PRIMARY CARE COMMITTEE Thursday 2 March 2017 at 1 ......• Kirkby – 18th November 2016 & 20th...

PRIMARY CARE COMMITTEE

Thursday 2nd March 2017

at 1:30pm in the Boardroom, Nutgrove Villa

AGENDA

ITEM

1:30pm Welcome and Introductions

Judith Mawer

Lay Member – Patient & Public Involvement

(Chair)

1:35pm

Supporting Carers Certificate Presentation made by Jan Box, Knowsley Carer’s Centre

Chair

Apologies for Absence

Chair

Declarations of Interest and Offers of Gifts, Hospitality and Sponsorship Note that GP members have a standing declaration of interest on this agenda as providers of primary care

services within Knowsley however, should GP’s have any specific interests in any particular item they must

be declared individually at each meeting. All other members of the Committee will also be asked

to declare an interest.

Chair

Confirmation of Quoracy

Chair

1:40pm

Minutes and Matters Arising of the Previous Meeting held on Thursday 19th January 2017

Document PC(17-03)01

Chair

1:45pm

Action Log


Chair

GOVERNANCE

1:55pm

Primary Care Committee Risks The Primary Care Committee is asked to NOTE the content of the report.


Paul Brickwood Chief Finance Officer

COMMISSIONING

2:05pm Primary Care Quality Report The Primary Care Committee is asked to NOTE the content of the report.


Helen Meredith Chief Nurse

CONTRACTING, FINANCE & PERFORMANCE

2:15pm Finance Update – 2016/17 Primary Care Budgets The Primary Care Committee is asked to NOTE the content of the report.


Paul Brennan Primary Care Accountant

MEDICINES MANAGEMENT

2:25pm Antimicrobial Resistance (AMR) Strategy and Action Plan The Primary Care Committee is asked to APPROVE the Anti-Microbial Resistance Action Plan.


Mark Pilling Interim Head of Medicines

Management

2:35pm

Medicines Management Work Plan Update The Primary Care Committee is asked to NOTE the content of the report.



Management

2:45pm

Evaluation of a Patient Group Direction for the supply of Varenicline (Champix ®) tablets The Primary Care Committee is asked to NOTE the content of the report.



Management

PATIENT FEEDBACK

2:55pm Healthwatch Knowsley Primary Care Patient Feedback Report The Primary Care Committee is asked to NOTE the content of the report.


Rosemary Sowerby Healthwatch Knowsley

SUB GROUP KEY ISSUES

3:05pm Medicines Management Sub-Committee


Dr Sue Benbow

The Primary Care Committee is asked to NOTE the content of the report

Secondary Care Doctor

ITEMS FOR RECEIPT

1. Finance & Performance Committee – 21st December 2016


2.

Medicines Management Sub-Committee – 7th December 2016


3.

Primary Care Quality Premium Assurance Meeting (Chair Approved Notes):

• East Knowsley – 30th November 2016 & 25th January 2017

• West Knowsley – 29th November 2016 & 17th January 2017

• Kirkby – 18th November 2016 & 20th January 2017

• Halewood – 25th November 2016 & 27th January 2017


DATE AND TIME OF NEXT MEETING:

Thursday 4th May 2017

1:30pm in the Boardroom, Nutgrove Villa

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NOTES OF THE PRIMARY CARE COMMITTEE held on Thursday 19th January 2017

in the Boardroom, Nutgrove Villa

Present ApologyMEMBERS

Dianne Johnson Chief Executive (Acting Chair) Paul Brickwood Chief Finance Officer

Iain Stoddart Chief Finance Officer

Helen Meredith Chief Nurse

Craig Porter Director of Commissioning & Service Transformation

Ian Stewardson Director of Strategy and Performance

Lorraine Hannon Lay Member – Audit & Governance Dr Sue Benbow Secondary Care Doctor

NON VOTING MEMBERS Dr Andrew Pryce Clinical Leader Dr David Stokoe Clinical Lead – Primary Care Dr Nisha Shah Clinical Membership Group Representative Dr John O’Donnell Clinical Membership Group Chair

IN ATTENDANCE Dr Thomas Kinloch LMC Representative

Sarah McNulty Health & Wellbeing Board Representative Rosemary Sowerby Healthwatch Knowsley Clare Barrow Deputy Chief Finance Officer Mark Pilling Interim Head of Medicines Management Paul Brennan Primary Care Accountant Present: Dawn Boyer Neil Rotherham Paul Mavers Andrea Kelly

Head of Governance (Item 6 Only) Primary Care Quality Officer Healthwatch Knowsley Personal Assistant

1. Welcome and Introductions: Action

Dianne Johnson welcomed everyone to the Committee meeting.

2. Apologies for Absence:

Apologies for absence have been received from Dr John O’Donnell, Dr Thomas Kinloch & Kendra Waring.

3. Declarations of Interest:

All GP’s present declared an interest as providers of primary care

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services in Knowsley. Mark Pilling declared that he is the Managing Director and a shareholder of MP Health Solutions Ltd. Rosemary Sowerby declared that her daughter is currently undertaking some research work with Public Health and Medicines Management. Iain Stoddart declared that he is also the Chief Finance Officer of St Helens CCG.

4. Minutes and Matters Arising of the Previous Meeting held on 3rd November 2016:

Dr Pryce referred to Page 3, Item 6.4, the word in Paragraph 3 should read determined not determine. Clare Barrow asked that the words ‘for PMS Practices’ are added to the first paragraph on Page 9 as followed: There is no financial implication for PMS Practices and no money needing to be recovered. With the above amendments, the minutes of the meeting held on 3rd November 2016 were agreed as an accurate record.

5. Action Log:

The Committee reviewed the action log and received the following updates on the two actions which are listed as ongoing: 5.1 Action 4 (3rd November 2016) – Contact CHP to determine if

the Liverpool practice still wishes to hold a temporary satellite site in Halewood PCRC.

Clare explained that she has been in discussions with Liverpool CCG about this. The practice is still keen to hold a satellite practice in Halewood and will contact Knowsley CCG if they wish to progress this any further.

5.2 Action 3 (1st September 2016) – Send a communication from the Primary Care Committee to practices encouraging them to sign their PPGs up to the National Associate for Patient Participation (NAPP)

Clare explained that she has ascertained that NAPP is a commercial organisation so it was felt upon reflection that it was not appropriate to send out this communication.

6. Primary Care Committee Risks:

Dawn Boyer introduced this item and accompanying report which presents the risks which are the responsibility of the Primary Care Committee for review and consideration of the level of assurance

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which can be provided to the Governing Body. Dawn advised the Committee that there are no key objectives specifically attributed to the Primary Care Committee but it does have responsibility for risks which are attributed to other Committees.

a) Objective 1 – Improve Health Outcomes for local people including vulnerable groups

b) Objective 3 – Ensure local people get good quality care c) Objective 4 – Achieve key financial duties

Dawn referred the Committee to the appendices which show the level and spread of these risks, the risk and assurance ratings for each risk, the detailed risk summary statements and the action log which details the actions identified to address any gaps in assurance. Lorraine Hannon referred to Appendix C, and asked whether the ‘By When’ column is the deadline for completion. Dawn confirmed it is, and advised that this is when the Committee would expect controls to be in place. Craig Porter referred to Risk O1 – “Lack of access to clinical systems/information results in services withdrawal by providers of GP additional capacity and extended hours” and advised that the CCG will now write to UC24 and this risk can be closed. Action – Close the Risk O1 – Lack of access to clinical systems/information results in services withdrawal by providers of GP additional capacity and extended hours The Primary Care Committee noted the content of the report.

DB

7. General Practice Operational Update:

Clare Barrow introduced this item and accompanying report which provides an update on operational issues within Primary Care. Practice Changes Tarbock Medical Centre has now completed its relocation to Manor Farm PCRC and the practice has reported a smooth transition. Practice List Closures

Prescot Medical Centre – Neil explained that the vacated space has now been developed and can be used by the practice. He noted there is some delay in agreeing the recharges to the practice and that Dr Heath is in contact with NHS England to resolve.

Action – Clare Barrow to draft a letter to Prescot Medical Centre to confirm that the list will reopen on 28th January 2017.

