Primary Care Commissioning Committee (part 1) in public Care Commissioni… · Times Description...

1

Primary Care Commissioning Committee (part 1) in public

Wednesday, 25th April 2018, 2.00 - 3.30pm Rooms GO4 & GO5, Bexley Civic Centre DA6 7AT

AGENDA

Item No

Times Description Enc.s Lead

1 Standing items

14/18 14.00 Welcome and introductions

Neil Ross

15/18 14.02 Declarations of Interest A Neil Ross

16/18 14.05 Review of Minutes from the previous meeting on 28th February 2018

B Neil Ross

17/18 14.07 Review of the action log C Neil Ross

2 Items for decision

18/18 14.10 Primary Care Commissioning Committee Terms of Reference

D Nisha Wheeler

19/18 14.20 London Operating Model E SEL PCT

20/18 14.35 Cairngall Medical Practice – Procurement Update F SEL PCT / Nisha

Wheeler

21/18 14.45 Cumberland Drive Branch Closure G SEL PCT

22/18 14.55 Primary Care Budget Allocation 2018-19 H Theresa Osborne

3 Items for discussion

23/18 15.05 Primary Care Finance Report Month 11 I Theresa Osborne

24/18 15.10 Primary Care Strategy Plan J Sukh Singh

4 Other agenda items

25/18 15.20 Questions from members of the public

Any member of the public who wishes to ask a question at the Primary Care Commissioning Committee should send it in advance to [email protected]. Members of the public are reminded that queries

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mailto:[email protected]

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Item No

Times Description Enc.s Lead

relating to individual staff or patients cannot be discussed. The chair reserves the right not to respond to queries relating to issues which are the subject of current confidential discussions or legal action or any other matter at his discretion without giving any reason.

26/18 15.25 Any other business All

5 Date of next meeting

Wednesday 27th June 2018 2.00 - 3.30pm Bexley Civic Offices, Watling Street DA6 7AT

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Primary Care Co-Commissioning Committee (Public)

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

Members with voting rights

Neil Ross - Chair (NR) Lay member, legal & procurement

Keith Wood (KW) Lay member, governance

Paul Cutler – Vice Chair

(PC) Lay member, patient & public involvement

Theresa Osborne (TO) Bexley CCG Managing Director & Chief Financial Officer

Michael Boyce (MB) Bexley CCG Director of Quality, Governance and Performance

Mary Currie (MC) Bexley CCG Registered Nurse

Dr Jhumur Moir (JM) Westwood Surgery

GP Member, Clocktower Locality Lead

Dr Varun Bhalla (VB) Belvedere Medical Centre

GP Member, North Bexley Locality Lead

Dr Sid Deshmukh (SD) Bexley CCG Clinical Chair

Dr Sonia Khanna-Deshmukh

(SKD) Sidcup Medical Centre

GP Member, Frognal Locality Lead

Non-voting members

Stuart Rowbotham (SR) London Borough of Bexley

Representative for Health and Wellbeing Board, Director of Adult Social Care & Health

Dr Richard Money (RM) LMC Chair Bexley & GP Station Road Surgery

Lotta Hackett (LH) Healthwatch Bexley Manager

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

Maxine Hastings (MH) NHS England Assistant Head of Primary Care South East London, Primary Care Team

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

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

SEL CCGs Director of Finance

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Enclosure: A Item: 15/18

Bexley CCG, Primary Care Commissioning Committee members Declaration of Interest 25th April 2018. Public Meeting

Name Role Description of relevant Interests Comments Updates Signature

Sid Deshmukh Bexley CCG Chair

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

1. Attends various locality/clinical meetings which could be sponsored by drug companies where sandwiches/meal is provided (from £5.00 to £30.00) 2. Received £200 form Astra Zenica for chairing educational meeting on Diabetes Management on 10/05/2017 3. Received £300 from Boehringer-Ingelheim for chairing Diabetes Education meeting on 28/09/2017 4. Received £200 from Astra Zenica for chairing educational meeting on Diabetes Management on 08/11/2017 5. Attended HSJ awards event on 22/11/2017at the O2. Estimated value of £375 and paid for by Bexley Care 6. Received £250 from Bayer for Chairing Educational meeting – Atrial Fibrillation Management on 08/03/2018

Varun Bhalla GB Locality Lead, North Bexley

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

Attends various locality/clinical meetings which could be sponsored by drug companies where refreshments are provided (from £5.00 to £30.00)

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Jhumur Moir GB Locality Lead, Clocktower

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

Attends various locality/clinical meetings which could be sponsored by drug companies where refreshments are provided (from £5.00 to £30.00)

Keith Wood 1. Lay Member for Audit and Governance

None None

Paul Cutler

Lay Member for Patients Participation and Involvement (PPI)

1. Director, Paul Cutler Consultancy 2. Associate for the National Children's Bureau, Centre for Public Scrutiny, CAN-Invest, Participation Works 3. Consultant / Advisor to a variety of charities, social enterprises and local authorities across England (None in SE London) 4. Extended family member works for the Alzheimer’s Society

None

Neil Ross Lay Member for Legal and Procurement

None None

Mary Currie Registered Nurse

1. Director Quality for Health Ltd - company offering consultancy service in healthcare sector – 50% Shareholding (Currently providing transformation consultancy to a CCG in SEL i.e. Bromley CCG). 2. Partner is a Director of Physiological Measurements Ltd (Company delivers NHS clinical services).

None

Michael Boyce Director of Governance, Quality and Performance

None None

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Nisha Wheeler Director of Primary Care

None None

Richard Money

LMC Representative, Primary Care Commissioning Committee

1. GP Partner, Station Road Surgery 2. Director, Bexley Health Ltd 3. Director, Bexley Neighbourhood Care

None

Jill Webb

NHS England Representative, Primary Care Commissioning Committee

NHS England None

Lotta Hackett Primary Care Commissioning Committee

Manager, Healthwatch Bexley None

Mark Burgess GB Locality Representative for Frognal

1. Practice Manager, Plas Meddyg Surgery None

Stuart Rowbotham

LB Bexley Director of Adult Social Care and Health

Member, LCN Programme Board None

Malcolm Hines Director of Finance; - Bexley CCG,

Director of Finance; - Bromley CCG - Southwark CCG

None

Maxine Hastings

Member, Primary Care Commissioning Committee

Assistant Head of Primary Care

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Enclosure: B Item: 16/18

1

PRIMARY CARE COMMISSIONING COMMITTEE Public Meeting

Wednesday 28th February 2018 2.00pm - 3.30pm

North Bexley meeting room, Bexley Civic Centre DA6 7AT Voting Members Present Neil Ross (NR) Chair Lay member, legal & procurement V Dr Sid Deshmukh (SD) Bexley CCG Chair V Keith Wood (KW) Lay member, governance Michael Boyce (MB) Director of Quality, Governance & Performance Paul Cutler (PC) Lay member, patient and public Involvement Theresa Osborne (TO) Managing Director & Chief Financial Officer Dr Varun Bhalla (VB) GP Member North Bexley Locality Lead V Dr Sonia Khanna-Deshmukh GP member, Frognal Locality Lead (SKD) Non-voting members Dr Richard Money (RM) LMC Chair V Nisha Wheeler (NW) Director of Primary Care, ICT & Information Governance V Sarb Bansal (SB) Assistant Head of Primary Care, SEL Primary Care Team Lotta Hackett (LH) Bexley Manager, Healthwatch Stuart Rowbotham (SR) LB Director of Adult Social Care & Health, Health and

Wellbeing Board Representative V denotes the member attended the meeting via teleconference/Omnijoin In attendance Clare Fernee (CL) Assistant Director of Medicines Management Lisa Luxford (LL) Primary Care Support Officer (Minutes) Apologies Jill Webb (JB) Head of Primary Care, SEL Primary Care Team Mary Currie (MC) Registered Nurse Dr Jhumur Moir (JM) Clocktower GP Locality Lead

Item No

Standing Items

1/18 1.18.1

Welcome and introductions NR welcomed everyone to the Bexley Primary Care Commissioning Committee (PCCC) meeting in public. Introductions were made and absences recorded. It was noted that due to the poor weather conditions the meeting had to be moved to a different room that supported teleconference facilities and therefore enabled some members of the committee to join the meeting virtually. Unfortunately, members of the public did not have access to the new meeting room however the minutes from the meeting will be available on the CCG website, together with

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the agenda papers for the public to view.

2/18 2.18.1

Declarations of Conflicts of Interest The declarations of interest register was passed amongst attendees and signed by those present. The following conflicts of interest were noted:

VB is conflicted on item 10/18 Cairngall Medical Practice Caretaking Update.

All GPs are conflicted on agenda items 6/18 Prescribing Incentive Scheme , 7/18 BGP CQC Inspection Report and 11/ 18 Primary Care Finance Report.

3/18 3.18.1

Review of minutes from the Primary Care Commissioning Committee meeting (held in public ) on 6th December 2017 The committee approved the minutes of the Primary Care Commissioning Committee meeting (held in public) on 6th December 2017.

4/18 4.18.1

Review of Action Log The action log was reviewed and updated.

Items for Decision

5/18 5.18.1 5.18.2 5.18.3

Dr Nandra – partnership request at Bullbanks Practice Dr K S Nandra is a single handed GP with a PMS contract at Bulbanks Medical Centre. Since the retirement of Dr A Sharma in 2010 the practice has been unable to find a suitable partner and has been using locum and salaried GPs and an Advance Nurse Practitioner in the interim period. The proposal is for Dr H S Nandra to become an additional signatory at Bulbanks Medical Centre from 1st April 2018. This will provide sustainability and resilience to the practice in addition to strengthening the clinical team. Dr H S Nandra has a specialist interest in substance misuse, minor surgery and MSK. Dr K S Nandra has given verbal assurance that he does not plan to retire in the near future. The committee approved the appointment of Dr H S Nandra as an additional signatory to the Bulbanks Medical Centre PMS agreement from 1st April 2018.

6/18 6.18.1 6.18.2

Prescribing Incentives Scheme 2018-19 All GPs are conflicted on this item. The aim of the Prescribing Incentives Scheme is to reward practices for implementing the CCG guidance on appropriate self-care and for achieving national targets in regard to the prescribing of antibiotics. The scheme replaces the delegated prescribing scheme in place since 2015/16. Consultation has taken place with the Local Medical Council (LMC) and the proposal has been taken to the Medicines Management Committee. Practice participation in the scheme is voluntary and there should be no additional cost to the CCG. The following correction was noted to Enc E Proposed prescribing incentive

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6.18.3 6.18.4 6.18.5 6.18.6 6.18.7

scheme 2018-19draft v3, page 3. Specification – part 2. Figures in row 1 of table, column titled description should read: Payment made on comparison of Q4 2017/18 average spend vs. Q1 2018/19 average spend. The committee discussed the proposal. CF confirmed that SEL CCGs had sought legal advice when drafting the scheme. The committee noted the benefits of a global prescribing approach to support GP’s in their prescribing and provide a consistent approach for patients, free of local variation. The scheme does not intend to undermine or replace the professional prescribing decision making processes of GPs or negatively impact patients experiencing hardship. The committee discussed the work of the practice pharmacists detailed in Part 1 Gateway Specification and the 10 working day timescales cited for the GP review to take place. It was agreed to discuss this issue in greater detail outside of the meeting. Action 6.18.5 CF & SD to discuss further, outside of the PCCC meeting, the proposed timescales for GP review of practice pharmacists/care home medication reviews as detailed in the Proposed prescribing incentives scheme 2018-19 draft v3. The committee noted the importance of ensuring there is a patient education campaign to support the implementation of the scheme. The committee were of the opinion that patients would be supportive of the scheme if they have an understanding of the supporting rationale. Subject to final amendments the committee approved the Prescribing Incentives Scheme 2018-19.

7/18 7.18.1 7.18.2 7.18.3

Bexley Group Practice Care Quality Commission (CQC) Inspection Report All GPs are conflicted on this item. Following a CQC inspection on 26th June 2017 Bexley Group Practice received an overall rating of “inadequate” and was placed under special measures. At this time the practice was located across four clinical sites. The CQC inspection report identified areas of concern across each of the four clinical sites. Following the closure of the Normanhurst Avenue site on 17th November 2018 and the planned closure of the Nuxley Road site on 29th March 2018 the practice will be consolidated onto two sites - the main purpose built facility at 76-78 Upper Wickham Lane and Station Road, Erith. Following publication of the inspection report on 23rd November 2017, the contractor was served a notice under the Section 29 of the Health & Social Care Act 2008. The practice will be inspected again by the CQC within six months of publication of the report. The committee discussed the history of the practice and considered the implications of the issue of a breach and remedial notice and whether it is a proportionate response. It was acknowledged that the practice had undertaken a number of positive steps and actions towards the recommendations made in the CQC report and it was also noted that the practice had an external audit and review undertaken by Modality in January 2018 to further support them with any

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7.18.4

additional actions and recommendations required prior to their next CQC inspection. The committee approved the issue of a breach and remedial notice to Bexley Group Practice for failure to adhere to and provide the following :

requirement to abide by all legislation

requirement to have an effective system of Clinical Governance

requirement to have appropriate storage arrangements for vaccines

Items for Discussion

8/18 8.18.1 8.18.2 8.18.3

GP Clinical Systems Migration Bexley Medical Group (BMG) and Westwood Surgery have submitted requests to change their IT clinical system from Vision to EMIS Web. As required by the CCG Practice Agreement, both practices have provided business justification papers. The issues experienced with Vision include poor performance, speed and reliability and poor integration with third party IT systems. The CCG has approved the migration of these practices in line with the GPIT Operating Framework: securing excellence in GP IT services operational framework and GP Systems of Choice guidance. The cost to the CCG for the migration of the two practices is £32,527 and will be funded through the GP IT maintenance budget. The practices will be required to fund any additional training required by staff , outside what is provided as part of the migration and ensure that practice resources are freed up as necessary to enable to staff to to take part in training and data quality verification and implementation processes. The committee discussed the performance issues with Vision that have resulted in BMG and Westwood Surgery reaching the decision to migrate to EMIS Web. The issues experienced with Vision by these practices are not unique and are replicated across other practices in Bexley. The CCG has identified a risk on the primary care risk register regarding the financial implications and resulting cost pressures to the CCG should a number of additional practices decided to migrate from Vision to EMIS Web at the same time.

9/18 9.18.1 9.18.2 9.18.3 9.18.4

PMS Contract Update The Primary Medical Services (PMS) contract letters were sent to all PMS practices in Bexley on the 28th September 2017. Of the 21 PMS practices in Bexley 19 have signed and returned the contract. There are 3 General Medical Services (GMS) practices within Bexley. The contract documentation and equalised PMS premium services offer was sent to GMS practices on 16th January 2018 and has been accepted by all 3 practices. A meeting to discuss the equalised APMS contract offer to the one practice in Bexley with an APMS contract, will be arranged to take place in due course. A PMS Implementation Group has been established to support the transition to the new contract. The group has representation from the CCG Primary Care Team, SEL PCT, LMC members and London Wide LMC. The first meeting of the PMS implementation group has been booked for Tuesday 13th March.

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10/18 10.18.1 10.18.2 10.18.3 10.18.4

Cairngall Medical Practice Caretaking Update Dr Akinsanya resigned from her position as the contract holder at Cairngall Medical Practice with effect from 31st January 2018. Dr Akinsanya should be complimented for her work with colleagues from the CCG to ensure a good handover. At an extraordinary meeting of the Primary Care Commissioning Committee (private) on 19th December 2017, the following decisions were made :

Accept the early resignation and handing back of the Cairngall Medical Practice PMS contract from Dr Akinsanya with effect from 6.30pm on 31st January 2018

Approval of the procurement of a temporary APMS Caretaking Provider was undertaken to provide primary care services to the patients of Cairngall Medical Practice up to October 2018.

Approval of the procurement of a substantive APMS contract The CCG received 13 expressions of interest and 4 bids to provide Caretaking services at Cairngall Medical Practice. In line with procurement protocols all bids were anonymised. The contract was awarded to Bidder 1 who received the highest or joint highest score on every metric. Belvedere Medical Centre was awarded the Caretaking contract from 01/02/2018 and the tendering process for the substantive contract is now underway.

11/18 11.18.1

Primary Care Finance Report The committee noted the Delegated Primary Care Finance Report as at month 10 (January 2018).

Other agenda items

12/18 12.18.1

Questions from members of the public The following question was emailed ahead of the meeting, a response was provided by NW Q1: I understand practices now receive a collective payment for PPG/Engagement. With this in mind I would like to know if PPG’s can access any funding dedicated for engagement activities which could then be used to help those who are struggling or require practical help?

Response:

From 1st April 2015 it became a requirement in the GP Contract for all practices to have a PPG. The funding associated with an Enhanced Service for patient participation ended at that time and it became part of the main GP contract.

It was considered that by the time this became a contractual requirement practices should have already had their PPGs up and running.

Therefore it is now the responsibility of each practice to provide any resources / funding required to assist with this activity. There is no additional funding dedicated for engagement activities other than what

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the practice provides. Page 23 of the second document attached, outlines what practices are

required to do to fulfil their contractual requirement

Q2: As CCG is responsible for primary care which includes PPG/Patient engagement for all GP practices in Bexley, how will it make sure that the practices are using their resources appropriately? Response:

The CCG is assisting practices by providing CCG staff to help establish PPGs and have also employed Healthwatch for a specific piece of work to help take this forward.

Q3: Finally, what financial measures can be taken against practices, including withdrawing funding, who are not compliant? Response :

As stated above practices are expected to have PPGs in place as part of their contract for services. If the CCG becomes aware that a practice does not have a PPG it could issue a breach notice but this is unlikely to lead to the withdrawing of funding.

Practices should have access to the guidance which explains what their contractual requirements are, however these are attached for your information

13/18 13.18.1

Any other business NHSE Primary Care Risk Register will be added as an agenda item to a future meeting of the PCCC (public).

Date of next meeting

14/17 Date of next meeting Wednesday 25th April 2018 2-3.30pm Bexley Civic Centre, Room G04/G05

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Enc C

Item: 17/18

Action Meeting

Date

Action Agreed Lead Action Taken Date for

completion

Status

6.18.5 28/02/2018 CF & SD to discuss further, outside of the PCCC meeting, the

proposed timescales for GP review of practice

pharmacists/care home medication reviews as detailed in the

Proposed prescribing incentives scheme 2018-19 draft v3

Clare Fernee

& Dr S

Deshmukh

30/04/2018 open

Primary Care Commissioning Committee (public) Action log updated 28-02-2018

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DATE: 25th April 2018

Title

Primary Care Commissioning Committee Terms of Reference

This paper is for discussion and decision

Recommended action for the primary care commissioning committee

That the primary care commissioning committee discuss and approve

1. The revised Primary Care Commissioning Committee’s (PCCC) Terms of Reference

Potential areas for conflicts of interest

N/A

Executive summary

The PCCC terms of reference were last reviewed and approved in March 2017. In line with the CCG’s corporate committee framework, an annual review of the terms of reference for every committee needs to take place. The attached terms of reference have been reviewed and are now aligned to the terms of reference for PCCCs across SEL CCGs. The key differences to highlight are as follows and can be seen in the terms of reference document as tracked changes:

Membership updated

Addition of Lambeth CCG with respect to the committees meeting in common with other SEL CCG’s

Update on some elements of presentation

Members of the PCCC committee are asked to review and discuss the proposed amendments and to approve subject to the outcomes of their discussions.

What are the organisational implications

Key risks

There is a risk that without an appropriate approved terms of reference in line with the CCG’s constitution that officers could be acting inappropriately and outside of their remit

ENCLOSURE: D1

AGENDA ITEM: 18/18

Primary care commissioning committee (held in public)

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Equality

N/A

Financial

N/A

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

Clinical lead: Sid Deshmukh, Chair CCG

Executive sponsor:

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

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Enclosure: D2 Item: 18/18

NHS Bexley CCG Primary Care Commissioning Committee Terms of Reference

1 April 2017April 2018

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Delegated commissioning terms of reference

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Terms of reference – NHS Bexley CCG Primary Care

Commissioning Committee

Introduction

1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014

that NHS England was inviting CCGs to expand their role in primary care

commissioning and to submit expressions of interest setting out the CCG’s

preference for how it would like to exercise expanded primary medical care

commissioning functions. One option available was that NHS England would

delegate the exercise of certain specified primary care commissioning functions

to a CCG.

