, risks have been

reviewed by the Head of Corporate

Assurance, in conjunction with the Chief

Commissioning Officer and the Associate

Director of Primary Care.

The table to the right shows the current risk

profile of the five risks.

There is one high / red risk in the Committee’s remit as outlined below.

Risk

Reference Risk Narrative

Current Risk

Score

RR 032

Reducing workforce capacity within General Practice may impact the

sustainability of some GP Practices. In responding to these

challenges, Practices should consider adapting their workforce

models to enable the sustained delivery of core services, whilst also

ensuring sufficient capacity to deliver/contribute to system and

transformation requirements.

Lack of pace of change may present a risk that the CCG's population

access needs are not met, adversely impacting patient experience

and/or outcomes.

Update: The ICS Primary Care Workforce Strategy continues to be in

place; updates in relation to the delivery of this work have been

requested from relevant CCG colleagues. The delivery of this

Strategy is recognised as not being a short-term 'fix' for current

workforce challenges. The CCG has contacted NHSEI to obtain the

latest Primary Care workforce statistics (from the June 2020

quarterly data collection). It is recognised that there will be a shift in

Primary Care workforce modelling as a result of the Covid pandemic.

Overall Score

16: Red

(I4 x L4)

Risk Matrix

Imp

act

5 - Very High

4 – High 1 1

3 – Medium 3

2 – Low

1- Very low

1

- R

are

2 -

unlik

ely

3 -

Po

ssib

le

4 -

Lik

ely

5 -

Alm

ost

Cert

ain

Likelihood

Risk Report


2

3. Risk Identification

There have been no new risks identified since the last meeting.

4. Archiving of Risks

There are no risks proposed for archiving.

5. Amendments to Risk Score/Narrative

There have been no amendments to risk narrative or score since the last meeting.

6. Recommendations

The Committee is asked to:

COMMENT on the risks shown within this paper (including the high/red risk) and those at

Appendix A; and

HIGHLIGHT any risks identified during the course of the meeting for inclusion within the

Corporate Risk Register.

Siân Gascoigne

Head of Corporate Assurance

July 2020

Risk Report


Risk Ref Oversight Committee Directorate Date Risk

Identified Risk Description Risk Category Existing Controls Mitigating Actions Mitigating Actions Progress Update:

Last Review

DateTrend

(Relevant committee in the

CCG's governance structure

responsible for monitoring

risks relating to their

delegated duties)

(as per April 2020

CCG structure)

(Date risk

originally

identified)

(These are operational risks, which are by-products of day-to-day

business delivery. They arise from definite events or circumstances

and have the potential to impact negatively on the organisation

and its objectives.)

Imp

act

Like

liho

od

Sco

re (The measures in place to control risks and reduce the

likelihood of them occurring).

(Actions required to manage / mitigate the

identified risk. Actions should support

achievement of target risk score and be

SMART (e.g. Specific, Measurable,

Assignable, Realistic and Time-bound).

Imp

act

Like

liho

od

Sco

re (To provide detailed updates on progress being made against any mitigating actions identified.

Actions taken should bring risk to level which can be tolerated by the organisation).

(Movement

in risk score

since

previous

month)

RR023 Primary Care Commissioning

Committee

Commissioning Jul-19 As practices have seen an increase in charges for non-

reimbursable costs for premises from Property Services and from

CHP (Community Health Partnerships), there is a risk that (for

some practices) this may impact viability of providing primary care

services from their current location.

This may, in turn, lead to service disruption, inability to invest

and/or risks to patient access to primary care services.

Finance

Lucy

Dad

ge

Lyn

ne

Shar

p /

Jo

e Lu

nn

3 3 9 • CCG meetings with NHS Property Services and

Community Health Partnerships (quarterly).

• Engagement with NHS England Primary Care national

and local teams

• LMC support to Practices

Action: To continue to work with local GP

practices, the LMC and property companies

(NHSPS and CHP) to ensure management

plans are in place.

Action: To escalate larger GP practice debts

to NHSE/I for further national support.

3 3 9 July 2020: The Associate Director of Estates presented an update to the June 2020 PCCC meeting

on Covid and non-Covid related Primary Care estate activity (including debt management). A

joint meeting between NHSEI, the CCG and the Practice(s) are being set up for those Practices

with the largest challenges regarding debt. It has been recognised that this needs to be re-

prioritised as an area of focus post Covid.

06/07/2020 ↔


Committee

Commissioning Jul-19 Reducing workforce capacity within General Practice may impact

the sustainability of some GP Practices. In responding to these

challenges, Practices should consider adapting their workforce

models to enable the sustained delivery of core services, whilst

also ensuring sufficient capacity to deliver/contribute to system

and transformation requirements.

Lack of pace of change (e.g. adaption of workforce models) may

present a risk that the CCG's population access needs are not met,

adversely impacting patient experience and/or outcomes.

Commissioning

Lucy

Dad

ge

Joe

Lun

n

4 4 16 • Role and remit of the Primary Care Commissioning

Committee (and supporting governance structures - e.g.

primary care quality / contracting teams)

• PCCC assurance reporting requirements.