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Cedar Cross Medical Centre – The CCG received a request to close the practice list but this request was declined on the basis that the CCG felt that the practice is currently 2 GP clinical sessions short and should increase the number of clinical sessions to match the list size.

Dr Pryce felt that the wording in the report was not clear and this needed to be changed to reflect the above explanation and further information should be included in future reports. Rosemary Sowerby noted that Healthwatch has received 14 comments around this particular practice and they are all positive. Dianne agreed that more detail will be included in future reports and also agreed to circulate the decision making process for managing applications to close practice lists

Action – Amend the wording in this report on the Cedar Cross Medical Centre list closure request and share further detail in future reports on the background and rationale for decisions around list closures Action – Circulate the decision making process for managing applications to close practice lists.

Lorraine Hannon asked whether there is a weighting on funding for practice in relation to the age, sex, deprivation etc. of the patients on the list. Neil confirmed that there is such a weighting given to practice funding. Dianne reminded the Committee that there is additional GP capacity (Winter Fix) operating throughout the CCG which all practices can access.

Care Quality Commission (CQC) Inspections Inspections have been carried out at 20 of the 26 practices within Knowsley with the two most recent being Millbrook Medical Centre and Stockbridge Village Health centre. Neil advised that the report for Stockbridge Village Health Centre has very recently been released and it has been rated as ‘requiring improvement’. Dianne asked that Mark Pilling and the team contact the practice to offer any support required. Action - Contact Stockbridge Village Medical Centre to offer support following CQC inspection. Clare advised that reports have been received for inspections carried out on Park House Medical Centre which received an overall rating of good, with some elements of outstanding practice noted. Cornerways Medical Centre also received a rating of ‘Good’ and Bluebell Medical Centre was re-inspected following a rating in January 2016 of inadequate and has now been rated as ‘Good’. Clare noted

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AK

MP

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this is a huge turnaround and the practice, together with the Hollies Medical Centre who provided managerial and GP support should be commended. Dr Benbow asked how the CCG and practices learn from these visits. Dianne explained that reports are circulated and peer review is to be brought in as part of the CCG’s quality premium approach. Lorraine asked whether there is a timeline for the practice manager at Bluebell Medical Centre to let the CCG know when the recommendations will be addressed. Clare advised this does need to be agreed and asked Neil to contact the practice for this information. Action – Contact Bluebell Medical Centre for details on how and when the CQC recommendations will be addressed. Seldom Heard Service Clare explained that this service is provided by Cornerways Medical Centre and includes site visits at Alt Bank House, Ross House Women’s Refuge, Yates Court & Knowsley Probation Centre. The number of patients registered with this service has steadily increased from 72 at the start of the contract in April 2016 to 186. Primary Care Quality Premium (PCQP) progress 16/17 Neil explained that during November 2016 the first of three required assurance meetings for each locality took place. Neil noted that there was good attendance at these meetings and the next series of these meetings will take place this month. PMS Agreements – Monitoring of Key Performance Indicators (KPIs) Neil informed the Committee that the CCG has recently put into place a monitoring process to determine whether PMS practices have been operating at their funding level. He explained that for this exercise the CCG requested evidence from 12 of the 25 KPIs. Neil explained that from the initial evidence the CCG was satisfied that 12 out of the 16 PMS practices had operated at the correct level. Following receipt of further evidence from the 4 remaining practices, the CCG was assured that all were operating at the correct level. Dr Stokoe noted that there would be some contract issues if the CCG wanted to reduce the funding as the contract only allows for a funding reduction in the first year. Clare noted that this exercise allowed the CCG to get a baseline for future exercises. Dr Benbow asked whether the CCG had any idea about the remaining KPIs that were not looked at as part of this exercise. It was noted that some of these areas are looked at using other methods e.g. through

NR

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public health, through the PCQP, CQC etc. Dianne suggested the PMS specification is shared with Dr Benbow so she can see all of the 25 areas. Action – Share the PMS Agreement Specification with Dr Benbow. Dianne noted that GMS contracts are held by the remaining practices. The Primary Care Committee noted the content of the report.

NR/AK

8. Operational Plan 2016/17 Priority Areas Update:

Craig Porter introduced this item and accompanying report which provides the Committee with an overview and status update on two priority projects for the CCG; Locality Working & MDTs and Nursing & Care Homes. Locality Working & MDTs Craig advised that all the Kirkby MDT meetings have now taken place and there has been good representation and involvement at these meetings. The CCG will now focus on speeding up the roll-out plan to the rest of the borough. There have been discussions around physically co-locating different teams together, this suggestion is to be subject to staff consultation within the providers and Council and Craig advised that a further update would be available at the next meeting. Care Homes Project Craig advised that central to the enhanced model of care for care home residents is the redesigned Care Home Liaison Service which will be led by a dedicated Community Matron who is now in post. Introductions have been made with the care homes and work has begun to identify those patients at high risk of admission. There have been conversations at a recent meeting of the Urgent Care Network regarding a local care home triage to avoid ambulances being the first point of call for care home staff. Work will now begin with North West Ambulance Service (NWAS) to look at a new care home triage tool. Craig also informed the Committee that the final version of the Care Homes Project dashboard has been agreed with Health Intelligence and he will bring this to the next Committee for discussion. Action – Craig to bring the Care Homes Project Dashboard to the next Primary Care Committee meeting. Dr Benbow asked about the process for people in care homes getting out of hours treatment. Craig explained that this treatment is currently provided by NWAS, and as part of the work with NWAS the CCG will look at up-skilling staff and the use of telehealth.

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Lorraine Hannon suggested that the CCG needs to look at the ratio of nursing staff to patients present in Care Homes. The Primary Care Committee noted the content of the report.

9. Evaluation of Primary Care Quality Premium 2014-16:

Neil Rotherham introduced this item and accompanying report which provides an evaluation of the Primary Care Quality Premium scheme which was in place during 2014-16. Practices could achieve a payment of £10 per head for their practice list size based on the following: Over 75s Accountable GP Neil explained that a key demonstrable outcome was to show a reduction in non-elective activity in this patient group for 2015/16. Neil referred the Committee to Appendix 1 which details the outcome. The Over 75s requirement has been included in the 2016/17 PCQP and practices have highlighted that although they are working hard to reduce emergency admissions there is a chance they may not make a further reduction in admissions. The Committee is asked to approve some proposed amendments to the PCQP specification which rewards practices that can demonstrate they are working hard towards the target and made reductions in previous years. Three areas for improvement. Practices were given the opportunity to select 3 areas for improvement to work on during 2015/16 chosen from their practice profiles which were developed by the CCG and supported by Public Health. Based on current available data 10 practices achieved improvements in all 3 areas, 10 practices in 2 areas and 7 practices in 1 area. Neil advised that there is further data to be published before the CCG can confirm final achievement of this element. Prescribing There were separate specifications drawn up for this element, one for each year. There was a good level of achievement of the prescribing element of the PCQP. Assurance Neil advised that quarterly assurance meetings have taken place which included a Lay Member as the Chair, Head of Service from the CCG and a Healthwatch representative. Lorraine Hannon suggested that in terms of the Healthwatch attendance it may be more useful to send out the agenda and papers to Healthwatch to allow their input rather than expect attendance at each meeting. Dr Benbow referred to the proposed new paragraph in Appendix 5 in

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relation to the Accountable GP role over 75 years old and asked on what factors the CCG will judge whether the work undertaken by practice is adequate to receive the premium. Dianne explained that she has asked that the team looks at developing a process with more than one decision maker and potentially LMC involvement, as currently practices write to Dianne and whilst it is easy to make decisions where information isn’t provided it is not appropriate for her to determine alone whether the work undertaken is adequate. Action – A formal PCQP appeals process to be developed for approval at the next Primary Care Committee. The Primary Care Committee did not approve the proposed change to wording of the Accountable GP role over 75 years old specification as an appeals process with robust governance is to be developed.