2. In accordance with its statutory powers under section 13Z of the National Health

Service Act 2006 (as amended), NHS England has delegated the exercise of the

functions specified in Schedule 2 to these Terms of Reference to NHS Bexley

CCG. The delegation is set out in Schedule 1.

3. The CCG has established the NHS Bexley CCG Primary Care Commissioning

Committee (“Committee”). The Committee will function as a corporate decision-

making body for the management of the delegated functions and the exercise of

the delegated powers as set out in NHS Bexley CCG’s Constitution and Scheme

of Delegation.

4. It is a committee comprising representatives of the following organisations:

NHS Bexley CCG;

In attendance:

o Bexley Council representative of the Health and Wellbeing Board;

o Bexley Local Medical Committee;

o Bexley Healthwatch;

o South east London CCGs Primary Care Contracts Team.

Statutory Framework

5. NHS England has delegated to the CCG authority to exercise the primary care

commissioning functions set out in Schedule 2 in accordance with section 13Z of

the NHS Act.

6. Arrangements made under section 13Z may be on such terms and conditions

(including terms as to payment) as may be agreed between the NHS England

Board and the CCG.

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7. Arrangements made under section 13Z do not affect the liability of NHS England

for the exercise of any 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 and including:

a) Management of conflicts of interest (section 14O);

b) Duty to promote the NHS Constitution (section 14P);

c) Duty to exercise its functions effectively, efficiently and economically

(section 14Q);

d) Duty as to improvement in quality of services (section 14R);

e) Duty in relation to quality of primary medical services (section 14S);

f) Duties as to reducing inequalities (section 14T);

g) Duty to promote the involvement of each patient (section 14U);

h) Duty as to patient choice (section 14V);

i) Duty as to promoting integration (section 14Z1);

j) Public involvement and consultation (section 14Z2).

8. The CCG will also need to specifically, in respect of the delegated functions from

NHS England, exercise those in accordance with the relevant provisions of

section 13 of the NHS Act

Duty to have regard to impact on services in certain areas (section 13O);

Duty as respects variation in provision of health services (section 13P).

9. The Committee is established as a committee of the CCG Governing Body in

accordance with Schedule 1A of the “NHS Act”.

10. The members acknowledge that the Committee is subject to any directions made

by NHS England or by the Secretary of State.

Role of the Committee

11. The Committee has been established in accordance with the above statutory

provisions to enable the membership of the committee to make collective

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decisions on the review, planning and procurement of primary care services in

Bexley, under delegated authority from NHS England.

12. In performing its role the Committee will exercise its management of the

functions in accordance with the agreement entered into between NHS England

and NHS Bexley CCG, which will sit alongside the delegation and terms of

reference.

13. The functions of the Committee are undertaken in the context of a desire to

promote primary care co-commissioning to increase quality, efficiency,

productivity and value for money and to remove administrative barriers.

14. The role of the Committee shall be to carry out the functions relating to the

commissioning of primary medical services under section 83 of the NHS Act.

15. This includes the following:

GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract);

Enhanced Services and newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);

Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);

Decision making on whether to establish new GP practices in an area;

Approving practice mergers; and

Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes).

16. The CCG will also carry out other activities as detailed in Schedule 1 of the

Delegation Agreement between NHS Bexley CCG and NHS England.

Geographical Coverage

17. The Committee will comprise of decisions in respect of the GP registered

population of NHS Bexley CCG.

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Membership

18. The Committee shall consist of:

Members with voting rights

3 * Lay Members

CCG Chair

2 * Governing Body GP Members

Registered Nurse or Secondary Care Specialist (single member)

CCG Chief OfficerManaging Director

CCG Finance Director Chief Financial Officer

Director of Primary Care, ICT & IG

Director of Governance, Quality & PerformanceAnother CCG Director

Non-Voting Members

Local Medical Committee Representative

Healthwatch Representative

Local Authority Representative of the Health and Wellbeing Board (Elected

Member or Mandated Officer)

Officers as required to undertake business of the committee

19. The Chair of the Committee shall be a Lay Member of NHS Bexley CCG. This

will not be the Lay Member responsible for Audit.

20. The Vice Chair of the Committee shall be a Lay Member of NHS Bexley CCG.

This will not be the Lay Member responsible for Audit.

Meetings and Voting

21. As a committee of the Governing Body, the Committee will operate in

accordance with the CCG’s Standing Orders (in line with NHS England Standard

Operating Procedures). This includes the capacity to manage urgent matters

outside the normal arrangements.

22. The aim of the Committee will be to achieve consensus decision-making

wherever possible. In the event a vote is required, each member of the

Committee shall have one vote. The Committee shall reach decisions by a

simple majority of members present, but with the Chair having a second and

deciding vote, if necessary.

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Quorum

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

Frequency of meetings

24. The Committee will meet regularly at least 4 times per year. After 12 months the

frequency will be reviewed.

Procedure

25. Meetings of the Committee shall:

a) be held in public, subject to the application of 2527(b);

b) the Committee may resolve to exclude the public from a meeting that is

open to the public (whether during the whole or part of the proceedings)

whenever publicity would be prejudicial to the public interest by reason of

the confidential nature of the business to be transacted or for other special

reasons stated in the resolution and arising from the nature of that business

or of the proceedings or for any other reason permitted by the Public

Bodies (Admission to Meetings) Act 1960 as amended or succeeded from

time to time;

c) the closed confidential part of the meeting (as provided for at 2527(b)

above) shall be referred to as Part 2 of the meeting and shall have a

separate agenda and minutes;

d) the Committee may invite the representatives of the local authority (Health

and Wellbeing Board), Local Medical Committees and Healthwatch to Part

2 of any meeting where it considers it is appropriate for such

representatives to attend all or part of Part 2 of the meeting.

26. The committee may meet in common with other CCGs in south east London

(NHS CCG Bexley CCG, NHS CCG Bromley CCG, NHS CCG Greenwich CCG,

NHS CCG Lewisham CCG, NHS Lambeth CCG and NHS CCG Southwark CCG

– or any combination of these CCGs) when there is common business to

transact.

27. Members of the Committee have a collective responsibility for the operation of

the Committee. They will participate in discussion, review evidence and provide

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objective expert input to the best of their knowledge and ability, and endeavour

to reach a collective view.

28. The Committee may delegate tasks to such individuals, sub-committees or

individual members as it shall see fit, provided that any such delegations are

consistent with the parties’ relevant governance arrangements, are recorded in a

scheme of delegation, are governed by terms of reference as appropriate and

reflect appropriate arrangements for the management of conflicts of interest.

29. The Committee may call additional experts to attend meetings on an ad hoc

basis to inform discussions.

30. Members of the Committee shall respect confidentiality in attending and

undertaking the business of the committee.

Procedure

30.31. The Committee will present an executive summary report and its minutes to

the governing body of NHS Bexley CCG and the London area team of NHS

England following each meeting for information, including the minutes of any

sub-committees to which responsibilities are delegated under paragraph 30 28

above.

31.32. The CCG will also comply with any reporting requirements set out in its

Constitution.

32.33. Terms of Reference will be reviewed on an annual basis.

Accountability of the Committee

33.34. The Committee will be accountable for the expenditure of the primary care

budget delegated from NHS England to the CCG. Responsibility for authorising

expenditure against this budget may be further delegated only as set out in the

Operational Scheme of Delegation ratified by the Governing Body.

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34.35. For the avoidance of doubt, in the event of any conflict between the terms of

the CCG’s Operational Scheme of Delegation, the Committee’s Terms of

Reference and the CCG’s Prime Financial Policies, the Operational Scheme of

Delegation will prevail.

Decisions

35.36. The Committee will make decisions within the bounds of its remit.

36.37. The Committee will ensure that any conflicts of interest are dealt with in

accordance with the CCG’s Constitution and Standards of Business Conduct

Policies which for the avoidance of doubt may include members (voting or

otherwise) being excluded from a decision and/or the discussions leading

thereto. The Committee will enact its responsibilities as set out in these Terms of

Reference in accordance with the Nolan Principles for Standards in Public Life.

37.38. The decisions of the Committee shall be binding on NHS Bexley CCG and

NHS England.

Review

38.39. Terms of Reference will be reviewed on an annual basis.

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Schedule 1 – Delegation

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Title

Revised London Primary Care Commissioning Operating Model

This paper is for Discussion and decision only


That the primary care commissioning committee ratify

1. The revised London Primary Care Operating Model and the related documentation


There may be conflicts of interests for GP committee members relating to specific aspects of the Operating Model

Executive summary

The Operating Model was developed in April 2015 and sets out how NHS England (London) region’s STP primary care teams contracting teams will consistently support CCGs with joint or delegated co-commissioning arrangements (as of April 2017). The Operating Model provides the standard offer of NHS England in terms of supporting Primary Care Commissioning activities, this document has been endorsed by NHS England Primary Care Management Board, which includes STP Primary Care Leads, prior to consideration by Primary Care Commissioning Committees. Primary Care Commissioning Committees (PCCC’s) and Primary Care Joint Committees (PCJC’s) were asked to adopt the first version of the Operating Model in autumn of 2015. The Operating Model has been revised to include up to date National and London policies, procedures and/ or guidance. It also summarises reporting required to support decision making and associated responsibilities, together with committee, governance, processes and capabilities. The revised Operating Model also reflects the geographical alignment of NHS England teams with London’s 5 STP footprints. PCCCs across London are being asked to consider the revised documentation for endorsement for adoption between February and April 2018 with the aim of complete coverage by the end of April 2018.

ENCLOSURE: E1

AGENDA ITEM: 19/18


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PCCC members will be aware that there are a significant number of National and London polices/guidelines/protocols that sit behind the Operating Model, which will used by STP Primary Care teams following the approval of this Operating Model. These have been made available to committee members and NHS Bexley CCG has made the information available on the publications area of its website www.bexley.nhs.net It is expected that there will be a regular need to review the Operating Model on an annual basis, as a minimum. However it is not intended that non material changes should result in PCCCs needing to sign off of such amendments, as these could be delegated by PCCCs to Chief Officers/Managing Directors. The main changes to the Operating Model and its accompanying documentation are: 1. The language in the document has been updated to reflect the fact that all CCGs across London will be level 3 delegated on 1st April 2018 2. NHS England functions are laid out in a table on page 19 and 20 and are the functions for decision making that were agreed under the delegation commissioning terms of reference, updated to include more up to date Strategy and Policy contractual decisions (e.g. resilience & sustainability of general practice), and no longer include potential activity figures, which are now out of date and no longer relevant given committees have been established for around 3 years. The table also describes whether a national or London policy or SOP exist to support decision making, and where it does, this is included in the pack of documents that were provided alongside the Operating Model )now available also on the FutureNHS portal). Some polices and SOPs are just being finalised e.g. London locum reimbursement FAQ and will be added/available asap. 3. The revised GP Quality &Performance Reporting Requirements are set out on pages 20 to 23, agreed by the STP PC leads agreements, following a review facilitated by NHS England. 4. Section 2.4 on page 27 covers other responsibilities that the Primary Care Committee is expected to be involved in. The document makes it clear that further discussion is required between STPs, NHS England and the CCGs before further delegation will be considered. In any event, further delegation of these responsibilities will not be made without agreement by the CCG or without consideration of the resource implications of such delegation, as outlined in the OM. It has since been confirmed that Counter Fraud function is contracted by NHSE (London) finance; that the Accountable Officer for controlled drugs reporting is a NHS England officer; and there is a process in place for incident reporting. 5. Pan- London responsibilities have been updated on page 47

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http://www.bexley.nhs.net/

3

onwards, in recognition of the STP alignment of the 5 former London primary care commissioning and contracting teams. Most pan-London leads are now being lead a STP Head of PC, and therefore by that STP, as opposed to being a retained London function. The importance of STP PC team regular communication to ensure all STP teams are up to date on such matters should be noted. 6. The London SOPs/policies have been refreshed to ensure they include agreements across London since the OM was signed off by CCG across London in 2015. 7. The NHS England, GP Policy Manual, on which the PCCC OM is both based and builds, has also been updated, with substantial changes to the Special Allocation Scheme and more specific guidance on managing patient dispersals.


Key risks

The Operating Model will mitigate the risk of making decisions that do not align with National or London policies, procedures and / or guidance.

Equality

The Operating Model enables consistent and standardised considerations to be taken on GP contractual matters.

Financial

The Operating Model will be primarily discharged through aligned STP Primary Care Team, and should therefore be cost neutral in terms of producing recommendations and PCCC decision making. Subject to the application of the relevant policies, procedures and / or guidance may have specific service related cost implications.

Author: Maxine Hastings, Programme Manager OD and Jill Webb Head of South East London Primary Care Team

Clinical lead: Sid Deshmukh, Chair Bexley CCG

Executive sponsor:


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1

Operating Model

Co-Commissioning of Primary Care

Services

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Document filename: Operating Model

Directorate / programme Primary Care Commissioning

Project Primary Care Commissioning

Document reference

Project manager Anne Whateley Status For Approval

Owner Primary Care Management

Board/ Primary Care Committees

Version 16.0

Author Patrick Newton Version issue date 08/03/2018

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Operating model: Co commissioning of primary care

Document management Revision history

Version Date Summary of changes

1.0 22.04.15 First draft

2.0 23.04.15 Revision following Christina Windle review

3.0 30.04.15 Revision following Heads of Primary Care review

4.0 30.04.15 Draft for review by David Sturgeon

5.0 05.05.15 Review by Primary Care Commissioning and Primary Care Management

Board

6.0 03.06.15 Draft updated following comments

7.0 09.06.15 Updated to reference initial comments from CCGs (to be approved in

PCMB)

8.0 20.07.15 Draft updated to reflect agreed comments

9.0 14.08.15 Updated following discussion at co-commissioning meeting

10.0 09.09.15 Updated following discussion at co-commissioning meeting

11.0 22.09.15 Final draft for approval

11.1 02.10.15 Factual amendments post approval by SE London (Joint Status of SE London Committees. Some minor editorial changes

12.0 01.06.17 Updated to reflect the geographical assignment of NHSE staff at lead

CCGs for each STP footprint

13.0 30.10.2017 Updated to reflect comments from CCG leads

13.01 01.12.2017 Revised version endorsed by the December PCMB

14.0 26.01.2018 Updated to reflect amendments for BHR CCGs

15.0 14.02.2018 Updated to incorporate the arrangements for GP Quality Performance

reporting

16.0 08.03.2018 Updated to reflect amendments regarding Occupational Health arrangements and new Director of Primary Care Commissioning

Reviewers This document must be reviewed by the following people before being shared externally:

Reviewer name Title/responsibility Date Version

Anne Whateley Director of Primary Care Commissioning

Jill Webb Head of Primary Care

Julie Sands Head of Primary Care

William Cunningham-Davis Head of Primary Care

Alison Goodlad Head of Primary Care

Vanessa Piper Head of Primary Care

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Approved by This document must be approved by the following groups:

NHS England:

Name Signature Title Expected

Date

Version

David Slegg (in

recognition of approval at the Primary Care

Management Board)

Regional Director for Finance (London)

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Following sign off by NHS England (London), this document must be accepted by each of the co-

commissioning committees. These groups are therefore shown below:

Co-Commissioning Committees:

Area Signature Title Expected

Date

Version

Barnet CCG

Primary Care Committees In Common

Camden CCG

Haringey CCG

Enfield CCG

Islington CCG

Croydon CCG Primary Care Committee

Kingston CCG Primary Care Committee

Merton CCG Primary Care Committee

Richmond CCG Primary Care Committee

Sutton CCG Primary Care Committee

Wandsworth CCG Primary Care Committee

Bexley CCG Primary Care Committee

Bromley CCG Primary Care Committee

Greenwich CCG Primary Care Committee

Lambeth CCG Primary Care Committee

Lewisham CCG Primary Care Committee

Southwark CCG Primary Care Committee

Brent CCG Primary Care Committee

Ealing CCG Primary Care Committee

Hammersmith and Fulham CCG

Primary Care Committee

Central London CCG Primary Care Committee

West London CCG Primary Care Committee

Hounslow CCG Primary Care Committee

Harrow CCG Primary Care Committee

Hillingdon CCG Primary Care Committee

Tower Hamlets CCG Primary Care Committee

Waltham Forest CCG Primary Care Committee

Newham CCG Primary Care Committee

Barking & Dagenham, Havering & Redbridge

CCGs

Primary Care

Commissioning Committee (Committee

in Common)

City and Hackney CCG Primary Care Committee

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Related documents (to be updated)

Title Owner Location

NWL Terms of Reference Primary Care Committee North West London

NCL Terms of Reference for

Joint Committee v0.2

Primary Care Committees in

Common North Central London

SWL Terms of Reference Primary Care Committee South West London

Annex F – Delegated TOR Tower Hamlets v0.1

Primary Care Committee Tower Hamlets

Annex F – Delegated TOR

Waltham Forest v1.0 Primary Care Committee Waltham Forest

Annex F – Delegated TOR

Newham v final Primary Care Committee Newham

Barking & Dagenham, Havering and Redbridge –

Updated Annex F (TOR)

Primary Care Commissioning Committee (Committee in

Common

Barking & Dagenham, Havering and Redbridge

Document control The controlled copy of this document is maintained by NHS England. Any copies of this document held outside of that area, in whatever format (e.g. paper, email attachment), are considered to have

passed out of control and should be checked for currency and validity.

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Contents Document management ....................................................................................................3

Revision history ...............................................................................................................3

Reviewers........................................................................................................................3

Approved by ....................................................................................................................4

Related documents (to be updated)..................................................................................6

Document control.............................................................................................................6

1. Introduction ..................................................................................................................9

1.1 Purpose of this document ...................................................................................9

1.2 Operating model processes for individual committees......................................9

1.3 Defining co-commissioning .............................................................................. 10

1.4 Terminology:...................................................................................................... 11

1.5 Differences between Joint and Delegated Committees.................................... 11

1.6 Responsibilities remaining with NHS England ................................................. 11

2. Decision Making ......................................................................................................... 12

2.1 Decision making principles ............................................................................... 12

2.2 Decision making process .................................................................................. 12

2.3 GP Performance and Quality Reporting Requirements ........ Error! Bookmark not

defined.

2.3.5 Conflicts of interest ............................................................................................ 24

2.3.5 Other decision-making processes – finance and strategy.................................... 25

2.4 Other potential Committee responsibilities ...................................................... 27

3. Governance and people ............................................................................................. 28

3.1 Committee constitution ..................................................................................... 28

3.2 Committee resourcing ....................................................................................... 28

4. Processes & Capabilities ............................................................................................ 29

4.1 Meeting process: ............................................................................................... 29

4.1.1 Agenda contents ............................................................................................ 29

4.2 Meeting Papers .................................................................................................. 30

4.3 Meeting in private .............................................................................................. 30

5. Annexes..................................................................................................................... 31

Annex Introduction ...................................................................................................... 31

Annex 1: Detailed processes ....................................................................................... 32

Annex 2: Section 13Z - CCG statutory duties ............................................................. 42

Annex 3: Performer Contract Decision Making Process ............................................ 43

Annex 4 - Safeguarding – responsibilities at different levels of CCG co-

commissioning delegation .......................................................................................... 45

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Annex 5 – Pan London Responsibilities of NHS England STP Based Teams............ 47

Annex 6 – Pan London Fora ........................................................................................ 55

Annex 7 - Template for Future NHS Access………………………………………………………………………59

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1. Introduction

1.1 Purpose of this document This document sets out NHS England national and London region policy and guidance to

inform, the way that NHS England (London) primary care commissioning and contracting

teams will support CCGs which have moved to joint or delegated co-commissioning

arrangements (as of April 2017).

As this document provides the standard offer of NHS England in terms of supporting Primary

Care Commissioning activities, this document will need to be signed off by NHS England

(through the Primary Care Management Board) and then CCG Commissioning Committees,

before it is considered final.

It is important to note that some specific details (i.e. the contact points for different

committees/ areas) will differ per committee and these added details should be cross

referenced with committee terms of reference or other supporting documents.

Governance of this document and processes

Once this document has been signed off by both parties, any variance from the processes

described here will need to be agreed between the Committee and NHS England (through

the Primary Care Management Board) as:

Having no impact on support (for example changes to the contact to be involved in

urgent decision making) and can therefore be adopted for a specific Committee

Is an adjustment or improvement to the process which would be beneficial for all

Committees and therefore should be made as a change to standard processes (for

example reporting format or processes which makes the reporting cycle more

efficient or information more easily understood)

Is a required change for a specific Committee(s) and therefore a change request will

need to be logged (i.e. additional reporting).

