Newham Primary Care Commissioning Committee Part I – 15.00-16.00 Wednesday 5 February 2020

FO21 Plaistow Room, 4th Floor, Unex Tower, 5 Station Street, London E15 1DA

Agenda

No Time Item Action Required Page Presenter

1. Administration and updates

1.1

3.00pm

Welcome, introductions and apologies Chair

1.2 Declarations of interests Monitor Chair

1.3

a) Minutes of the previous meeting – 18December 2019

b) Chair’s Action – APMS Tranche 7 Lot10 Contract Extension

Approve

Approve

Page 2

Page 4Chair

1.4 Action log Monitor Page 6 Chair

1.5 3.10pm The Project Surgery Update Monitor Page 7 Joseph Lee

1.6 3.20pm PCN DES Draft Specifications Monitor Page 11 Leilla Shaikh

1.7 3.25pm Finance Report

Monitor Page 60 Vince Henaghan

2. Decision items

2.1 3.35pm Terms of Reference – Updated Decision Page 67 Lauren Sibbons

2.2 3.40pm Boleyn Medical Centre (Dr M Khan) – temporary list closure

Decision Page 78 Lorna Hutchinson

2.3 3.50pm The Forest Practice – temporary list closure Decision

To Follow Lorna Hutchinson

3 Any Other Business

3.1 3.55pm Proposed change of Committee

schedule Chair

Next meeting:

TBC

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Primary Care Commissioning Committee Part I meeting: 4.30pm-5.30pm Wednesday 18th December 2019

Committee rooms, 4th Floor, Unex Tower, 5 Station Street, E15 1DA

Minutes

Voting members present:

Phil Horwell (Chair) Lay Member

Ellie Robinson Lay Member

Steve Collins Executive Director of Finance, WEL CCGs

Fiona Smith Board Nurse, NCCG

Jenny Mazarelo Director of Primary Care (Interim), WEL CCGs

Non-voting members present:

Nadeem Faruq GP Board Member, NCCG

Fiona Hackland Head of Commissioning, Public Health – Adults, LBN

In Attendance:

Yusuf Olow Interim Committee Officer, NCCG (minutes)

Lorna Hutchinson Assistant Head of Primary Care, NEL Primary Care Team

Lauren Sibbons Head of Primary Care, Newham CCG

Apologies:

Chetan Vyas Director of Quality & Safety, WEL CCGs

Leonardo Greco Healthwatch Newham

Greg Cairns Director of Primary Care Strategy, Londonwide LMC

Zulfiqar Ali Cabinet Member for Health and Adult Social Care, LBN

No Item

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1.1 Welcome, introduction, apologies for absence and declarations of interest

The Chair welcomed everyone to the meeting and noted the apologies above.

1.3 Minutes of the meeting held on 30th October 2019

The Committee agreed that the minutes of 30th October 2019 were a fair and accurate account of the meeting.

Minutes of the meeting held on 27th November 2019

The Committee agreed that the minutes of 27th November 2019 were a fair and accurate account of the meeting.

1.4 Action log

PCCC111 Strategic Estates Plan

This action was not due.

PCCC122 Newham Health Report

J Mazarelo clarified that the Newham Health Report would be presented by Leonardo Greco at the next meeting he attends. The Chair requested that should L Greco be unable to attend that a paper be tabled regardless. The Chair expressed concern that this report, offered by Newham Healthwatch to the Committee in August and deferred again in October remained outstanding. The Committee requested that the report be presented to the next meeting without further delay

Action: L Greco to be advised that the outstanding report is expected at the next meeting

2. Any Other Business

2.1 The Chair requested that an update be given in relation to the Project Surgery and how the situation had changed, whether for better or for worse, suggesting that it would be useful for the Committee.J Mazarelo agreed to follow up on the request.

Action: JM to seek an update from The Project Surgery

2.2 Next meeting:

NEL Primary Care Commissioning Committees in Common

Monday 13th January 2020

2.00pm-4.00pm, Old Town Hall, 29 The Broadway, Stratford, E15 4BQ

Newham CCG Primary Care Commissioning Committee

Wednesday 5th February 2020

2.30pm-3.30pm Plaistow room 4th Floor, Unex Tower, 5 Station Street, London E15 1DA

3

Chair’s Action

Primary Care Commissioning Committee (PRCO)

a) Newham CCG’s Constitution gives the Chair of a meeting of its Governing Structure the authority totake a decision normally reserved for that body by virtue of the following paragraphs within itsConstitution:

5.1.3 The provisions of these standing orders shall apply where relevant to the operation ofthe Practice Member Council, Board, the Board’s Committees and Sub-Committees and allCommittees and Sub-Committees unless stated otherwise in the Committee or Sub-Committee’s terms of reference

4.6. Chair's ruling

4.6.1. The decision of the Chair of the Board on questions of order, relevancy and regularityand their interpretation of the Constitution, standing orders, Scheme of Reservation andDelegation and prime financial policies at the meeting, shall be final.

4.9. Emergency powers and urgent decisions

4.9.1. The powers which the Board has reserved to itself within these Standing Orders mayin emergency or for an urgent decision to be exercised by the Chief Officer and the Chairafter having consulted at least two non-executive members. The exercise of such powers bythe Chief Officer and Chair shall be reported to the next formal meeting of the Board inpublic session for formal ratification.

And that as a matter of interpretation it is deemed that the phrase “where relevant to the operation of …Committees and Sub-Committees” is appropriate in relation to paragraphs 4.6 and 4.9

b) These paragraphs relate to;

The Executive Committee

The Audit Committee

The Remuneration Committee

The Quality Committee

The Primary Care Commissioning Committee

c) The terms of reference of the following Committees (approved by the Executive Committee), whichare not part of the Constitution, gives the Chair of these meetings the authority to take a decisionnormally reserved for that meeting with guidance on the requirement to report back on the actiontaken to the next meeting;

The Integrated Care Committee

The Acute Commissioning Committee

The Community Commissioning Committee

The Mental Health Commissioning Committee

The Children and Maternity Commissioning Committee

The Urgent Care Working Group

The Information Management and Technology Committee

The Finance Committee

The Medicines Management Committee

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2

1. Decision taken normally within the terms of reference of the Committee

Approval to extend an APMS contract end date from 31 March 2020 to 30 June 2020.

2. Reason decision cannot await consideration at next meeting

A delay in issuing outcome letters to bidders from 7 October to 3 December 2019 hasadversely impacted on the mobilisation period that should have commenced on 23 October2019. Both the current incumbent and new provider are in agreement that commencing thenew contract on 1 July 2020, rather than 1 April 2020 will allow for a smoother transition,including engagement with patients and staff affected by a TUPE transfer.

3. Date of next meeting where decision will be reported to the Committee: 29 January 2020

Signed…………………………………… Date:

Chair of the Primary Care Commissioning Committee

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Action

referenceMeeting date Action Owner Deadline Update

PCCC111 31/10/2018

Strategic Estates Plan

Strategic Estates Plan approved by PCCC on 31.10.18 on an annual

review cycle S Collins 30.06.20

No annual update to the Newham SEP required. WEL SEP

development underway which will incorporate Integrated Care

System plans and be shared with PCCC when complete.

Item 1.4: 5 February 2020 Primary Care Commissioning Committee - Action Log Part I

Highlighted items represent a recommendation to remove from register

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Primary Care Commissioning Committee Part I meeting: 15.00-16.00 Wednesday 5 February 2020 FO21 Plaistow Room, 4th Floor Unex Tower, 5-7 Station Street, London E15 1DA

Title Update of Subcontracting of Primary Medical Services – The Project Surgery

Agenda item 1.5

Author Joseph Lee, Senior Transformation Manager, WEL CCGs

Presented by Joseph Lee, Senior Transformation Manager, WEL CCGs

Contact for further information

Joseph Lee, Senior Transformation Manager, WEL CCGs,

josephlee@nhs.net

020 3688 2227

This paper is for ☐ Decision ☐ Monitor ☐ Discussion ☒ For Information

Action required The Committee is requested to note the contents of the report regarding The Project Surgery’s subcontracting of its core service delivery to MD International Limited, trading as Docly.

Executive summary

The Project Surgery comprises of a sole Personal Medical Services (PMS) contract holder. The practice is located in Plaistow with a registered population of 5,052 patients with a Good CQC rating.

The contract holder’s previous request to partially sub contract primary medical services provision to a third party provider due to maternity leave within the practice, was approved by the Committee on 30 October 2019 and an update requested at a future meeting.

The update provides high level data on the usage so far, including utilisation and waiting times, and the practice and patient experience of the service.

Supporting papers None

Next Steps/ Onward Reporting

No planned further presentation or reporting.

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Where has the paper been already presented?

Previously presented to Primary Care Committee on 30 October 2019

How does this fit with NHS Newham CCG strategic Priorities?

Strategic Priorities • To commission a Newham-based integrated health and care system which

delivers high quality services for the residents of Newham, in accordance withstatutory requirements

• To commission and develop GP services that are modern, accessible and fitfor the future in caring for our residents

Enabling Priorities • Ensuring we maintain our performance across the key business areas

Outcomes • We will improve access to, and, the quality of, Primary Care• We will clearly be able to demonstrate how we have improved outcomes for

our residents

Commissioning Priorities • To implement the five-year framework for GP contract reform to implement

The NHS Long Term Plan.

Risk BAF.05– Failure to effectively monitor the quality, performance and activity ofcommissioned services, with a focus on ensuring the delivery of better clinicaloutcomes.

BAF.07.01 Failure to effectively deliver a primary care strategy that isadequately resourced to service Newham residents

Equality impact There is no anticipated adverse impact to patients. The proposal enables an element of current service provision to be sub-contracted resulting in no loss of face to face access for patients. The approval enabled an increase in clinical capacity in the short term to negate negative impact for patients wishing to access the service.

Stakeholder engagement

Presented at Practice PPG in September 2019

Further patient engagement has been conducted upon roll out

Financial Implications

Newham CCG faces a significant financial challenge in 2019/20 and is undertaking a range of measures to ensure sustainability. This paper presents issues that may have financial consequences. These are yet to be fully determined but if not already embedded in budgets or reserve provision, a further Board decision would be required to release any additional expenditure commitment.

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1. Introduction and background

1.1

1.2

1.3

1.4

The Project Surgery has a registered patient population of 5,052 (as at 1 October 2019) and five GPs (headcount) delivering twenty one clinical sessions a week. The practice currently offers online consultations, telephone consultations and face-to-face appointments for its patients.

The practice contacted the CCG to request approval to sub-contract 20 clinical hours of its primary medical service provision, with effect from 1 November 2019, as a result of three Salaried GPs about to go on maternity leave.

The request was to subcontract to MD International Limited, trading as Docly, who are a CQC registered provider of digital consultations. This request was approved by Primary Care Commissioning Committee on 30 October 2020.

The approval was made with a request that an update be provided to the Committee regarding the usage of the service including patient and practice feedback.

2. Sub-Contracting Update

2.1

2.1.1

2.1.2

2.1.3

2.1.4

2.1.5

2.1.6

2.1.7

The sub-contracting of in hours services to Docly is delivered through an online consultation platform which requires patients to register and submit an online consultation form to be reviewed.

Whilst the practice did have access to the CCG’s commissioned online consultation platform, the need to subcontract the GP led review of these forms meant that Docly’s in house software had to be utilised.

The practice has reported that there was some initial hesitation from patients regarding the additional platform, however once they had signed up they seemed extremely happy with the service that they received.

To date the practice has had 367 patients register for the service and 240 consultations or cases submitted. Of these, 98% of patients have submitted only 1 case which would suggest that the platform is predominantly accessed by patients without complex co-morbidities or long term conditions.

The practice have not made the use of Docly mandatory within the practice and therefore traditional access routes and telephone triage remain available for patients.

In relation to patient feedback the service has collected 80 unique sets of patient data and reported that 86% of patients would recommend the service. The practice has reported one complaint has been received as a result of the service, as the patient wanted a face to face appointment prior to triage, this has since been resolved.

The practice has reported that 80% (192) of cases have been submitted in hours with 20% (48) submitted out of hours. The average response time is 2.7 hours and the median is 1 hour.

Of the 240 cases submitted, 24% (58) resulted in a face to face appointment being offered, with the remaining 182 being concluded remotely, freeing up clinical and administrative time. It should be noted that this is in line with previous evaluations that the CCG has conducted on commissioned online consultation products.

9

2.1.8

In summary the practice are extremely satisfied with the additional capacity the service provides and the quality of the consultations provided by Docly.

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Primary Care Commissioning Committee Part I – 15:00 – 16:00 Wednesday 5 February 2020

FO21 Plaistow Room, Unex Tower, Station Street, London E15 1DA

Title Primary Care Network Draft Enhanced Service Specifications

Agenda item 1.6

Author Leilla Shaikh, WEL CCGs, Deputy Director of Primary Care (Interim)

Presented by Leilla Shaikh, WEL CCGs, Deputy Director of Primary Care (Interim)

Contact for further information

Leilla Shaikh, WEL CCGs, Deputy Director of Primary Care (Interim)

E: leilla.shaikh1@nhs.net / T: 020-3688-2334

This paper is for ☐ Decision ☐ Monitor ☐ Discussion x For Information

Action required The Committee is asked to note the response from WEL CCGs to the draft Primary Care Network Directed Enhanced Service Specifications published in December for consultation.

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Executive summary

The report asks the Committee to note the joint response from WEL CCGs, based on feedback from commissioners, local authorities and General Practice colleagues on the draft Primary Care Network Direct Enhanced Service Specifications.

WEL CCGs welcomed the opportunity to give feedback on the specifications, in order to ensure that the final versions would support local initiatives and need.

Supporting papers Appendix A: Draft PCN DES Specifications

Next Steps/ Onward Reporting

Await publication of the final specifications from NHSE

Where has the paper been already

presented?

An overview of the draft specifications was shared at the NEL Primary CareCommissioning Committees in Common

NHSE have hosted webinars to encourage discussion and feedback on thedraft specifications

How does this fit with NHS Newham

CCG strategic Priorities?