CB/NR

10. Finance Update – 2016/17 Primary Care Allocation:

Paul Brennan introduced this item and accompanying report which provides the Committee with an update on primary care budgets based on Month 8 information. Paul referred the Committee to Appendix 1 which details the delegated primary care budgets position. He noted that the budgets are currently projecting a £670,000 underspend which is due to a duplication of the Fairness in Primary Care budget as previously reported to the Committee, and also a budget for the Dementia (Case Finding) Direct Enhanced Service which is now longer required. Paul noted that there is a current overspend of £86,000 in GMS core contracts which is due to the Cross Lane Surgery being supported in a caretaking capacity. Clare Barrow explained that the CCG was required to fund an element of UC24 from non-recurrent, and this year has been funded from additional resources There is a £129,000 overspend in PMS+ core contracts which are due to actual costs against estimates being higher than anticipated. Dr Pryce asked what the spend in professional fees included. Paul Brennan advised this is mainly for hard of hearing and interpretation services. Clare Barrow asked whether it may be more cost effective for the CCG to hold a contract for these services or arrange something across the borough. Neil advised that some clarity is still needed as to whether the CCG or NHS England commissions that service. Dr Benbow asked what the spend in subscriptions relates to. Paul Brennan explained that NHS England commission this on the CCG’s behalf and he is waiting for clarity on what this includes. Action – Confirm what the spend in subscriptions relates to.

PBre

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Action – Determine if NHSE or the CCG commissions interpretation services. The Primary Care Committee noted the content of the report.

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11. Anti-Microbial Resistance Strategy and Action Plan:

Mark Pilling introduced this item and accompanying report which describes the context of national and local action plans to reduce the spread of antimicrobial resistance. Mark explained that Knowsley has historically experienced high levels of antibiotic prescribing when compared nationally and locally and the gap is not narrowing despite a focus on the issue over a few years. Knowsley CCG is currently around 40% higher than the national average. Mark noted that antibiotic prescribing was a requirement of the prescribing element of the PCQP, and antibiotic prescribing is part of a practice based peer review process. Work to address the high levels of prescribing has been a key focus for Knowsley CCG and partners over the last eighteen months. Mark explained that antimicrobial resistance is not only due to prescribing. He noted that there is a need to work with Trusts towards a joint antimicrobial formulary. Mark noted that the CCG is working with pharmacies so they are aware of the plans. Lorraine Hannon asked whether the CCG has a responsibility for education regarding the link with farming and antibiotics. Dr McNulty advised she does not know the detail of this, but noted there is national work on this. Ian Stewardson asked what the potential is for savings to be made. Mark suggested this could be approximately £200,000 per year. Dianne Johnson referred to the draft Action Plan in Appendix 1 and noted there are no dates or names against these actions. She advised that the plan needs to be more ‘Knowsley’ focused and asked whether the Medicines Management Sub-Committee could look at this. The Committee agreed that it could not sign off the action plan until the work described above has been undertaken and there is additional clarification regarding governance. The revised action plan will be brought to the next meeting of the Primary Care Committee. Action - The Antimicrobial Resistance Action Plan requires names and dates against it before it can be approved at the next Primary Care Committee. The Primary Care Committee noted the content of the report.

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12. Medicines Management Workplan Update:

Mark Pilling introduced this item and accompanying report which provides the Committee with an update on progress of the Medicines Management Workplan 2016-17. Mark noted that there is local evidence of medicines waste within care homes. He advised that a Standards Operating Procedure (SOP) has been produced for dissemination and the Committee is being asked to approve this SOP. Mark explained that work is moving forward in relation to the improvement of current systems for third party ordering of repeat prescriptions. Both he and Dr Benbow have discussed the plans with the Local Pharmaceutical Committee (LPC) and the CCG is now developing a plan to review third party ordering on a practice level. Current planned work includes drafting the themes and objectives for the prescribing element of the PCQP. The Medicines Management Sub-Committee is asked to propose and consider areas and targets for inclusion in the draft PCQP which will come to the Primary Care Committee for approval. Helen Meredith asked how the SOP implementation will be monitored. Mark explained this will be implemented collaboratively with the Council; there is no firm timeline at present. Dianne noted that the Section 75 Partnership Board is currently looking at improving care within care homes. The Primary Care Committee noted the content of the report and approved the Standard Operating Procedure for dissemination.

13. Healthwatch Knowsley Primary Care Patient Feedback Report:

Paul Mavers introduced this item and accompanying report which details experiences of GP services shared by community members from Knowsley for the Quarter 3 period. There have been 116 reviews in this period which gives an average Healthwatch rating of Primary Care services as 4 out of 5 stars. Paul advised that the most common theme to receive comments on is ‘access to services’. Paul explained that following on from a focused piece of work around accessing primary care services in Knowsley a more detailed report will be published later this month and will contain a full analysis of issues around access that patients have shared with Healthwatch. Paul informed the Committee that Healthwatch is going to be arranging visits to practice to capture comments in the waiting room to get a better age profile of views. The Primary Care Committee noted the content of the report.

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14. Workforce Sub-Group Key Issues:

The Primary Care Committee noted the content of the key issues from the Primary Care Workforce Sub-Group meetings held on 12th September 2016 and 10th October 2016.

15. Medicines Management Sub-Committee:

Dr Benbow explained that some work has gone into amending the Terms of Reference for the Sub-Committee and that herself and Mark Pilling will be meeting with Dianne to discuss these potential changes. The Primary Care Committee noted the content of the key issues from the Medicines Management Sub-Committee meeting held on 7th December 2016.

16. Quality Committee Minutes – 27th September 2016:

The Primary Care Committee received the minutes of the Quality Committee meeting held on the 27th September 2016.

17. Finance & Performance Committee Minutes – 26th October 2016:

The Primary Care Committee received the minutes of the Finance & Performance Committee meeting held on the 26th October 2016.

18. Medicines Management Sub-Committee Minutes – 5th October 2016:

The Primary Care Committee received the minutes of the Medicines Management Sub-Committee meeting held on the 5th October 2016.

19. Any Other Business

Dianne Johnson informed the Committee that Paul Melia has recently left his role as Lay Member for Patient & Public Involvement and that there are interviews taking place next week for two new Lay Members. Dianne offered her thanks to Paul as he was the Chair of this Committee.

20. Date & Time of Next Meeting:

Thursday 2nd March 2017 1:30pm

In the Boardroom, Nutgrove Villa


Date of last update

Updated by Version

23-Feb-17 Andrea Kelly 0.1

No Date of meeting Task Responsibility Deadline RAG Comments Archive Date

1 20/01/2017Draft letter to Prescot Medical Centre to advise that the list will re‐open on 28th January 2017

Clare Barrow 24/01/2017 G

2 20/01/2017Circulate the decision making process for managing applications to close practice lists

Andrea Kelly 24/01/2017 G Emailed to the Committee 23.01.17

3 20/01/2017Contact Stockbridge Village Medical Centre to offer support following CQC inspection

Mark Pilling 06/03/2017 G

4 20/01/2017Circulate the PMS+ contract specification with Dr Benbow

Neil Rotherham/Andrea

Kelly24/01/2017 G Emailed to Dr Benbow 23.01.17

5 20/01/2017Present the Health Intelligence Dashboard to the next Primary Care Committee

Craig Porter 04/05/2017 A

6 20/01/2017A formal appeals process to be developed and implemented

Clare Barrow/Neil Rotherham

01/04/2017 A

7 20/01/2017Find out what the £16,800 spend on 'Subcriptions' is

Paul Brennan 02/03/2017 G

NHSE has confirmed that the £16,800 subscription charge relates to funding provided to a Knowsley practice under the Vulnerable Practices initiative. This should not have been charged to the CCG and I have raised an invoice to NHSE since the last Primary Care Committee meeting to recover the cost.

8 20/01/2017Determine if NHSE or the CCG commissions interpretation services.

Neil Rotherham 02/03/2017 G Is the responsibility of the CCG

9 20/01/2017The Antimicrobial Resistance Action Plan requires names and dates against it before it can be approved at next PCC

Mark Pilling 02/03/2017 G On the 02.03.17 agenda.

Primary Care Committee Action Log


Report to Knowsley Clinical Commissioning Group

Primary Care Committee Date of meeting: 2nd March 2017

Report title: Primary Care Committee Risks

Report presented by: Paul Brickwood, Chief Finance Officer

Purpose of the report: To present the strategic and operational risks which are the responsibility of the Primary Care Committee for review and to consider the level of assurance which can be provided to the Governing Body.