Agreement of these changes will require sign off at the Primary Care Management Board

and then with Primary Care (Co) Commissioning Committees before it can be considered

confirmed. This may require resource and/ or cost implication assessments, and the

ownership for any impact of these would need to be discussed as part of the agreement

discussions.

Updates of and additions to working policies and guidance, referred to by this document,

may be approved by Accountable Officers and NHS England (London). Any changes would

be considered and approved by London Region’s Primary Care Management Board.

1.2 Operating model processes for individual committees As mentioned above, this document aims to provide a standardised version of the operating

model. However the below details will need to be discussed in each individual committee,

and therefore decisions relating to the below are seen as acceptable levels of customisation

within this standard model:

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Incr

easi

ng

CC

G c

on

tro

l

Standard policies to assist decision making should be reviewed and agreed by the

committee; the committee may wish to add others

The sub-committee structure is likely to be different per committee. This should follow

the principles defined here and be discussed and agreed with NHS England if

involved.

The CCG representative(s) to be contacted in the event of urgent decisions being

required.

These elements should be discussed and agreed as part of committee discussions, and

should be included as appendices or linked documents.

1.3 Defining co-commissioning Co-commissioning for primary care refers to the increased role of CCGs in the

commissioning, procurement, management and monitoring of primary medical services

contracts, alongside a continued role for NHS England. The scope for co-commissioning is

general practice services only. CCGs have the opportunity to discuss dental, eye health and

community pharmacy commissioning with their regional team and local professional

networks, but have no decision making role.

There are three co-commissioning models, and as of April 2017 there are London CCGs at

Levels 2 and 3:

Level 1: where CCGs have involvement in primary care decision making,

Level 2: which is where the CCG (or CCGs) participate in decision making with NHS

England in a Joint Committee

Level 3: delegates decision making regarding certain functions (see below) entirely to

the CCG (or CCGs)

A high level overview of responsibilities is shown below:

Figure 1: High level breakdown of co-commissioning responsibilities

Level 1*: Greater involvement in

primary care decision-making

Level 2*: Joint commissioning

arrangements

Level 3*: Delegated

commissioning arrangements

CCGs participate in discussions about primary care, but there is no

“committee”, or other new governance arrangements, required to take

on added responsibilities.

NHSE retains its statutory decision making responsibilities.

NHSE and the CCG(s) form a “joint committee” (or “joint committee in

common”) to support commissioning of primary care. Together they

vary/ renew existing contracts for primary care , make decisions on

contractual GP performance management and commission some

specialised services. Can also design local incentive scheme as an

alternative to the Quality and Outcomes Framework (QOF) or Directed

Enhanced Services (DES).

The CCG assumes full responsibility for commissioning GP services,

forming a committee on their own. Responsibilities are as above, but

includes budget management. NHSE retain legal liability for

performance of primary medical commissioning, and therefore retain

oversight of the committee.

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Figure 1: Co-Commissioning Levels

1.4 Terminology: At levels 2 and 3, co-commissioning decision making is conducted through a, or several,

‘committee(s)’, which is joint with NHS England, or delegated. The committee could either

consist of:

Committees of single CCGs (with or without NHS England)

Committees in common of more than one CCG (with or without NHS England)

For simplicity, throughout this document, the body which conducts decision making

for co-commissioning is referred to simply as “the committee”, and it may refer to any

of the parameters above. Where different processes are required for joint or delegated

committees, these are called out.

1.5 Differences between Joint and Delegated Committees The move to co-commissioning, means that certain decisions (see Figure 2) which were

previously conducted directly by NHS England, will now be made by the body constituted to

support the level of co-commissioning each CCG has applied for – i.e. committees with NHS

England (for joint commissioning) or without NHS England (for delegated commissioning).

Regardless of whether the CCGs are conducting Joint or Delegated commissioning, the

functions enacted will be for the most part the same; the main difference is whether NHS

England is part of the decision making process or not. It should be noted that there will be a

joint responsibility for ensuring quality, through the reporting of performance data

It should be noted that the CCG may ask NHS England to attend and/ or present papers at

delegated committees, but this should be done on request and NHS England will not be a

voting member.

1.6 Responsibilities remaining with NHS England At all levels of co-commissioning, NHS England will retain a role in supporting delivery of

commissioning and contracting functions. This will be discharged by NHSE teams that will be

accommodated by a lead CCG for each of London’s STPs. Also the following responsibilities

will remain with NHS England and will not be included in joint or delegated committees:

Continuing to set nationally standing rules to ensure consistency and delivery goals

outlined in the Mandate set by government.

The terms of GMS contracts and any nationally determined elements of PMS and

APMS contracts will continue to be set out in the respective regulations/ directions.

Functions relating to individual GP performance management (medical performers’

lists for GPs, appraisal and revalidation).

Administration of payments to GPs.

Patient list management will remain with NHS England.

Capital expenditure functions.

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2. Decision Making

2.1 Decision making principles One of the exceptions to this as a standard document across all committees is that there

may be some variation as to what and how decisions are made in the commit tees. Decisions

will be taken in line with the criteria set out in each committee’s Terms of Reference. In

addition to principles of good practice which are set out in the Next Steps in Co-

Commissioning document, conflicts of interest policy, terms of reference etc., the following

principles should be considered:

Any urgent decisions made outside of the committee should be based on what

is necessary to maintain patient care; wherever possible decisions will be taken

within the committee.

In the event that an urgent decision is required and action must be taken to

maintain patient care outside of a committee, NHS England will communicate

with the contact nominated in the committee’s terms of reference (via phone

and email) to ensure that an urgent unplanned decision is made to maintain

and safeguard patient care.

2.2 Decision making process Co-commissioning of Primary Care will enable committees to take full or partial responsibility

for many decisions which previously sat with NHS England. Any CCG functions which are to

be delegated into this committee are not included here.

Decisions have been classified into three types in order to help capacity in the committee.

These types are:

1. Decision making through policies which therefore require minimal/ do not require

discussion because there is a clear approved policy which provides clarity on the

action required

2. Urgent decisions which cannot wait until the committee. These decisions require

emergency processes (see below)

3. Decisions to be discussed in the committee. Other General Practice

commissioning decisions should be made within the committee. It is expected in

many cases recommendations will be made into the committee from pre-work or sub-

committees as appropriate.

These decision types and the related processes can be seen in the below processes:

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2.2.1 Decision Making through policies

The below diagram shows how decisions where policies which are already defined might be used to support the co -commissioning committee.

Please note, this process would be the same for both Joint and Delegated commissioning decisions:

Figure 2: Decisions made through policies

This policy shows that although the policies referred to here would be Nationally or Regionally agreed policies, and therefor e with limited scope for

change, it is proposed that these are discussed and agreed at one of the early committee meetings in order to confirm that the members are

comfortable with the scope and approach. The process also includes provision for addendums to the policy. If for example ther e are concerns

regarding the way a decision has been reached then the committee should talk about the way that this can be improved in the f uture. It is

important to note that the content of an agreed policy may not be able to be changed, and the impact of any material change would need to be

signed off at the Primary Care Management Board as well as the committee, but this is to illustrate the opportunity for continual improvement.

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The purpose of this process is to relieve agenda pressure in the committee. If there are any

decisions or elements of the report which the committee would like to discuss, this can be

done and should be offered by the chair at the start of the meeting.

2.2.1.1 Decisions with defined policies

The decisions which can be made through defined policies will be discussed and agreed by

each co-commissioning committee, however the expected decisions where policies are

expected to be used to make decisions:

List closure

Boundary changes

Discretionary payments

Contractual changes

There are several other areas where standard operating processes or policies exist, but it is

expected that decisions will still need to be made within the committee and therefore are not

included here. The full list of potential decisions with policies can be found in Figure 5.

2.2.2 Urgent decision making:

‘Urgent’ is defined in this document as a decision which cannot be made within a committee

because of timing and nature of the decision. The main co-commissioning committee is

accountable for all decisions, and should agree to the decision process for this and expected

circumstances where this would arise and these agreed arrangements should be reflected in

the relevant terms of reference. It is important to note that there are two types of urgent

decisions. These are described below, with suggested processes.

It should be noted however that the process and individuals involved should be decided and

agreed by the Primary Care Committee, and this should be reflected in their terms of

reference (either referring to this operating model and providing details of the individuals to

be involved or outlining any changes within the agreed principles).

2.2.2.1 Urgent unplanned decisions

An urgent unplanned decision arises when something unexpected occurs that requires

immediate action. For example if a practice goes bankrupt a decision will need to be made

immediately in order to support the patients on the registered list.

The below principles apply to urgent unplanned decisions:

o Wherever possible, only decisions necessary to maintain patient care should

be taken outside of the committee

o The terms of reference of co-commissioning committees should set out

member’s responsibilities for making urgent decisions The NHS England team

accommodated at the lead CCG will communicate with this contact (by phone/

email) to ensure a decision is made which will be:

A joint decision between the NHS England and CCG representatives if

operating in joint commissioning, or

The CCG is asked to make a decision in delegated commissioning

o In the event that the CCG is made aware of the need to make an urgent

decision, they are:

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Required to communicate with NHS England to make the decision

together if operating in joint commissioning

Able to communicate with NHS England if they require support/ advice

to make the decision in delegated commissioning

The below diagram shows how urgent unplanned decisions might be made. Please note,

these processes would be the same for both Joint and Delegated commissioning

decisions:

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Figure 3: Urgent unplanned decisions

This process is also described below:

In the event that a situation occurs unexpectedly in which an urgent decision is made, the NHS England team accommodated by the lead

CCG will communicate with the relevant CCG contact (by phone/ email) in order to support the decision making process

o For joint commissioning CCGs, the decision will be made by NHS England and the CCG together

o Delegated commissioning CCGs will make the decision, supported by NHS England as required

These decisions will be reported back to the committee and discussed. Any further action will be agreed by the committee.

It should be noted that both NHS England and CCGs should aim to learn from and if able create processes for making decisions in these

circumstances. Also in the event that the CCG becomes aware of the decision that needs to be made, they will need to:

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In joint commissioning – communicate with NHS England (the relevant Head of

Primary Care or Director of Primary Care) in order to jointly make the decision

In delegated commissioning, the CCG may wish to seek advice or support from NHS

England but is not obligated too. They should however inform them of the decision as

there may be impacts or other communications which should reflect the decision

made.

Some CCGs have outlined a process if the decision making window is longer (for example

two weeks), allowing them to bring together a slightly bigger group of people (e.g. Chief

officers, the chair of the committee and NHS England representatives). This enables

decisions to be more widely considered and tested however it is noted that it may be

challenging to gather a wider group at short notice, and it is suggested that virtual or

telephone discussions may be easier. CCGs are advised to make the process of planned and

unplanned urgent decision making clear in their committee TOR.

2.2.2.2 Urgent planned decisions

There may be some decisions which are expected, but:

Cannot be made at an earlier committee as, for example there is insufficient

information

Must be made before the next committee

This means that decisions do need to be made through an urgent process, but that some

planning can be undertaken ahead of the decision. Specific arrangements and decision

rights, for each CCG, should be referenced in their Terms of Reference. The principle of how

this should operate is shown below:

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Figure 4: Urgent planned decisions

This process is also described below:

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In the event that a decision cannot be taken in the committee because sufficient

information is not known, or there are some other inhibiting circumstances, planning

should be undertaken as much as possible to ensure the committee is able to input

into the decision making process

Therefore any elements of the decision or process relating to the decision should be

discussed, and if necessary a sub or working group may be set up to continue work

towards this decision

o Please note, there may be an existing group or sub-committee which would

undertake this work.

These decisions will be reported back to the committee and discussed. Any further

action will be agreed by the committee.

It should be noted that both NHS England and CCGs should aim to learn from and if

able create processes for making decisions in these circumstances. CCGs are advised

to make the process of planned and unplanned urgent decision making clear in their

committee TOR.

2.2.3 Main decision types required

2.2.3.1 Business as usual decisions

The table below sets out of the main formerly NHS England functions which will now be

decided in the committee. This includes a recommendation as to the type of decision the

committee will be asked to make (this is not confirmed until this document has been

approved by each committee).

Name Function Committee decisions

needed (section 2.2)

Decision possible

with approved policy (s 2.2.1)

Need for urgent

decisions (s 2.2.2)

Does a

national/London SOP/policy/report

exist?

Determin -

ation of

key

decisions

or

requests

List Closure Yes

List suspension Yes

Practice mergers/ moves Yes

Boundary Changes Yes

Securing services through

APMS contracts

Yes – options appraisal doc

PMS (review s etc) Yes

Discretionary Payments Yes (Appeal/ complaint SOP)

Remedial and breach

notices

Yes (Contractual issues of concern)

CQC Inadequate &

Requires Improvement

ratings

Yes – National (Inadequate) Yes – London (Requires Improv ement) .

Contract termination-e.g.

Death/ Bankruptcy/ CQC

Yes (bankruptcy, and options)

Contractual changes

(contentious/ important)

Contractual changes

(transactional)

Yes (Contract signatory changes)

Locum reimbursements Yes Yes plus London FAQ, which is being considered f or national adoption

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Locum cover or GP

performer payments for parental and sickness

Leave

Yes plus London FAQ which is being considered f or national adoption

Infection prevention &

control

SLA

GP Rent review process green green green Under dev elopment

Edec irregularities green green Under dev elopment

Financial

Processes

Ensuring budget

sustainability

Management Accounting

Strategy &

Policy

Securing quality

improvement

Request to issue breach ov er quality attached

Developing and agreeing

outcome framew ork e.g. LIS

Yes (f or LIS schemes)

Securing consistent

population based provision

of advanced and enhanced

services

As abov e

Premises plans, including discretionary funding

requests in accordance w ith

current NHS (GMS -

Premises costs) Directions

yes Yes, example PID attached Premises Directions Financial assistance towards premises running costs and serv ice charges –

Resilience & sustainability

of general practice

yes Section 96 agreement and MOU

Figure 5: Table showing former NHS England functions which will now be decided in the

committee

Relevant national policies and guidance can be found here

Extant London policies and guidance can be found here:

2.2.3.2 Strategic Discussion and decision making

The committee should also be used to support discussion on Primary Care strategies, such

as delivery of the General Practice Forward View, Five Year Forward View Next Steps

and Strategic Commissioning Framework and other strategic aims.

2.3 GP Performance and Quality Reporting Requirements The following outlines the agreed principles which will underpin future GP Quality and Performance reporting arrangements Collaborative working

London region, its STP primary care leads and constituent CCGs will work together to deliver, common approaches and shared protocols/operational procedures to enable timely, reliable, meaningful and consistent quality and performance reporting arrangements across London.

Over time, collaborative working will enable the system to make comparisons between practices against set standards in order to stimulate and motivate change.

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https://www.england.nhs.uk/commissioning/policies/

https://future.nhs.uk/connect.ti

21

In recognition that there are further developments in quality and performance data and information, a minimum of an annual review of the London quality and performance offer will be undertaken with STP PC leads at the Primary Care Management Board.

NHS England will:

Provide standardised data reports, cut at different aggregated levels e.g. Practice, CCG, STP, Regional, National

Adhere to a planned refresh and publication schedule.

Clarify what can and can’t be shared and/or what can be shared through the NHS England team, but cannot be accessed by CCGs/STPs directly, based on clear Information Governance requirements.

Where NHSE governance allows, upload dashboards, data and analytical information onto the FutureNHS platform, which is a single accessible work space, for named STP/CCGs users to access

Will enable comparisons to be made between practices and used by STPs/CCGs against set standards over time in order to stimulate and motivate change.

STPs and/or CCGs will:

• Develop capacity to support standard reporting and analysis at STP/CCG level, subject to local agreement

• Be responsible for presentation, analysis and the ‘so what? Subject to local agreement.

• Target areas where quality needs improving based on local needs, which will also enable focus on specific issues e.g. DNA rates.

• Determine what data they use from the NHS England repository and may choose to use more up to date information, subject to its availability

• Share dashboards/tools that have been developed or are under development to promulgate good practice/what works

• Make a clear differentiation between what is information/data provided to review quality standards and that which is used to monitor performance in respect of contractual obligations and compliance

• Offer training to practices to support improved completion of returns, where required

Dashboards, data and analytical information and frequency of reporting

Whilst recognising that STP/CCG access to some NHS England data had not yet been

authorised by the latter, the initial list of reports and information available will consist of:

Resilience & Sustainability Tool (see yellow cells in Annex 1 for data items and reporting frequency)

CQC ratings trend analysis (monthly)

GPPS (General Practice Patient Survey) trend analysis, focused on questions relating to accessing services, coordinated care and patient experience (annual)

London Complaints dashboard (monthly)

Under development:

HEE workforce data

FFT trend analysis

Awaiting NHS England authorisation clearance:

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Primary Care Activity Report (see red cells in Annex 1 including reporting frequency). NHS England STP contract management teams will provide information on items such as list closures; temporary list suspension; breaches; contractual disputes in the meantime (most up to date information provided, based on report timing)

GPFV Dashboard (see white cells in Annex 1, including reporting frequency). A small number of the extended access metrics will be shortly published externally. In time all of it will be and it will be gradually incorporated into reports.

Other information supplied by NHS England STP contract management teams:

Performer concerns being addressed by NHS England’s Medical Directorate that may impact on GP contracts (most up to date information provided, based on report timing)

Access to Dashboards, data and analytical information

FutureNHS will be the collaborative online resource that will allow NHS England London

region to host and share the latest iterations of dashboard reports each month. NHS England

will setup the workspace and invite delegates to join.

The list of delegates will include CCGs, STPs and primary care contracting team nominated

representatives across London.

As this process develops and governance requirements allow, additional dashboards/reports

will be included and shared as part of the Operating Model.

Attached is a template (Annex 7) that should be shared via STP leads with relevan t

stakeholders, and populated with the required information, following which it should be sent

back to Adrian Mccloskey [email protected] who will enable access.

Access to FutureNHS can take place from the beginning of January, subject to when STP

leads return their completed templates

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Data sources and reporting frequency

Data Source Frequency

Active practices Quarterly

Branch practices Quarterly

Registered patients Quarterly

Practice size Annual

Delegation arrangements Annual

Contract type Annual

Dispensing practice Annual

Deprivation Annual

Patient demographics Annual

Workforce overview Quarterly/Bi-annual depending on measures

Workload reporting Frequency TBD

CQC ratings Monthly

Complaints Monthly

QOF Annual

GPPS Annual

FFT Annual

Average payments Annual

Patient online (POMI) Monthly

Extended access Bi-annual/Quarterly depending on source

Provider development measures for care redesign Monthly

Estates and Technology Transformation Fund Monthly

Secondary care measures (e.g. A&E attendance, elective admissions etc) Monthly

Care coordination (e.g. Care Navigators and Medical Assisstants) Quarterly

Online consultation systems Quarterly

Practice closures Annual

Procurement exercises Annual

Section 96 discretionary payments Annual

Patient list closures Annual

Patient and public participation planning and asssessment forms Annual

Contractual reviews Annual

Contractual disputes Annual

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2.3.5 Conflicts of interest

All committees must adhere to the conflicts of interest guidance1 and this must also be

adhered to for any sub groups set up to support the committee.

1 i .e. Managing conflicts of interest: Revised statutory guidance for CCGs and Code of Conduct guides

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2.3.5 Other decision-making processes – finance and strategy

Finance

Joint Co-Commissioning Committees

For Joint Committees, NHS England Finance teams accommodated at Lead CCGs will

continue to do all financial and management accounting. However, it will produce monthly

financial reports (for instance, covering spending against forecast and narrative on variance)

which will be provided to each CCG. The CCG may then choose to add information to these

reports before they are submitted to the committee(s).

Delegated Co-Commissioning Committees

For Delegated Committees, transactions for delegated functions will be posted directly to the

CCG’s ledger., NHS England Finance teams accommodated at Lead CCGs will be

responsible for reporting, and management accounting of primary care costs. The CCG may

also make further queries of NHSE, to support this process. Management accounting

activities will likely include, but not be restricted to:

Month end procedures

Accruals, prepayments, and any payments additional to those in the financial plan

The production of monthly & quarterly CCG management reports at GP practice or

locality level to ensure robust financial forecasts and analyse variances to ensure

they are explained

Practice list size analysis by CCG locality for GM/system report downloads

Quarterly forecasting on CQRS

Additional year end tasks including working papers and support to AOB process

Liaise with internal and external audit as required.