Strategic Priorities

• To commission a Newham-based integrated health and care system whichdelivers high quality services for the residents of Newham, in accordance withstatutory requirements

• To commission and develop GP services that are modern, accessible and fitfor the future in caring for our residents

7 Outcomes

• We will have a borough based Integrated Care System that is utilised,understood and valued by our residents

• We will ensure we plan, design, and commission accessible high qualityservices for our residents with our residents

• We will improve access to, and, the quality of, Primary Care• We will clearly be able to demonstrate how we have improved outcomes for

our residents• We will support our entire CCG workforce to deliver what we need to for our

residents• We will promote equality as a commissioner of health services and as an

employer

Risk Failure of NHSE to secure sign up to the new specifications could slow thedevelopment of PCNs

Equality impact This report relates to all Newham residents in the ten protected characteristics that are covered by the Equality Act 2010 and our Equality Duties.

Stakeholder engagement

NHSE have carried out extensive engagement through webinars and social media. Locally we have encouraged stakeholders (General Practice, Local Authorities,

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Community Services) to share feedback to contribute to the joint response.

Financial Implications

Directed Enhanced Services are commissioned and funded by NHS England, so there are no local financial implications. However resource from local teams will be needed to support implementation of the services.

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1. Introduction and background

1.1

1.2

The GP contract framework sets out seven national services specifications that will be added to the Network DES. Draft outline requirements, including proposed network dashboard metrics, for the first five services have now been made available to enable opportunities for stakeholders to review and comment.

The deadline for comments was 15 January 2020. This report gives a brief overview of the specifications, and the response from WEL CCGs to the draft specifications. The final version of the specifications will be published in early 2020 as part of the wider GP contract package for 2020/21. The final versions will include further detail for each requirement, followed by guidance for implementation.

2.

2.1

2.1.1

2.1.2

2.1.3

2.2

2.2.1

Draft PCN DES Specifications

The five national PCN specifications, which will be implemented in a phased approach between 20/21 and 23/24 are:

Structured medication review and optimizations

Enhanced Care in Care Homes

Anticipatory Care

Personalised Care

Early Cancer Diagnosis

Funding has not been allocated directly for delivery of these service specifications. PCNs are expected to use the additional workforce from the roles reimbursement scheme, and additional clinical leadership from GPs to deliver these schemes. CCGs and ICSs will be asked to support PCNs and their community providers to institute shared workforce models to help maximise collaboration.

It is recognised that, for some of the specifications, a locally commissioned service may already exist which covers some or all of the proposed requirements set out in the document. As these proposals are in draft, CCGs are advised that they should not, therefore, take final decisions about existing locally commissioned services until the final Network Contract DES for 2020/21 is published.

Our feedback to NHSE is detailed below.

Clinical Leadership

Across the WEL CCGs, significant work has taken place in partnership with key stakeholders to develop our system plans to improve outcomes relating to care homes, anticipatory care, personalised care, cancer and medicines optimisation. Borough based plans are clinically led, factor local need, as well as system resource and capacity. Any new specifications should encourage PCNs to work as part of their local system to develop the requirements, and to use the existing leadership and management infrastructure in place to support local service and development. PCNs should not be mandated to nominate additional clinical leadership time, as this reduces the amount of time available for patient care.

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2.2.2

2.2.3

2.2.4

2.2.5

Population Health

There are significant variations in population demographics across WEL CCGs. PCNs with a higher number of complex patients cannot be expected to deliver the same outcomes with the same resource as those with a lower number of patients requiring anticipatory care. If the specifications are to address population health inequality, this needs to be factored into the resource. In our experience of commission MDTs, PCNs need flexibility in identifying patient groups that would most benefit from anticipatory care based on their demographics. For example where a PCN has a high proportion of children they may want to develop anticipatory care plans and MDTs linked to the needs of this patient group. PCNs across a borough or ICS should be encouraged to utilise the same tools so that data and information can be shared to support collaboration and sharing of best practice.

Workforce

If the only resource available to deliver the service specifications is the additional roles reimbursement scheme, the expected workload should only relate to this workforce. The specifications need to factor that the workforce will not be in post for a full financial year and needs to consider gaps for any delays in recruitment or staff being on leave. There is also no allowance for London weighting in the roles. From our experience in year one of the PCN DES the majority of staff recruited into the roles reimbursement scheme have little or no experience in primary care. The expectation of any specifications to be delivered by the roles reimbursement scheme, needs to reflect the capability of the skill mix. Should we wish to develop these new roles and sustain them, there needs to be training schemes available to staff. The training hub matrix mentions workforce planning, but this needs to happen at PCN level to make the most of the existing resource and to plan how best to utilise additional staff. There are no easy tools to support workforce and skillmix planning in primary care, without understand current capability it is difficult to plan future need. We need to create an environment where PCNs are not competing with each other or community providers for the same workforce, the approach should support collaboration. For example as well as PCN pharmacists carrying out medicines reviews, other pharmacists working in the community could also provide this service. HEE should ensure that funding to training hubs supports the development of the PCN workforce to deliver national specifications and local need.

Implementation

The maturity matrix sets out a developmental journey for PCNs and their Clinical Directors over the next few years. Many PCNs are just starting to understand how they can work together and with the system. Implementation of the new specifications will require further changes to ways of working for General Practice, and potentially changing the roles for new staff employed. There will be local initiatives and schemes in place that complement or overlap the proposed specifications, commissioners need to have the opportunity to engage with LMCs, PCNs and other stakeholders on the best approach based on local population need and current provision.

Structured Medications Review

In order to support a patient-centred approach that covers all patient groups and multi-

morbidities, we recommend that the spec includes the following points as recommended by

NICE:

People of any age with multi-morbidity conditions

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2.2.6

2.2.7

People prescribed fewer than 10 regular medicines but are at particular risk ofadverse events

The specification should also include a requirement for a referral pathway to PCNs from

health and social care professionals for SMRs for patients identified as needing one. There

also needs to be a consideration of domiciliary SMRs for housebound patients. Reference

needs to be made that the Structured Medication Reviews (SMR) and Enhanced Health Care

Home (EHCH) must to be integrated with other Medicines Optimisation and Pharmacy

services across health economies including CCGs Medicines Optimisation teams, Community

and Hospital Pharmacy and Local Authority Social Care services (e.g. medicines

administration support is provided through care workers). The outcome of the interventions

must be effectively communicated to Community Pharmacists and other healthcare

professionals in a timely manner.

Care Homes

Patient choice applies to residents of care homes, and should patients need to register with particular PCNs, the impact on choice would need to be considered. Residential and nursing homes are not spread out proportionately across our 3 boroughs. PCNs with a higher number of care homes would need to allocate a disproportionate amount of time to these patients in comparison to the rest of the registered list. Also some residential homes have a very small number of beds, so when planning the resource allocated to care homes, this needs to be a factor.

NHSE have acknowledged our feedback.

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Appendix 1

Network Contract Direct

Enhanced Service Draft Outline Service Specifications

17

NHS England and NHS Improvement

18

Version number: 1

First published: December 2019

Updated: NA

Prepared by: Primary Care Strategy and NHS Contracts Team england.networkscontract@nhs.net

Classification: Official - Draft

Publishing Approval Reference: 001238

1 19

Contents

Contents ..................................................................................................................... 2

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

2. Structured Medication Review and Medicines Optimisation ................................ 9

3. Enhanced Health in Care Homes ...................................................................... 14

4. Anticipatory Care ............................................................................................... 22

5. Personalised Care ............................................................................................. 29

6. Supporting Early Cancer Diagnosis ................................................................... 35

2 20

1. Introduction

1.1. In January 2019, NHS England and GPC England agreed Investment and

Evolution: a five-year GP contract framework which aimed to alleviate the workforce

pressures on general practice, secure enhanced investment into primary medical care,

and roll out new service models – in collaboration with community services and other

providers – to secure major improvements in proactive and preventative care for patients.

The GP contract framework, launched in January 2019, commits £978m of additional

funding through the core practice contract and £1.799bn through a new Network Contract

Direct Enhanced Service (DES) by 2023/24, as part of our wider commitment that, on

current plans, funding for primary medical and community services will increase faster

than the rest of the rising NHS budget over the next five years. By 2023/24 spending on

these services will rise by over £4.5 billion in real terms – £7.1 billion in additional

cash investment each year by the end of the period.

1.2. A cornerstone of the new GP contract framework is the creation of

primary care networks (PCNs) through the new Network Contract DES. A PCN

consists of groups of general practices working together with a range of local providers –

including across primary care, community services, social care and the voluntary sector –

offering more personalised, coordinated care to their local populations. There has been

an enthusiastic response to PCNs across the country: over 99% of practices have signed

up to participating in around 1,250 networks, firmly establishing PCNs as a route to

greater collaboration across general practice and the wider NHS.

1.3. The GP contract framework set out seven national services specifications that

will be added to the Network Contract DES: five starting from April 2020, and a further

two from April 2021. The purpose of this document is to provide

PCNs, community services providers, wider system partners and the public with

further detail of – and seek views on – the draft outline requirements for the first

five services, as well as how we plan to phase and support implementation.

Feedback we receive will shape the final version of the service requirements for

2019/20, as well as guidance for implementation. The five services are:

• Structured Medication Reviews and Optimisation • Enhanced Health in Care Homes (jointly with community

services providers) • Anticipatory Care (jointly with community services providers) • Personalised Care; and • Supporting Early Cancer Diagnosis

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1.4. We recognise that PCNs are at the early stages of development and

capacity-building, and that there are concerns about limiting their chances of

success by overburdening them at an early stage with unrealistic expectations for

new service delivery. We therefore propose to phase-in service requirements in a

way that is commensurate with the capacity available to PCNs through the contract

and the support available through wider system. Though a combination of the

additional workforce capacity within primary care, and the redesign of community

services provision to link with and support PCNs, we expect the Network Contract

DES both to reduce workload pressures on GPs and support improved

primary care services to patients.

1.5. The new PCN service specifications are only one part of the wider GP

Contract package. No decisions will be made on individual aspects of the

Network DES and the core Practice Contract without considering all aspects in the

round.

Developing the outline service specifications

1.6 NHS England and NHS Improvement (NHSE/I) has undertaken a wide-ranging process of evidence-gathering and engagement in order to inform these outline service specifications. This has included convening expert working groups for each of the five specifications, with 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. The input from these groups has been invaluable in shaping these proposals.

1.7 As a result of our engagement to date, we are confident that these specifications

are supported by a strong clinical evidence base and will enable PCNs to draw upon

the partnerships with other providers that are at the

heart of the network philosophy. The service requirements set out in the

specifications focus on interventions and cohorts where there is

significant scope to improve outcomes and people’s health and wellbeing.

1.8 The outline service specifications also illustrate the proposed metrics which –

through a new Network Dashboard – will enable PCNs to understand their own

position and support peer learning and quality improvement.

1.9 NHSE/I will continue to develop and refine the proposals in discussion with

GPC England on behalf of general practice through the annual GP contract

negotiations, and in response to feedback from patients, clinicians and

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22

organisations with an interest in primary care and the subject areas of the

specifications. The final version of the specifications will be published in early

2020 as part of the wider GP contract package for 2020/21. The final versions

will include further detail for each requirement, followed by guidance, to

support PCNs and other providers to deliver the requirements as effectively as

possible.

1.10 NHSE/I will continue to consider the opportunities and risks arising from these

specifications (and primary care networks more broadly) in relation to health

inequalities.

Funding and Additional Roles

1.11 The Network Contract DES provides funding entitlements worth £552m in

2020/21, rising to £1.799bn by 2023/24. This comes on top of increases to the core

practice contract worth £296m in 2020/21, rising to £978m in 2023/24.

Funding is not allocated directly for delivery of the service specifications; rather,

the largest portion of network funding (£257m in 2020/21, rising to £891m in 2023/24)

provides reimbursement for additional workforce roles that PCNs can engage to support

the delivery of the specifications and alleviate wider workforce pressures. This funding

enables the deployment of over 6,000 additional staff by 2020/21, rising to over 20,000

by 2023/24. For a PCN covering a population of 50,000 people, that could equate to

around five additional staff in 2020/21 and around 16 additional staff by 2023/24. This

represents a major uplift in the workforce capacity within primary care.

1.12 Providing that PCNs move forward swiftly to engage new staff and use their

additional roles reimbursement entitlement, there will be significant additional

capacity within primary care in 2020/21 to deliver the specifications.

Recruitment decisions by PCNs will depend on their priorities but an average PCN

could – indicatively – engage around 3 WTE clinical pharmacists, 1.5 WTE social

prescribing link workers, 0.5 WTE physiotherapists and 0.5 WTE physician

associates from April 2020. This would provide more than sufficient capacity

to deliver the requirements across all five services with significant capacity

remaining for these additional roles to provide wider support to GP

workforce pressures by handling appointments or queries that would otherwise

have been the responsibly of the GP.

1.13 We will be asking CCGs and ICSs to support PCNs and their community

providers to institute shared workforce models that can help maximise the

collaboration between local partners to deliver the specifications and build the

wider PCN.

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1.14 In addition to the funding for additional workforce roles, a typical practice within

a PCN will receive funding of £14,000 for participating in a PCN through their PCN

participation payment. Each PCN is guaranteed a cash payment of £1.50 per

registered patient and 0.25 FTE funding to support its Clinical Director.

Taken together, this provides over £109,000 for a PCN covering 50,000

people.

1.15 Other funding is available to PCNs through the contract agreement, for

example through their share of the Investment and Impact Fund (IIF) where they

make strong progress in delivering the service specifications. The IIF is worth

£75m in 2020/21, rising to £300m in 2023/24. An average PCN could secure

funding of c.£60,000 in 2020/21, rising to an additional c.£240,000 by 2023/24.

1.16 Alongside PCNs, community services providers will also see significant

funding increases over the next five years and, under our proposals, will take

a significant role in co-delivery in two of the service specs for Enhanced

Health in Care Homes and Anticipatory Care (via the proposed NHS Standard

Contract) – enabling the development of an integrated multidisciplinary team to take

forward the requirements in the outline specifications as a shared endeavour across

different partners. Consultation on the NHS Standard Contract will take place

December 2019 – January 2020.