• Establishment of Primary Care Cell, as part of CCG's

Covid-19 incident response

• ICS Primary Care Workforce Strategy; ICS Primary Care

Board

• Establishment of Primary Care Networks (PCNs) (and/or

other collaboration/federation activities)

• Ensuring the best use of funding via the GP Forward

View, targeting resources to areas of need e.g. GP

Resilience Funding, Practice Manager training and

development funding.

• CQC Inspection Rating(s) / Report(s).

Action: Implement and embed PCCC

supporting governance and reporting

requirements to ensure appropriate

assurance is provided regarding primary

care services (e.g. quality of services,

delivery of contract requirements, patient

experiences).

Action: To continue to deliver requirements

of Primary Care Workforce Strategy: to

request further update regarding delivery

of the Strategy to the CCG's PCCC.

4 4 16 July 2020: The ICS Primary Care Workforce Strategy continues to be in place; updates in relation

to the delivery of this work have been requested from relevant CCG colleagues. The delivery of

this Strategy is recognised as not being a short-term 'fix' for current workforce challenges. A

further update in relation to the Strategy is to be requested for a future meeting of the PCCC.

The CCG has contacted NHSEI to obtain the current/latest Primary Care workforce statistics

(from the June 2020 quarterly data collection). It is recognised that there will be a shift in

Primary Care workforce modelling as a result of the Covid pandemic.

06/07/2020 ↔


Committee

Commissioning May-20 Covid-19 may present a risk to the sustainability of safe and

effective delivery of primary care services to members of the CCG's

population.

This may be due to Primary Care workforce having to 'shield' or

self-isolate, lack of PPE to ensure safe working, or challenges with

GP Practice estate not meeting infection, prevention and control

(IPC) requirements.

This risk may be exacerbated if/when there is a surge in primary

care activity.

Workforce

Lucy

Dad

ge

Joe

Lun

n

4 4 16 • Primary Care 'Cell' within the CCG's emergency response

infrastructure

• Roll-out of IT infrastructure/technology to support

virtual working (e.g. telephone appointments, etc.)

• Routine OPEL reporting and escalation processes

• Establishment of CMCs and ability to step up/step down

if needed

• PCN 'buddying' processes in place

• 'Roving' workforce support across Practices.

Action: To continue with incident response

structures as described.

Action: To take appropriate actions, as

identified, following the Remote Working

Hazard Workshop.

4 3 12 July 2020: GP workforce capacity continues to be monitored daily via the Primary Care Cell

(which has been established as part of the incident response structure). Daily Primary Care OPEL

reports are in place to monitor primary care workforce and service pressure, as well as concerns

and issues (such as lack of PPE, for example). All Practices have been required to complete risk

assessments for BAME/clinically vulnerable staff.

In addition, each Primary Care Network (PCN) has identified a business continuity plan to

respond to workforce pressures. Joint working through CMCs is also an option with 'step up' and

'step down' arrangements in place. This will build more capacity and resilience to delivering core

General Practice services.

The CCG held a Remote Working Hazard Workshop with GP colleagues to held identify the

potential quality hazards/risks to remote working and what mitigations need to be put in place

to stop these materialising. This is scheduled to be fed back to the July PCCC meeting.

06/07/2020 ↔


Committee

Commissioning May-20 There is an increased risk of Covid-19 infection to clinically

vulnerable (including BAME) primary care workforce which may

impact the provision of primary care services across the CCG's

population.

This may particularly impact areas of Mid-Nottinghamshire and

Nottingham City.

Workforce

Lucy

Dad

ge

Joe

Lun

n

3 4 12 • Primary Care 'Cell' within the CCG's emergency

response infrastructure




• Establishment of CMCs and ability to step up/step

down if needed



Action: To continue to seek assurance

regarding the completion of risk

assessments and progressing any actions

identified from these (or the IPC Estates

Reviews).

3 3 9 July 2020: The main mitigation to this risk is the digitalisation of Primary Care service provision.

The CCG has sought assurance from all GP Practices that risk assessments have been completed

and any subsequent actions identified. Further actions have also been identified following

review of Primary Care Estate to determine whether it is compliant with new IPC requirements.

Mitigations are also via the GP Practice business continuity plans and the ability to 'step up' and

'step down' CMCs.

06/07/2020 ↔


Committee

Commissioning Jun-20 The impact of Covid-19 test, track and trace on workforce may

impact primary care service provision. The likelihood of this risk

materialising is greater for smaller/single-handed practices.

Workforce

Lucy

Dad

ge

Joe

Lun

n

3 4 12 • Primary Care 'Cell' within the CCG's emergency

response infrastructure




• Establishment of CMCs and ability to step up/step

down if needed



Action: To continue to seek assurance

regarding the completion of risk

assessments and progressing any actions

identified from these (or the IPC Estates

Reviews).

3 3 9 See update for risk RR 137 above. 06/07/2020 ↔

Current Risk RatingInitial Risk Rating

NHS Nottingham and Nottinghamshire CCG Corporate Risk Register (June 2020)

Exe

cuti

ve L

ead

Ris

k O

wn

er

Risk R

eport

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