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Figure 7: Process map showing financial processes

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2.4 Other potential Committee responsibilities In addition to the above standard processes, there are other Primary Care elements which

the Committee is expected to be involved in. Some of these areas are listed below however

it should be noted that further discussions are required as to how these would be enacted

and supported between NHS England teams accommodated at Lead CCGs and the CCGs

at different co-commissioning levels. Further delegation from NHS England to CCGs will not

be made without agreement, and without consideration of the resource implications of such

delegation.

Item Committee Requirement

Appeals and disputes

The committee is asked to note the standard operating procedure for managing appeals and disputes submitted by GPs in relation to their GP contract.

Counter Fraud Ensuring that proper processes are in place to prevent fraud within the NHS

Interpreting services Ensure that patients can access interpreting services when using GP practices.

Occupational Health The committee shall ensure that GPs have access to occupational health services in accordance with national guidance

Controlled drugs reporting

The Committee is responsible for ensuring that practices are complying with legal requirements for use of controlled drugs and that CCGs and NHSE have proper controls in place to maintain patient safety. The RT will carry out reporting, analysis and compliance that aids this.

Safeguarding To set policy and to set the expectation that GP Practices have effective safeguarding systems in place in accordance with statutory requirements, national guidance and Pan London Policy/ Procedures. CCGs will be responsible for ensuring that the GP services commissioned have effective safeguarding arrangements in place to improve the well-being of children and adults. The CCG will proactively support Primary Care through advising on training and good practice guidance and monitoring safeguarding issues, providing assurance to NHSE that there is compliance with safeguarding standards. Further detail on responsibilities for safeguarding are provided under Annex 4.

Incident management

For both serious and non-serious incident management, the Committee is responsible for ensuring that there are proper processes in place for the reporting and review of incidents, so that they can be identified and managed. The CCG and NHS E will support and contribute to investigations, as required.

Domestic Homicide Reviews

The Committee will ensure that GPs contribute to domestic homicide reviews, where necessary. The CCG and NHS E will support this where their resources are appropriate. Further detail on responsibilities for safeguarding are provided under Annex 4.

Communications For CCGs at level 3 delegation, lead responsibility will be determined by what is appropriate, on the merits of each communication. NHS England remains responsible for communications for CCGs at level 2 delegation.

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Figure 8: Other potential Committee responsibilities

3. Governance and people

3.1 Committee constitution While much of the decision-making processes will be determined by Committees/ Joint

Committees, the constitution of the Committees themes have been set by NHSE, as a

condition of co-commissioning. The following are the criteria for a Committee (for Level

Three co-commissioning), and for a Joint Committee (for Level Two co-commissioning).

Figure 9: Committee and Joint Committee constitution

Other Committee attendees

In the interests of transparency and the mitigation of conflicts of interest , other interested

local representative bodies have the right to join the joint committee as non-voting attendees,

such as LMC, HealthWatch and Health and Wellbeing members. Invitees should be

determined in line with national guidance, and local terms of reference. Attendees should be

agreed so as to support alignment in decision making across the local health and social care

system. Other organisations may be invited, and as the committee meets openly it is likely

that members of the public and others will attend.

3.2 Committee resourcing There will not be a nationally-determined model of resourcing for co-commissioning, and

there is a recognition of the additional workload these new ways of working will result in . We

Committee is made up entirely of CCG

members (NHS England will not be

members of the board).

The Chair and Vice/Deputy Chair of the

committee are CCG Lay Members.

There is a secretary, responsible for

minutes, actions, the agenda, and

reporting back Committee decisions to

the CCGs.

NHS England will also have access to the

minutes etc. from the board for

assurance purposes, and all of these

documents will also be publically

available on CCG websites.

Committee includes representation of

both CCG and NHS England members

and both bodies have equal voting

representation*

The Chair and Vice/Deputy Chair of the

committee are CCG Lay Members.

There is a secretary, responsible for

minutes; actions, the agenda, and

reporting back Committee decisions to

NHS England and CCGs; and these will

also be publicly available on CCG websites

Level Two: Joint Committee Level Three: Delegated Committee

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expect, therefore, local dialogue between CCGs and their regional teams to determine how

the Committees can access the existing primary care team support, recognising that

CCGs are taking on significant responsibilities from NHSE, and therefore will require

access to a fair share of the regional team’s primary care commissioning staff

resources

Area teams need to retain a degree of this resource, in order to safely and effectively

continue with their remaining responsibilities.

Currently, there is no possibility of additional administrative resources from NHS England at

this time, but this will be kept under review.

4. Processes & Capabilities

4.1 Meeting process:

It is proposed that the method of operating the committee should follow processes already

established in CCG’s. The below illustrates a standard process for meeting setup:

Figure 10: Meeting process map

4.1.1 Agenda contents It will be important for engagement between NHS England and CCGs ahead of meetings,

particularly in cases where a particularly significant matter is on the agenda to be discussed.

This may involve the need for additional meetings, or for information from NHS England to

inform thinking. This will be particularly important for delegated commissioning, where NHS

England will not be participating in the committee discussion. Each Committee should set out

how this engagement will take place, as well as when, in the standard meeting process set

out above (Figure 10), submissions will be accepted for discussion at each meeting.

In general, clear and active engagement with NHS England, as well as the Committee sub

groups, will help inform the content of the agenda we expect that agendas are likely to have

the following components:

Standard agenda items, which might involve items that can be expected at each

meeting, such as an overview of finance and performance reports.

Work-plan items, such as a review of the annual budget or developing a Primary

Care Strategy, which is determined by the known upcoming work

Length of meeting cycle, and regularity of meetings, to be defined by Committee/ Joint Committee

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Any other items, which could include submissions from NHSE, sub groups, and the

CCG.

There will also need to be a determination for whether part of the meeting needs to be in

private. The process for determining the privacy of meetings is set out in 4.2, below.

4.2 Meeting Papers As outlined in the reporting section on page 21, papers created by NHS England should be

submitted to the committee secretary 4 days before the papers are circulated in order to

allow time for them to be reviewed and comments and adjustments made.

It is expected according to standard meeting processes that papers may be circulated a

week before the meeting, although this should be determined by each committee and

referenced in their terms of reference.

It is important that requirements in terms of papers and presenters is made clear by the time

the agenda is finalised. Working groups and sub-committees should have clarity regarding

upcoming meetings and how work should feed into these boards, including the timelines

required.

Delegated CCGs should also ensure that where advice, recommendations or papers a re

required from NHS England, that this is sought and discussed in advance. The CCG may or

may not request NHS England presents the paper at the committee.

4.3 Meeting in private As standard, the Committee meetings will be held in public. However, the Committee may

require to close part of the meeting on account of the matters to be discussed. Only

members of NHS statutory bodies, that are bound by standard NHS confidentiality

agreements are expected to attend the closed part of meetings. Only attendees of the private

part of the meeting will receive the papers for that part of the agenda. If necessary it may be

important to redact names and other details from the minutes.

It may be appropriate for the committee to seek the views of the audit chairs once a definition

of this policy has been created for each committee. Below is some guidance which

Committees may wish to consider:

Whenever publicity would be prejudicial to the public interest by reason of the

confidential nature of the business to be transacted or for other special reasons

stated in the resolution and arising from the nature of that business or of the

proceedings; or

If the discussion is commercially sensitive; or

Where the matter being discussed is part of an ongoing investigation; or

For any other reason permitted by the Public Bodies (Admission to Meetings) Act

1960 as amended or succeeded from time to time.

The provision for private meetings should only be used where required (as per the criteria

above). Where the discussion is not as sensitive, other mechanisms could potentially be

used, such as anonymising the reports. Additionally, Members of the Committee shall

respect confidentiality requirements as set out in the CCG Constitution and Standing Orders.

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5. Annexes

Annex Introduction The annexes included with this document aim to provide further detail to elements of the

Operating model where it is too detailed to include in the main body of the text. These are

not meant to be read as continuous chapters, but are included as reference material if

required. A short description of the purpose of each annex is included in a table below:

Annex Reference/ Name Purpose Annex 1: Detailed processes – including differences in responsibility by delegation level

This is the detailed memorandum of understanding aiming to outline the relative responsibilities of the CCG, NHS England and “the committee”. The committee includes both joint and delegated committees. This can be used if more detail is required on process and ownership, however it is suggested that where activities are unclear it may be beneficial to discuss with an NHS England or CCG colleague.

Annex 2: 13Z – CCG Statutory duties This lists the duties which effect the CCG that NHS England does not have liability for under section 13Z. This is included for its reference to roles and responsibilities.

Annex 3: Performer Contract Decision Making Process

This process aims to outline the decision making process specifically related to contract decisions arising from performer issues. It links into the overall decision making process flows (section 2).

Annex 4: Safeguarding – responsibilities at different levels of CCG co-commissioning delegation

This annex provides a high level analysis of responsibilities related to safeguarding at different levels of co-commissioning:

Annex 5: Pan London Responsibilities of NHS England STP Based Teams

This annex provides a list of matters dealt with on a pan-London basis, with lead NHS England STP based team responsibilities

Annex 6: Pan London Fora This annex provides an overview of pan-London Primary Care for a, their remit and membership

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Annex 1: Detailed processes The tables below set out the key Co-Commissioning responsibilities and tasks of the Committee, the CCGs and NHS England.

Responsibilities Tasks/ Standard

Definition The Committee CCG NHS E The Committee CCG NHS E

1. Determination of key decisions/ requests

Determination to secure services through an APMS contract either a consequence of a practice vacancy, a finding that there are inadequate services in the area or following a contract expiration

To decide whether it is appropriate to undertake a procurement to appoint an APMS provider where there is a vacancy or a contract has expired. In making this decision the Committee must ensure that it is a viable and vfm service that will meet the needs of the current and future population, addresses inequalities, improves quality choice and access. The Committee is responsible for ensuring that appropriate engagement processes are in place to support decision making

To secure & provide, to the RT, local intelligence and feedback to support decision making. The CCG shall also provide relevant local strategic context to support decision making. The CCG may, if appropriate, agree additional resourcing for the service. To work jointly with the RT and local representative to identify new or alternative solutions to address the practice vacancy and additional local KPI requirements.

To secure & provide necessary information to support decision : - performance and service data; - equality impact assessment; - needs assessment; - available funding, including transitional funding; -service viability; - feedback from stakeholders and the CCG; -relevant guidance. To implement the decision of the Committee. To work jointly with the RT and local representative to identify new or alternative solutions to address the practice vacancy

Tasks: 1. Determine whether procurement is the best option in the interests of patients and the public and that no other options are viable to secure adequate services 2. Assure that correct processes have been followed, particularly in relation to patient and stakeholder engagement; 3. Confirm that the contract is affordable; 4. Confirm that the service is viable 5. Set tolerances for the cost and timeframe for implementation. 6. Ensure that an equality impact assessment has been undertaken 7. Ensure that the proposed procurement processes are undertaken in accordance with SFI's and regulations. Standard: Maintain a record of the decision, particularly in relation to potential conflicts of interest; Notify RT of decision with details of agreed funding and tolerances for implementation;

Tasks: 1. Provide local intelligence to the RT to support their report: 2. Provide relevant information about local strategies to be included in the RT report: 3. Where necessary present paper to The Committee, with RT 4. Where appropriate, secure additional CCG funding to support a new service prior to the Committee's determination 5. Provide relevant specifications and data to support local KPI's. Standard: To provide relevant information to the RT within 15 WD's of the request. To ensure that the Committee has information to support their decision making, including confirmation of any funding the CCG intends to make available for the service.

Tasks: 1. Undertake required needs assessment, feasibility analysis, financial modelling and impact assessments to support the decision making process. 2. Implement an appropriate engagement plan. 3. Work jointly with the CCG to identify any local KPI's or other commissioning opportunities. 4. Identify and secure any additional resources required to support options. 5. Establish a procurement project team to implement the Committee's decision, if required. 6. To maintain and update a database of fixed term contracts. 7. To procure the service in accordance with directions, regulations and guidance. Standard: To process in accordance with regulatory requirements, Relevant SFI's and agreed procurement processes.

Procurement of new Services under APMS agreements

The Committee is responsible for approving a preferred provider following procurement process following the evaluation process

The CCG is responsible for providing local standards and specifications to address local issues of access, quality and choice

The RT shall develop and implement procurement policies & programmes aimed RT securing new APMS providers.

Tasks: Develop local standards and KPI's to be incorporated into APMS contracts. Support providers to ensure optimum delivery. Communicate with local stakeholders as required.

Tasks: Develop London standards and KPI's to be incorporated in APMS Contracts. Standard: Use standard frameworks to secure services and ensure good value for money - Support providers to ensure optimum delivery. Standard: Procure APMS in line with the agreed commissioning strategy - Initiate formal procurement activity for each APMS scheme, within terms of any national procurement support. - Sign off/ finalise contracts with preferred bidder. - Agree/ implement the local mobilisation plan. - Undertake appropriate checks prior to service commencement (for example, premises inspection). - Make provision for emergency primary medical care services in the event of an unforeseen circumstance.

Determination of a requests; - to close a branch practice; -for practice mergers; -PMS partnerships; -List Closures; -Rent Reviews

To consider and determine requests in a timely manner following appropriate consultation and in accordance with statutory requirements and agreed policy; ensuring that any decision will secure continuity of services and provide benefits for patients and the public. The Committee will pay due considerations to Strategic imperatives and Statutory

To secure & provide, to the RT, local intelligence and feedback to support decision making. The CCG shall also provide relevant local strategic context to support decision making.

To secure & provide necessary information to support decision: - performance and service data; - feedback from stakeholders and the CCG; -relevant guidance. To implement the decision of the Committee.

Tasks: 1. Determine request; 2. Assure that correct processed have been followed, particularly in relation to patient and stakeholder engagement; 3. Provide minutes and decision rationale 4. Ensure continuity services as a consequence of their decision: 5. Maintain records of all decisions; 6. Respond to questions and queries relevant to the decision, including FOI requests.. Standard: Provide decision and rationale within 5 WD of the meeting:

Tasks: 1. Provide local intelligence to the RT to support their report: 2. Provide relevant information about local strategies to be included in the RT report: 3. Work jointly with RT to ensure patient benefit and service continuity; 4. Where necessary present paper to The Committee, with RT . Standard: All requested information to be provided within 10 WD: To make available relevant staff for meetings and case conferences pertinent to the decision

Tasks: 1. Processing the application; 2. Engagement/consultation with stakeholders and patients; 3. Notifying the CCG and The Committee secretariat ; 4. Preparing & presenting the report to the Committee, using agreed format; 5. Issue decision letters/ notices; 6. Support any practice closure using agreed protocol; 7. Updating databases and notifying 111 via CSU. Standard: To process in accordance with:

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requirements to secure primary care services to meet the current and future needs of the population.

- Ensure that service continuity is not compromised as a consequence of their decision: - Ensure patient and public benefits are secured: - Acknowledge all queries within 5 WD offering full response within 20 WD: - Comply with FOI timescales

- National & London SOP; - Regulations- Contract and Patient Public engagement

GP Practices list maintenance

The Committee is responsible for decisions on any ad hoc list maintenance requests and for the setting of cleansing periods

NHS England is responsible for commissioning a process of practice list maintenance and will liaise with NHS Shared Business services and any other external partner as part of that.

Issue of Contract Breach Notice

To determine whether a provider has breached the terms of their contract and to make a proportionate decision as to whether: -a remedial or breach notice is warranted; -the practice should be asked to submit a improvement plan; -no action is required under the circumstances. To review outcome of remediation /improvement plans.

To identify & manage any resulting risk to services they commission as a consequence of an adverse finding. To provide support or facilitation for any relevant improvement plan/actions

To investigate concerns and provide evidence where a contract has been breached together with any mitigation offered by the provider using an agreed London template: To implement decisions

Tasks: 1. Review evidence and confirm that a contract has been breached; 2. determine the most appropriate and proportionate response to the breach taking account of relevant mitigation . Standard: Provide decision and rationale within 5 WD of the meeting: Ensure that service continuity is not compromised as a consequence of their decision: Ensure that there is a formal review of the outcome of all remediation and improvement plans.

Tasks: The CCG may be informed of concerns when a finding has been made, if it is relevant to any contract held between them and the provider. .

Tasks: 1. Identify concerns: 2. Investigate concerns: 3. Notify the provider of concerns and any evidence to support they have breached the contract: 4. Present evidence of the breach to the The Committee along with any mitigation provided by the provider: 5. Issue notices to the provider: 6. follow up remedial actions /action plans 7. liaise with the CQC and carry out actions to support registration 8. Produce format for local notices and breaches. Standard: Contract Regulations; National SOP Local protocols

Contract Termination

Determine the appropriateness of contract termination

To identify & manage any resulting risk to services they commission as a consequence of an adverse finding. To provide support or facilitation for any relevant improvement plan/actions

To investigate concerns and provide evidence where a contract has been breached together with any mitigation offered by the provider using an agreed London template: To implement decisions

Tasks: 1. Review evidence and confirm that a contract has been breached; 2. determine the most appropriate and proportionate response to the breach taking account of relevant mitigation . Standard: Provide decision and rationale within 5 WD of the meeting: Ensure that service continuity is not compromised as a consequence of their decision: Ensure that there is a formal review of the outcome of all remediation and improvement plans.

Tasks: The CCG may be informed of concerns when a finding has been made, if it is relevant to any contract held between them and the provider.

Tasks: Develop contract termination documentation, systems and processes. - Prepare Reports and Evidence for the Committee, securing necessary legal advice. - Issue termination notices. - Develop action plans to manage termination of contracts and implement in consultation with and supported by stakeholders. Update the contractor database with sanction information.

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Contractual Payments

The Committee is responsible for assuring that systems and processes are in place to ensure accurate and prompt payments to GP Practices in accordance with Contracts, Agreements, The SFE and SFI's

The CCG is responsible for notifying the Committee of any systematic failure to promptly pay GP Providers in accordance with the Contract / Agreements and SFE, setting out how this is to be addressed

NHS E is responsible for notifying the Committee of any systematic failure to promptly pay GP Providers in accordance with the Contract / Agreements and SFE, setting out how this is to be addressed

Tasks: 1. Review evidence and confirm that a contract has been breached;2. determine the most appropriate and proportionate response to the breach taking account of relevant mitigation . Standard: Provide decision and rationale within 5 WD of the meeting:Ensure that service continuity is not compromised as a consequence of their decision:Ensure that there is a formal review of the outcome of all remediation and improvement plans.

Tasks: The CCG may be informed of concerns when a finding has been made, if it is relevant to any contract held between them and the provider.

Tasks: - Agree appropriate contract variations (for example, list size changes) including their input to payment systems. - Calculate any agreed local quality and outcomes framework arrangement. - Calculate the impact of key performance indicators on contractual payments (alternative provider medical services contracts). - Determine entitlements to personal allowances (for example, seniority/ locum reimbursement). - Calculate and pay enhanced services that are specified nationally.- Calculate payments for GP registrars in respect of salary, mileage and travel grants. - Calculate prescribing and dispensing drug payments. - Calculate entitlements under the GP retainer/ GP returner and flexible career schemes.- Calculate payments in respect of the dispensary service quality scheme. Administer superannuation regulations, including all deductions, in relation to joiners, leavers, retirements, increased benefits, adjustments and pay these to the pensions division. - Administer and validate GP annual certificates. - Administer GP locum and GP- Solo contributions. - Provide the NHS pension assurance statement.- For suspended contractors, ascertain the individual’s entitlements, advise the contractor, validate all documentation, and adjust payment accordingly.

Disputes and Appeals

The Committee is responsible for agreeing a policy and procedure for managing appeals and disputes submitted by GP's in relation to their GP Contract. This includes ensuring there is a local resolution process and that a Panel is established to consider disputes and appeals where local resolution is not successful.

Tasks: The Committee shall establish a Panel who will consider any appeal or dispute.. Standard: The Committee shall ensure that all decisions are made in accordance with the Contract Regulations, SFE, SOP and previous determinations.

Tasks: The RT shall : 1. Ensure that contractors receive a clear and concise notice setting out any determination under the contract; 2. Implement local resolution where a contractor disputes a determination; 3. Where Local Resolution is not successful notify the Committee of the need to establish a Panel; 4. Provide a report to the Panel setting out their rationale and evidence in support of their decision; 5. Present evidence & representations to the Panel 6. Notify the contractor of the outcome; 7. Provide information as required by the Litigation authority in relation to any appeal

2. Financial processes

Determine total budget requirements for all primary care services, including premises and information technology

The Committee is responsible for ensuring that financial balance is secured and maintained.