Phasing of service requirements

1.17 NHSE/I is proposing to phase in the requirements over time in order to

ensure that they are deliverable as PCN workforce capacity grows, and as the

wider system infrastructure develops to support them. This means:

• implementing the requirements of two of the five specifications

(Structured Medication Reviews and Optimisation, Enhanced Health in Care

Homes) in full from 2020/21, as agreed in the GP contract framework; and

• phasing in the requirements of the Anticipatory Care, Personalised

Care and Early Cancer Diagnosis specifications over the period from 2020/21 to

2023/24. For these specifications, we have set out a headline trajectory for the

requirements over the next four years, with the detail subject to further annual

contract negotiations between NHSE/I and GPC England.

1.18 There are also significant overlaps between the requirements of the

specifications, as well as with other elements of the wider GP contract

package:

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• A significant proportion of the individuals who we propose should benefit

from a structured medication review will be care home residents for many PCNs.

• Delivery of the requirements in the Early Cancer Diagnosis specification

will support practices’ completion of the relevant Quality Improvement (QI) module

of the 2020/21 Quality and Outcomes Framework (QOF). Similarly, efforts made by

practices and networks to fulfil the Prescribing Safety QI module in 2019/20 will

facilitate their ability to meet the elements of the structured medication review and

optimisation specification.

Support from the wider system

1.19 The establishment of PCNs will improve the links between providers of

primary and community services, so that general practice feels much more

connected and supported by the wider NHS system. CCGs will be required to

play a major role in helping to co-ordinate and support delivery of the specifications,

in particular those that involve close collaboration with other partners such as the

care homes specification. CCGs will also support PCNs to develop standard

operating processes for their partnership, and ensure a clear and agreed

contribution to service delivery is made by other system partners within Integrated

Care Systems (ICSs) – documented in a local agreement. We will recommend that

the Local Medical Committee should be involved in the development of the local

agreement.

1.20 Where the outline specifications contain requirements for community services

providers, we intend to incorporate these into the NHS Standard Contact from

2020/21 to ensure they are taken forward everywhere in a reliable way.

1.21 In addition, where PCNs are struggling to recruit, CCGs and systems

should take action to support them. This may include, for example:

• running shared recruitment processes across multiple PCNs, or

supporting PCNs to carry out collaborative recruitment; potentially providing

management support to PCNs to help them run recruitment processes;

• brokering integrated workforce arrangements with other providers,

for example through rotational posts; and

• working with local representative groups and other stakeholders

to match people to unfilled roles.

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Relationship with existing locally commissioned services

1.22 We recognise that, for some of the specifications, a locally commissioned

service may already exist which covers some or all of the proposed requirements

set out in this document. These proposals are in draft: Clinical

Commissioning Groups (CCGs) should not, therefore, take final decisions

about existing locally commissioned services until the final Network Contract

DES for 2020/21 is published.

1.23 Once these specifications have been finalised, CCGs should work with

PCNs, community services providers, Local Medical Committees (LMCs), and

other stakeholders to support the transition – and, where required,

enhancement – of existing local service arrangements to meet the new

requirements whilst avoiding the unwarranted destabilisation of existing provision.

We would expect CCGs to make an assessment of any investment that they

continue to make in these areas, recognising that particularly as the expectations of

the specifications rise up to 2023/24, it may in the meantime be appropriate for them

to maintain delivery of a service where it currently exceeds the national requirements

for 2020/21.

1.24 Funding previously invested by CCGs in local service provision which is

delivered through national specifications in 2020/21 should be reinvested

within primary medical care and community services in order to deliver the

£4.5bn additional funding guarantee for these services. NHSE/I will be

collecting data on current spend and discussing how to ensure that the transition to

the national specification is manageable and affordable. Further requirements in

this respect will be set out at the conclusion of the GP contract negotiations for

2020/21.

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2. Structured Medication Review and Medicines Optimisation

Introduction

2.1 Structured Medication Reviews (SMRs) are a NICE approved clinical

intervention that help people who have complex or problematic polypharmacy1. SMRs

are designed to be a comprehensive and clinical review of a patient’s medicines and

detailed aspects of their health and are delivered by facilitating shared decision making

conversations with patients aimed at ensuring that their medication is working well for

them.

2.2 Evidence shows that people with long term conditions using multiple medicines

have better clinical and personal outcomes following an SMR.2 Timely application of

SMRs to individuals most at risk from problematic polypharmacy will support a reduction

in hospital admissions caused by medicines related harm in primary care. It is estimated

that £400 million is wasted in unnecessary medicines related harm admissions to

hospital annually.3

2.3 Most prescribing takes place in primary care. Through the increased

collaboration brought about by the establishment of PCNs, there is a significant

opportunity to support the meeting of international commitments on anti-microbial

prescribing. Undertaking SMRs in primary care will result in a reduction in the number of

people who are over-prescribed medication, reducing the risk of an adverse drug

reaction, hospitalisation or addiction to prescription medicines. Better prescribing will also

ensure better value for money for the NHS, reduce waste and improve its environmental

sustainability, for example by reducing the use of short acting beta agonist inhalers

(SABA) and switching to low carbon alternative inhalers.

Existing provision and available support for PCNs

2.4 Since 2015, NHS England has funded two pilot schemes to support the

establishment of Clinical Pharmacists working in general practice. Significant progress

in medicines optimisation has already been made across the country in using the skills

of these individuals, and the service requirements to undertake SMRs will be more

achievable as a result.

1 Problematic polypharmacy arises when multiple medicines are prescribed inappropriately, or when the intended benefit of the medicines are not realised or appropriately monitored, potentially due to clinical complexity or clinical capacity.

2 NICE Guideline 5 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, 2015

3 Medicines related harm in older adults, Pharmaceutical Journal: https://www.pharmaceutical-journal.com/news-and-analysis/news/medication-related-harm-in-older-adults-costs-the-nhs-400m-each-year-study-finds/20204894.article?firstPass=false

9 27

2.5 The additional roles reimbursement scheme introduced as part of the Network

Contract DES in 2019 has made funding available for Clinical Pharmacists to be

recruited in all PCNs from April 2019, building upon the existing base from the

earlier pilots. This workforce will be key in delivering SMRs, and given this degree

of existing capacity and expertise, we believe it is reasonable to expect the new

national SMR service requirements to be delivered in full from April 2020.

2.6 It is expected that a number of GP appointments may be prevented when

individuals have a proactive SMR: supporting the alleviation of workforce pressures

on GPs and reducing the risk of harm to patients – an evaluation will be

commissioned in year one.

Proposed Service Model

2.7 We propose that PCNs identify people who would benefit most from receiving

an SMR. The following groups have been identified as being most likely to benefit

from an SMR:

• all patients in care homes as per the Enhanced Health in Care Home

specification;

• patients with complex and problematic polypharmacy, specifically those on

10 or more medications;

• patients who are being prescribed medicines that are commonly and

consistently associated with medication errors;

• patients with multiple long-term conditions and/or multiple comorbidities –

in particular respiratory disease and cardiovascular disease;

• housebound, isolated patients and those with frailty – particularly patients

who have had recent admissions to hospital and/or falls;

• patients who have received a comprehensive geriatric assessment as

per the anticipatory care requirements; • patients with severe frailty; and • patients prescribed high numbers of addictive pain management

medication.

2.8 A variety of tools have been developed to help clinicians to identify patients with

complex and problematic polypharmacy with multi-morbidity, including PINCER,

EPACT2, Openprescribing and Eclipse Live. PCNs can select appropriate tools that

help them to proactively identify patients from the cohorts outlined above through

audit of GP IT systems. Guidance will be published to support PCNs in the

identification of patients, including a guide to the selection of these tools.

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2.9 We propose that PCNs also develop processes for identifying patients who

need to be referred for an SMR reactively. PCNs must consider guidance

concerning reactive referrals.

2.10 PCNs must ensure that only appropriately trained clinicians working within their

sphere of competence should 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 these skills – and must be

able to take a holistic view of a patient’s medication. This could include:

• Clinical Pharmacists • General Practitioners • Advanced Nurse Practitioners

2.11 We expect that undertaking a SMR would take considerably longer than an

average GP appointment, although the exact length should vary. PCNs should allow

for flexibility in appointment length for SMRs depending on the level of complexity

presenting with individual cases. Clinicians should conduct SMRs in line with the

principles of shared decision making, and consider the holistic needs of the patient,

providing advice, signposting and making onward referrals where relevant, including

new responsibilities to signpost to healthy living pharmacies.4

2.12 SMRs should be an ongoing process in which an individual appointment or

discussion constitutes an episode of care. Regular review and management

should be undertaken and SMRs should not be treated as a one-off exercise.

2.13 As part of our commitment to a more sustainable NHS, SMRs should also

support patients to switch to low carbon inhalers, where clinically appropriate.

2.14 Further guidance will be issued on processes to undertake an SMR, built from

NICE guidance, the Scottish Polypharmacy model and evidenced best practice.

Proposed service requirements for 2020/21

2.15 From April 2020, practices working as part of PCNs will:

• identify a clinical lead who will be responsible across the PCN for the

delivery of the service requirements in this section.

4 Community pharmacy contractors will be required to become an HLP Level 1 by 1st April 2020 as agreed in the five-year deal between PSNC, NHS England and NHS Improvement and the Department of Health and Social Care; this reflects the priority attached to public health and prevention work. https://psnc.org.uk/services-commissioning/locally-commissioned-services/healthy-living-pharmacies/

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• run locally-defined processes at least twice yearly, on a six-monthly basis, to

identify the patients within the practice-registered population that require SMRs.

This must include consideration of patients within the cohorts described in

paragraph 2.7.

• develop local processes for reactive SMR referrals, adhering to

published guidance;

• provide written communication to patients invited for an SMR, detailing

the process and intention of the appointment;

• offer SMRs to 100% of identified patients, except in exceptional

circumstances where the commissioner agrees that proven capacity constraints

(where the PCN had demonstrated all reasonable attempts to ensure capacity

had been undertaken) would justify a lower proportion of identified patients to

be offered a SMR;

• undertake SMRs and follow-up consultations in line with detailed guidance.

CCGs will review variation in the numbers of SMRs undertaken, which will inform

the potential development of a standardised requirement in future years;

• use appropriate clinical decision-making tools to support the delivery

of SMRs, examples of which will be provided through guidance;

• clearly record all SMRs within GPIT systems, as well as using appropriate

clinical codes to signify the reasons for an SMR;

• develop local PCN action plans to reduce inappropriate prescribing of (a)

antimicrobial medicines, (b) medicines which can cause dependency, and (c)

nationally identified medicines of low priority. This plan will react to guidance

specifying how the PCN will deliver against the guidance;

• work with community pharmacies locally to ensure alignment with delivery of

both the New Medicines Service (to support adherence to newly-prescribed

medicines) and developing medicines reconciliation services (to support effective

transfers of care between hospital and community);

• ensure delivery of SMRs and medication optimisation aligns to the work of

medicines optimisation teams within CCGs local to the PCN.

Proposed Metrics

2.16 Proposed metrics to monitor the success of the service are set out below:

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Metric description

1. The number of individual SMR episodes undertaken, including:

• The number of SMR processes undertaken (number of

individual patients given one or more SMR appointment)

• The number of SMR follow-up appointments

2. Outcome measurement to monitor impact of SMR

3. Prescribing rate of nationally identified medicines of low value that

should not be routinely prescribed

4. Prescribing rate of low carbon inhalers

5. Prescribing rate of medicines that can cause dependency

6. Prescribing rate of anti-microbial medication

2.17 Reducing unwarranted prescribing spend in particular areas is likely to be one

early focus of the Investment and Impact Fund, with progress expected to be

measured against baseline levels of performance in 2019/20.

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3. Enhanced Health in Care Homes

Introduction

3.1 One in seven people aged 85 or over permanently live in a care home. People

living in care homes account for 185,000 emergency admissions each year and 1.46

million emergency bed days, with 35-40% of emergency admissions being potentially

avoidable5. Evidence suggests that many people living in care homes are not having

their needs assessed and addressed as well as they could be, often resulting in

unnecessary, unplanned and avoidable admissions to hospital and sub-optimal

medication regimes.

3.2 People living in care homes should expect the same level of support as if they

were living in their own home. This can only be achieved through collaborative working

between health, social care, the voluntary sector and care home partners.

3.3 In 2016, the New Care Models programme developed and tested the Enhanced

Health in Care Homes (EHCH) Framework6 to improve health and care provision for

people living in care homes. In implementing the EHCH service, local areas showed how

to improve services and outcomes for people living in care homes and those who require

support to live independently in the community7.

3.4 Given the efficacy of the model, the Long-Term Plan and GP Contract

Framework made a commitment to implementing the clinical elements of EHCH

nationally during 2020/21. Implementation of the EHCH service is a national priority for

primary and community care-based service integration, and we will be expecting all

ICSs/STPs and CCGs to prioritise supporting full and successful delivery.

Existing provision and available support for PCNs

3.5 There is evidence of substantial existing enhanced primary and community

provision to residential and nursing homes. Data collected from CCGs for 2018/19

suggests that there is already significant local spend on such services. In combination

with additional support described below, we believe that this existing capacity and

expertise will enable implementation of this specification at a faster pace than other

services.

5 https://www.longtermplan.nhs.uk/online-version/chapter-1-a-new-service-model-for-the-21st-century/1-we-will-boost-out-of-hospital-care-and-finally-dissolve-the-historic-divide-between-primary-and-community-health-services/#ref 6 https://www.england.nhs.uk/wp-content/uploads/2016/09/ehch-framework-v2.pdf 7 https://www.health.org.uk/publications/reports/emergency-admissions-to-hospital-from-care-homes

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3.6 We have drawn on evidence from these service models as well as evaluations

of the New Care Models to design the service requirements below, and to inform

forthcoming guidance for implementation, which will include advice on collaborative

service redesign with other providers such as community services.

3.7 Delivery of this specification must happen in partnership between general

practice and community services. The proposed Standard Contract requirements will

ensure a contractual basis for the requirements attributable to community service

providers, and CCGs will oversee local agreements between providers within a PCN

to ensure that primary and community care are supported in delivery by relevant

partners being held to account.