Recommendations:

Action / Decision required

The Primary Care Committee is recommended to review the risks and associated controls, identify any further risks in relation to the work of the committee, and to consider the level of assurance which can be provided to the Governing Body.

Delegated Powers: For decision reports only

N/A

Justification for Part B agenda N/A

Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply

1. Patient centred x

2. Safe x

3. High quality x

4. Cost effective x

5. Outcome focussed

6. Closer to home

7. Affordable

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PRIMARY CARE COMMITTEE – 2nd MARCH 2017

PRIMARY CARE COMMITTEE RISKS Executive Summary All government bodies, including the NHS, are required to have processes in place to provide a full annual governance statement. The assurance framework is a key piece of evidence to support the Governing Body in reaching their conclusions on the effectiveness of their internal control systems. The committees of the Governing Body play a key role in this process through their oversight of committee risks, holding Executive Leads to account, and providing assurance to the Governing Body. This report identifies the strategic, operational and programme risks from the CCG risk and assurance framework that are attributable to this Committee. It provides details of the key controls for each risk, and assurances on those controls including the role of this Committee in providing assurance, together with identified gaps in control and assurance and the actions being taken to address these. The Committee is asked to review the risks and associated controls, identify any further risks in relation to the work of the committee, and to consider the level of assurance which can be provided to the Governing Body.

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1. Purpose of the report 1.1 The purpose of the report is to present the risks which are the responsibility of the Primary

Care Committee for review and consideration of the level of assurance which can be provided to the Governing Body.

2. Background 2.1 All government bodies, including the NHS, are required to have processes in place to

provide a full annual governance statement. The assurance framework is a key piece of evidence to support the Governing Body in reaching their conclusions on the effectiveness of their internal control systems.

2.2 The committees of the Governing Body play a key role in this process through their oversight

of committee risks, holding Executive Leads to account, and providing assurance to the Governing Body.

2.3 The CCG’s Risk Management Strategy sets out the process for identifying, analysing,

evaluating, treating, monitoring and reviewing risks. Key to this is: a) The Governing Body Risk and Assurance Framework which identifies and quantifies

strategic risks within the organisation. The Framework is the means by which the Governing Body monitors and controls the risks which may impact on the organisation’s capacity to achieve its objectives;

b) The Corporate Risk Register which provides a summary of the principal risks facing the

organisation, together with the actions needed and being taken to reduce these risks to an acceptable level.

2.4 The risk and assurance framework focuses on the local plans and priorities for the current

year to maintain and improve delivery against the outcomes and standards, and is the mechanism by which the Governing Body assures itself that risks to the achievement of these are being appropriately managed. It does this by identifying the principal risks to the achievement of these objectives, the risk rating, key controls, and what assurances are planned or in place to demonstrate that the key controls are effective. Where a gap in either control or assurance is identified this, together with the corrective action and responsible person, is also included.

2.5 An overall assurance rating of significant, reasonable or limited assurance is provided for

each risk, based on the number and strength of key positive assurances which are actually in place. Where this is significant or reasonable this provides assurance to the Governing Body that the risks are being effectively managed. Where the assurance rating is limited this indicates that further attention and action is required. As the year progresses and corrective action is completed the Governing Body can expect the levels of assurance to increase.

3. Key Issues 3.1 The CCG’s Risk and Assurance Framework is structured around the CCG’s key goals and

objectives. Responsibility for each of the objectives in the framework is attributed to either the Governing Body itself or one of its Committees. There are no key objectives specifically to the Primary Care Committee but it does have responsibility for risks to objectives attributed to other committees as follows:

a) Objective 1 – Improve Health Outcomes for local people including vulnerable groups

(Finance & Performance Committee); b) Objective 3 – Ensure local people get good quality care (Quality Committee);

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c) Objective 4 – Achieve key financial duties (Finance & Performance Committee).

3.2 The level and spread of strategic risks to the delivery of the CCG’s goals and objectives which are attributable to this committee is illustrated in Appendix A. The committee should focus its attention on any risks in the top right hand area of the heat map. While risks in the top left area have significant impact they are unlikely to occur and the focus is on contingency planning to reduce the impact should they occur.

3.3 The committee’s strategic and operational risks are listed with current risk and assurance

ratings in the committee risk register at Appendix B. This is supported by detailed risk summary statements for each risk at Appendix C which list the controls and assurances in place.

3.4 There are 4 risks attributed to this committee; all of which are currently rated moderate. The

risks in relation to prescribing O9 and O20 are also monitored by the Medicines Management Committee and should be reflected in assurance provided to this Committee.

3.5 It is the role of the executive lead and operational lead for each risk to manage the risk

through the implementation and effective operation of controls and to identify and address any gaps in controls. The committee is requested to review the information contained in this report, alongside the assurances provided by reports elsewhere on the agenda, and to seek further information and assurances from executive and operational leads where required, to enable it to provide assurance to the Governing Body regarding the management of its risks.

3.6 A number of reports elsewhere on today’s agenda aim to provide assurance in relation to the

committee’s risks, as follows:

a) Personal Medical Services (PMS) Plan, Primary Care Quality Report, Primary Care Nursing Education and Training Report and Primary Care Workforce Sub-Group and Quality Committee Key Issues - in relation to risk P4;

b) Finance update - in relation to risk O20; c) Medicines Management Workplan Update, Anti-Microbial Resistance Strategy & Action

Plan and Medicines Management Sub-Committee Key Issues - in relation to risks O9 and O20;

d) Extended Access to Primary Care - in relation to risk 01. 3.7 In reviewing the information presented, the committee should consider:

a) Are the controls relevant and appropriate to the risk described and do they cover the full scope of the risk?

b) Is there evidence that the controls are working effectively? c) What level of confidence is there in the information presented? Is it complete? Is it

current? How is it sourced? What quality assurance is in place? Have systems and processes for producing information been validated?

d) Does it provide assurance in relation to the management of the risks? 4. Implications for the CCG 4.1 A risk summary and assessment of assurance level has been completed for each of the

risks. These are subject to review and update following discussion at today’s meeting.

4.2 Initial assessment indicates that there are currently no risks where only limited assurance is available.

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5. Actions being taken by the CCG 5.1 The risk assessments identify a number of gaps in control and gaps in assurance in relation

to the risks attributable to this committee. Actions have been identified to address the gaps and these have been collated in the Action Log at appendix D.

5.2 The CCG has reviewed its risk and assurance framework for 2016/17. This is still in the

process of being embedded and further work is underway to:

a) Populate individual risk summaries in a consistent way ensuring that these are focussed on relevant and significant key controls and assurances. It is expected that this will evolve through the year as the summaries are used by executive and operational leads and by committees and any feedback would be welcome;

b) Develop roles and skills of operational leads in managing risks and of committees in oversight, scrutiny and assurance of risk management. The committee are asked to consider their training and development needs in respect of risk management;

c) Further embed risk management by improving linkages between the assurance framework and Governing Body and committee reporting.

6. Summary 6.1 The report presents the risks which are the responsibility of the Primary Care Committee.

The Committee is asked to review the risks and associated controls, identify any further risks in relation to the work of the committee, and to consider the level of assurance which can be provided to the Governing Body.

Managerial Lead – Paul Brickwood, Chief Finance Officer

Signatory details: Dawn Boyer, [email protected], 0151 244 4127

Appendices:

A – Heat Map B – Risk Register C – Risk Summary Forms x 4 D – Action Log

Page 5 of 17

mailto:[email protected]

Appendix 1 - Primary Care Committee - March 2017Heat Map - ALL

1 Rare 2 Unlikely 3 Possible 4 Likely 5 Almost certain

5 Catastrophic

4 Major O1

3 Moderate P4 O20

2 Minor O9

1 Negligible

Likelihood

Co

nse

qu

ence

Page 6 of 17

Risk and Assurance Framework 2016/17 Primary Care Risk Register – March 2017

1

Appendix 2

Risk No Committee Risk Description Risk Type

Timescale

Current Risk

Rating (L & C)

Change Executive Lead Assurance

Rating Change

Date Reviewed

GOAL 1: To commission high quality services to meet the needs of the patients and the requirements of the NHS Constitution

Key Objective 1: Improve health outcomes for all local people

O1 Primary Care

Lack of access to clinical systems/information results in service withdrawal by providers of GP additional capacity and extended hours.