Under Delegated Arrangements the CCG CFO will approve the financial plan plus any in year revisions

NHS England finance teams accommodated at lead CCGs will carry out the day to day financial management tasks, including the production of monthly reports showing spending vs the agreed budget and variance analysis.

Tasks: Ensure appropriate financial controls are in place to securely manage the budgets.. Standard: Operates in accordance with NHSE or CCG SFIs.

Tasks: a) Maintain control total for revenue and capital limits and agreement of RFTs

Tasks: b) Financial Planning & Reporting including input to monthly board report, external reports, financial plan submissions and in year review of plans, budget setting & team co-ordination, month end overview. non ISFE reports to region, QIPP reporting.

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Management Accounts

The Committee will: - review the financial reports; - Make decisions to address financial deficits; - Approve any payments additional to those in the financial plan

The CCG will scrutinise the financial reports prepared by the RT and will ensure that the appropriate decisions are brought to the attention of the Committee

NHS England finance teams accommodated at lead CCGs will provide appropriate monthly financial reports to enable budget holders to monitor and take decisions on the budgets,

Tasks: The production of monthly & quarterly CCG management reports at GP practice or locality level to ensure robust financial forecasts and analyse variances to ensure any variances are explained: Month end procedures a) complete regular task file b) variance analysis & narrative c) accruals & prepayments d) monthly year end forecasts at practice level or locality level and input to system e) meet with budget holders f) Practice list size analysis by CCG locality for GM/system report downloads g) Quarterly forecasting on CQRS(inform forecasting h) additional year end tasks including working papers and support to AOB process i) liaise with internal and external audit as required..

Tasks: The production of monthly & quarterly management reports at GP practice or locality level to ensure robust financial forecasts and analyse variances to ensure any variances are explained: Month end procedures a) complete regular task file b) variance analysis & narrative c) accruals & prepayments d) monthly year end forecasts RT practice level or locality level and input to system e) meet with budget holders f) Practice list size analysis by CCG locality for GM/system report downloads g) Quarterly forecasting on CQRS(inform forecasting h) additional year end tasks including working papers and support to AOB process i) liaise with internal and external audit . Standard:

Financial systems and BI

The Committee shall assure that appropriate systems and SOPS are in place to manage and maintain financial control in line with the relevant financial instructions

The CCG will ensure correct calculations and payments are carried out in line with the contracts by ensuring appropriate internal and external audit arrangements in place

NHS England finance teams accommodated at lead CCGs are responsible for the correct calculation of payments to all contractors in line with their contracts

Tasks: Ensuring compliance with central requests and timelines and utilising their system and BI reports to best effect: a) Financial System Management including setting up new ISFE reports, locality reporting, controls, exception reporting

Tasks: a) Ensuring compliance with central requests and timelines and utilising the system and BI reports to best effect: b) Set up new suppliers or amend existing suppliers on ISFE e.g changes to bank account details, and to reflect practice mergers c) Financial System Management including setting up new reports, locality reporting to CCGs, controls, exception reporting d)Liaison with SBS and central NHS England

3. Strategy and policy

Develop and agree a Primary Care Strategy (SPG)

The Committee to: - approve strategy and, - provide oversight to development and implementation

To contribute information & resources to: -support strategy development, -implement plans and strategies, - contribute resources to facilitate joint working To ensure primary care strategies are aligned to CCG strategies and plans To develop and implement engagement plans in line with primary care strategy.

To contribute information & resources to: -support strategy development, -implement plans and strategies, - contribute resources to facilitate joint working To develop and implement engagement plans in line with primary care strategy.

Standard: Engage and consult with key stakeholders, including patients, carers and the public in relation to priority areas for improvement, Ensure that the London Specifications / Framework is integrated into Local CCG and SPG Strategies, Ensure that primary care is integrated into local joint strategic needs assessment planning processes, Integrate and align primary care strategies with health and wellbeing strategies, Integrate and align primary care strategies with CCG and SPG strategies, particularly in relation to urgent care and collaborative care

Primary Premises Plan /Strategy

The Committee is responsible for reviewing and determining business cases for new premises developments in accordance with local CCG premises development plans, national guidance and primary care directions

The CCG is responsible for developing local Strategies and Development Plans in conjunction with NHS E and NHS property holding organisations (Trusts, NHS PS and CHP)

The RT is responsible for providing information to CCG's and other organisations to support the development of strategic premises plans

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W orkforce Audit and planning

The Committee shall ensure that appropriate workforce audit and planning is place to support service delivery

The CCG to undertake local audits as required

The RT shall implement the national workforce audit and is responsible for ensuring that all practices submit their return

GP Provider Development -Organisation Structures

The Committee is responsible for determining responses to requests to close or merge practices

To support the below : - performance and service data; - feedback from stakeholders and the CCG; -relevant guidance. To implement the decision of the Committee. The CCG will consult with local stakeholders to arrive at a final decision.

To secure & provide necessary information to support decisions : - performance and service data; - feedback from stakeholders and the CCG; -relevant guidance. To implement the decision of the Committee.

Standard: The Committee shall ensure that all decisions in relation to mergers, closures and procurement support the London and Local aims for provider development

Develop and agree outcome frameworks for GP Services For Level 2 CCGs NHS E remain ultimately accountable

The Committee shall agree an outcome framework for GPs services that enables continuous quality improvement and that it is aligned to national and local strategies. The framework shall be based on the national primary care GPOS and High performance indicators plus any local outcome and indicators set by the CCG

The CCG shall make available performance against locally agreed outcome and indicators required under the framework as required

NHSE shall make available practice and CCG performance against national GPOS and High Level indicators via the Primary Care Web-Tool

Tasks: The CCG develop a local Outcomes Framework under the guidance of The Committee by -Collecting and validating performance data against locally agreed outcomes and standards - Providing locally agreed performance reports Undertake Service reviews : LIS (or LES) Specifications.

Tasks: The RT will support the development of a local Outcomes Framework under the guidance of The Committee by -Collecting and validating performance data against nationally agreed outcomes and standards - Providing nationally agreed performance reports on an annual or quarterly basis via the Primary Care Web Tool Undertake service reviews :GP Contracts, Advanced Services & DES. Standard:

Planning PMS Review

The Committee shall oversee the implementation of the national PMS review to ensure that all contracts are reviewed within the national timescales and that agreements are varied to reflect new prices and premium payments

CCGs shall lead on the development and implementation of Local PMS Premium specifications and payments.

NHS England may be asked to support the PMS review

Tasks: The CCG develop a local Outcomes Framework under the guidance of The Committee by -Collecting and validating performance data against locally agreed outcomes and standards - Providing locally agreed performance reports Undertake Service reviews : LIS (or LES) Specifications .

Tasks: Financial Review, contract review, engagement (public and stakeholder), implementation of agreement changes

Securing Quality Improvement For Level 2 CCGs NHS E remain ultimately accountable

The Committee is responsible for review and approval of all Local Improvement Schemes (LIS's). The Committee is responsible for review and approval of the use of APMS to secure quality improvement under collaborative arrangements

The CCG will develop and lead the implementation of local schemes /Local Enhanced Services aimed at improving the quality in primary care. This will include development of clinical leadership and of peer support for practices.

The RT shall make available information to support quality improvement, and will support the CCG in the implementation of local schemes.

Tasks: Develop and implement local improvement schemes /Local Enhanced Services aimed at improving quality in primary care. -- Procurement and implementation of collaborative services aimed RT quality improvement under APMS arrangements. - Support and develop peer support for practices and practice staff. - Support and develop clinical leadership Standard: LCSF

Tasks: The RT will incorporate any Local Incentive Schemes into the provider contracts as stated in Schedule 2 Part 1 Sections 2.11 The RT will negotiate, in partnership with clinical commissioning groups, quality improvement plan with each practice. Standard:

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Securing Directed Enhanced Provision

The Committee shall review uptake and performance of all national DES and where necessary direct CCG's and RT's to take action to improve uptake or develop alternative local schemes

To support implementation as directed within the specifications

To support implementation as directed within the specifications. To provide information to the Committee on uptake and performance

Tasks: The CCG shall support local implementation and training as required under the national specification.

Tasks: The RT will disseminate all national DES specifications to practices together with local implementation guidance and a sign up sheet in accordance with the national timetable/ MOU (KPI's).

Securing Advanced Service Provision

The Committee shall review uptake and performance of all additional service provision and where necessary direct CCG's and RT's to take action to improve uptake or develop alternative local schemes

To provide information to the Committee about uptake and performance of non GP providers, making recommendations where additional services should be commissioned

To provide information to the Committee about uptake and performance of GP (& Pharmacy) providers, making recommendations where additional services should be commissioned

Tasks: Where necessary to direct the CCG or RT to take action to improve service provision.

Tasks: Procure additional services from non GP providers where practices do not wish to undertake them.

Tasks: Agree opt outs from the general medical services contract. Discuss locally the provision of additional services (where practices wish not to undertake them) with clinical commissioning groups.

Development of Policies and Procedures

The Committee shall approve all Local and endorse all London policies procedures in line with regulations

Tasks: Develop and maintain policies and procedures in line with regulations.

Contract Maintenance

The Committee shall ensure that the RT and CCG maintain all GP contracts in line with national and local variations and that systems are place to implement material changes

The RT will be responsible for the carrying out of several responsibilities specifically highlighted in the Delegation Agreement, including: 1. Managing Contract Variations The RT shall report, by exception, any failure to properly maintain contract documentation and provide an action plan to address this oversight

Tasks: - Issue national standard contract variations in line with changes to regulations. - Produce and issue local contractor specific variations (including, partnership changes, relocations, and mergers). - Implement changes to relevant systems to contractor payments. - Raise contract variations which may have a significant impact on the delivery of patient services and finances with localities and commissioners. - Maintain the contractor data base, including hard copies of all signed contracts for primary care providers, pertinent to the geographical area covered by the local regional team (including contract variations and breaches).

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Quality Assurance GP Services For Level 2 CCGs NHS E remain ultimately accountable

The Committee will review reports to ensure GP's services are safe and meet all national and local standards. This will be monitored through an annual report on performance and the use of exception reports as required or as a result of a critical incident - Monitor activity on performers lists alongside practice performance data to generate a complete picture of quality

The RT will provide a regular quality report, based on the national framework to The Committee to support locality-wide quality assurance of primary care. This will include exception reports as required.

Tasks: Support practices and performers in the achievement of their quality improvement plan.

Tasks: The RT shall, using the national GPOS, High Level indicators, practice E-Declarations & CQC reports: 1. Collate Compliance Reports 2. Assess practice performance from analysed data and identify priorities for further interrogation 3. Provide an Annual Performance Report and any exception reports 4. Conduct contractual compliance and quality reviews, developing and agreeing action plans to address performance issues with contractors.. - Support each clinical commissioning group in the development of a primary medical care quality improvement strategy involving all practices . - The RT will support the CCG with information to establish any cause for concern and act accordingly, including a quality review where necessary and performance management arrangements for poorly performing practices. In particular the RT will ensure that: 1. It maintains regular and effective collaboration with the CQC and responds to CQC assessments 2. Ensure and Monitor Practice remedial action plans .

Develop processes and systems to ensure fair, open and transparent decision making

The CCG is responsible for implementing processes and systems as required by the Committee

The RT is responsible for implementing processes and systems as required by the Committee

4. Other Counter fraud To ensure that proper processes

are in place to prevent fraud within the NHS

Where CCGs hold contracts with GPs in their own name, where they contract and fund the services e.g. Enhanced Services, CCGs would continue to be allocated these allegations for investigation.

Implementation of the Deloitte Counter-Fraud service Deloitte will need to liaise with primary care staff who would have performance information in relation to GP contracts or perform Post Payment Verification visits

Tasks: Issue notification of stolen prescription forms or persons attempting to obtain drugs by deception, to GPs, pharmacists, counter fraud, drug squads and other interested parties.

Interpreting Services To ensure that patients have access to interpreting services when using GP practices

FOI For Level 2 CCGs NHS E remain ultimately accountable

Dependant on source of information as to owner of FOI responsibility

Tasks: To provide any information that the CCG holds about GP services as requested under the FOI act. Standard:

Tasks: To provide any information that the RT holds about GP services as requested under the FOI act.

Occupational Health The Committee shall ensure that GP practices have access to occupational health services in accordance with national guidance

Tasks: To secure contracts and access to OH services in line with the national guidance.

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EPRR The Committee shall ensure that the RT and CCG develop strategies and plans to respond to rising tides, major incidents and service failure.

- Responding to local service disruption. - Responding to major service disruption. - Planning for major service disruption. - Flu Pandemic Planning. - Other Public Health Responses (e.g Ebola). - Issuing Communications to practices.

Implementation of Premises Directions

Approval of DV Rent Reviews, responding reimbursement appeals; Approval of discretionary payments for SDLT, Legal Fees and Development costs to practices; Procurement of Support for the Development of Strategic business cases; Approval of improvement grants; Approval of business cases for new premises / expansion; Approval of capital schemes; Approval of business cases for new premises /expansion

The RT shall bring to The Committee's attention as part of the regular reporting any matters requiring decision in relation to the Premises Cost Directions Functions including but not limited to: - new payments applications - existing payments revisions

Tasks: The CCG will respond to any requests from NHS England for relevant information to support the assurance of primary care commissioning.

Tasks: The RT will provide sufficient information to support The Committee's decision. Following decision from The Committee the RT is responsible for carrying out all subsequent payments. The RT must liaise where appropriate with NHS Property Services Ltd., Community Health Partnerships Ltd and NHS Shared Business Services.

Information sharing The Committee is responsible for ensuring that information relevant to assure the quality of primary care commissioning is shared in accordance with legislation and guidance.

The CCG is responsible for making available any information required to assure the quality of primary care commissioning as provided within IG rules

The RT is responsible for making available any reasonable and available information required to support primary care commissioning.

Tasks: The CCG will respond to any requests from NHS England for relevant information to support the assurance of primary care commissioning.

Tasks: The RT will respond to any requests from NHS England around information sharing as specified and will be responsible for auditing and ensuring that providers accurately record and report information.

Controlled drugs reporting

The Committee is responsible for ensuring that practices are complying with legal requirements for use of controlled drugs and CCGs and NHSE have proper controls in place to maintain patient safety

The RT will carry out any reporting, analysis, compliance or investigations involving controlled drugs.

Tasks: The CCG shall 1. Analyse prescribing data available 2. Complete the periodic self-assessments / self-declarations. 3. Report all incidents and other concerns to NHS England’s CDAO.

Tasks: The RT will support The Committee to comply with its obligations under Controlled Drugs regulations by Reporting all complaints

Safeguarding – children

To ensure that GP Practices have effective safeguarding systems in place in accordance with statutory requirements and national guidance and Pan London Policy and Procedures . Ensure appropriate response from primary care to safeguarding enquiries and serious case reviews (including approval of IMRs)

Support and facilitate Primary Care to proactively improve the safety and wellbeing of children registered within the practice setting, providing assurance to NHSE that practices are compliant with safeguarding standards.

To monitor and review compliance with safeguarding standards

Tasks: The RT will ensure that: 1. GP Contracts include requirements for safeguarding; and 2. GP practices annually declare compliance; The CCG shall provide representation at the LSCB. The CCG shall support GPs in engaging with serious case reviews, safeguarding adult reviews and domestic homicide reviews. Would recommend that NHSE RT approve GP IMRs. NHSE shall approve GP IMRs.

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Safeguarding – adult To ensure that GP Practices have effective safeguarding systems in place in accordance with statutory requirements, NHSE national safeguarding guidance and Pan London Policy and Procedures Ensure appropriate response from primary care to safeguarding enquiries and serious case reviews (including approval of IMRs)

Support and facilitate Primary Care to proactively improve the safety and wellbeing of those adults most vulnerable registered within the practice setting, providing assurance to NHSE that practices are compliant with safeguarding standards.

To monitor and review compliance with safeguarding standards through CCG

Tasks: The RT will ensure that: 1. GP Contracts include requirements for safeguarding; and 2. GP practices annually declare compliance; NHSE shall approve GP IMRs. CCG shall have oversight of training compliance relating to safeguarding, MCA and Prevent. CCG is a statutory member of the LSAB and shall agree appropriate representation from health services including primary care

Domestic homicide Ensure that GPs contribute to domestic homicide reviews – where relevant and where necessary take action to remedy any oversight, including sharing and embedding learning to improve outcomes for service users.

To support practices in undertaking DHR where resources are held by the CCG

To support practices in undertaking DHR where resources are not held by the CCG

Tasks: Provide funding and advice where resources are not held by the CCG Provide representation at DHR Panels.

Serious incidents The Committee shall ensure processes are in place to report and review incidents so that serious incidents can be identified and managed. This includes reviewing the outcome of SI investigations and where necessary making recommendations to improve patient safety

To support and contribute to investigations

To support and contribute to investigations. To monitor compliance

Tasks: The RT will ensure that: 1. GP Contracts include requirements for reporting incidents; and 2. GP practices annually declare compliance; - Provide Advice and guidance to primary care practitioners and practice staff who wish to report an incident; Co-ordinate SI case management, including evaluation of final report; Liaison with NHS England Performance and Revalidation team regarding performance concerns.

Incident management

The Committee shall ensure that there are proper processes in place for GP practices to report incident (subject to a national review) and shall review reports on incidents at least once annually or where necessary by exception. The Committee shall make recommendations where necessary as a consequence on incident reports

To support and contribute to investigations

To support and contribute to investigations. To monitor compliance

Tasks: The RT will ensure that: 1. GP Contracts include requirements for incident management; and 2. GP practices annually declare compliance; Regularly log into the NRLS site to access any eForms (reported incidents); Ensure reported incidents are assessed to determine if SIs – and manage accordingly; Provide expert guidance on NRLS form/function.

Central Alerting System (CAS) Alerts

The Committee shall ensure that processes are in place to ensure that CAS alerts are disseminated in accordance with guidance.

To monitor compliance Tasks: The RT will ensure that: 1. GP Contracts include requirements for incident management; and 2. GP practices annually declare compliance; Regularly log into the NRLS site to access any eForms (reported incidents); Ensure reported incidents are assessed to determine if SIs – and manage accordingly; Provide expert guidance on NRLS form/function.

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Engagement and Consultation For Level 2 CCGs NHS E remain ultimately accountable

The Committee shall ensure that all parties comply with statutory requirements to consult and engage with stakeholders. This is includes reporting to Local OSC, Healthwatch and HWB

For undertaking local engagement Engagement related to strategic planning Engagement linked to changes in urgent care or LES Engagement and consultation associated with changes to GP services, including: -closures, - premises development, - mergers

Supporting engagement and consultation associated with changes to GP services

Tasks: Consultation with LMC Presentations to OSC. HWB and Healthwatch

Tasks: Notification letters to patients Consultation letters to patients and stakeholders, with wording agreed with CCGs

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Annex 2: Section 13Z - CCG statutory duties

Arrangements made under section 13Z do not affect NHS England liability for exercising any

of its functions, and in turn, CCG must comply with its statutory duties, including:

a) Management of conflicts of interest (section 14O);

b) Duty to promote the NHS Constitution (section 14P);

c) Duty to exercise its functions effectively, efficiently and economically (section 14Q);

d) Duty as to improvement in quality of services (section 14R);

e) Duty in relation to quality of primary medical services (section 14S);

f) Duties as to reducing inequalities (section 14T);

g) Duty to promote the involvement of each patient (section 14U);

h) Duty as to patient choice (section 14V);

i) Duty as to promoting integration (section 14Z1);

j) Public involvement and consultation (section 14Z2).

Still subject to any directions and decisions made by NHSE or by the Secretary of State.

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Annex 3: Performer Contract Decision Making Process

Figure 11 – Interface between the Performer Management and Contract Issue processes

Interface between the Performer Management and Contract Issue processes

Concerns about performer performance may come to NHS England’s attention through a number of

channels, including:

- Complaints from patients;

- Whistle-blowers;

- CCGs;

- CQC;

- GMC or other professional regulator;

- MPs; or

- The Police.

Concern raised

PAG

PLDP

Appropriate body investigates and

takes action (may be joint investigation)

Closed

Contract issue process (CCG or

CCG/NHS E)

Contractual issue

Individual performer issue

Concerns may come through a number of channels:- Complaints- Whistle blowers- CCGS- CQC- GMC- MPs- Police

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Responsibility for Performer List Management

NHS England retains the responsibility for Performers being admitted to the National Performers List.