3.8 We anticipate CCGs will also support delivery of this service by holding a list of

care homes in the area and agreeing the responsibilities of PCNs in relation to each

home, including making sure that each care home is aligned to a single PCN. An

approach to the reinvestment in primary care of existing expenditure by CCGs in

this area of work and the potential for uneven distribution of care homes between

PCNs will be discussed as part of contract negotiations. CCGs can also support

improved joint working between PCNs and social care their established

relationships with social care commissioners in local authorities.

3.9 We acknowledge that the geographical distribution of care homes means that

PCNs will be affected differently by the service requirements in this specification.

We are considering this issue further, alongside the potential economies of scale

provided by the opportunity to provide enhanced support to care homes at a

network level rather than through individual practices.

Proposed Service Model

3.10 The EHCH service will focus on national roll out of the first four clinical

elements of the EHCH framework: enhanced primary care support;

multidisciplinary team support; reablement and rehabilitation; and high-quality end-

of-life care and dementia care. The service requirements are shared across both

PCNs and other providers (particularly community services) who will work together

to deliver the model.

3.11 In implementing this model nationally, we expect to:

• Improve the experience, quality and safety of care for people living in

care homes, their families and their carers;

• Reduce avoidable ambulance journeys, A&E attendances and

emergency admissions to hospital for people living care home residents;

15 33

• Improve sub-optimal medication regimes in care homes; and

• Support more people living in care homes to die in a place of their

choosing.

3.12 Given the significant progress already made across the country in implementing

these model elements, we expect this service to be delivered, in full, during 2020/21.

In future years we will consider whether and how to bring out of hours provision

under the authority of PCNs, to ensure more effective and coordinated out of hours

support for care homes.

In scope population

3.13 All people who live permanently in care homes (both residential and nursing)

are eligible for the service. This includes people living in residential and nursing

homes that deliver specialist support (such as specialist learning disability and

dementia units) but does not include people living in secure units for mental health.

3.14 Supported living environments and extra care facilities are not currently in

scope for this service but may be covered by other services to be delivered

through the network contract DES, including anticipatory care, medications

reviews and personalised care.

3.15 For the purposes of this document, the term ‘care home’ encompasses all types

noted above.

Proposed service requirements:

3.16 During 2020/21, practices working as part of PCNs and working with providers

of community services, will:

Practices, working as part of PCNs Other providers of community

services, including mental health

1 By 30 June 2020, identify a clinical

lead who will be responsible across

the PCN for the delivery of the

service requirements in this section.

2 From no later than 30 June 2020, Work alongside PCNs and care

ensure every person living homes to ensure delivery of the

permanently in a care home has a multidisciplinary elements of the

named clinical team, including staff service model described below

from the PCN and relevant providers

16 34

of community services, who are

accountable for the care delivered

through the EHCH model.

3 From no later than 30 June 2020,

ensure every care home is aligned to

a single PCN, and its multidisciplinary

team (MDT), which is responsible for

supporting that care home and

delivering the EHCH service for

people living in that home that are

already registered with a practice in

the PCN or choose to register with a

practice in the PCN.

By 30 June 2020 each PCN will

agree the care homes for which it has

responsibility with its CCG. People

entering the care home should be

supported to re-register with the

aligned PCN and have the benefits of

doing so clearly explained.

Where people choose not to register

with a practice in the aligned PCN,

requirements 4-9 below should be

delivered by their registered practice,

either directly or through local sub-

contracting arrangements.

4 From no later than 30 June 2020, By no later than 30 June 2020, co-

establish and manage a design with the PCN, and thereafter

multidisciplinary team (MDT) of participate in, a multidisciplinary team

professionals, working across (MDT) of professionals, to work in

organisational boundaries to develop close collaboration with care homes

and monitor personalised care and to develop and monitor personalised

support plans, and the support offers care and support plans.

defined in them, for people living in

care homes. Attend MDT meetings and manage

delivery of the MDT if agreed locally.

5 From no later than 30 June 2020, From no later than 30 June 2020,

establish protocols between the care support the establishment of

home and wider system partners for protocols between the care home

information sharing and shared care and wider system partners for

planning, use of shared care records information sharing and shared care

planning, use of shared care records

17 35

and clear clinical governance and and clear clinical governance and

accountability accountability.

6 From no later than 30 September From no later than 30 September

2020, deliver a weekly, in person, 2020, deliver, participate in or

‘home round’ for their registered prepare for home rounds as agreed

patients in the care home(s). The with the PCN and provide initial triage

home round must: of people living in care homes who

have been flagged for review.

• be led by a suitable clinician. On

at least a fortnightly basis this

must be a GP. With local

agreement the GP can be

substituted by a community

geriatrician.

• involve a consistent group of staff

from the MDT.

• focus on people identified for

review by the care home, those

with the most acute and

escalating needs or those who

may require palliative or end-of-

life care.

7 From no later than 30 September From no later than 30 September

2020, own, and coordinate delivery 2020, deliver, as determined by the

of, a personalised care and support MDT, elements of holistic

plan with people living in care homes assessment for people in care homes

based on relevant assessments of across five domains; physical,

needs and drawing on assessments psychological, functional, social and

that have already taken place where environmental, drawing on existing

possible and: assessments that have taken place

where possible.

• ensure that this plan is developed

and agreed with each new Provide input to the person’s care

resident within seven days of and support plan within seven

admission to the home, and within working days of admission to the

seven days of readmission home, and within seven working days

following a hospital episode. of readmission following a hospital

Review the plan when clinically episode.

appropriate and refresh it at least

annually;

18 36

• ensure the plan is developed with Deliver palliative and end of life care,

the person or/or their carer, and as required, to care home residents

reflects their personal goals; 24 hours a day.

• ensure the plan is tailored to the

person’s particular needs (for

example if they are living with

dementia) and circumstances

(such as those people

approaching the end of their life).

8 From no later than 30 September From no later than 30 September

2020, coordinate, alongside 2020, provide one-off or regular

community providers, one-off or support to people within care homes

regular support to people within care based on the needs defined in the

homes, based on the needs defined personalised care and support plan

in the personalised care and support and those identified by care home

plan and those identified by care staff.

home staff.

This support must include, but is not

Directly deliver or support delivery of limited to:

elements of this support where

appropriate, including: • community nursing

• tissue viability

• structured medication reviews • falls prevention, advice and

(SMRs), delivered according to strength and balance training

the requirements of the SMR • oral health

specification. • speech and language therapy

• activities to support the

including dysphagia assessment

and support

achievement of goals identified as • dietetics

important to the person in their • hydration and nutrition supportpersonalised care and support • continence assessment and careplan, including reasonable efforts (urinary and faecal) to build links with local

• psychological therapies e.g. viaorganisations outside of the

IAPT services or local older home.

people’s mental health services

• cognitive stimulation or

rehabilitation therapy and

reminiscence therapy for people

with dementia

9 From no later than 30 September From no later than 30 September

2020, provide, through the MDT, 2020, support the identification and

identification and assessment of

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eligibility for urgent community assessment of eligibility for urgent

response services community response services and:

• deliver urgent community

response services (which include

provision of crisis response within

two hours and reablement within

two days of referral);

• deliver specialist mental health

support in cases of mental health

crises and challenging

behavioural and psychological

symptoms of dementia

Where the above would help a

person to remain safely and recover

in their care home as an alternative

to hospital admission or to support

timely hospital discharge.

10 Provide support and assistance to Make opportunities for training and

the care home by: shared learning available to care

home staff, drawing on existing

• supporting the professional continued professional development

development of care home staff programmes for staff working in

by identifying opportunities for community services.

training and shared learning;

• working with the care home and

wider system partners to address

challenges the home is facing in

coordination with the wider health

and care system;

• delivering relevant vaccinations

for care home staff, in line with

the provisions set out in the

seasonal influenza DES.

11 From no later than 30 September From no later than 30 September

2020, working with the CCG to 2020, support the development and

establish processes that improve delivery of transfer of care schemes.

efficient transfer of clinical care

between residential homes, nursing

homes and hospices and between

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care homes and hospitals, as

described by NICE guidance89.

Facilitate and support local and

national initiatives to support

discharge from hospital and

psychiatric inpatient units, such as

trusted assessor schemes.

12 From no later than 30 September From no later than 30 September

2020, establish clear referral routes 2020, support the development of

and information sharing clear referral routes and information

arrangements between care homes, sharing arrangements between the

PCNs and out of hours providers and care home and other providers.

providers of a full range of

community-based services including

specialist mental health, dietetic,

speech & language therapy, palliative

care and dementia care.

Proposed Metrics

3.17 Potential metrics to monitor the success of the service include, but are not

limited to:

Metric description

1. The rate of emergency admissions for people living in care homes.

2. The rate of urgent care attendances for people living in care homes.

3. The proportion of people living in a care home who have a

personalised care and support plan in place.

4. The number of people living in a care home who receive an

appointment as part of the weekly care home round

5. The number and proportion of people living in a care home who

receive a structured medication review.

6. The number and proportion of people living in a care home who

receive a delirium risk assessment.

8 https://stpsupport.nice.org.uk/transfer-of-care/index.html 9 https://www.nice.org.uk/guidance/ng27/chapter/Recommendations#supporting-infrastructure

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4. Anticipatory Care

Introduction

4.1 Anticipatory care helps people to live well and independently for longer through

proactive care for those at high risk of unwarranted health outcomes. Typically, this

involves structured proactive care and support from a multidisciplinary team (MDT).

It focuses on groups of patients with similar characteristics (for example people living

with multimorbidity and/or frailty) identified using validated tools (such as the

electronic frailty index) supplemented by professional judgement, refined on the

basis of their needs and risks (such as falls or social isolation) to create a dynamic

list of patients who will be offered proactive care interventions to improve or sustain

their health.

4.2 It supports the focus on prevention in the Long-Term Plan, and the ambition

that people can enjoy at least five extra healthy, independent years of life by

2035.

4.3 The service has three key aims:

• Benefitting patients with complex needs, and their carers, who are at

risk of unwarranted health outcomes by enabling them to stay healthier for longer,

with maintained or improved functional ability and enjoy positive experiences of

proactive, personalised and self-supported care.

• Reducing need for reactive health care for specific groups of patients and

supporting actions to address wider determinants of health.

• Delivering better interconnectedness between all parts of the

health system and the voluntary and social care sectors

4.4 These aims will be achieved through a combination of:

• population segmentation, followed by risk stratification and clinical

judgement, to identify people who would benefit most; and

• multi-disciplinary primary and community teams, including social care

and the voluntary sector working together.

4.5 Anticipatory care is intrinsically linked to population health management models

developing and already in place in systems across the country. The service focuses

on the “rising risk population”, comprising those with multiple long-term conditions

and/or frailty, who may have underlying risk factors like unhealthy

22 40

lifestyles, behavioural risks, social isolation or poor housing. Addressing many of

these risk factors will require non-clinical interventions and strong working

relationships with local voluntary, community and civic groups, as well as system

public health teams.

4.6 In future years we will establish a standardised approach to the identification of

individuals to receive the service. There is a range of approaches currently in place

across the country, and the evidence base is still developing. 2020/21 therefore

represents an opportunity to build and embed ways of working and service models

which will expand and develop in future years. We will continue to monitor outcomes

from different local approaches, and would welcome submissions of evidence where

these have been successful.

Existing provision and available support for PCNs

4.7 Population health management (PHM) tools that can support risk stratification

are already in place in a number of areas across the country. They are usually

hosted by ICSs but drawing on data from MDTs based across PCNs and

community service providers. PHM tools will predict and identify patients who are

at risk of adverse health outcomes, and the particular interventions that would

support them to remain healthy.

4.8 The first year of the service is predominately a preparatory year, with target

populations to be agreed by the PCN through discussion with their CCG and their

ICS/STP. CCGs and ICSs will support PCNs by sharing information and access to

risk stratification tools successfully in use that could be used by PCNs

4.9 General practices already have a unique understanding of the health needs of

the communities they serve. By joining together health and social care information

with other information from wider public sources like housing and education, and

applying predictive modelling techniques, PCNs have the opportunity to draw on

deeper intelligence to better understanding which people in their areas might

benefit from more targeted and proactive care.

Proposed phasing of objectives from 2020/21 to 2023/24

4.10 By 2023/24, we expect all PCNs and community service providers – working

together – to offer an Anticipatory Care model based on the following

components:

o Identification of specified key segments of the PCN’s registered practice

populations who have complex needs and are at high risk of unwarranted

health outcomes.

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Population health management tools – hosted by ICSs but drawing on data from

MDTs based across PCNs and community service providers – will predict and

identify patients who are at risk of adverse health outcomes, and the particular

interventions that would support them to remain healthy.

Over time, as population health management tools are validated for increasing

cohorts, this will mean a reduction in the need for additional manual segmentation

and stratification of the identified patients. By 2023/24, PCNs and community service

providers will access, interrogate and filter a list of which individuals are most likely

to benefit from different health and care interventions.

o Maintenance of a comprehensive and dynamic list of identified

individuals who would benefit from anticipatory care, based on the

outcome of the population segmentation approach above.

This list will be dynamic: it will be maintained and updated in real time based on

population health intelligence.

o The delivery of a comprehensive set of support for those individuals

identified as eligible through the anticipatory care list, through an MDT

based across PCNs and community service providers.

The available support provided to each individual will be based upon each their

personalised care and support plan, but support offers will include a broad range

of primary and community services support via the MDT. Establishing this

support infrastructure is a key component of the 2020/21 requirements.

4.11 Complex population cohorts require the skills of different healthcare

professionals working together as a multidisciplinary team. For MDTs to achieve

their goal, PCNs and other health and care partners must share relevant patient

information and develop whole system data sharing and data processing

agreements, drawing on national guidance. In time, this data will be sourced from

Local Health and Care Records.