Operational Medium 2x4 = 8 ► Craig Porter Reasonable ► 08/02/17

P4 Primary Care

Failure to deliver Primary Care Programme Programme Long Term 2x3 = 6

►

Dianne Johnson Reasonable ► 02/02/17

Key Objective 3: Ensure local people get good quality care

O9 Primary Care Risk of patient harm arising from unsafe prescribing practice Operational Immediate 4x2 = 8 ► Dianne Johnson Reasonable ► 03/02/17

GOAL 2: Ensure effective and efficient governance of the CCG

Key Objective 4: Achieve key financial duties

O20 Primary Care

Financial pressures arising from failure to stay within agreed Prescribing Budget Operational Medium 3x3 = 9 ► Dianne Johnson Reasonable ► 06/02/17

Page 7 of 17

Appendix C – Risk Summaries

Moderate and Low Risks

Page 8 of 17

Risk Summary Risk Context and Description

Risk ID O1 Date Raised

01/04/16 Committee Primary Care

Strategic / Operational

Operational Executive Lead

Craig Porter

Primary Risk Appetite Theme

Transformation Operational Lead

Alex Robertson

Goal and Objective

GOAL 1: To commission high quality services to meet the needs of the patients and the requirements of the NHS Constitution Key Objective 1: Improve health outcomes for all local people

Risk Description and Cause - Source of risk - Event & nature –

affecting nature of source - Effect on organisation

Lack of access to clinical systems/information results in service withdrawal by providers of GP additional capacity and extended hours.

Mitigation Strategy

Controls in place

Policies – Processes – Telephone transfer / referral, analyse requirements, appraise technical options Plans – Project plan Contracts – Information Sharing Agreement, NHS Contract Reporting – Steering Group, F&P workplan updates

Gaps in controls

Decision yet to be made on preferred technical option

Timescale Medium Term Risk Appetite

Open Mitigation Strategy

Contingency plan

Action to address

Revised specification and options for EMIS to be operationalised awaiting outcome of consultation discussions

Who Alex Robertson

When 31 January 2017

Risk Rating Likelihood Consequence 1 Rare 2 Unlikely 3 Possible 4 Likely 5 Almost certain

5 Catastrophic 5 10 15 20 25

4 Major 4 8 Current 12 16 20

3 Moderate 3 6 9 12 15

2 Minor 2 4 6 8 10

1 Negligible 1 2 3 4 5

Page 9 of 17

Assurance

Planned assurances on controls To include scope, frequency & source

Internal Contract management meetings? Highlight reports to fortnightly workplan steering group Workplan progress reports to F&P Committee External

Evidence of assurance To include scope, date, source and rating

Internal Highlight reports to fortnightly workplan steering group April to Sept (Reasonable) Workplan progress reports to F&P Committee 29/6 & 4/8 (Reasonable) External

Gaps in assurance

Action to address

Who When

Progress and Review Date Commentary

To include review of controls, assurances and action plan, update of risk and assurance rating

Assurance Rating

21/10/16 Interim process established for telephone transfer from practices to UC24. Information sharing agreement presented to LMC and agreed subject to clarification on system & methodology. Discussion and presentation of EMIS options for shared appointments and recording / sharing of consultations.

Reasonable

29/12/16 New specification in draft form for consultation which includes option to introduce EMIS to current and any future provider Reasonable

08/02/17 Current specification in draft form (awaiting sign off) which includes option to introduce EMIS to current and any future provider Reasonable

Page 10 of 17


Risk ID O9 Date Raised




Dianne Johnson


Quality Operational Lead

Mark Pilling

Goal and Objective

GOAL 1: To commission high quality services to meet the needs of the patients and the requirements of the NHS Constitution Key Objective 3: Ensure local people get good quality care

Risk Description and Cause - Source, effect and impact

on organisation

Risk of patient harm arising from unsafe prescribing practice

Mitigation Strategy

Controls in place

Policies – Good practice guidance on systems in practice, deferred script policy for antibiotics, controlled drugs policy Processes – Shared care and interface work including prescribing for Transgender and non-binary adults. Work on HCAI and AMR, Controlled drugs audit, Audit of drug monitoring and repeat prescribing, Incident recording, Care homes reviews Plans – Medicines Management Workplan Contracts – Primary Care Quality Premium Reporting – Feedback to practices on risk assessments, Assurance of action on safety alerts, controlled drugs assurance from practices

Gaps in controls

Improvements required to community pharmacy ordering system Specific safety alert and incident reporting to MMSC No process for sharing lessons learned from incidents and near misses

Timescale Immediate Risk Appetite

Minimal Mitigation Strategy

Reduce

Action to address

Working group to improve community pharmacy ordering system and PID to EMT Develop & document incident reporting & management process Review current MM arrangements and resource in 5BP and deploy to mitigate safety risks

Who Mark Pilling Mark Pilling Mark Pilling

When Mar 2017 31.1.2017 31.1.2017



4 Major 4 8 12 16 20

Page 11 of 17

3 Moderate 3 6 9 12 15

2 Minor 2 4 6 8 Current 10


Assurance


Internal Reports on medicines management workplan progress to Meds Mgmt Sub Committee and Primary Care Committee Receipt of medicines management sub committee minutes by Primary Care Committee External


Internal Reports on medicines management workplan progress to Meds Mgmt Sub Committee on 6/4 & 1/6 and Primary Care Committee on 3/5, 7/7, 1/9, and 3/11 (reasonable) CD assurances to EMT 28th November 2016 (reasonable) External Work with 5BP on CCG management and focussing overall MM resource for medicines safety in the community by 31st January 2017 (reasonable)

Gaps in assurance

Safety reporting to MMSC not yet commenced Safety issues in the community

Action to address

Safety reporting to MMNSC Review of 5BP medicines management contract delivery, monitoring and reporting processes

Who Mark Pilling Mark Pilling

When 28th February 2017 28th February 2017



Assurance Rating

29/9/16 Care Home medication reviews overdue – to be undertaken by MMT Pharmacists by 30.11.2016 Reasonable

18/11/16 At request of the CCG Care Home Project the number of homes to have medication reviews was increased and St Helenas added in with a revised end date of 30th November 2016). Safety reporting to MMSC not yet commenced but discussed in a meeting with Sue Benbow and Dr Adit Jain October 2016.

Reasonable

16.12.16 Meeting between SB, AJ and MP, agreed a Management of Safety Alerts, and a Management of Incidents SOP be drafted by 31st January 2017. There has since been further discussion at IGG and EMT and liaison with Chief Executive as to a final decision on what is required.

Reasonable

16/01/17 Care homes reviews pilot completed 31/12/16 Reasonable 31/01/17 Work with 5BP on CCG management and focussing overall MM resource for

medicines safety in the community, Director to Director engagement and revised review date and decision by 28th February 2017.

Reasonable

03/02/17 Safety Reporting commenced at MMSC 1.2.17. Management of Safety Alerts, and Management of Incidents. There has since been further discussion at IGG and EMT and liaison with Chief Executive as to a final decision on what is required by 28th February 2017.