The National Health Service (Performers Lists) (England) Regulations 2013 entrusts the responsibility

for managing the performers lists to NHS England. Issues raised are triaged by the performance

advisory groups (PAGs) within regional teams. Where the issue raised may have an impact on the

performance of a contract, PAG will escalate information relating to the contractual impact, to the

appropriate CCG (Level 3 delegation) and NHS England body (Level 2 delegation).

For issues with a contractual impact, the PAG may carry out a joint investigation with the CCG, with

the PAG considering performer issues, and the CCG considering contractual issues. If action is

considered to be necessary under the performers’ lists regulations, the case is referred to a PLDP.

Commissioner Involvement

Where there are no contractual issues arising, commissioners may choose to receive a quarterly

report, for information only, on performer performance issues which provides an overview of the

numbers of issues by CCG, and key themes of issues arising. This may be submitted to part one of

committee meetings.

Commissioner involvement is expected in instances where poor individual performance will have a

contractual impact. Incidents which affect the medical services contract will be discussed at a joint

committee or sub-committee, depending on the timeline for providing a response, with a decision

provided for the contractual action taken to be taken.

Only information relevant to the contractual impact of issues should be shared. Discussion of

sensitive issues should be carried out in a private pre-meeting, or submitted to a private part two

committee to maintain confidentiality and to allow for the relevant information to be made

available, discussed and any actions agreed. The decisions made on contractual actions should be

reported in part one of committee meetings.

Performer List Decisions

NHS England has established performers lists decision panels (PLDPs) within regional teams in order

to support its responsibility in managing performance of primary care performers. The role of the

PLDP is to make decisions under the performers lists regulations. As a retained role of NHS England,

there is no basis for CCG involvement in this process.

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Annex 4 - Safeguarding – responsibilities at different levels of CCG co-commissioning delegation

Task Level 2 Level 3

IMR sign off Joint sign off process CCG sign off

Named GPs* – role transfer Financial transfer Recruitment Training

MOU in place Costs met from delegated budget HR process with NHS England, joint appointment panel Responsibility for training sits with NHS England

MOU in place Costs met from delegated budget Recruitment process and appointment panel under CCG control Responsibility for training sits with CCG

LSCB attendance Based on risk based approach NHS England and CCG attendance

Based on risk based approach CCG attendance

Domestic homicide Attendance at panel and support to GP to complete IMR negotiated with CCG

CCG attends panel and supports GP to complete IMR if required

Performance issues NHS England leads on any performance issues

NHS England leads on any performance issues

CQC safeguarding issues in practices

NHS England and/or CCG, by negotiation,

CCG follow up individual issues raised

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The table below provides a high level analysis of responsibilities related to safeguarding at different levels of co-commissioning:

dependent on each regional arrangements

Further detail related to the functions expected of fully delegated (level 3 CCGs) is shown below. The Nursing directorate would retain oversight of these

responsibilities, and it is important to note that the tasks might vary dependant on area etc.:

Summary of responsibilities Overview of tasks (not exhaustive)

Provide advice for GPs undertaking investigations relating to primary care safeguarding issues

Manage named GP roles Contribute to the system wide

oversight of safeguarding

Quality monitoring and improvement of primary care

Approval final IMRs or investigations including DH panels

Ensure any actions resulting from investigations

Recruit, line manage and provide training for role

Represent health system at safeguarding boards

Undertake safeguarding assurance of practices. Follow up on practice issues identified at CQC inspections, review trends and themes

follow up individual issues raised by CQC with practices Themes/trends shared with CCG

by CQC with practices Themes/trends shared with CCG

Primary care safeguarding quality assurance

Jointly NHS England and CCG responsibility

CCG responsibility

Quality improvement CCG responsibility, working with NHS England

CCG responsibility, working with NHS England

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Annex 5 – Pan London Responsibilities of NHS England STP Based Teams Category Responsibilities Lead STP Responsibilities Other STP responsibilities Forum Lead Notes

T&F Contract Management policies/

Standard Operating Framework

Task and Finish proposals to ensure consistency. One engagement with local

committees

Comment and agree PCMB TBD for each task

T&F Homeless specification Input to Public Health initiative from a primary care commissioning perspective

Comment and agree PCMB NWL & NEL Time limited

Contract Management

Infection Control SLA Oversight of SLA with NEL CSU. Delivering infection control framework which gives assurance that primary care and dental

practitioners are meeting required standards. Activities include: - quarterly SLA performance review meetings with NHSE dental lead

- negotiation of annual budget - ensuring network meetings are operational where CCGs have local arrangements in place to undertake aspect of GP/dental infection prevention

and control support or monitoring visits - annual review of specification to agree priority visits, informed by liaison with STP leads - dissemination of arrangements,

including reinforcement of process flow for urgent and planned visits - negotiation of revisions to audit tool for general practice, as and when necessary with London LMC reps

- Feedback on service priorities - implementation of STP day to day process, based on agreed process flows for planned

and urgent visits - Feedback on any issues of concern in terms of SLA activities undertaken by NELCSU to lead - provision of STP footprint information/data, as requested by lead

- attendance at ad hoc meetings that may be called

PCMB SEL To be reviewed annually

Retained Business Rates and Rent

Review - Backlog

Challenge session on business rates and

rent; QIPP measure for practices

Feedback PCMB SWL Time limited

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Category Responsibilities Lead STP Responsibilities Other STP responsibilities Forum Lead Notes

Contract Management

National contracts - Clinical Waste

Set up of new clinical waste contract Feedback PCMB SWL Time limited

Contract Management

National contracts - PCSE PCSE - stakeholder management Feedback PCMB SWL Time limited

Retained Quality and performance management

Liaise with analytical services on BI development Provide primary care input into quality

and clinical governance meetings

Feedback on BI developments required. Provide insight into quality / clinical governance issues for escalation

Provide insight into local quality initiatives

SMT Retained team

Retained GP IT Co-ordination of London response on non-ETTF capital proposals on GP IT.

Liaison with National.

Co-ordination of development of STP level GP IT capital proposals

PCMB FIPA

Retained team

Retained Risk management Co-ordinate response and updates of London Region risk register for Primary Care Medical Services

Identification of new / changed risks Update on risk management actions / crystallisation of risks

SMT Retained team

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Retained APMS Responsibilities include: - complete and update the suite of

toolkits, templates and guidance produced for the programme in order that they can be shared with commissioners for future use (London retained responsibility).

- maintain and update the baseline number of, and information about, contracts identified as to be procured, negotiated, extended or continued (London information is dependent upon

STPs maintaining up to date baselines). - identify a list of contracts for primary medical services expiring before the end of each financial year for which

commissioners will need to determine commissioning options - ensure the London APMS contract, including Schedules, is brought up to date and reporting arrangements finalised

(London retained responsibility). - manage the arrangements for updating and putting in place required contract variations of all London APMS live contracts (London initial responsibility).

- - procurement of STP APMS contracts in tranches, based on same consistent timelines (London retained function)

-Designate STP programme lead - Input of STP strategic commissioning intentions into the development of

procurement programme. - designate procurement lead responsibilities either on a contract by contract, or STP basis - undertake required commissioning activities, strictly in line with agreed

project/programme timetable including (but not limited to): - strategic review of expiring APMS contracts - preparation of report to PCCCs and feedback on outcome to Programme lead (CCG

responsibility) - patient engagement events(CCG responsibility) - preparation of MOIs, including liaison with

current APMS provider and input to ITT, in collaboration with relevant CCG(CCG responsibility) - prepare report on outcome of patient engagement (CCG responsibility)

- respond to clarification questions(CCG responsibility) -support site visits to practice premises(CCG responsibility) - evaluation and moderation of ITT responses,

based on agreed London (or STP) arrangements (CCG responsibility) - nominated officer to attend interview panels(CCG responsibility) - mobilisation of new APMS contracts(CCG

responsibility) -attendance at local project or STP programme meetings (CCG responsibility) NOTE – this is not an exhaustive list of activities but is indicative of type of activities

STP Programme leads are responsible for co-ordinating, regardless of whether APMS contracts are procured on a London or STP footprint basis. In addition, all activities must be undertaken with strict adherence to

procurement programme timescales approved.

PCMB FIPA

Retained procurement team Role of Band 8b London

Asst Head to maintain best practice tools STPs responsible for Programme management, linking in

to consistent London procurement programme

See revised lead responsibilities to be

discussed at extraordinary PCMB meeting on 15th September 17

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Retained Premises (incl ETTF and LIG)

SRO for General Practice Premises Programmes, including:

- Member of London Estates Delivery Unit - Policy lead and adviser on GP premises, including disseminating information and learning to NHSE and STP/CCG responsible commissioners

- Leads on formal consultation and meetings with London LMCs on interface issues every 6 weeks, including CHP and NHSPS London leads - London region’s ETTF and London IG

lead, responsible for performance of programmes and monthly formal reporting to LCC and bi monthly to GP DOG - Responsible for ETTF & London IG

programmes, including regular programme meetings involving technology PMO in the former Reports every other month to national ETTF programme board and GPFV DOG

on London’s performance; takes part in weekly regional teleconferences

Responsible for: - advising and making recommendations CCGs

on application of Premises Directions and London premises policies, which form part of their GP contract/commissioning delegated responsibilities - managing and making decisions on STP

footprint general practice premises issues, including liaison with practices - ensuring up to date on new or revised premises policies, and their implementation - providing information/data, on premises

matters within STP footprint to London lead, as appropriate - dealing with and making decisions/advising CCGs on rent review and lease matters, obtaining advice, as necessary from DV or

London/STP responsible team

GP DOG for oversight of GPFV

infrastructure programme London Estates Primary Care

Capital Panel for oversight of and advice about all schemes that include general

practice LCC/FIPA for capital and business case sign

off PCCCs for decisions on GP contract changes

London Estates Delivery Unit for strategic system wide schemes

Retained team

Initial 12 month post to support SRO with SEL pc commissioning and contracting work and premises lead

responsibilities agreed, subject to review as London Estates Board arrangements crystallise.

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and supports national ETTF team on

policy matters that affect London - Leads design and oversees implementation of STP and CCG communication plans in the context of new or revised policy and operational

requirements, supported by relevant colleagues. - Responsible for establishment & management of commissioner led London Estates Primary Care Capital Panel to

replace London’s Pipeline, supported by ETTF band 6 and ETTF PMOs & London IG Programme lead. - Responsible for bi annual review of London’s ETTF Pipeline

- Development & oversight of implementation of London’s policy of financial assistance for GPs with running costs & services charges, in collaboration

with Finance lead & providing national support to roll out

Retained Media, MP correspondence, FOIs (pan London)

Co-ordinate and manage responses to queries

Provide information and locally agree responses

By correspondence

Retained team

Project PMS Lead customer of CSU PMO Progress reporting Sharing leading practice LMC engagement

PMS stakeholder reference group

NWL

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T&F For example: - Violent patient scheme - Minor surgery portal

- Caretaking framework - Occupational health service procurement

Lead on development of pan-London approach

Input into T&F group. Local implementation.

PCMB TBD per T&F

NEL have been leading on a task and finish group for moving to new primary

care occupational health arrangements in line with national guidance. Following procurement, as from 1st December 2017

there are now three providers, contracted to provide a limited range of OH services, funded by commissioners. This will

entail a small amount of contract management going forward covering both dental and general

practices. This contract management will be a retained function.

Working Group Enhanced Services Lead on development of process to implement national ES

Provide input into development Ensure pan-London approach followed

Working Group Recommendations to PCMB

NWL

Working Group CQRS Systems lead to escalate issues and to

ensure Primary Care staff trained on CQRS

Liaise with lead on any CQRS issues Virtual network NWL

Assigned STP team responsibility

EPRR Not applicable To act as liaison point for in-hours incident management

Not applicable Individual STPs


Quality and performance management

Not applicable Production of reports for Committees Not applicable Individual STPs


National Primary Care Leads

Attend HoPC and PC-DOG Input into meetings Note output of meetings

SMT HoPC


CAS alerts Not applicable Cascade CAS alerts highlighted by Nursing Directorate

Not applicable Individual STPs

52 of 56

53


STP responsibility Resilience Planning - e.g. Winter / Bank Holiday opening

Not applicable Ensure Primary Care included in resilience planning Provide information to NHSE L assurance process

Not applicable A&E Boards

STP responsibility Complaints Not applicable To include in quality reporting Feedback on local complaints management

Feedback on complaints process

Not applicable STP Complaints Leads

53 of 56

54

Forum Description Frequency Invitees

PCMB Part 1 Issues with operation of MOU Bi-monthly Deputy Regional Director Regional Director of POD Director of Primary Care Commissioning STP Leads

Part 2 GP & DOP commissioning matters of pan-London interest (incl agree T&F groups) Non-delegated financial issues

As above, plus: Heads of Primary Care DOPs Regional Lead NHSE Finance Senior Reps NHSE Medical Directorate Reps

NHSE Nursing Directorate Reps DCOs

Part 3 Assurance Deputy Regional Director Director of Primary Care Commissioning DCOs

SMT Operational and staffing issues Emerging National or pan-London guidance Suggest Task and Finish Groups

Fortnightly Director HoPC Assistant HOPC DOPs Regional Lead

DOPs Assistant Regional Lead DOPs Heads

All staff meeting National and pan-London developments Staff development sessions Team news

Quarterly All NHSE Primary Care Commissioning Staff

All staff call National and pan-London developments Team news

Monthly All NHSE Primary Care Commissioning Staff

54 of 56

55

Annex 6 – Pan London Fora

Forum Description Frequency Invitees

All staff forum / email

group

Ongoing queries

Vacancy notifications

Continuous All NHSE Primary Care Commissioning Staff

ES working group Develop and implement national ES schemes on a consistent pan-

London basis

Bi-monthly ES Group Lead (HoPC - NWL)

Once for London 8B STP nominated reps

T&F Groups Set up as required to develop and implement agreed pan-London

projects (identified at SMT and ratified at PCMB)

As required Group lead

Once for London 8B STP nominated reps

55 of 56

56

Annex 7 – Template - Access for FutureNHS

The template below should be shared via STP leads with relevant stakeholders, and populated with the required information, following

which it should be sent back to Adrian Mccloskey [email protected] who will enable access.

Access to FutureNHS can take place from the beginning of January, subject to when STP leads return their completed templates :

Name Role CCG or STP? Organisation Name Email Address

56 of 56


1


Title

Cairngall Medical Practice – APMS Procurement

This paper is for information


That the primary care commissioning committee note

1. The procurement schedule for the substantive APMS contract of Cairngall Medical Practice


Dr Varun Bhalla is conflicted as the incumbent caretaker provider of the Cairngall Medical Practice. All GPs could be potentially conflicted as the procurement process is still underway.

Executive summary

At the PCCC meeting on the 28th February 2018, members were advised of the resignation of the sole contractor of the Cairngall Medical Practice. This subsequently gave rise to an extraordinary PCCC meeting taking place on the 19th December 2017 to consider and take forward the following decisions:

Accept the early resignation and handing back of the Cairngall Medical Practice PMS contract from the sole contractor, Dr Akinsanya, with effect from 6.30pm on 31st January 2018.

Approval of the procurement of a temporary APMS Caretaking Provider was undertaken to provide primary care services to the patients of Cairngall Medical Practice up to October 2018.

Approval of the procurement of a substantive APMS contract through the London APMS tranche 6 procurement programme.

As there was insufficient time for the CCG to go out to full procurement; it was recommended that a caretaking contract be put in place for a period of eight months to allow the CCG to proceed with the full procurement of a substantive APMS contract as part of the recently initiated London APMS Tranche 6 procurement programme. This decision was upheld and the publication of the procurement documentation for the caretaking contract

ENCLOSURE: F

AGENDA ITEM: 20/18


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2

took place on the 22nd December 2017 with the subsequent contract award being notified on the 25th January 2018 to Belvedere Medical Centre. The temporary contract started on the 1st February 2018. In parallel to this, the CCG has been working with NHS England colleagues leading the London APMS Tranche 6 procurement programme for the substantive contract for Cairngall Medical Practice. Members are asked to note the procurement timetable below:

Key Milestones Date

SEL STP to submit final business cases for FIPA endorsement (FIPA - Finance, Investment, Procurement and Audit committee)

05-Mar-18

FIPA to submit business cases to CEG (Commercial Executive Group)

09-Mar-18

CEG Business case approval 12-Apr-18

Advert published on Contracts Finder / OJEU / ProContract

10-Apr-18

Invitation to Tender (ITT) issued 10-Apr-18

Deadline for receipt of ITT clarification questions

30-Apr-18

Deadline for receipt of ITT submissions 14-May-18

ITT Evaluation 17-May-18 to 7 June

2018

Moderation 12-Jun-18 to 22-Jun-18

Presentations (Interviews with bidders) w/c 25-Jun-18

Recommendation to PCCCs 06-Jul-18

PCCCs approval secured by 20-Jul-18

Inform bidders of outcome and observe standstill period

23-Jul-18

Contract award 06-Aug-18

Mobilisation 06-Aug-18 to 30-Sep-18

Service Go-Live 01-Oct-18

Members are also asked to note that there is a further paper being presented to the PCCC regarding a potential closure of the Cumberland Drive branch site of Cairngall Medical Practice. Bidders have been alerted to the fact that this decision is yet to be made and that they will be informed

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3

once a final decision has been made at the PCCC meeting on the 25th April 2018.


Key risks

Cairngall Medical Practice was at risk of being without any contract holders in place to manage a significant list size practice in excess of 9,000 patients. The sole contractor, Dr Akinsanya, had indicated that she was under immense stress since having taken over the sole contractor status in May 2017 after the death of Dr Piers Ross and felt that she was unable to continue to manage and maintain the practice alone and that she was considering tendering her resignation.

Equality

Ensuring continuity of primary care services for and the equitable provision of these services being commissioned for Bexley patients ensuring that a standard quality service provision could be received from this practice.

Financial

Both the caretaking APMS contract and the substantive APMS contract will be procured based on the PMS equalisation commissioning arrangements

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

Clinical lead: Dr Sid Deshmukh, Chair CCG

Executive sponsor:


3 of 3

DATE: 25th April

Title

Request for Closure of Branch Surgery – Cumberland Drive Surgery (Cairngall Medical Practice)

This paper is for discussion and decision

Recommended action for the Primary Care Commissioning Committee

Recommendation: To approve the branch surgery premises closure of Cumberland Drive Surgery of Cairngall Medical Practice, with effect from 1st July 2018, ensuring that patients have sufficient notice to consider the options of continuing to see the clinicians of Cairngall Medical Practice at its main site, receiving home visits, as clinically appropriate, or registering with an alternative practice which covers patient’s home address, well in advance of this close date. This recommendation is subject to:

Writing to regular patient users of Cumberland Drive Surgery to communicate the intention to close the branch and advise patients that there will be engagement events to discuss this proposal and support patients to make an informed choice about which local practices would best suit their needs in the event they do not wish to or are unable to continue to access GP services from Cairngall Medical Practice’s main site.

Potential areas for Conflicts of interest

Dr Bhalla is the APMS contract provider and is also a GP member of the PCCC.

Executive summary

Cairngall Medical Practice is an APMS practice with a list size of 9156 patients. It currently comprises one main site at 2 Erith Road, DA17 6EZ and one branch site at 58 Cumberland Drive, DA7 5LB which are approximately one mile apart or a 20 minute walk. Dr Bhalla has submitted a formal request (Appendix 1) to NHS Bexley CCG to close Cumberland Drive Surgery in the Brampton electoral ward with immediate effect which the PCCC is being asked to consider. Considerations that the PCCC may wish to take into account in reaching its decision include:

Dr Bhalla has looked at attendances over the last 3 months at Cumberland Drive Surgery and can identify about 100 regular users

NHS Bexley CCG recently commissioned a professional schedule of

condition and the conditions survey demonstrates that the premises

cannot be made fit for purpose and brought up to required NHS standards

If patients registered at the Cumberland Drive Surgery wish to continue seeing the same clinicians, they can do so at the main surgery at 2 Erith

ENCLOSURE: G1 AGENDA ITEM: 21/18

Primary Care Commissioning Committee

1 of 4

Road

Access to a full range of services is available at the main site including extended hours on a Monday evening and Wednesday morning, family planning clinic, asthma and diabetes clinic, smoking cessation advisor and weight and lifestyle clinics

If current Cumberland Drive Surgery patients do not wish to receive services at the main site, they have the option to register with any of six practices, all of which have open lists and are registering patients, within 1 mile of the existing branch site

All of the six alternative practices are rated as ‘Good’ by the CQC. Appendix 2 provides an analysis of Patient Choice Considerations

The Chairman of Bexley Council’s People's Overview & Scrutiny Committee has confirmed that providing communications are properly managed and patients are not lost in transfer, the proposed change can proceed without further formal engagement with the council.