Proposed service requirements for 2020/21

4.12 During 2020/21, practices working as part of PCNs and working with providers

of community services, will:

Practices, working as part of PCNs Other providers of community

services, including mental health

24

42

1 From no later than 30 June 2020, From no later than 30 June 2020,

present a coherent local Anticipatory assist with the development and

Care model by: improvement of system-level

• identifying a responsible clinical population health management

lead for delivery of the model; approaches to identify patients with

• assisting with the development complex needs that would benefit

and improvement of system-level from Anticipatory Care.

population health management

approaches to identify patients Support the coordination of the care

with complex needs that would and support of people being treated

benefit from anticipatory care; by the Anticipatory Care model,

• working with others to develop building links and working across the

and establish, clinical system to facilitate development of a

accountability and governance wider model of integrated care for

arrangements to manage the individuals living with complex needs

model, through shared design with

providers of community services Work with others to develop and

and mental health care, engaging agree delivery, clinical accountability

with social care and voluntary and governance arrangements with

services, drawing on existing practices working as part of a PCN,

system-level programmes where engaging with other providers of

possible; community services, mental health

• taking a leading role in care, social care and voluntary

coordinating the care and support services.

of people as patients begin to be

Work with the CCG, PCN, providers treated by Anticipatory Care -

building links and working across of social care and voluntary sectors

the system to facilitate and patient representative groups to

development of a wider model of co-design and clearly set out how and

integrated care for individuals where the range of support service

living with complex needs. offers described below (which will be recurrently available through MDTs

for those receiving anticipatory care)

and other support services will be

delivered.

2 From no later than 30 June 2020, From no later than 30 June 2020

with CCG support, work with others to work with others to develop and sign

develop and sign data sharing data sharing agreements with

agreements between practices and practices and with other providers

with providers delivering community delivering community and mental

and mental health services, local health services, local acute Trusts,

acute hospitals voluntary sector voluntary sector organisations and

organisations and social care to providers of social care to support the

support the operation of MDTs and operation of MDTs and the

25 43

the development of population health development of population health

analytics data sets. data sets.

Support the development of system- Support the development of system-

level linked data sets to build level linked data sets to build

population health analytics population health analytics

capabilities, including the extraction capabilities, including the extraction

of anonymised, patient level data. of anonymised, patient level data.

3 From no later than 30 June 2020, From no later than 30 June 2020,

identify a priority list of patients who support the prioritisation of a target

are at rising risk of unwarranted cohort of patients based on

health outcomes, based on the CCG professional judgement and/or

standard approach where applicable. validated tools.

Prioritisation should focus upon:

• individuals with complex

needs: including multiple long-

term conditions and/or with

frailty.

• those that are amenable to

improvement through multi-

disciplinary intervention and

• those that are at high risk of

their condition progressing or

circumstances or needs

substantially changing within

the next six months.

4 From no later than 30 June 2020, From no later than 30 June 2020,

establish and manage an MDT, to align relevant community nursing and

meet regularly to coordinate and therapy staff to the local PCN and

manage the care of the cohort of identify other professions that may

people on the Anticipatory Care list. need to be involved in the MDT

discussion.

Attend and participate in the MDT

discussion – using available

information to plan and co-ordinate

the care of patients discussed.

5 From no later than 30 June 2020, co- From no later than 30 June 2020, co-

ordinate and deliver comprehensive ordinate and deliver constituent parts

needs assessments, targeted needs

26 44

assessments or care co-ordination of comprehensive and targeted needs

reviews for the people in this cohort, assessments with the PCN.

recording this activity and the

person’s individual goals in a

personalised care and support plan. Develop or add to care and support

plans for the individuals which the

MDT identifies should be supported

by community health professionals

6 From no later than 30 June 2020, From no later than 30 June 2020, co-

coordinate the delivery of support ordinate support offers if locally

offers as identified by the needs agreed.

assessment and the patient’s

personal goals. Via the responsible Deliver relevant support offers as

lead, retain overall clinical identified in the patient’s needs

responsibility for the delivery of this assessment and care and support

plan. plan, to include (not exhaustive):

The available support offers must • fall risk assessment and

include (not exhaustive): intervention including bone health

• medicines optimisation to address management and strength and

problematic polypharmacy, in line balance training

with the process established in the • rehabilitation services

SMR specification • continence services

• social prescription using a broad • tissue viability service

range of community assets to • care co-ordination

support well-being and address • mobility assessment

•

loneliness and isolation • continence assessment (urinary

carer identification and and faecal)

signposting to local support • carer identification and

• annual comprehensive or targeted signposting to local support

needs assessment for other • annual comprehensive or targetedvalidated cohorts with complex needs assessment for other needs. validated cohorts with complex

• annual care coordination review needs.

for other validated cohorts with • annual care coordination reviewcomplex needs. for other validated cohorts with

• adoption of patient activation complex needs.

•

measures • relevant outreach services for

non-medical interventions from hard to reach groups and those

the personalised care and support with protected characteristics. plan

• mental health assessment and

interventions to identify and

27 45

manage depression and anxiety,

including IAPT

• cognitive assessment (to identify

dementia and delirium risk) and

post diagnosis dementia support

(including cognitive stimulation

therapy and cognitive

rehabilitation therapy).

Deliver annual review of those

patients actively supported by

community health providers

(especially those patients who are

housebound)

Proposed metrics

4.13 Potential metrics to monitor the success of the service include, but are not

limited to:

Metric description

1. Number of individuals in receipt of the Anticipatory Care model

2. Number of needs assessment carried out for individuals in receipt of

the Anticipatory Care model.

3. Number of individuals in the active cohort of the anticipatory care

model with a personalised care and support plan.

4. Number of individuals in the active cohort of the anticipatory care

model receiving a falls risk assessment.

5. Number of individuals in the active cohort of the anticipatory care

model receiving a delirium risk assessment

6. Number of SMRs for the active cohort on the anticipatory care model

7. Number of SMR follow-ups in the active cohort on the anticipatory care

model

8. Number of individuals in the active cohort on the anticipatory care

model given a referral to social prescribing service or where social

prescribing is declined

28 46

5. Personalised Care

Introduction

5.1 Chapter one of the NHS Long Term Plan (LTP) makes personalised care

business as usual across the health and care system as one of the five major,

practical changes to the NHS service model. Personalised care means people

have choice and control over the way their care is planned and delivered, based on

‘what matters’ to them and their individual diverse strengths, needs and

preferences. This happens within a system that supports people to stay well for

longer and makes the most of the expertise, capacity and potential of people,

families and communities in delivering better health and wellbeing outcomes and

experiences.

5.2 Universal Personalised Care: Implementing the Comprehensive Model”10 is the

delivery plan for personalised care, published by NHS England in January 2019

following the LTP. The Comprehensive Model builds on the success the NHS has

had in implementing personalised care in a variety of settings and locations across

the country. The experience and evidence thus far (and as set out in Universal

Personalised Care) has shown that benefits include:

• improvement to people’s experiences of care and their health

and wellbeing, including for people who face the greatest health inequalities;

and

• more effective use of NHS services, including reduced crises that

lead to unplanned hospital or institutional care.

Existing provision and available support for PCNs

5.3 There is substantial existing provision and support available to PCNs through

the personalised care national programme, and its regional networks. This

includes:

• Dedicated clinical support tools are available via GPIT systems to

support professionals in having shared decision making conversations with

cohorts where this is a service requirement in 20/21; and

• Well-developed social prescribing in many areas – often occurring at a

scale that already exceeds the 2020/21 requirement. Building on this success,

there will be free training provided by HEE available to all

10 https://www.england.nhs.uk/wp-content/uploads/2019/01/universal-personalised-care.pdf

29 47

social prescribing link workers, as well as access to regional support networks.

5.4 Evidence from existing social prescribing schemes and clinical expertise

suggests that GP appointments can be prevented when individuals receive a social

prescribing intervention, and onward referral to appropriate services. Delivery of this

service (which will be mostly be carried out by staff funded in full via the Network

DES) has a clear potential to reduce GP burden at a local and national level.

Proposed Service Model

5.5 The Comprehensive Model for Personalised Care brings together six evidence-

based and inter-linked components, each of which is defined by a standard,

replicable delivery model. The six key components are11:

1. Shared decision making 2. Personalised care and support planning 3. Enabling choice, including legal rights to choose 4. Social prescribing and community-based support 5. Supported self-management 6. Personal health budgets (PHBs) and integrated personal budgets.

Proposed phasing of service objectives from 2020/21 to 2023/24

5.6 To achieve the benefits of personalised care the Comprehensive Model needs

to be delivered in full. For example, social prescribing is more effective when it is

delivered with a complementary approach to shared decision making. Over the four

years of Network Contract DES, we will phase in increasing levels of activity across

the six component areas as summarised below:

2020/21 Personalised Care and Support Planning

Requirement of personalised care and support plans to be in place for at least 5-

10:1000 weighted population. This must include:

• All people in last 12 months of life • All individuals eligible in the Anticipatory Care and Enhanced

Health in Care Homes cohorts

Promotion of Personal Health Budgets

Requirement to promote of Personal Health Budgets for:

• People with a legal right to a Personal Health Budget

11 Further detail of each of the six components can be found in the Universal Personalised Care: Implementing the Comprehensive Model.

30

48

• Any other cohorts identified as eligible for a Personal Health Budget

within the CCG local offer

Shared Decision Making

Priority shared decision-making clinical situations, to include at least:

• MSK: Back pain, hip pain, knee pain and shoulder pain (led by

physiotherapists)

Training and shared learning

Prioritise the following roles for training:

• Team members undertaking personal care and support planning

conversations • Clinical pharmacists hosting Structured Medicine Reviews • MSK practitioners • Social prescribing link workers

Social prescribing

Required number of social prescribing referrals at least:

• 4-8:1000 weighted population.

Supported self-management

PCNs to use the Patient Activation Measure (PAM)12 for the following cohorts:

• People living with newly diagnosed Type 2 diabetes • People referred to social prescribing link

workers 2021/22 Personalised Care and Support Planning Requirement of personalised care and support plans to be in place for 10-

15:1000 weighted population.

Promotion of Personal Health Budgets

Continue to promote as per 2020/21, and develop offer to directly provide

Personal Health Budgets for specific cohorts

Shared Decision Making

Priority shared decision-making clinical situations, to include at least:

• MSK: Back pain, hip pain, knee pain and shoulder pain • Reducing stroke risk in people with AF

Training and shared learning

• Further staff cohorts to be confirmed

12 The PAM is a tool designed to measure the level to which people feel engaged and confident in taking care of their condition. Further information is available here:https://www.england.nhs.uk/personalisedcare/supported-self-management/patient-activation/pa-faqs/

31 49

Social prescribing

Required number of social prescribing referrals:

• 8-12:1000 weighted population.

Supported self-management

• PCNs to use the Patient Activation Measure for additional cohorts to

be confirmed.

2022/23 Personalised Care and Support Planning

Requirement of personalised care and support plans to be in place for 15-

20:1000 weighted population.

Promotion of Personal Health Budgets

Continue to promote as per 2020/21, and begin to offer Personal Health Budgets

directly for specific cohorts Shared Decision Making

Priority shared decision-making clinical situations, to include at least:

• MSK: Back pain, hip pain, knee pain and shoulder pain • Reducing stroke risk in people with AF • Additional clinical situations to be confirmed.

Training and shared learning

• Further staff cohorts to be confirmed

Social prescribing

Required number of social prescribing referrals:

• 12-16:1000 weighted population.

Supported self-management

• PCNs to use the Patient Activation Measure for additional cohorts

to be confirmed.

2023/24 Personalised Care and Support Planning

Requirement of personalised care and support plans to be in place for 20-

25:1000 weighted population.

Promotion of Personal Health Budgets

Continue to promote as per 2020/21, and have in place a clear offer of Personal

Health Budgets directly for specific cohorts

Shared Decision Making

Priority shared decision-making clinical situations, to include at least:

• MSK: Back pain, hip pain, knee pain and shoulder pain • Reducing stroke risk in people with AF

32 50

• Additional clinical situations to be confirmed.

Training and shared learning

• Further staff cohorts to be confirmed

Social prescribing

Required number of social prescribing referrals:

• 16-22:1000 weighted population.

Supported self-management

• PCNs to use the Patient Activation Measure for additional cohorts

to be confirmed.

Proposed service requirements for 2020/21

5.7 From April 2020, practices working as part of PCNs will:

• Identify a clinical lead who will be responsible across the PCN for

the delivery of the service requirements in this section.

• increase the number of personalised care and support conversations and

plans for identified cohorts across a PCN, in line with the standard replicable model,

so that at least 5:1000 weighted population receive a PCSP. In 2020/21 the required

cohorts are:

o People in last 12 months of life

o Individuals eligible in the Anticipatory Care and Enhanced Health in

Care Homes cohorts

Further cohort options to consider include:

o People with multiple long-term conditions and/or at high risk of hospital

admission o People with a diagnosis of Cancer

• promote personal health budgets across a PCN to enable delivery of legal

rights to a PHB and any other cohorts identified as eligible within the CCG’s local

offer.

• deliver shared decision making for different clinical situations using available

decision support tools. The priority cohorts for 2020/21 are patients with

musculoskeletal conditions such as back pain, hip pain, knee pain and shoulder

pain. These conversations will be led by trained physiotherapists

33 51

• facilitate relevant training, shared learning and quality improvement for staff in

PCNs. For 2020/21 PCNs should prioritise the following roles for training:

o Team members undertaking personalised care and support planning

conversations

o Clinical pharmacists hosting Structured Medicine Reviews o PCN MSK practitioners o Social prescribing link workers

• support the delivery of effective social prescribing so that at least 4:1000

weighted population receive a referral.

• use Patient Activation Measure to enable more personalised support for

people with different levels of knowledge, skills and confidence. For 2020/21 the

required cohorts are:

o People living with newly diagnosed Type 2 diabetes

o People referred to social prescribing link workers

Proposed metrics

5.8 Potential metrics to monitor the success of the service include, but are not

limited to:

Metric description

1. The number of personalised care and support plans delivered

(including measure of delivery rate for required cohorts)

2. The quality of personalised care and support plans

3. The number of shared decision making conversations completed

(including measure of delivery rate for required cohorts)

4. The quality of shared decision making conversations

5. The number of social prescribing referrals made

6. The number of patient activation measurement assessments

undertaken (including measure of delivery rate for required cohorts)

7. The number of Personal Health Budgets

34 52

6. Supporting Early Cancer Diagnosis

Introduction

6.1 The NHS Long Term Plan (LTP) sets an ambition that, by 2028, the proportion

of cancers diagnosed at stages 1 and 2 will rise from around half now to three-

quarters (75%) of cancer patients. Achieving this will mean that, from 2028, 55,000

more people each year will survive their cancer for at least five years after

diagnosis.