Reasonable

Page 12 of 17

Risk Summary

Risk Context and Description Risk ID O20 Date

Raised 01/04/16 Committee Primary Care



Dianne Johnson


Financial Management Operational Lead

Mark Pilling

Goal and Objective

GOAL 1: To commission high quality services to meet the needs of the patients and the requirements of the NHS Constitution Key Objective 4: Achieve key financial duties

Risk Description and Cause - Source, effect and

impact on organisation

Financial pressures arising from failure to stay within agreed Prescribing Budget

Mitigation Strategy Controls in place

Policies – Prime and detailed financial policies Processes – Budget monitoring, Optimise Rx system, Recharge NHSE and LA, SIP feed reviews, Care homes reviews Plans – Medicines management work plan, Cost optimisation plan, QIPP target £1.6 m Contracts – MIAA, CCG Dietician, Repeat Prescription Coordinators Reporting – MM Dashboard to Meds Mgmt & Primary Care Committees, Receipt and dissemination of prescribing data to practices. CCG Workplan Steering Group

Gaps in controls

Improvements required to community pharmacy ordering system Public / patient awareness of medicines waste

Timescale Medium Risk Appetite


Reduce

Action to address

Working group to improve community pharmacy ordering system. Publicity and media campaign for medicines waste

Who Mark Pilling Mark Pilling

When Mar 2017 Mar 2017



4 Major 4 8 12 16 20

3 Moderate 3 6 9 Current 12 15

2 Minor 2 4 6 8 10


Page 13 of 17

Assurance


Internal Reports on medicines management workplan progress to Meds Mgmt Sub Committee and Primary Care Committee Receipt of medicines management sub committee minutes by Primary Care Committee Finance reports to F&P Committee and Governing Body Medicines Management Strategic Plan approval by Primary Care Committee External MIAA audit of prescribing


Internal Reports on medicines management workplan progress to Meds Mgmt Sub Committee on 6/4 & 1/6 and Primary Care Committee on 3/5, 7/7 1/9 and 3/11 (reasonable) Report on waste reduction project to Meds Mgmt Sub Committee on 6/4 (reasonable) Presentation on SIP feeds review to Meds Mgmt Sub Committee on 1/6 (reasonable) Finance reports to F&P Committee on 2/4 & 24/8 and Governing Body on 7/4, 2/6, 4/8 & 26/10 (reasonable) Draft Medicines Management Strategic Plan approved for engagement and implementation by Primary Care Committee on 1/9 (reasonable) External

Gaps in assurance

Action to address

Who When



Assurance Rating

29/9/16 CSU medicines waste publicity campaign underway PID to EMT on community pharmacy ordering and £100k increase to QIPP target.

Reasonable

18/11/16 At request of the CCG Care Home Project the number of homes to have medication reviews was increased and St Helenas added in with a revised end date of 30th November 2016). Current monitoring indicates that the projected overspend is static but still within overall budget when the reserve is added back in.

Reasonable

21/12/16 Assurances have been received from CSU around delivery and a meeting to discuss public messages and materials design agreed for early January. The latest financial reports show an improved position with forecast expenditure reducing by £180K. St Helena’s reviews coming to an end by 31st December 2016. MM Strategic Plan Report Update on the agenda of MMSC 1.2.2016. PID for Third Party Ordering has been produced and the implementation plan drafted to be included in WorkPlan report to PCC 18.1.2016.

Reasonable

16/01/17 Care homes reviews pilot was completed on 31/12/16. Reasonable 03/02/17 Waste campaign, materials and launch timetable now available for

discussion with Chief Executive. Expenditure within overall prescribing budget – full reserve deployed, cost growth continues to reduce. Update MM Strategic Plan presented to MMSC 1.2.2017. Third Party Ordering – working in collaboration with LPC and the final draft of implementation plan to be presented to PCC – March 2017 if agreed with Chief Executive, and the plan will also be shared as draft with LMC and CCG Repeat Ordering group which has HealthWatch representation.

Reasonable

Page 14 of 17


Risk ID P4 Date Raised




Dianne Johnson


Transformation Operational Lead

Kendra Waring

Goal and Objective

GOAL 1: To commission high quality services to meet the needs of the patients and the requirements of the NHS Constitution Key Objective 1: Improve health outcomes for all local people

Risk Description and Cause - Source of risk - Event & nature –

affecting nature of source - Effect on organisation

Failure to deliver Primary Care Programme

Mitigation Strategy

Controls in place

Policies – Processes – Programme Management, Contract / Quality monitoring Plans – Operational Plan, Primary Care Programme Plan Contracts – Primary Care Quality Premium, Delegated commissioning agreement Reporting – Primary Care Committee, PCQP Assurance meetings

Gaps in controls

4 year programme plan yet to be approved Programme documentation to be developed based on plan

Timescale Long Term Risk Appetite


Monitor

Action to address

Complete development / approval of 4 year plan Develop programme documents

Who Dianne Johnson TBC

When TBC TBC



4 Major 4 8 12 16 20

3 Moderate 3 6 Current 9 12 15

2 Minor 2 4 6 8 10


Page 15 of 17

Assurance


Internal Contract / quality monitoring reports to Primary Care Committee Programme updates to Primary Care Committee PCQP assurance reporting External Internal Audit of Primary Care Quality Premium Internal Audit of delegated commissioning


Internal Regular updates provided to bi-monthly Primary Care Committee; any issues specific to practices are covered under “Part B”.

External

Gaps in assurance

PCQP 2 out of 3 of the assurance meetings have been completed, and the final one has been scheduled for March 2017.

Action to address

N/A Who Kendra Waring When Nov 2016



Assurance Rating

21/10/16 Further clarification and discussion of risks and programme plan required Reasonable 02/02/17 Primary Care Development Plan document drafted and issued to a

selection of GPs for comment. Milestones plan drafted and under review. Reasonable

Page 16 of 17

Appendix D

PRIMARY CARE COMMITTEE

RISK AND ASSURANCE ACTION LOG

Ref Task

Responsibility Deadline RAG

P4 Complete development / approval of 4 year plan

Dianne Johnson TBC A

P4 Develop programme documents TBC TBC P4 PCQP assurance meetings to be arranged for Q3 &

Q4 Kendra Waring Nov 2016 G

O9 & O20

Care home reviews pilot

Mark Pilling Nov 2016 G

O9 & O20

Working group to improve community pharmacy ordering system and PID to EMT

Mark Pilling Mar 2017 A

O9 Commence safety reporting to MMSC Mark Pilling Dec 2016 G O9 Develop & document incident reporting &

management process Mark Pilling 31st Jan 2017

A

O9 Review current MM arrangements and resource in 5BP and deploy to mitigate safety risks

Mark Pilling 31st Jan 2017 A

O20 Publicity and media campaign for medicines waste

Mark Pilling Mar 2017 A

O1 Revised specification and options for EMIS to be operationalised awaiting outcome of consultation discussions

Alex Robertson 31st Jan 2017 A

Key

Green – done

Amber – on schedule

Red – deadline passed and not done

Date of last update Updated by Version

20th February 2017 Anne-Marie Dibble/ Jacqui Johnson

0.1

Page 17 of 17



Primary Care Committee

Date of meeting: Thursday 2nd March

Report title: Primary Care Quality Report

Report presented by: Helen Meredith, Chief Nurse

Purpose of the report: To inform the Primary Care Committee of the quality and safety of primary care services.

Recommendations:


The Primary Care Committee is recommended to:

Note the content of the report

Delegated Powers:

For decision reports only

Not applicable

Justification for Part B agenda (if applicable)

Not applicable



2. Safe x

3. High quality x

4. Cost effective

5. Outcome focused x

6. Closer to home

7. Affordable

[one page only]

Page 1 of 19


PRIMARY CARE QUALITY REPORT Executive Summary This briefing is to inform the Primary Care Committee on the quality and safety of Knowsley CCG primary care services commissioned through delegated commissioning arrangements, and ensuring the quality of care for Knowsley patients.

The CCG must ensure it is regularly reviewing the quality and safety of its commissioned services, and acting upon underperformance and / or risks identified which could cause harm to patients. The CCG must ensure services are commissioned to meet the needs of patients, and are continuously looking to ensure that patients are receiving safe, quality care.

Updates are provided with regards to the development of the primary care dashboard, GP patient survey results (including variation between practices), and the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) audit.

Page 2 of 19

1. Purpose of the briefing 1.1 This briefing is to inform the Primary Care Committee on the quality & safety of Knowsley

CCG primary care services. 2. Background 2.1 The CCG, through delegated commissioning of primary care services, is responsible for

improving and monitoring the quality of primary care services in an effort to support the development of integrated out-of-hospital services, based around the needs of local people.

2.2 The means by which the Primary Care Committee assures itself of the quality and safety of

primary care services commissioned by the CCG is to produce regular quality and safety reports detailing service performance of care provided and aspects of care delivery requiring remedial action.

2.3 Quality and safety within primary care is monitored through a number of different

approaches, including the development of a primary care dashboard. 3. Key Issues 3.1 Draft Primary Care Dashboard

3.1.1 The latest version of the Primary Care Dashboard was reviewed at the previous

Primary Care Committee. This version was presented to the Clinical Management Group on 14th February. Members of the group have been asked to review the dashboard and provide feedback prior to the next CMG.