What are the Organisational implications

Key risks

There have been a number of GP premises site closures over a relatively short period of time and this proposal may be considered a step too far.

Prior to Purdah, the Chairman of Bexley Council’s People's Overview & Scrutiny Committee was advised that the CCG had received a business case from Cairngall Medical Practice asking to close the Cumberland Road branch surgery, based on the information included in this report.

The chairman has confirmed that providing communications are properly managed and patients are not lost in transfer, the proposed change can proceed without further formal engagement with the council.

Equality

As a result of there only being a small number of patients who are regular users of the site, it is not possible to open and maintain a comprehensive range of services at this branch site for the full core hours that general practice should be accessible (i.e. 8am to 6:30pm Monday to Friday).

Closure of the branch surgery site will enable the APMS contact provider to focus on improving equality of access to services at its main site, as more resources will be available on one site, rather than split over two.

For patients that wish to remain registered and are classified as vulnerable, the APMS provider will be asked to confirm it will see patients on a home visit basis, where clinically appropriate.

Financial

The cost of remedying serious defects Red rated defects is estimated as £5,100.00, and remedying Amber defects (not immediate) is estimated as £4,300.00. Overall, the estimated investment to remedy defects is around £12.5k + VAT, but these

2 of 4

will not remedy the disabled toilet room size or enable HBN compliant clinical rooms.

The conditions survey demonstrates that the premises cannot be made fit for purpose.

A small cost saving per annum of £3200 would be realised should it be agreed that the branch surgery site closes.

Author: Jill Webb & Sally Edwards

Clinical lead:

Executive sponsor:

Introduction and Purpose The purpose of this paper is to enable the PCCC to make a decision as to whether to agree to the request of the current caretaker APMS provider of Cairngall Medical Practice, to close the branch surgery – Cumberland Drive Surgery. Cairngall Medical Practice is an APMS practice located within the borough of Bexley. The main site at 2 Erith Road is situated in the Belvedere ward and the branch site at 58 Cumberland Drive is located in the Brampton ward, about a mile from the former. The main surgery is located in a predominantly residential area close to a small local high street. The purpose-built premises offer a large reception area with room for storage of patient records and a waiting area with ample seating. The site offers disabled access as well as good parking, with a small patient car park and ample on street parking directly outside. The nearest train station to the main site is Belvedere Railway Station which is 1.7 miles away, an approximate 8 minutes’ drive. It is open Monday to Friday 8am to 18.30pm surgeries with the addition of 4.5 extended hours (Monday evening and Thursday morning). Family planning, asthma, diabetes, qualified smoking cessation advisor, weight and lifestyle clinics are also offered from the main site. On 19 December 2017, the Bexley Primary Care Committee (PCCC) agreed that a caretaking provider should be procured to provide primary care medical services to the registered patients of Cairngall Medical Practice from the existing premises. This was an urgent planned decision which was approved following the resignation and handing back of the Cairngall Medical Practice PMS contract from the contractor with effect from 6.30pm on 31st January 2018. The Primary Care Committee approved the procurement of an APMS caretaking contract until 30th September 2018 and this was awarded to Belvedere Medical Centre (Dr Varun Bhalla). The PCCC also agreed to procure a new provider of a time limited APMS contract, who could have access to both the current main and branch surgery, wef 1st October 2018, subject to formal confirmation from the landlords (former GPs and trustee of Dr Ross (deceased) about their intentions. On 15th March 2018, Dr Varun Bhalla formerly submitted a request to NHS Bexley CCG to close Cumberland Drive Surgery, the branch of Cairngall Medical Practice with immediate effect. Appendix 1 refers. The Cumberland Drive Surgery branch is a small converted residential property which, until recently, acted as a site for the provision of Primary Medical Services to approximately 100 of its 9156 (approx. 1%) patients (as at 1st January 2018) that are registered with Cairngall Medical Practice. Dr

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Bhalla has identified that approximately 500 patients are registered at Cumberland Drive Surgery, but only 100 patients use it on a regular basis. Dr Bhalla has confirmed that the caretaker APMS provider temporarily ceased all clinical activity from Cumberland Branch Surgery from 5th March 2018 due to ‘underutilisation and shortage of clinical staff’. As part of the patient engagement process relating to the procurement of a new time limited contract, patients and stakeholders were asked about their views through a patient letter and patient survey. GPs and staff have been in dialogue with the PPG and Bexley CCG, the latter of which agreed to the temporary pause in clinical services provision, pending a review of the number of patients who regularly attend the site and that the caretaker provider had undertaken to arrange visits to vulnerable patient’s homes, where clinically necessary. Patients using Cumberland Drive Surgery were informed of this decision by posters, website, letters and text messages. Dr Bhalla has confirmed that the reception is currently open at the branch site however is for a small amount of administration only. Until this pause in clinical service provision at the branch surgery, there had only been minimal clinical sessions provided from Cumberland Drive Surgery, leading to under-utilisation of already stretched clinical staff. The main site provides a comprehensive range of services. The Chairman of Bexley Council’s People's Overview & Scrutiny Committee was advised that the CCG had received a business case from Cairngall Medical Practice asking to close the Cumberland Road branch surgery, based on the information included in this report. The chairman has since confirmed that providing communications are properly managed and patients are not lost in transfer, the proposed change can proceed without further formal engagement with the council. In parallel with the utilisation of this branch surgery site by registered patients, the CCG recently commissioned a professional schedule of condition which covered the external and internal areas of the property and included RAG rating and cost estimates to address statutory and contractual compliance issues, where it is possible to do so. There were a number of compliance issues identified including:

Room sizes, which are not in line with Health Building Note (HBN) best practice guidance standards, but meet permissible minimum requirements of 8m2.

Sinks and flooring that needs replacing to comply with Infection control requirements

The disabled toilet which should be 3.3m2 as per the Building Regulations, and measures 1.28m2 with no opportunity to address within the space confines of the premises footprint

The cost of remedying serious defects Red rated defects is estimated as £5,100.00, and remedying Amber defects (not immediate) is estimated as £4,300.00. Overall. the estimated investment to remedy defects is around £12.5k + VAT, but these will not remedy the disabled toilet room size or enable HBN compliant clinical rooms. The conditions survey demonstrates that the premises cannot be made fit for purpose. The full survey is available on request.

Attachment(s): (i) Appendix 1 - Dr Bhalla’s business case to close the branch surgery (ii) Appendix 2 - Patient Choice Considerations

4 of 4

Enclosure: G2 Item: 21/18

FORMAL NOTIFICATION OF THE INTENDED PERMANENT CLOSURE OF CUMBERLAND SURGERY BRANCH OF CAIRNGALL MEDICAL PRACTICE (G83005), BEXLEY This letter provides formal notification to NHS England and Bexley CCG of the intended permanent closure of the Cumberland Drive Surgery Branch of Cairngall Medical Practice (CMP), Bexley and that the APMS contract between the parties be varied accordingly. 1.0 Background

Care taking contract for Cairngall Medical Practice has been awarded to Belvedere Medical Centre to provide Primary Medical Services under APMS contract in the London Borough of Bexley. The total registered list of the practice is 9211. The practice currently provides Primary Medical Services from two sites

Cairngall Medical Practice

2 Erith Road, Belvedere,

Kent DA17 6EZ

and

Cumberland Drive Surgery, 58 Cumberland Drive,

Bexleyheath, Kent DA7 5LB

2.0 Cumberland Drive Branch details & Information

The Cumberland Drive branch is a small converted residential property which currently acts as a site for the provision of Primary Medical Services to approximately 100 of the 9211 (1%) patients that are registered with CMP. Even though approximately 500 patients are registered at Cumberland Branch Surgery only one hundred patients use it on regular basis. The opening hours of the Cumberland Drive Branch are as follows: Mondays to Fridays- 8 AM to 12:30 PM and 3:30 PM to 6:30 PM. Saturdays and Sundays closed Cairngall Medical Practice temporarily ceased all clinical activity from Cumberland Branch Surgery from 5th of March 2018. CMP had consulted the PPG and Bexley CCG prior to this action. Patients using Cumberland Branch Surgery were informed of this decision by posters, website, letters and texts. The reception is currently still open at Cumberland Branch Surgery as before. Patients who cannot attend main CMP Site on medical grounds are offered home visits. CMP was providing minimal clinical activity from Cumberland surgery and under-utilisation of already

1 of 3


stretched clinical staff was not seen to be appropriate use of NHS resources. Only about 100 patients use Cumberland surgery regularly and most patients traveled to the main site at 2 Erith Road which provides a more comprehensive range of services and is nearby.

3.0 Reason for intended permanent closure

1) Only 100 patients attended Cumberland Branch Surgery regularly.

2) Provision of clinical sessions with less utilisation does not represent

good value for the use of NHS resources.

3) No patients have complained about stopping clinical activity from Cumberland Surgery.

4) King Harold’s Way Surgery (KHW) is in very close proximity of Cumberland branch surgery and would be happy to register new patients.

5) KHW is in 2 minutes walking distance of Cumberland Drive.

6) Bexley CCG will save notional rent and rates if Cumberland Surgery is closed without compromising any health services to its patients.

7) Cumberland Branch Surgery is not fit and safe to provide good quality clinical services. Closure of branch surgeries, when the opportunity arises, is in line with the CCG’s estates strategy.

4.0 Mitigating Factors

The Cumberland Branch is only 1.7 kms (1 mile) from 2 Erith Road, the main surgery site.

Patients may choose to re-register with a number of other practices locally including KHW all of which are open for new patient registration, and willing to receive new patients.

5.0 Proposed date of intended closure

As clinical activity has already been temporarily stopped from Cumberland Surgery, CMP can close Cumberland Branch Surgery as soon as it has Bexley CCG’s approval.

6.0 Patient and Stakeholder consultation CMP have already engaged with patients and Stakeholders in the following ways

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The GP & staff have been in dialogue with the PPG and Bexley CCG about intended permanent closure and have received no objection in principle. It is understood that discussions will need to take place with the overview and scrutiny committee.

Flyers have been available from the Cumberland Branch and main surgery at 2 Erith Road regarding closure.

Posters have been put up in both the main Erith and Cumberland Drive surgeries re closure of Cumberland Drive Branch.

A notice has been placed on the CMP website about the temporary closure.

CMP have written or texted Cumberland patients advising them of the closure

The CCG and NHS England have been kept fully briefed about the proposals and updates as circumstances have been changed

To date there has been no significant adverse reactions to the closure from either patients or local stakeholders.

The proposal is line with the Bexley estates strategy that recommends the reduction of branch surgeries within Bexley when the opportunity arises, to support the sustainability of general practice.

7.0 Approvals We trust that this notification provides sufficient information and case for the Commissioners of Primary Care to approve the closure of the Cumberland Branch Surgery permanently and amend our APMS contract accordingly. Yours Sincerely Dr V Bhalla

3 of 3

Enclosure: G3

Item: 21/18

Page 1 of 2

Appendix 2 Cumberland Drive Surgery

(Cairngall Medical Practice G83005)

Patient Choice Considerations Table Analysis – Cumberland Drive Surgery

All practices within 1 mile of Cumberland Drive Surgery have PMS contracts, with the exception of

Bursted Wood Surgery (APMS). They have varying patient list sizes ranging from 2571 to 11649.

Out of the six practices that are within one mile radius of Cumberland branch surgery, all 6 were

rated as ‘Good’ following their CQC inspections.

With regards to GPOS rating, Cairngall is the only practice rated as “Review Identified”, and for

GPHLI no practice has been highlighted as an outlier.

The CCG average for FFT rating – (would recommend practice) is 85% (January 2018 data).

Cairngall has the lowest score of this cohort with 68% (October data as January’s is not available);

all other practices within its vicinity score above the CCG average.

Out of a maximum 5 stars ratings for NHS Choices, two practices are rated as 4 stars, one is rated

as 3.5 stars, two are rated as 2.5 stars (including Cairngall) and one is rated as 1.5 stars.

With regards the GP Survey:

Would not recommend Practice (CCG Average 13%) – three practices had a less favourable

score then the CCG average, with Cairngall having the highest percentage of patients not

recommending it at 23%

Not easy getting through on phone (CCG Average 11%) – only Cairngall has a poorer score

than the CCG with 15%

Not able to get appointment (CCG Average 16%) – three practices had a higher percentage of

patients not being able to get an appointment when compared to the CCG, Cairngall had the

second highest percentage of patients that reported not being able to get an appointment at

25%.

1 of 2

Enclosure: G3

Item: 21/18

Page 2 of 2

Table 1 data for practices within a mile of the Cumberland Drive Surgery

Name Little Heath (AKA Dr

Thavapalan) Bexley Medical

Group Pickford Lane Sur-

gery Belvedere Medical

Centre Cairngall Medical

Practice Bursted Wood

Surgery

Distance from Cumberland Drive Surgery (miles)

0.3 0.3 0.5 0.7 0.9 1

CCG Area Bexley Bexley Bexley Bexley Bexley Bexley

Contract Type PMS PMS PMS PMS PMS APMS

Contract End Date *N/A (not applicable)

N/A N/A N/A N/A N/A 30/04/2019

Raw List Size 4371 16879 9185 10279 9156 5097

Known Capacity issues TBA TBA TBA TBA TBA TBA

Workforce outlier? No No No No No No

Number of patients per FTE GP 2,622 1,530 2,596 6,032 1,957 7,739

Selected for resilience programme support?

No No No No Yes No

GPOS review identified? Approaching Review Approaching Review Achieving Achieving Review Identified Achieving

CQC rating Green Green Green Green Green Green

GPHLI outlier? No No No No No No

Number of outlying points 0 0 1 0 2 3

FFT rating (would recommend practice) (CCG Average 85%)

86% 88% 85% 88% No ratings yet 90%

NHS Choices star rating (full rat-ings is 5)

4 (20 reviews) 1.5 (14 reviews) 2.5 (13 reviews) 4 (22 review) 2.5 (48 reviews) 3.5 (3 reviews)

GPPS Feedback

Would not recommend Practice (CCG Average 13%)

14% 11% 19% 8% 23% 4%

Not easy getting through on phone (CCG Average 11%)

1% 11% 7% 1% 15% 0%

Not able to get appointment (CCG Average 16%)

19% 11% 31% 6% 25% 11%

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1


Title

Delegated Primary Care 2018/19 Budget Setting

This paper is for decision


That the primary care commissioning committee;

1. RECOMMEND to the Governing Body the approval of the 2018/19 budgets as shown in Appendix 1, noting the potential cost pressure, the use of the contingency and the inability of this directorate to contribute to the overall QIPP ask of the organisation.


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

Executive summary

Appendix 1 shows the proposed 2018/19 budget for delegated prescribing which initially shows a cost pressure of £411k on the allocation received of £29,312k. The delegated primary care allocation has increased by £763k from that received in 2017/18 which represents an increase of 2.67%. In order to make the delegated primary care budget balance, the 0.5% contingency has been fully utilised at month 1, £100k of GMS equalisation funding has been provided from the CCG main programme funding leaving the requirement for a negative reserve balance of £164k to be included to meet the breakeven requirement. No QIPP contribution has been made to the overall organisational ask or to assist in balancing the budget. The assumptions made by the primary care team on each area of expenditure are included on the last tab of appendix 1 and appear to be reasonable. The team still has some work to undertake on these budgets but it is anticipated that this version will be uploaded into SBS as the first cut with any changes being actioned via budget virements. Following further work by the primary care team, it is hoped that the negative budget can be reduced and some in year benefit identified possibly from 2017/18

ENCLOSURE: H1

AGENDA ITEM: 22/18


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2

unused accruals to move to a breakeven position with no negative reserve. The second tab of Appendix 1 shows the summary values for each type of spend area with the total reconciling to the summary on the first tab of the spreadsheet.


Key risks

The key risks in recommending this 2018/19 budget are the fact that there is a cost pressure on the budget which is being mitigated by the use of a small negative budget, the 0.5% contingency is fully utilised in assisting in bridging the financial gap and £100k of GMS equalisation funding is being utilised from the main CCG programme budget in order to contribute to the financial cost pressure. This therefore leaves the delegated primary care budgets with no reserves or funding source for any unforeseen circumstances which may occur in year. Also, the delegated primary care budgets are not able to make any contribution to the overall QIPP requirements of the CCG.

Equality

N/a

Financial

The delegated primary care budget for 2018/19 has been made to a break even position as described above but this is with some funding from the CCG programme allocation and also the full use of contingency. There is no scope within this budget for any one off or exceptional costs in year. Therefore, there is a risk that this budget will overspend in year and will rely upon non recurrent measures to stay within this budget. However, it should be noted that although a deficit budget was planned for and expected in 2017/18, the final outturn position was a surplus. This is because a number of the budgets are estimated. It is therefore hoped that the costs will be lower than budgeted again in 2018/19 and reduce the possibility of an overspend.

Author: Julie Witherall, Deputy Director of Finance

Clinical lead: Dr V Bhalla. Finance lead

Executive sponsor:

Malcolm Hines, Chief Financial Officer

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Budget 18/19

CCG Bexley

£000

Total Core funding 21,824

QOF 2,960

DES 642

Premises 2,837

seniority 158

CQC, indemnity 248

dispensing fees 190

Other 0

Total of budgets at practice level 28,860

Locum 117

DES LD and SAS (not practice level) 42

Clinical waste 84

Occ health 17

DV 14

subtotal before reserves 29,133

Demographic growth (ONS % on Core contract) 227

QOF pop growth 30

Premises Growth Fund 2% 57

Business rates reserve 0

Premises devts PCIF and IG 0

Total budgets including reserves, before QIPP 29,447

QIPP 0

Total after QIPP 29,447

allocation 29,312

1% headroom 0

0.5% contingency -147

Increase in costs of indemnity costs -

information received from NHS England for the

30/04 planning submission -130

net Allocation 16/17 reduced for headroom and

contingency 29,035

net allocation less budget incorporating QIPP -

surplus/(deficit) -411

Funded by;

Use of contingency 147

GMS equalisation funding from CCG programme

allocation 100

Negative Reserve 164

Overall spend less allocation and adjustments -0

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CCG

raw list

1/1/18

wgtd list

1/1/18 Core contract Caretaking

OOH

deduction

Total Core

funding QOF DES Premises seniority Indemnity CQC

dispensing

fees Other

Total of

budgets at

practice

level

Locum -

incl GP

retainer LD DES

VP/SAS

schemes

not

practice

specific

Clinical

waste incl

Mgt Chg

Occ health,

delivery,

sterile

products DV

Total before

Reserves

Demographic

growth (ONS

% on Core

contract)

r

e

c

u

r

r

Premises

devts PCIF

revenue

costs

Rates

reserve

Premises

2%

QOF 0%

increased ach

plus dem

growth

Total proposed

budgets

including

reserves, before

QIPP

£ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ ££ £ £ £

Bexley 0

BexleyAPMS 5,097 4,872 495,968 0 -21,400 474,568 62,345 10,477 83,372 0 2,630 4,526 24,621 0 662,539 2,310 510 665,359 4,960 1,667 623 672,610

BexleyAPMSC 9,156 8,985 914,212 89,851 -38,456 965,607 126,990 28,313 129,778 0 4,724 4,526 9,677 0 1,269,616 1,269,616 9,142 2,596 1,270 1,282,624

BexleyGMS 21,052 19,153 1,892,855 0 -49,654 1,843,201 228,278 58,399 306,689 15,271 10,863 13,578 14,975 0 2,491,255 9,198 1530 2,501,983 18,929 6,134 2,283 2,529,328

BexleyPMS 205,310 191,586 19,382,237 0 -842,110 18,540,127 2,542,839 545,192 2,317,098 143,199 105,940 101,475 140,507 0 24,436,376 105,196 11730 24,553,302 193,822 46,342 25,428 24,818,894

Bexleyclosed 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

BexleyOther 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40,164 1,800 84,235 17,039 143,238 0 0 143,238

BexleyTotal 240,615 224,595 22,685,273 89,851 -951,620 21,823,504 2,960,453 642,381 2,836,937 158,469 124,157 124,105 189,779 0 28,859,786 116,704 40,164 1,800 84,235 17,039 13,770 29,133,498 226,853 0 0 56,739 29,605 29,446,694

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January Base

Using January list sizes and assumptions about pay deal plus

1.5% uplift on core

GMS

Global Sum Based on January 18 GSUM MPIG at 48p and Seniority at 31p added

GMS OOHs Based on January 18 GSUM

MPIG

Based on January 18 payment, reduced by 1/3rd. Baseline

increase assumed to be 48p pwp as for 17/18 Being reduced in 1/7ths - started 14/15, final year 2020/21

Premium Budgeted for but some CCGs may fund from elsewhere?