6.2 Primary care has a vital role to play in delivering this ambition, working closely

with wider system partners including Cancer Alliances, secondary care, local

Public Health Commissioning Teams and the voluntary sector. Through the

requirements in the Network Contract DES, primary care networks will:

• Improve referral processes across GP practices, including by introduction

of locally agreed standardised systems and processes for identifying people with

suspected cancer, referral management and safety netting13.

• lead and coordinate the contributions of practices and the PCN to efforts to

increase the uptake of existing National Cancer Screening programmes among

their local populations.

• Improve outcomes through reflective learning and collaboration with local

partnerships

6.3 An average PCN will have around 250 new cancer diagnoses each year.

Moving from around one half to three quarters of these getting a diagnosis at

stage one or two would mean around 60 more people being diagnosed early,

increasing their likelihood of survival.

Existing provision and available support for PCNs

6.4 The service requirements support and further embed the clinical best practice

detailed in NICE Guideline 12: Suspected cancer: recognition and referral. All

practices are already implementing the NICE guidelines and the development

process for this specification has shown that much of general practice is already

engaged in the actions set out in this specification to improve referrals, screening

uptake and reflective practice

13 Safety netting is defined for these purposes as ensuring attendance at appointments following urgent referrals for suspected cancer the results of investigations are received and acted upon appropriately and reviewing people with any symptom that is associated with an increased risk of cancer but who do not meet the criteria for referral or other investigative action.

35 53

6.5 PCNs will be supported by local system partners in the delivery of the

specification and the ultimate improvement of local early diagnosis rates:

• Improving early diagnosis is a strategic and delivery priority for the 20

Cancer Alliances across England and they will support and work with PCNs to

deliver the outcomes in this specification.

• The Public health national service specifications set out programmes for

supporting early diagnosis for breast, cervical and bowel cancers and regional public

health commissioning teams and Cancer Alliances will work with PCNs on local

screening improvement plans.

• Voluntary organisations also have a defined local support offer which includes

training, communities of practice with expert cancer GPs and practice nurses, and

advice on population-level data to help drive service improvement.

6.6 The implementation of wider Long Term Plan commitments will also support

PCN implementation of this service. National Screening Programmes are being

modernised and the development of a new referral pathway for people with serious

but non-specific symptoms through Rapid Diagnostic Centres (RDCs) starting in

2019/20 will provide support faster diagnosis through more efficient diagnostic

pathways and a clearer route for those with unclear symptoms.

Proposed Service Model

6.7 Over the four-year period, PCNs should provide a leadership, enablement and

support function across their component practices to deliver the service

requirements and ensure the highest standards across its practices. By 2023/24, all

PCNs will be expected to be undertaking a range of activity to contribute to

realisation of their local Cancer Alliance target for number of people diagnosed at

stages 1 and 2, set through the LTP planning process.

6.8 Through the PCN Dashboard, PCNs will have access to a variety of data

allowing them to understand and explore trends in cancer presentation and

diagnosis locally. National data sets will also enable comparison with other areas

and encourage PCNs to learn from one another. Working with partners, such as

Cancer Alliances, local public health commissioning teams and voluntary

organisations, offers an opportunity for PCNs to leverage available support,

guidance and training.

6.9 It is anticipated that the scope of activity undertaken by PCNs will increase year

on year, as PCNs become more established and are able to build on what is learnt

through audit and exploration of data and significant event analysis in the

36 54

early years. The proposed trajectory for this is set out in more detail in the table

below, with specific requirements to be determined in future years.

6.10 The requirements for 2020/21 complement the content of the Quality

Improvement QOF domain – Early diagnosis of cancer, which includes activity on

improving referral practice and increasing screening uptake. Where practices take

up this Quality Improvement QOF Domain, PCNs will ensure that associated

learning and best practice is shared. Delivery of some parts of this specification will

also contribute to Continued Professional Development requirements for practice

and staff working in the PCN.

Proposed phasing of service objectives from 2020/21 to 2023/24

6.11 The requirements in this specification will be phased over time, as capacity

both within PCNs and the wider pathway for cancer diagnosis and treatment

increases. The table below summarises the expected phasing of objectives from

2020/21 to 2023/24:

2020/21 Improving referral practice

• Enable and support practices to improve the quality of their referrals

for suspected cancer (including recurrent cancers), in line with NICE guidance and

making use of new RDC pathway for people with serious but non-specific

symptoms where available.

• Introduce safety netting approach for monitoring patients referred for

suspected cancer and those who have been referred for investigations to inform

decision to refer. • Ensure patients receive high-quality information on their referral.

Increasing uptake of National Cancer Screening Programmes

• Building on existing practice-level actions, lead and coordinate

practices’ contribution to improving screening uptake.

• Develop a PCN screening improvement action plan for 2021/22 that

contributes to delivery of the local system plan (shared with Public Health

Commissioning team and Cancer Alliance)

Improving outcomes through reflective learning and local system

partnerships

• Develop a community of practice across the PCN and encourage

practices’ engagement with local system partners, in particular the Cancer

Alliance, to enable delivery of the service requirements.

2021/22 Improving referral practice

• Increase the proportion of people diagnosed at stages 1 and 2

by identifying and referring suspected cancer early, contributing to delivery of

local CA target for improvement

37 55

• Continue to review and improve referral practices, building on

2020/21 learning and activities, including through Significant Event Analysis and

peer to peer learning and further analysis of local population data

• Expand safety netting to include monitoring of patients with non-

specific symptoms where the GP has a significant clinical concern but are not

immediately referred for suspected cancer.14 • Continue to ensure patients receive high-quality information on their

referral (for all future years)

Increasing uptake of National Cancer Screening Programmes

• Deliver agreed actions from their 2021/22 PCN screening

improvement action plan, in line with Public Health Commissioning and Cancer

Alliance plan. Update plan for 2022/23

Improving outcomes through reflective learning and local system

partnerships

• Working with local system partners (including patient groups), PCNs

to proactively engage the local community to promote healthier lifestyles,

awareness of signs and symptoms and availability of support.

2022/23 Improving referral practice

• Increase the proportion of people diagnosed at stages 1 and 2

by identifying and referring suspected cancer early, contributing to delivery of

local CA target for improvement

• PCNs continue to review and improve referral practices, building

on 20/21 learning and activities, including through Significant Event Analysis and

peer to peer learning

Increasing uptake of National Cancer Screening Programmes

• Update & implement local screening improvement action plan.

Improving outcomes through reflective learning and local system

partnerships

• Working with local system partners, PCNs proactively engage the

local community to promote healthier lifestyles, awareness of signs and

symptoms and available support. This includes identifying people at higher risk of

developing cancer.

2023/24 Improving referral practice

14 NG12 recommends considering a review for people with any symptom that is associated with an increased risk of cancer where the GP has a concern, but who do not meet the criteria for referral or other investigative action. The review may be planned within a time frame agreed with the person or patient-initiated if new symptoms develop, the person continues to be concerned or their symptoms recur, persist or worsen. GP IT systems are structured to enable this practice.

38

56

• Increase the proportion of people diagnosed at stages 1 and 2

by identifying and referring suspected cancer early, contributing to delivery of

local CA target for improvement

• All patients are receiving high-quality information about their referral.

Those that are deemed to require additional support for their referral are

signposted to the PCN social prescribing link workers.

• Continued implementation of a consistent approach to safety netting

across the PCN, and all people with serious but non-specific symptoms into Rapid

Diagnostic Centres.

Increasing uptake of National Cancer Screening Programmes

• Subject to success of pilots, Targeted Lung Health Checks are

scheduled for national roll out. PCNs should help practices to encourage

participation in the programme for those who could benefit.

Improving outcomes through reflective learning and local system

partnerships

• Working with local system partners, proactively engage the local

community to promote healthier lifestyles, awareness of signs and symptoms

and availability of support. This includes identifying people at higher risk of

developing cancer.

Proposed service requirements for 2020/21

6.12 From April 2020, practices working as part of PCNs will:

• identify a clinical lead who will be responsible across the PCN for the

delivery of the service requirements in this section.

• improve referral practice for suspected cancers, including recurrent cancers.

This will be done by:

o using local data including practice level data to explore local patterns in

presentation and diagnosis of cancer.

o enabling and supporting practices to improve the quality of their referrals for

suspected cancer, in line with NICE guidance and making use of Clinical Decision

Support Tools and the new RDC pathway for people with serious but non-specific

symptoms where available.

o introducing a consistent approach to monitoring patients who have beenreferred urgently with suspected cancer or for further investigations

39 57

undertaken to exclude the possibility of cancer (‘safety netting’) in line with NICE

Guideline 12. This should build on relevant approaches already in place in

constituent practices and drawing on evidence.

o ensuring that patients receive high-quality information on their referral

including why they are being referred, the importance of attending

appointments and where they can access further support.

• increase uptake of National Cancer Screening Programmes. This will be done

by:

o leading and coordinating constituent practices’ contribution to a local

screening uptake improvement plan, working with the local Public Health

Commissioning team and Cancer Alliance. PCNs should identify actions relevant

for their particular populations that they will take forward.

o building on actions already underway across practices to agree and deliver

with practices any 2020/21 improvement activity identified.

o standardising processes across the PCN to encourage the uptake of

National Cancer Screening Programmes.

o working with local system partners to agree a 2021/22 Network-level

action plan for improving uptake of cancer screening programmes across the PCN.

• improve outcomes through reflective learning and local system partnerships.

This will be done by:

o developing a community of practice among practice level clinical staff

that will inform Network-level improvement action plans

o investigating historic referral diagnosis data to identify trends and

opportunities for proactive work across the PCN to improve referrals and early

diagnosis, and to identify cases which should be used for peer to peer learning

and significant event analysis (including patients who presented many times

before diagnosis and those diagnosed late).

o facilitating and supporting constituent practices to conduct Network-wide

Significant Event Analyses and peer to peer learning sessions, taking advantage

of the broad range of cases across a PCN.

40

58

o facilitating and encouraging practices’ engagement with local system

partners, including Patient Participation Groups, secondary care, the relevant Cancer

Alliance and Public Health Commissioning teams, to inform ongoing improvement

activity.

Proposed metrics

6.13 Potential metrics to monitor the success of the service may include, but are not limited

to:

Metric description

1. The proportion of cancers diagnosed at early stage (stage 1 and 2) –

progress towards local Cancer Alliance target

2. PCN-level participation in breast, bowel and cervical screening

programmes

3. Proportion of urgent cancer referrals that were safety netted

4. The number of new cancer cases treated that have resulted from a two

week wait referral (the ‘detection’ rate)

5. The number of two week referrals resulting in a diagnosis of cancer

(the ‘conversion’ rate)

6. Number of cancers diagnosed via emergency presentation

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1

Newham CCG Month 09 Finance Report – 2019/20

1. Summary

This report provides an update on the Primary Care delegated commissioning financial position for the Clinical Commissioning Group (CCG).

2. Key Risks and Issues

Since April 2016, the CCG has had fully delegated responsibility for Primary Care from NHS England. This means that the CCG is responsible for the budgeting and authorisation of primary care payments, and meeting any shortfalls in expenditure.

This summary provides an update on the Primary Care delegated financial position for the

CCG.

At Month 09 (December 2019) the CCG is reporting a £0.2m overspend and is forecasting a year end overspend of £0.3m against the budget of £55.3m. Although this overspend is comprised of a number of issues; the key issues are as follows:

Rent – a number of practices have not claimed rent reimbursements for a number ofyears, work has been ongoing throughout 2019/20 to ensure that claims are made bypractices and that where needed revaluations are completed. This has led to a numberof rent reclaims being higher than previous years and has attributed to the reserves lineyear to date (YTD) overspend of £0.5m.

Additional Roles Reimbursement Scheme – It is understood that whilst the AdditionalRoles Reimbursement scheme has started and Networks have employed additionalmembers of staff, not all PCNs have yet submitted claims to the NEL Primary CareTeam for staff engaged.

60

2

3. Primary Care Revenue financial position for December 2019

The summarised CCG’s revenue financial position;

YTD Predicted FOT

Budget Actual Variance Variance Budget Forecast Variance Variance

£'000 £'000 £'000 % £'000 £'000 £'00 %

General Practice - APMS 4,118 4,248 130 3% 5,306 5,846 541 10%

General Practice - GMS 6,558 6,483 (76) (1)% 8,939 7,687 (1,252) (14)%

General Practice - PMS 18,160 18,149 (11) - 24,302 24,072 (230) (1)%

QOF + Other Medical Services 2,704 2,712 7 - 3,606 3,606 - -

Premises 5,145 5,615 471 9% 6,859 6,827 (32) -

Enhanced Services 3,984 3,605 (379) (10)% 5,198 5,679 481 9%

PCN Network 703 660 (43) (6)% 963 996 33 3%

QIPP - - - - - - - -

Primary Care Commissioning Staff - - - - - - - -

Primary Care Winter Resilience - - - - - - - -

Co-Commissioning Levies - - - - - - - -

Additional Spend 18 115 97 527% 25 25 - -

Co-Commissioning Reserve - - - 120 830 710 593%

Co-Commissioning Headroom Reserve

- - - - - - - -

41,390 41,586 196 55,317 55,567 250

General Practice Contract payments

The APMS contract budget line represents 5 GP practices and is 10% of the total

budget.

The GMS contract budget line represents 17 GP practices and is 16% of the total

budget.

The PMS contract budget line represents 26 GP practices and is 44% of the total

budget.

The overall combined spend for APMS, GMS and PMS contracts has resulted in an

adverse over-spend of £0.1m year to date and a break even forecast outturn. The

expected list size growth in Q4 will be mitigated by the release of the residual delegated

commissioning reserve.

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3

Quality Outcomes Framework

The YTD QOF position for 19/20 is based on a total level achieved in 2018/19.

Practices received aspiration payments calculated as 70% of 18/19 QOF achievement

which is paid in monthly instalments during the year.

Premises Costs Reimbursement

Premises expected outturn for the year are reported with an overall under-spend of

£(0.1m), broken down below:

FOT

Budget Forecast Variance Variance RAG

£'000 £'000 £'000 %

Rent Reimbursements 5,285 5,247 (37) (1)%

Business Rates 975 988 13 1%

Water Rates 31 31 - - 3

Clinical Waste 22 22 - - 3

Other Premises Cost 170 162 (9) (5)% 3

Voids and Subsidies 377 377 - -

Premises 6,859 6,827 (32) 3

Rent: FOT risks relating to rent are currently allocated against the delegated

commissioning reserve.