3.1.2 Further development of the dashboard will occur once this feedback has been

received. 3.2 Primary Care CQC Inspections: A further 6 CQC inspection reports have been published

since the last update, listed below:

GP Practice Date of

Inspection

CQC Inspection Rating

Are services safe?

Are services

effective?

Are services caring?

Are services

responsive to people’s

needs?

Are services well-led?

Overall rating

Bluebell Medical Centre

August 2016 (re-

inspection) Good Good Good Good

Requires Improvement

Good

Park House Medical Centre

October 2016 Good Good Good Good Good Good

Cornerways Medical Centre

October 2016 Good Good Good Good Good Good

Millbrook Medical Centre

November 2016 Good Good Good Good Good Good

Aston Healthcare

November 2016 Good Good Good Good Good Good

Stockbridge Village

November 2016

Requires Improvement

Good Good Good Requires

Improvement Requires

Improvement

Page 3 of 19

3.2.1 Comments from the Primary Care Committee on future content will be acted upon and included as part of future reporting. The aim is to produce a document to encompass all aspects of quality performance, whilst developing further mechanisms to assess care.

3.3 GP Patient Survey: The national GP Patient Survey is an England-wide survey providing

practice level data about patients’ experiences of their GP practice. The survey is undertaken over 2 separate periods each year, the survey asks patients about their experiences of their local GP practice and other local NHS services and also attempts to ascertain details about patients’ general health. The survey contains questions regarding a range of issues including the following:

a) Making appointments b) Helpfulness of staff c) Telephone access d) Waiting times e) Patients’ perception of the care received during GP and nurse appointments f) Practice opening hours

3.3.1 The survey is an opportunity for patients to have their say about how well they believe

their practice is doing at providing these services to patients. The latest results, which cover the surveys run in July to September 2015 and January to March 2016, have now been published and can be found on the GP Patient Survey website at https://gp-patient.co.uk/surveys-and-reports.

3.3.2 Although only approximately 6% of Knowsley patients received a survey between July

2015 and March 2016 the survey uses a consistent methodology developed over a number of years and the results should help practices to identify where improvements are needed. The CCG continues to fare well in comparison to the national results and levels of satisfaction have improved in a number of areas compared to the previous survey results published in January 2016. The results show increased satisfaction in the following areas:

a) The % of patients whose overall experience of their practice was good b) The % of patients who said they were able to get an appointment to see or speak

to a GP or nurse last time they tried c) The % of patients whose experience of making an appointment was good d) The % of patients having trust and confidence in their GP

3.3.3 Areas that have remained consistent but are above the national average include:

a) The % of patients who said that the receptionists at their GP practices are helpful b) The % of patients who said they would recommend their practice to someone who

had just moved to the local area

3.3.4 Areas where the CCG has seen a slight decline are:

a) The % of patients who said they found it easy to get through to someone at their practice on the phone (this has dropped by 1% but is 5% above the national average)

b) The % of patients who said they were satisfied with the hours their GP practice is open (this has dropped by 2% but is 2% above the national average)

Page 4 of 19

https://gp-patient.co.uk/surveys-and-reports

https://gp-patient.co.uk/surveys-and-reports

c) The % of patients who said they had confidence and trust in the nurse they last saw or spoke to at the practice (this has dropped by 1% and is now 6% below the national average)

3.3.5 The table below contains a selection of results for the CCG from the latest 3 surveys

compared with the national averages for each of the categories. The trend column shows where the CCG has improved, stayed the same or seen a decline.

3.3.6 What the results also show is continued variation between practices in a number of areas. These include;

a) The % of patients whose overall experience of their practice was good ranged

from 75% to 99% b) The % of patients who found it easy to get through to their practice on the phone

ranged from 51% to 96% c) The % of patients who said that the receptionists at their GP practice are helpful

ranged from 79% to 98% d) The % of patients who were able to get an appointment the last time they tried

ranged from 76% to 97% e) The % of patients whose experience of making an appointment was good ranged

from 64% to 98% f) The % of patients who were satisfied with the opening hours of their practice

ranged from 71% to 97%

3.3.7 As an example of this variation, 2 practices (Bluebell Lane Medical Centre and The MacMillan Surgery) at opposite ends of the survey results in terms of patient satisfaction are outlined below comparing the July 2016 results for these practices with the results published in January 2016.

Page 5 of 19

Bluebell Lane Medical Centre

MacMillan Surgery

3.3.8 Practice 2 remained at the top end and above the CCG and national averages in virtually all categories, although patient satisfaction had declined slightly in a number of individual areas. In contrast, Practice 1 remained at the lower end of the scale and below CCG and national averages. However, patient satisfaction increased in virtually all areas which is encouraging.

3.3.9 The CCG will be sharing the latest results with all member practices and they will be encouraged to work with their peers to share best practice.

3.4 Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) audit

3.4.1 The latest results from the DNACPR audit (covering the period August 2016 – February 2017) show a 24.5% increase (a total of 239 returns received) in audit returns from the previous period.

Page 6 of 19

3.4.2 The majority of questions reviewed in the audit relate to the quality of recording of key information, or communication with significant others or external health providers to ensure the DNACPR details are available for healthcare professionals to action.

3.4.3 The main issues are summarised below:

a) 13% of patients did not consent to share their decision with other health professionals.

b) 56.5% of DNACPR decisions were based on the fact that CPR was unlikely to be successful. 45.2% were based on the fact that while CPR may be successful, it may be followed by a length and quality of life which would not be of overall benefit to the person.

c) 38.5% (92 patients) had not been consulted/informed of the decision, but of those 92 patients, the ‘relevant other’ person had been informed and consulted on the decision.

d) 98.7% of DNACPR decisions were made by a GP. e) In 91 cases there was no evidence of the decision being discussed with the

person, and in 41 cases there was no evidence of discussion with a person’s ‘relevant other’.

f) Almost half of DNACPR decisions had not been reviewed during the period of the audit.

g) There were 5 cases where CPR had been carried out following a DNACPR decision.

3.4.4 Dr Barry (Clinical Lead for End of Life) has reviewed the audit report and made a number of recommendations for further scrutiny of the DNACPR process and its reporting.

3.4.5 The results for each question are included in Appendix 1.

4. Implications for the CCG 4.1 The CCG must continue to assess the quality and safety of primary care services and

provide assurance that services are delivering both quality and safety to Knowsley patients. 4.2 By assessing all aspects of patient care, the CCG will be able to understand services which

require improvement, and moving forward will be able to base its commissioning intentions on the quality and safety delivered by primary care services.

5. Actions being taken by the CCG 5.1 The CCG continues to develop the performance monitoring framework through which

quality and safety issues within primary care can be monitored and identified early to enable the successful implementation of remedial actions where required.

6. Summary 6.1 The primary care dashboard continues to be developed in line with feedback from GP

colleagues. Following recommendations from CMG, the dashboard will be presented at future primary care committee meetings.

6.2 4 CQC inspections have been carried out, with the majority of results classed as ‘Good’.

Page 7 of 19

6.3 GP patient survey results continue to identify variation between GP practice results,

particularly in relation to GP access measures. 6.4 DNACPR audit results are presented to the committee for review. A number of

recommendations for further scrutiny have been provided and will be followed up with the provider.