PMS

Assume all now on new contracts, GSE (GS plus London

Allowance plust MPIG 48p plus Seniority 31p) plus PMS

Premium, reduced for MPIG reinvestment, assumed at 48p pwp

PMS Bexley PMS practices have additional £ 4.33

PMS Bromley

PMS Greenwich

PMS Lambeth Premium value used excludes element funded by £3per head

PMS Lewisham

PMS Southwark

PMS uplifts

APMS

APMS Londonwide Adjusted for MPIG and Seniority

APMS Not Londonwide Adjusted only for Seniority

APMS C caretaking contracts assumed run for full year

QOF

Currently based on 16/17 increased for CPI, £ per point uplift in

17/18 and 100% ach

£ per point increased from £165.18 16/17 to £171.20 17/18 to

compensate for change to the Contractor Population Index (CPI)

Minor

Use all payments in 17/18 ie pick up Q4 16/17 payments as

estimate of Q4 17/18

Extended hours

Budget for all except those on London APMS which excludes

eligibility

Learning

Violent Based on payments set up for 17/18 -

Seniority

Based on Dec 18 payments, reduced as for 17/18, with uplift

pwp as for 17/18 (31p pwp)

need to be reduce for annual reinvestment into core, assume

equal reduction over 6 year, 17/18 is year 3, so reduce by 1/4 of

16/17 value. Phasing out started Oct 2015 (when full year

adjustment made over second half of the financial year) and

continues to March 2020

CQC fees

Fees published by CQC. Current all budgeted at 17/18 rates

(adjustment not made for the multiple providers eg Hurley/AT

Medics - 17/18 payments suggest the share tends to be less

Indemnity

16/17 rate? Guidance from centre has been that for 17/18 this

will be funded nationally. Budget set again at 16/17 rate (£prp)

GP retainer

clinical waste As 17/18

Occ health

locum As 17/18

DV

Population growth reserve ONS %s

Premises

NHS PS spreadsheet

CHP spreadsheet Assume RPI 4% CHP rents increased annually by Feb RPI Feb 17 RPI announced is 3.2308%

PVT and other NHS landlords

BID reimbursement Not identified separately, part of rates reimbursments

Business Rates Assume CPI 2.7%. GLH figures

From April, rates will rise in line with the lower Consumer Prices Index

(CPI) measure of inflation, not the Retail Prices Index (RPI).

Developments

No budgets included for non recurrent or recurrent costs arising

from premises developments

GMS PMS APMS

£ pwp £ pwp £ pwp

MPIG reinvestment 0.41

Seniority reinvestment 0.41

Inflation uplift 1.75

Total uplift 2.57

85.35

87.92

18/19 17/18

OOH deduction % 4.87% 4.92%

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Title

Delegated Primary Care Finance Report as at month 11 (February 2018)

This paper is for information


That the primary care commissioning committee; 1. NOTE the year to date and forecast out-turn position on the delegated primary care budget for 2017/18. 2. NOTE the reasons for the year to date underspends on the budget and support the CCG in reminding GPs to make the required claims in a timely manner which would also improve their cash flow. 3. NOTE the refunds of cash from NHS England in respect of 2016/17 year end creditors and note the write back of the remaining 2016/17 year end creditors.


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

Executive summary

From 1st April 2017, the CCG became responsible for the primary care medical services budget under the delegated primary care regime. The expenditure budgets have been set based on the following: • Practice level detailed contractual commitments for April 2017 list sizes at 17/18 prices. • List growth reserves set aside based on the office of national statistics’ figures for predicted population growth for 17/18. • Premises budgets have been set based on known practice reimbursements and where not known, for example 17/18 business rates and impact of in-year rent reviews; reasonable reserve budgets have been incorporated. • Other practice level budgets have been estimated based on the prior year outturn adjusted for known 17/18 changes to remuneration, e.g. seniority and QOF, contractual commitments linked to 1st April list sizes and to meet all known and anticipated costs.

ENCLOSURE: I1

AGENDA ITEM: 23/18


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The CCG weighted practice list size has increased by 0.42% from April 2017 to January 2018, the cost of which (£33k) leaves a favourable variance against a reserve budget which was based on the ONS predicted annual growth of 1%. This is shown in the table below which also shows the growth for the other SE London CCGs.

CCG

Normalised

weighted list as at

April 2016

Normalised

weighted list as at

April 2017

Year on

Year %

Move-

ment

Normalised

weighted list as at

01/07/2017

April to

July %

Move-

ment

Normalised

weighted list as at

01/10/2017

April 17 to Sept 17 % Move -

ment

Normalised

weighted list as at

01/1/2018

April 17 to Dec 17 % Mov

e- ment

ONS %

16_17

ONS %

17_18

Bexley 219,428 223,645 1.92

% 223,789

0.06%

224,186 0.24

% 224,595

0.42%

1.00%

1.00%

Bromley 320,947 323,703 0.86

% 324,499

0.25%

325,518 0.56

% 325,908

0.68%

1.10%

1.10%

Greenwich

277,556 288,440 3.92

% 288,660

0.08%

290,666 0.77

% 291,980

1.23%

1.20%

1.10%

Lambeth 376,673 385,999 2.48

% 388,270

0.59%

391,176 1.34

% 393,723

2.00%

1.20%

1.10%

Lewisham

306,819 311,924 1.66

% 312,859

0.30%

314,324 0.77

% 315,346

1.10%

1.50%

1.40%

Southwark

313,341 319,177 1.86

% 320,526

0.42%

323,403 1.32

% 325,799

2.07%

1.50%

1.30%

Total SEL 1,814,765 1,852,888 2.10

% 1,858,603

0.31%

1,869,274 0.88

% 1,877,350

1.32%

Prior year expenditure has been removed from the financial position. A calculation of the value of these transactions has been completed and an invoice has been raised to NHS England for circa £1.1m for these items, this invoice was settled in November 2017. An additional invoice was raised in January for circa £80k which has just been settled. NHS England have now reviewed the unused 2016/17 creditors with the intention of passing these back at an STP level and the month 11 position of the CCG includes the Bexley share of these accruals with the actual value transferring on month 12. The primary care medical budgets calculated for the CCG leaves a gross deficit position of £525k against the 17/18 allocation of £28,549k. This has then been closed by the use of the 1% headroom and contingency to give a net gap of £104k. There are no QIPP schemes in place for 2017/18 but it is expected that this deficit will be managed within the population growth reserve following low levels of list size increase in all quarters to date. The CCG has also reviewed all budgets with NHS England to ensure both a better understanding but also to assess if there is likely to be a cost pressure for the CCG against this area of spend. Appendix 1 shows that at month 11 the financial position is showing an underspend of £143k (-1.2%) YTD, the increased level of underspend compared with last month (£57k) arises from the arrangement for 17/18 to fund indemnity inflation from national primary care budgets. The low levels of population growth mean that both caretaking arrangements and other minor overspends (such as seniority) can be managed within the population growth budgets. The forecast year end outturn is an underspend of £128k. This forecast takes into account the

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cost pressure of a caretaking contract which started in February 2018.

What are the organisational implications Key risks

The main risk to this budget is that all of the contingency and 1% headroom have been utilised in balancing the budget for 2017/18 and so there are no reserves in place should an unexpected cost pressure arise. The caretaking arrangements for Cairngall practice have managed to be contained within the existing envelope due to rent savings following practice mergers during the year and list size growth not being as high as expected. The CCG has been assured that any backdated rent for practices (there is an on going backlog which both NHS England and the CCG is aware of) will be accrued by NHS England as their liability and so the write back of 2016/17 creditors which was included in the overall financial position of the CCG in month 11 will not need to be adjusted for these items.

Equality

N/a

Financial

At this late point in the financial year, it appears that there are no major cost pressures against this element of the CCG budget as the caretaking arrangements can be contained within the existing budgets due to savings on rent etc during the year and so it is forecast that this budget will show an underspend at year end having used the 1% headroom and contingency to address the initial cost pressures at the beginning of the year.

Author: Julie Witherall, Deputy Director of Finance

Clinical lead: Dr V Bhalla

Executive sponsor:

Malcolm Hines, Director of Finance

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Enclosure: I2 Item: 23/18

Appendix 1 – Month 11 Primary Care Position

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Title

Primary Care Strategy Plan

This paper is for discussion *delete as applicable


That the primary care commissioning committee note

1. Achievements made against the current primary care strategy 2. Strategic changes in Primary Care which support the need for the

strategy to be reviewed 3. Next steps with regard to the Primary Care Strategy review

*delete as applicable


N/A

Executive summary

The Bexley CCG Primary Care Strategy was developed in 2015 with a 5 year outlook. The strategy set out the CCG’s plans to improve coordination of care, access to services and take a more proactive approach to our patients’ health and wellbeing. Since 2015 Primary Care has evolved significantly. With this in mind, the CCG need to review and update their existing Primary Care strategy to ensure alignment with these changes and the other strategic developments impacting upon Primary Care.


Key risks

Primary Care Strategy may not currently be reflective of Primary Care as it is today or will be in the future.

Equality

Primary Care should be equally accessible to all Bexley residents; the strategy for Primary Care will look to address this.

Financial

Financial vulnerability is a key risk in primary care, the strategic direction for primary care should look to implement initiatives which will address some of the financial challenges faced and seek to obtain funding and support where available.

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

Clinical lead: Dr Sid Deshmukh, Chair

Executive sponsor:

Nisha Wheeler, Director of Primary Care, ICT and IG

ENCLOSURE: J1

AGENDA ITEM: 24/18


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Enclosure: J2 Item: 24/18

1

Primary Care Strategy Plan

Background The Bexley CCG Primary Care Strategy was developed in 2015 with a 5 year outlook. The strategy set out the CCG’s plans to improve primary care services for the patients in Bexley specifically around coordination of care, access to services and to take a more proactive approach to patients’ health and wellbeing. The strategy planned for the following strategic priorities:

Taking a more proactive, population health management approach to focus more on prevention of ill-health, wellbeing and supporting people to self-manage

Improving access to primary care and reducing inequalities in access to primary care

Better care coordination by strengthening service integration

Implementing initiatives supporting the aspirations outlined in the FYFV with respect to a digital primary care services focus

Use primary care co-commissioning to help secure high quality services and reduced variation in quality and outcomes

Ensure that the necessary IT, workforce and estate infrastructure is in place to enable transformation

Facilitating organisational development in general practice to move to new models of provision that sit within local care networks

Establishing and developing a Bexley federation that can support the on going sustainability and resilience of general practices through the provision of at scale services

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Since 2015 primary care has evolved significantly with the development of Local Care Networks (LCN’s), Integrated Care Systems (ICS), Sustainability and Transformation Partnerships (STP’s), GP Federation (Bexley Health Neighbourhood Care), Community Education Provider Network (CEPN) and Primary Care Co-Commissioning. With this in mind, the CCG now needs to undertake a full review of its strategy and update it to ensure its alignment with the changes highlighted above, and to include national and regional strategic developments that have impacted upon Primary Care since it was first developed. Prior to outlining the plan by which to undertake this review, this paper has also been developed to provide an update to primary care commissioning members of the achievements that have taken place since the primary care strategy was developed and approved in 2015.

Achievements Accessible Care:

Consistent core GP opening hours are now in place across Bexley with no GP practices closing for a half day on a Thursday

GP 8-8 extended access at Queen Marys Hospital Sidcup and Erith Hospital has been established since May 2017 and June 2017 respectively

Development of an accessible information standard guidance pack created for general practice use based on NHS England accessible standards framework

Online consultations available to patients, enabling patients to consult with their GP or access self-help advice/guidance online.

Patient online access to appointments, prescriptions and medical records available for all. 24 of 25 practices have over 10% of their patients registered with online access and 13 of the 25 practices have over 20% of their patients registered.

Every practice has access to sign language interpretation to support their patients Co-ordinated Care

Local Care Networks are now fully developed and established with clinical leads recruited into each locality

Self-care promotion to patients, with particular emphasis on education to patients on services available and when it is appropriate to use them

Provision of e-Frailty risk stratification tool to practices. Enabling practices to easily identify patients aged over 65 who are classed as moderately or severely frail and deliver a clinical review providing an annual medication review, and where clinically appropriate discuss whether the patient has fallen in the last 12 months and provide any other clinically relevant interventions.

Proactive Care

Full roll out of social prescribing across Bexley

On-going promotion of self-care

Development, recruitment and training of care navigators

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Joint prevention programmes with schools to improve health/attendance of school age children

Regular primary care updates to patient council, valuing the role PPG’s play in supporting the health and wellbeing agenda

Communication and engagement with LMC ensuring they are kept informed and abreast of services planned and commissioned

Established and proactive primary care development working group with representation of stakeholders from across the health economy

Co-Commissioning

Development and implementation of primary care commissioning committee

Collaborative working between CCG and South East London primary care team with support for primary care contracting

Collaborative working with SEL CCG’s across the STP on various primary care strategic commissioning work streams, including workforce, resilience, vulnerable practices and community based care.

Review and implementation of PMS contracts

Development of primary care quality dashboard

On-going provision of iPlato FFT module

On-going maintenance and enhancements to the Primary Care Activity Reporting Tool (PCART)

Infrastructure

Estates strategy in place with updated addendum recently added recognising the changing landscape since the estates strategy was developed in 2016. A full refresh is due for June 2018.

Successful ETTF schemes implemented, including: o Lloyd George digitisation o Infrastructure to support virtual consultations and training o Erith Health Centre additional capacity o Bexley Group Practice – new purpose built building enabling consolidation of

disparate sites

CEPN and workforce development schemes in place

Bexley Linked Care project implemented enabling access to integrated patient records across the primary care, acute, mental health and community settings

Workforce planning o Vacancy mapping o Planned retirements

Recruitment schemes o Bid for International GP’s o GP trainees o Development of new roles including care navigators, medical assistants, GP

pharmacists o Promotional recruitment video o Recruitment and retention pack

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o Job fair, which brings together practices looking for staff with newly qualified GPs looking for employment

Resilience o Support to struggling practices by offering external diagnostic visits and

guidance to achieve what may have been identified as part of the visits. o Support for practice mergers o Support to practices migrating to new clinical system o Externally facilitated support – the Vulnerable Practice Programme o Peer support

Local Care Networks (LCN)

Integrated Care System board in place

Local Care Network (LCN) clinical leads in post

MOU signed off by all health and care economy stakeholders Primary Care team developments

Primary care directorate expanded ensuring capacity to meet the on-going needs/requirements of primary care in Bexley

Director of primary care in post

Relationships between practice staff and primary care team have enhanced further, working together collaboratively to meet the on-going strategic requirements for primary care (e.g. Five year forward view, GP forward view, strategic commissioning framework).

Supporting and working with GP federation (Bexley Health Neighbourhood Care) on development of GP 8-8 extended access service and supporting at scale working in the future

Primary Care Strategy Review As highlighted above, since the Bexley primary care strategy was originally developed in 2015, a number of further national and regional strategies and guidance papers have been published on primary care. Whilst the CCG has been working towards the aims and aspirations outlined in the strategic reviews, it is fair to say that these are not reflected in its current primary care strategy fully. Outlined in the section below are the relevant national and regional strategies with a summary of their strategic aims that need to be reflected in how these will be delivered in the Bexley CCG primary care strategy. General Practice Forward View

Building the wider workforce

Retaining the current medical workforce

Direct route to returning to practice

Practice resilience programme to support struggling practices

Cut inappropriate demand on general practice – streamline pathways, processes, patient education, support services

Estates and Technology Transformation Fund (ETTF)

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Direct practice investment in technology to support better online tools and appointment, consultation and workload management systems

Better record sharing to support team work across practices Transforming Primary Care in London strategy

Local Planning involving GP’s

Contracting – federated working, sharing resources, working at scale

Infrastructure – workforce, estates and technology

Leadership – change management, recruitment and retention

Business Development – new models of care, innovate

Monitoring and Evaluation – improve outcomes, patient experience

Primary Care Co-Commissioning Sustainability and Transformation Partnership (STP)

Improving integrated and community based care – partnership working

Supporting people to be more in control of their health

Helping people to live independently

Helping communities to support one another

Making sure primary care services are consistently excellent and with an increased focus on prevention

Reducing variation in healthcare outcomes and addressing inequalities by raising the standards in health services to match the best

Developing joined up care so that people receive the support they need when they need it

Delivering services that meet the same high quality standards whenever and wherever care is provided

General Practice Resilience

Supporting GP practices to improve their sustainability and resilience

Developing more effective ways of working

Working towards future sustainability/new models of care

RCGP Peer Support Programme providing support to practices entering CQC special measures

Rapid intervention and management support for practices at risk of closure

Specialist advice and guidance – e.g. Operational HR, IT, Management, and Finance

Coaching / Supervision / Mentorship as appropriate to identified needs

Coordinated support to help practices struggling with workforce issues Access

Understanding demand vs. capacity

Timing of appointments

Effective access to the wider health system

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Extended GP access

Patient education to understand services available and when to access them

Reducing inequalities Working at scale With the challenges facing general practice it’s recognised that working at scale is one way to meet these challenges. This may involve two or more organisations working collaboratively (either formally or informally) in their front or back office functions or work to group together to win provider contracts. Groupings can involve federations, networks, multi-specialty community providers (MCPs), primary and acute care settings (PACs), joint ventures, super practices, multi-site practices. Opportunities for practices are to support:

Resilience

Economies of scale

System Partnerships

Skill mix

Innovation and improvement

Staff development Releasing time for care This is a development programme for general practice that will spread awareness of innovations that release time for care with support to facilitate local change programmes to implement them. It is estimated that most practices can expect to release about 10 per cent of GP time. National expertise and resources will be used to facilitate locally hosted collaborative action learning programmes, supporting groups of practices to come together, learn about proven innovations of interest, agree priorities for action, and implement changes that release time for care. 10 high impact actions to release time for care:

Active signposting: Provides patients with a first point of contact which directs them to the most appropriate source of help. Web and app-based portals can provide self-help and self-management resources as well as signposting to the most appropriate professional.

New consultation types: Introduce new communication methods for some consultations, such as phone and email, improving continuity and convenience for the patient, and reducing clinical contact time

Reduce Did Not Attend (DNAs): Maximise the use of appointment slots and improve continuity by reducing DNAs. Changes may include redesigning the appointment system, encouraging patients to write appointment cards themselves, issuing appointment reminders by text message, and making it quick for patients to cancel or rearrange an appointment.

Develop the team: Broaden the workforce in order to reduce demand for GP time and connect the patient directly with the most appropriate professional.

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Productive work flows: Introduce new ways of working which enable staff to work smarter, not harder.

Personal productivity: Support staff to develop their personal resilience and learn specific skills that enable them to work in the most efficient way possible.

Partnership working: Create partnerships and collaborations with other practices and providers in the local health and social care system.

Social prescribing: Use referral and signposting to non-medical services in the community that increase wellbeing and independence.

Support self-care: Take every opportunity to support people to play a greater role in their own health and care with methods of signposting patients to sources of information, advice and support in the community.

Develop QI expertise: Develop a specialist team of facilitators to support service redesign and continuous quality improvement.

Next Steps

Primary Care Strategy - High Level Plan Date

Update to strategy to ensure alignment with strategic developments outlined earlier in this paper May-18

Update to strategy to ensure alignment with GP Contractual requirements (PMS and GMS) May-18

Presentation and discussion of draft PC strategy to Practice Managers forum Jun-18

Presentation and discussion of draft PC strategy to Primary Care Development Working Group Jun-18

Presentation and discussion of draft PC strategy to locality meetings Jun-18

Presentation and discussion of draft PC strategy to Bexley patient council Jun-18

Circulation and feedback to stakeholders from LMC, LPC, GP Practices, GP Federation, LCN leads, Hospice, BVSC, Local Authority, Bexley Care Jun-18

Final Strategy Revision Jul-18

Presentation to PCCC Board Aug-18

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