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4

Direct Enhanced Services (DES)

Enhanced Services are projected to be over-spend by £0.5m, based on current claims

of which £0.4m is related to Q1 pressure for Extended Hours DES (prior to the

implementation of the new scheme under the PCN framework) and an increase in

provisions relating to unclaimed EHA. The balance is primarily driven by (1) An

increase in prescribing fees (2) An extension of the year 1 PMS transitional payments.

The CCG has seen significate levels of under achievement against outcome measures

within the current year; which will result in a number of clawbacks. However the

requirement to reinvest these clawbacks within primary care means the CCG will not

realise any benefit from these clawbacks.

FOT

Budget Forecast Variance Variance RAG

£'000 £'000 £'000 %

Extended Hours Access 971 1,366 396 41%

Minor Surgery 139 141 2 1% 3

Prof Fees Prescribing 154 214 59 38%

Learning Disability 146 146 - - 3

Unplanned Admissions - - - - 3

Equalisation List (KPIs) 3,788 3,812 24 1% 3

Enhanced Services 5,198 5,679 481 9%

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5

4. Breakdown of Primary Care Allocation for financial year 2019/20

Table 3: PC Allocation by category - 2019/20

Budget Budget

£000's %

General Practice - APMS 5,306 10%

General Practice - GMS 8,939 16%

General Practice - PMS 24,302 44%

QOF + Other Medical Services 3,606 7%

Premises 6,859 12%

Enhanced Services 5,198 9%

PCN Network 963 2%

QIPP - -

Primary Care Commissioning Staff - -

Primary Care Winter Resilience - -

Co-Commissioning Levies - -

Additional Spend 25 -

Co-Commissioning Reserve 120 -

Co-Commissioning Headroom Reserve - -

Co-Commissioning Contingency - -

55,317

10%

16%

44%

7%

12%

9% 2%

General Practice - APMS

General Practice - GMS

General Practice - PMS

QOF + Other Medical Services

Premises

Enhanced Services

PCN Network

QIPP

Primary Care Commissioning Staff

Primary Care Winter Resilience

Co-Commissioning Levies

Additional Spend

Co-Commissioning Reserve

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6

5. Comparison of the Primary Care Allocation for financial years 2018/19 and

2019/20

Comparison of PC Allocations by category by Financial Year

PC Allocation

19/20

PC Allocation 18/20

Variance

£0 £0 £0

General Practice - APMS 5,306 4,908 398

General Practice - GMS 8,939 7,813 1,125

General Practice - PMS 24,302 27,322 (3,019)

QOF + Other Medical Services 3,606 4,176 (571)

Premises 6,859 6,624 235

Enhanced Services 5,198 1,068 4,130

PCN Network 963 - 963

QIPP - - -

Primary Care Commissioning Staff - - -

Primary Care Winter Resilience - - -

Co-Commissioning Levies - - -

Additional Spend 25 - 24

Co-Commissioning Reserve 120 971 (852)

Co-Commissioning Headroom Reserve - - -

Co-Commissioning Contingency - - -

55,317 52,884 2,433

This table highlights where the allocation changes have occurred;-

in Premises where the budget had been optimistically reduced in the belief that rental

reviews will not negatively impact on spend in this financial year even though they will in

future years,

on the DES line which includes several new initiatives (as specified in the publication: A

five year framework for GP contract reform to implement The NHS Long Term

Plan)

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7

6. Breakdown of allocation for the component parts of the Primary Care Network

DES

PC Networks Allocation - 2019/20

PCN Budget

2019/20

Budget as % of

Allocation

£000 %

PCN Clin Pharmacist

PCN Soc Prescribing

PCN Participation 758 79%

PCN Clinical Director 205 21%

963

Primary Care Network DES

This Primary care Network DES is a new addition for this financial year. This is part of the

strategy, more fully described in A five year framework for GP contract reform to

implement The NHS Long Term Plan, published in January 2019, where the Department of

Health describes how the NHS will meet the challenges facing primary care.

PCN Participation and PCN Clinical Director are projected to plan, in-line with monthly

payments already setup for the schemes.

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Primary Care Commissioning Committee Part I meeting: 15.00-16.00 Wednesday 5 February 2020 FO21 Plaistow Room, 4th Floor Unex Tower, 5-7 Station Street, London E15 1DA

Title Updated Terms of Reference (ToR)

Agenda item 2.1

Author Lauren Sibbons, Head of Primary Care - Newham, WEL CCGs

Presented by Lauren Sibbons, Head of Primary Care - Newham, WEL CCGs

Contact for further information

Lauren Sibbons, Head of Primary Care - Newham, WEL CCGs,

laurensibbons@nhs.net

020 3816 3858

This paper is for ☒ Decision ☐ Monitor ☐ Discussion ☐ For Information

Action required The Committee is asked to approve minor administrative amendments to the Committee’s Terms of Reference reflecting the establishment of the Newham, Tower Hamlets and Waltham Forest (WEL) CCGs arrangements.

Executive summary

The Committee’s Terms of Reference were previously approved by the CCG’s Governing Body on 19 December 2018. The following revisions have been made to the ToR by way of update:

Schedule 1 – List of Members

Voting Attendees

Vice – Chair: Newham CCG Board Nurse amended to Newham CCG Lay Member

CCG Managing Director: Newham CCG Managing Director amended to WEL CCGs Managing Director

CCG Chief Finance Officer: Newham CCG Interim Chief Finance Offer amended to WEL CCGs Executive Director of Finance

CCG Primary Care Lead: Newham CCG Associate Director of Primary Care amended to WEL CCGs Interim Director of Primary Care

The note “For the remainder of 2018/19, in the absence of a second Lay Member, the Board nurse will assume the role of Vice-Chair” has been deleted.

Non-Voting Attendees

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Reference to ‘North East London Commissioning Alliance’ amended to ‘North East London Primary Care Team’

Supporting papers Appendix A: Terms of Reference (updated January 2020)

Next Steps/ Onward Reporting

No planned further presentation or reporting, as due to the minor nature of the administrative amendments these revised ToR do not require ratification by the CCG’s Board.

Where has the paper been already presented?

This paper has not been presented elsewhere.

How does this fit with NHS Newham CCG strategic Priorities?

Strategic Priorities • To commission a Newham-based integrated health and care system which

delivers high quality services for the residents of Newham, in accordance withstatutory requirements

• To commission and develop GP services that are modern, accessible and fitfor the future in caring for our residents

Enabling Priorities • Ensuring we maintain our performance across the key business areas

Outcomes • We will improve access to, and, the quality of, Primary Care• We will clearly be able to demonstrate how we have improved outcomes for

our residents

Commissioning Priorities • To implement the five-year framework for GP contract reform to implement

The NHS Long Term Plan.

Risk BAF.05– Failure to effectively monitor the quality, performance and activity ofcommissioned services, with a focus on ensuring the delivery of better clinicaloutcomes.

BAF.07 Failure to effectively deliver a primary care strategy that isadequately resourced to service Newham residents

Equality impact This report conserves the duty of Newham CCG in respect of equality and this has been considered when developing the risks for consideration and any mitigating actions described. An Equality Impact Assessment has previously been conducted for Primary Care and the delivery of primary care services and concluded that services are available and accessible for all Newham residents.

Stakeholder engagement

There has been no formal engagement on the amendments made to the report as they are minor administrative points with no material change.

Financial Implications

There are no financial implications associated with this report other than those identified within the specific risks and actions. Any resulting financial impact will need to be managed within existing resource and if needed, further discussion at Board level if budgets are exceeded.

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69

Appendix A –

Newham CCG Primary Care Commissioning Committee Terms of Reference

(Revised January 2020)

1. Introduction and Background

1.1 Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that NHS England was inviting Clinical Commissioning Groups to expand their role in primary care commissioning. Each Clinical Commissioning Group (‘CCG’) was invited to submit an expression of interest setting out its preference for how it would like to exercise expanded primary medical care commissioning functions.

1.2 One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to individual CCGs. Accordingly, in October 2014 the CCG submitted an application to NHS England to exercise these commissioning functions for its own geographical area.

1.3 In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended) (‘NHS Act 2006’), NHS England subsequently delegated the exercise of the functions specified in section 4 below to Newham CCG.

1.4 Newham CCG has established its Primary Care Commissioning Committee as a committee of its Governing Body. The purpose of the Primary Care Commissioning Committee is to be a corporate decision making body for the management of the delegated functions and the exercise of the delegated powers.

1.5 These Terms of Reference set out the membership, remit, responsibilities and reporting arrangements of the Committee.

2. Statutory Framework

2.1 NHS England has delegated to Newham CCG the authority to exercise the primary care commissioning functions set out in section 4 below for its own geographical area in accordance with section 13Z of the NHS Act 2006.

2.2 Arrangements made under section 13Z of the NHS Act 2006 may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and the CCG.

2.3 Arrangements made under section 13Z of the NHS Act 2006 do not affect the liability of NHS England for the exercise of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it) it must comply with the statutory duties set out in Chapter A2 of the NHS Act 2006 and including:

No. Statutory Duty Section of NHS Act 2006

1. Management of Conflicts of Interest 14O

2. Duty to promote the NHS Constitution 14P

3. Duty to exercise its functions effectively, efficiently and economically

14Q

4. Duty as to improvement in quality of services 14R

5. Duty in relation to quality of primary medical services

14S

6. Duties as to reducing inequalities 14T

7. Duty to promote the involvement of each patients 14U

8. Duty as to patient choice 14V

9. Duty as to promoting integration 14Z1

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10. Public involvement and consultation 14Z2

2.4 In respect of the delegated functions from NHS England the CCG will need to exercise those functions in accordance with the relevant provisions of section 13 of the NHS Act 2006 including:

No. Statutory Duty Section of NHS Act 2006

1. Duty to have regard to impact on services in certain areas

13O

2. Duty as respects variation in provision of health services

13P

2.5 The Primary Care Commissioning Committee is established by the Governing Body in accordance with Schedule 1A of the NHS Act 2006.

2.6 The members of the Committee acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.

3. Role of the Committee

3.1 The role of the Committee is to carry out the function relating to the commissioning of primary medical services under section 83 of the NHS Act 2006. This includes the following:

Decisions in relation to the commissioning, procurement and management of Primary Medical

Services Contracts, including but not limited to the following activities:

o Decisions in relation to Enhanced Services;

o Decisions in relation to Local Incentive Schemes (including the design of such schemes)

o Decisions in relation to the establishment of new GP practices (including branch surgeries)

and closure of GP practices;

o Decisions about ‘discretionary’ payments;

o Decisions about commissioning urgent care (including home visits as required) for out of

area registered patients;

o The approval of practice mergers;

o Planning primary medical care services in the area, including carrying out needs

assessments;

o Undertaking reviews of primary medical care services;

o Decisions in relation to the management of poorly performing GP practices and including,

without limitation, decisions and liaison with the CQC where the CQC has reported non-

compliance with standards (but excluding any decisions in relation to the performers list);

o Management of delegated funds;

o Premises costs directions functions;

o Co-ordinating a common approach to the commissioning of primary care services with

other commissioners in North East London where appropriate; and

o Such other ancillary activities that are necessary in order to exercise the Delegated

Functions.

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3.2 In performing its role, the Committee will exercise its management of the functions in accordance with

the Delegation and the Delegation Agreement that the CCG entered into with NHS England. The Delegation and the Delegation Agreement sit alongside these Terms of Reference. The Delegation Agreement is contained in Schedule 2.

3.3 In addition to carrying out the function relating to the commissioning of primary medical services under section 83 of the NHS Act 2006, the role of the Committee will also be to provide assurance to the Board that the CCG is obtaining value for money for grant funding invested in the development of the GP Federation.

3.4 The functions of the Committee are undertaken in the context of a desire to promote increased co-

commissioning to increase quality, efficiency, productivity, value for money and remove administrative barriers.

3.5 The Committee will have due regard to any relevant quality and safety issues which may arise as

agreed by Committee members. 3.6 In performing its role, the Primary Care Commissioning Committee will act within the powers

delegated to it by NHS England. 3.7 Decisions made by the Primary Care Commissioning Committee will be binding on NHS England as

long as decisions are made within the scope of the powers delegated to it. 3.8 In performing its role, Committee members will act in good faith towards each other, work

collaboratively, review evidence, share information, provide objective expert input and endeavour to reach a consensus and collective view.

5. Membership

5.1 The membership of each of the Primary Care Commissioning Committee will meet the requirement of its Constitution.

5.2 The Committee shall have a lay and executive majority. 5.3 The Committee shall have the following non-voting attendees:

NHS England representative(s);

Health and Wellbeing Board representative(s);

Healthwatch Representative(s);

LMC Representative(s);

Non-conflicted external clinicians.

5.4 The list of members and non-voting attendees is set out in Schedule 1. 5.5 Committee members may nominate deputies to represent them in their absence and make decisions

on their behalf. Non-voting attendees may nominate deputies to represent them in their absence. 5.6 The Committee may call additional experts to attend meetings on a case by case basis to inform

discussion. 5.7 The Committee may invite or allow additional people to attend meetings as attendees. Attendees may

present at Committee meetings and contribute to the relevant Committee discussions, but are not permitted to participate in any formal vote.

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5.8 The Committee may invite or allow people to attend meetings as observers. Observers may not present at Committee meetings, contribute to any Committee discussion or participate in any formal vote.

6. Chair and Vice Chair of the Committee

6.1 The Chair of the Committee shall be a Lay Member from Newham CCG. The Committee Chair shall not be the Chair of the CCG’s Audit Committee nor a Conflict of Interest Guardian.

6.2 The Vice Chair of the Committee shall be a Lay Member from Newham CCG. The Committee Vice Chair shall not be the Chair of the CCG’s Audit Committee nor a Conflict of Interest Guardian.

7. Voting

7.1 Each voting member of the Primary Care Commissioning Committee shall have one vote with resolutions passing by simple majority.

7.2 The Chair or Vice-Chair Lay Member will have the casting vote.

8. Decisions

8.1 The Committee will make decisions within the bounds of their remit.

8.2 Decisions of the Committee will be binding on NHS England in respect of the management of functions delegated to it by NHS England (section 13Z of the NHS Act 2006).

8.3 Due to the nature of primary care commissioning, the Committee recognises that some urgent and immediate decisions may need to be made outside of Committee meetings. The Primary Care Commissioning Committee may therefore delegate urgent and immediate decisions that need to be made outside of Committee timescales in accordance with clauses 8.4 – 8.5 and 8.7 below.

8.4 Urgent decisions requiring a response within 24 hours will be made collectively by the following people or their nominated deputies:

The Single Accountable Officer/Managing Director;

The Chair or Vice-Chair Lay Member.

8.5 Immediate decisions requiring a response within two weeks will be made at a Committee meeting where practicable. Where this is not practicable the following people or their nominated deputies will collectively make the decision:

The Single Accountable Officer/Managing Director

The Chair or Vice-Chair Lay Member

8.6 Due to the nature of primary care commissioning the Committee recognises that the following non-contentious, low risk, decisions may be made outside of Committee meetings by those listed in clause 8.7 below: :

Requests to add or remove a partner;

Retirement of a partner and addition of a new partner;

Partnership changes - 24 hour retirement;

Opening of a patient list;

Increases in practice boundaries.

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8.7 The following people or their nominated deputies may collectively make the non-contentious, low risk decisions set out in clause 8.6 above:

The Chair or Vice-Chair Lay Member;

The Single Accountable Officer/Managing Director

8.8 Decisions made outside of Committee meetings will be reported to the Committee at the next Committee meeting. This may be in a public or private part of the meeting depending on the nature of the business and the decision(s) made.

9. Quorum

9.1 The Primary Care Commissioning Committee must have a Lay and Executive majority to be quorate with three of the five voting members in attendance. One Lay Member must also be present.

9.2 If any representative is conflicted on a particular item of business they will not count towards the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted to satisfy the quorum requirements.

10. Frequency of Meetings

10.1 The Committee shall meet monthly or as otherwise agreed by the Committee.

11. Notice of Meetings

1.1 Notice of a Committee meeting shall be sent to all Committee members no less than 7 days in advance of the meeting.

11.2 The meeting shall contain the date, time and location of the meeting.

11.3 Where Committee meetings are to be held in public the date, times and location of the meetings will be published on Newham CCG’s website.

12. Agendas and Circulation of Papers

12.1 Before each Committee meeting, an agenda setting out the business of the meeting will be sent to every Committee member no less than 7 days in advance of the meeting.

12.2 Before each Committee meeting the papers of the meeting will be sent to every Committee member no less than 7 days in advance of the meeting.

12.3 If a Committee member wishes to include an item on the agenda they must notify the Chair via the Committee’s Secretariat no later than 7 days prior to the meeting. The decision as to whether to include the agenda item is at the absolute discretion of the Chair.

13. Minutes and Reporting

13.1 The minutes of the proceedings of a meeting shall be prepared by the Committee’s Secretariat and submitted for agreement at the following Committee meeting.

13.2 The approved minutes will be presented to the NHS England area team.

14. Conflicts of Interest

14.1 Conflicts of Interest shall be dealt with in accordance with Newham CCG’s Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest.

14.2 The CCG shall ensure appropriate local safeguards are in place to maintain the integrity of the role of Conflicts of Interest Guardian.

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14.3 The Committee shall have a Conflicts of Interest Register that will be presented as a standing item on the Committee’s agenda.

15. Gifts and Hospitality

15.1 Gifts and Hospitality shall be dealt with in accordance with the CCG’s Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest.

15.2 The Committee shall have a Gifts and Hospitality Register that will be presented as a standing item on the Committee’s agenda.

16. Meetings Held in Public

16.1 Meetings of the Committee shall be held in public unless the Committee resolves to exclude the public from a meeting. In which case the meeting, in whole or in part, may be held in private. The Committee may also exclude non-voting attendees and observers. Meetings or parts of meetings held in public will be referred to as ‘Meeting Part 1’. Meetings or parts of meetings held in private will be referred to as ‘Meeting Part 2.’

16.2 Non-voting attendees, observers and the public may be excluded from all or part of a meeting at the Committee’s absolute discretion whenever publicity would be prejudicial to the public interest by reason of:

The confidential nature of the business to be transacted; or

The matter is commercially sensitive or confidential; or

The matter being discussed is part of an on-going investigation; or

The matter to be discussed contains information about individual patients or other individuals

which includes sensitive personal data; or

Information in respect of which a claim to legal professional privilege could be maintained

in legal proceedings is to be discussed;

Other special reason stated in the resolution and arising from the nature of that business or of

the proceedings; or

Any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as

amended or succeeded from time to time; or

To allow the meeting to proceed without interruption, disruption and/or general disturbance.

17. Confidentiality

17.1 Members of the Committee shall respect the confidentiality requirements set out in these Terms of Reference unless separate confidentiality requirements are set out for the Committee in which event these shall be observed.

17.2 Committee meetings may in whole or in part be held in private as per section 16 above. Any papers relating to these agenda items will be excluded from the public domain. For any meeting or any part of a meeting held in private, all members and/or attendees must treat the contents of the meeting and any relevant papers as strictly private and confidential.

17.3 Decisions of the Committee will not be published by Committee members except where matters under consideration or when decisions have been made in private and so excluded from the public domain in accordance with section 16 above.

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18. Standards of Business Conduct

18.1 Committee members, attendees and/or observers must maintain the highest standards of personal conduct and in this regard must comply with:

The law of England and Wales;

The NHS Constitution;

The Nolan Principles;

The standards of behaviour set out in each NCL CCG Constitution;

Any additional regulations or codes of practice relevant to the Committee.

19. Training and Information

19.1 It is the responsibility of the CCG to ensure that their representatives at the Committee are provided with appropriate training and information to allow them to exercise their responsibilities effectively.

20. Sub-Committees

20.1 The Committee may not delegate any of its powers to a Committee or Sub-Committee but it may appoint sub-committees and/or working groups to advise and assist it in carrying out its functions.

20.2 Any sub-committees or working groups must abide by Newham CCG’s Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest.

21. Review of Terms of Reference

21.1 These Terms of Reference will be reviewed from time to time, reflecting experience of the Committee in fulfilling its functions and the wider experience of the CCG in primary medical services co-commissioning.

21.2 These Terms of Reference will be formally reviewed in April each year following the establishment of the Committee. These Terms of Reference may be changed or amended by mutual agreement of the Committee and on approval by the Governing Body in accordance with its Constitution.

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Schedule 1 - List of Members

This schedule sets out the membership, attendees, Chair and Vice Chair of the Primary Care Commissioning Committee

Voting Members

Position Title

Chair Newham CCG – Lay Member

Vice-Chair Newham CCG – Lay Member

CCG Board Nurse Newham CCG – Board Nurse

CCG Managing Director or nominated deputy

WEL CCGs – Managing Director

CCG Chief Finance Officer or nominated deputy

WEL CCGs – Executive Director of Finance

CCG Primary Care Lead or nominated deputy

WEL CCGs - Interim Director of Primary Care

Non-Voting Attendees

Health and Wellbeing Board representative

Health and Wellbeing Board, London Borough of Newham

Healthwatch representative Healthwatch Newham

Local Medical Committee representative or nominated deputy

Director of Primary Care Strategy, Londonwide LMCs

CCG GP representative Newham CCG – Elected GP representative

North East London Primary Care Team representative

Head of Primary Care Commissioning or Assistant Head of Primary Care Commissioning

Public Health representative Director of Public Health, London Borough of Newham

Local Authority representative

Head of Public Health Commissioning, Adults

The roles referred to in the list of voting members and non-voting attendees above describe the members’ and non-voting attendees’ substantive roles and/or any successor equivalent roles only and not the individual title or titles of any member. Names and job titles are provided for information purposes only and may be updated as required without the need to formally amend the Terms of Reference.

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Primary Care Commissioning Committee Part I – 15:00 – 16:00 Wednesday 5 February 2020

FO21 Plaistow Room, Unex Tower, Station Street, London E15 1DA

Title Boleyn Medical Centre – Temporary List Closure

Agenda item 2.2

Author Abdul Rawkib, NEL Primary Care Team, Senior Commissioning Manager

Presented by Lorna Hutchinson, NEL Primary Care Team, Assistant Head of Primary Care

Contact for further information

Abdul Rawkib, NEL Primary Care Team, Senior Commissioning Manager, e: a.rawkib@nhs.net, t: 020 3688 2121

This paper is for x Decision ☐ Monitor ☐ Discussion ☐ For Information

Action required To approve the request for Boleyn Medical Centre to temporarily close its patient list for a period of 4 – 6 months.

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Executive summary

Boleyn Medical Centre was rated ‘Inadequate’ by the Care Quality Commission (CQC) in the published September 2019 report and was placed in special measures. As a result of the findings from the CQC the practice are trying to embed changes in order to ensure CQC compliance. Significant workforce issues are having an impact on the daily operations of the practice and also implementing the changes advised by the CQC.

The practice has submitted a proposal to temporarily close its patient list for a period of 4 – 6 months, in order to undertake the relevant changes which would help the practice be taken out of special measures by the CQC.

Supporting papers Appendix A: Application to close practice list.

Next Steps/ Onward Reporting

Inform practice of Committee decision – February 2020

Review practice progress in achieving CQC compliance – May 2020

Practice list to re-open – August 2020

Where has the paper been already

presented?

This report has not been presented to any other Committee

How does this fit with NHS Newham

CCG strategic Priorities?

Strategic Priorities

• To commission and develop GP services that are modern, accessible and fitfor the future in caring for our residents

Outcomes

• We will improve access to, and, the quality of, Primary Care

Risk BAF.07.01 Failure to effectively deliver a primary care strategy that isadequately resourced to service Newham residents

Equality impact Although the practice has applied to temporarily close its patient list, the practice has agreed to register the newly born children of current patients and in extenuating circumstances vulnerable patient groups.

Stakeholder engagement

The practice have engaged with the practice which is co-located and alsowith members of its Primary Care Network (PCN).

Financial Implications

Newham CCG faces a significant financial challenge in 2019/20 and is undertaking a range of measures to ensure sustainability. This paper presents issues that may

have financial consequences. These are yet to be fully determined but if not already embedded in budgets or reserve provision, a further Board decision would

be required to release any additional expenditure commitment.

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80

1. Introduction and Background

1.1 Boleyn Medical Centre is a single handed Personal Medical Services (PMS) practice located within East Ham and is a member of the Central 1 Primary Care Network (PCN). Boleyn Medical Centre has a patient list size of circa 10,700 patients (raw list size – January 2020). Below is a breakdown of the patient list size from 2017 to present:

Raw list size Percentage increase/decrease

January 2017 9909

January 2018 9560 -4%

January 2019 9646 +1%

January 2020 10753 +11%

The patient list has been relatively steady, however there was a significant increase between January 2019 and January 2020 which saw the patient list grow by over 1000 patients in a year.

The practice was inspected by the Care Quality Commission (CQC) in July 2019 and was rated ‘Inadequate’ overall in the published September 2019 inspection report. Previously the practice was rated ‘Good’ across all domains in the published December 2016 report.

As a result of the inspection outcome in September 2019, the practice submitted a proposal in December 2019 to temporarily close its patient list. A summary of the proposal has been provided in section two of this report. The original application submitted by the practice for the temporary list closure is attached as Appendix A.

2. Proposal Summary

2.1

2.1.1

2.1.2

Rationale

Boleyn Medical Centre has applied to temporarily close its patient list in order to embed the changes identified by the CQC following the last inspection. Issues with recruitment have significantly impacted on the practice workload, which has made it difficult to implement the relevant changes successfully. The practice has encountered problems recruiting a salaried GP, practice nurse and full-time administrative staff. The practice most recently went out to advert in December 2019 for a salaried GP and practice nurse. No applications were received for either vacancy and the practice is exploring alternative recruitment options. At present the practice is using long-term locums to fill these posts.

Due to a lack of staffing, the practice are experiencing difficulty in implementing the changes advised by the CQC and the increase in patient registrations is further adding to the issue. The practice has advised that they are registering on average approximately 50 new patients a week.

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2.1.3

2.1.4

2.2

2.2.1

2.3

2.3.1

2.4

2.4.1

The practice has tried to implement a number of different measures in order to relieve the difficulties experienced as part of having an open list. This has included the following:

Upskilling of administrative staff to undertake HCA duties

Recruitment of additional administrative staff and a management consultant to support withCQC compliance

The Lead GP has changed working pattern in order to undertake administrative duties ondays off

Changes to appointment system – the practice piloted telephone triage, but reverted backto face-to-face due to feedback from clinicians following the pilot. The practice are nowonly using telephone consultations for test results were deemed appropriate.

Two additional telephone lines have been added and introduction of a phone queuingsystem.

Although the above measures have been introduced, this has not fully resolved the issues in achieving compliance with the CQC recommendations.

Engagement

As part of the proposal to temporarily close the practice list, the practice has engaged with its PCN members and the practice which is co-located within the same building (The Azad Practice). The practice have submitted evidence confirming that the PCN are in support of the proposal, which includes a supporting statement from the co-located practice. In addition, there are two practices within the PCN who are keen to grow their lists and would be happy for patients to be signposted to them to register. These two practices fall within a one mile radius of the practice.

Duration of Closure

The practice has proposed a temporary list closure of six months. However the practice is happy to accept a shorter period of four months if approved by the Committee.

Future Sustainability

The practice is currently operating at maximum capacity, which is adding to the difficulty of implementing the changes identified by the CQC. The practice is of the view that the temporary list closure would allow the practice to undertake the necessary compliance work as identified by the CQC and it would also allow the practice to recruit to the vacant substantive posts. This in effect would help the practice to manage its workload.

3.0 Recommendation

3.1 The Committee is asked to approve the temporary list closure for a period of six months in order to ensure that:

The practice is able to implement the changes as advised by the CQC in order to achievecompliance and be taken out of special measures.

The practice is given sufficient time to recruit and fill the vacant substantive posts.

The short-term stability of the practice is maintained.

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