Clinical Lead – Dr Dave Stokoe, Clinical Lead – Primary Care

Managerial Lead – Helen Meredith, Chief Nurse

Signatory details: Andrew Holden, [email protected], 0151 244 3109

Background Documents:

None

Appendices:

Appendix 1: DNACPR audit report

Page 8 of 19


Appendix 1

DNACPR AUDIT RETURNS

AUGUST 2016 – FEBRUARY 2017

Aug 2014 - Jan2015

Feb 2015 - Jul2015

Aug 2015 - Jan2016

Feb 2016 - Jul2016

Aug 2016 -Feb 2017

216 207

196 192

239

DNACPR AUDIT RETURNS

Aug 2014 - Jan 2015

Feb 2015 - Jul 2015

Aug 2015 - Jan 2016

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

Page 9 of 19

DNACPR Form Questions 1 – 12

YES NO NOT RECORDED

190

2 0

238

1 0

Q1 - Is the date of DNACPR decision completed?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

YES NO NOT RECORDED

52

137

3

58

180

1

Q2 - Is the institution name completed?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

Page 10 of 19

YES NO NOT RECORDED

43

108

41 57

138

44

Q3 - Was the form completed electonically?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

YES NO NOT RECORDED

92

38

12

148

31

60

Q4 - Has the patient consented to to share this decision with other health professionals?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

1a 1b 1c

105

85

2

135

108

1

Q5 - What reason for DNACPR decision has been completed - 1a, 1b or 1c?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

Page 11 of 19

YES NO NOT ANSWERED

10

182

19

220

0

Q6 - Has more than 1 reason been ticked?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

Feb 2016 - Jul 2016 Aug 2016 - Feb 2017

104

141

1 0

Q7 - If section 1a has been ticked is there CLEAR & APPROPRIATE information regarding why the

decision has been made?

YES

NO

Page 12 of 19

YES NO NOT RECORDED

90 88

14

132

92

15

Q8 - Has the person be consulted about/informed of the decision? (1a & 1b only)

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

YES NO NOT RECORDED

94

2 11

92

0

15

Q9 - If the person has not been informed has a relevant other?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

Feb 2016 - Jul 2016 Aug 2016 - Feb 2017

192 236

0 3

Q10 - Who has made the decision?

GP

Other

Page 13 of 19

Persons Notes Questions 1 – 10

YES NO NOT RECORDED

157

34

1

194

45

0

Q11 - Is the record clearly dated & timed correctly?

Feb 2016 - Jul 2016

Aug 20016 - Feb 2017

YES NO NOT RECORDED

89 99

4

121 117

1

Q12 - Review

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

Page 14 of 19

YES NO NOT RECORDED

151

6 6

219

3 17

Q1 - Has ERISS been informed of DNACPR decision?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

YES NO NOT RECORDED

136

23 6

210

19 10

Q2 - Has OOH provider been informed?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

YES NO NOT RECORDED

168

3 0

234

1 4

Q3 - Is the decision documented in the persons notes?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

Page 15 of 19

YES NO NOT RECORDED

166

3 0

230

3 6

Q4 - Are the notes clearly dated, timed and signed?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

YES NO NOT RECORDED AUDIT NOTCOMPLETED

107

48

2 2

137

91

11

Q5 - Is there evidence of discussion with person?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

YES NO NOT ANSWERED

113

35 10

168

41 30

Q6 - Is there evidence of discussion with relevant other?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

Page 16 of 19

YES NO NOT ANSWERED

50

17 19

73

28

138

Q7 - If there is no evidence of discussion, is there evidence of why decision was not discussed with

the person? Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

YES NO NOT ANSWERED

56

11 30

99

33

107

Q9 - Where patient lacks capacity, has appropriate consultation taken place with those close to the

patient?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

YES NO NOT ANSWERED

34

72

29

67

110

62

Q8 - Is there evidence of a Mental Capacity Assessment?

Aug 2015 - Jan 2016

Aug 2016 - Feb 2017

Page 18 of 19

YES NO NOT ANSWERED

3

164

3 5

218

16

Q10 - Is there evidence since the DNACPR has been made, that CPR has been carried out?

Feb 2016 - Jul 2016

Aug 2016 - Feb 2017

Page 19 of 19




Date of meeting: 2nd March 2017

Report title: Finance Update – 2016/17 Primary Care Budgets

Report presented by: Paul Brennan, Primary Care Accountant

Purpose of the report: To provide an update on primary care budgets based on month 10 information and to identify those areas that contain the greatest degree of financial risk.

Recommendations:



Note the contents of the report.

Delegated Powers:


N/A


N/A


1. Patient centred

2. Safe

3. High quality

4. Cost effective x

5. Outcome focused

6. Closer to home

7. Affordable x

[one page only]

Page 1 of 8


FINANCE UPDATE – 2016/17 PRIMARY CARE BUDGETS

Executive Summary Nationally NHS England (NHSE) notified CCGs of their total planned allocations for 2016/17 to 2020/21 in January 2016. Included in this document was the Primary Care Medical services allocation for each of these five years. This represents the level of funding that has been made available to enable the CCG to meet the requirements of delegated primary care commissioning.

This report provides a forecast outturn position based on the devolved budgets that have previously been noted by the committee following receipt of the allocation. The estimates included in this report are based on the financial position at January 2017.

The report also details financial performance against CCG primary care budgets for both Prescribing and Local Enhanced Services.

The report indicates those budgets which contain the greatest risk and provides a summary of the key issues which may impact on the current forecast.

At Month 10, the CCG is forecasting the following full year position for each of the primary care budgets:

Devolved primary care allocation: £0.537m underspend

Prescribing: £0.169m overspend

Local Enhanced Services: £0.006m underspend

Primary care budgets will continue to be reviewed and risk-assessed in the context of the overall financial position as the year progresses, and the committee will be kept informed of any changes to the position.

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1. Purpose of the report 1.1 The purpose of this report is to inform the committee of the latest financial position based

on information at January 2017. This includes the full year forecast outturn against the delegated primary care allocation and also the prescribing and local enhanced service budgets.

1.2 The report also provides a summary of those budgets that contain the greatest degree of risk.

2. Recommendations 2.1 The Primary Care Committee is asked to note the financial position and the key risks for the

remainder of the year.

3. Background

3.1 Delegated Primary Care Allocation 3.1.1 The CCG has received a primary care allocation of £30.140m to support the

commissioning of primary medical services during 2016/17. This equates to funding equivalent to £186.00 per patient.

3.1.2 Devolved budgets have been set at practice level to enable the accurate reporting of expenditure against the allocation received.

3.1.3 Each budget has been set based on historic information inherited from NHS England (NHSE). All budgets have also been uplifted in accordance with national guidance – ‘Implementing the 2016/17 GP Contract’ – Government Gateway reference 05111.

3.2 Local Enhanced Services 3.2.1 The CCG continues to invest in Local Enhanced Services. This enables the CCG to

commission services in primary care beyond those available nationally through Direct Enhanced Services.

4. 2016/17 Forecast Outturn

4.1 Delegated Primary Care Allocation 4.1.1 Based on information available at January 2017, it is forecast that the delegated

primary care budget will generate an underspend of £0.537m. Appendix 1 provides a breakdown of the projection based on those budgets that have been devolved by contract type.

4.1.2 A total of £29.039m of the total allocation is devolved to a detailed level so that expenditure can be recorded against various budget types. This includes an analysis of expenditure by provider, contract type (GMS and PMS) and a range of recurring subjectives such as QOF, Premises and Direct Enhanced Services.

Page 3 of 8

4.1.3 Savings of £0.800m have been released non-recurrently in 2016-17 to contribute to the CCG’s QIPP plan following the re-provision of the APMS “options” contract that ceased in March 2016. It is anticipated these funds will be utilised differently in future to support primary care development on a recurrent basis.

4.1.4 NHSE set devolved primary care budgets on behalf of the CCG for 2016/17. This

included a duplication of the Fairness in Primary Care budget and also a budget for the Dementia (Case Finding) Direct Enhanced Service which is no longer required. These are the two most significant contributing factors to the current projected underspend.

4.1.5 The savings identified following the review of the Fairness in Primary Care and

Dementia budgets have had a favourable impact on the overall forecast outturn. However, the Committee should note that there are other devolved budgets, funded from the primary care allocation, that have had an adverse movement. These include:

a) GMS core contracts – after a review of the contracts at month 10 it is anticipated that there will be forecast full year overspend of £0.123m. These costs include the additional cost of Cross Lane Surgery being supported in a caretaking capacity;

b) PMS+ core contracts – it is anticipated that there will be a full year overspend of £0.151k. The majority of this being due to 2015/16 actual costs, which had been incurred in 2016/17, being higher than had been anticipated when estimates had been included in last year’s annual accounts. The forecast outturn, for both PMS+ and GMS contracts, also takes account of the latest practice weighted list sizes at January 2017.

c) Locum costs– based on expenditure at Month 10 it is now anticipated that the full year cost to the CCG of reimbursing practices for locum cover will amount to £0.102m. This is £0.068m above the annual budget and an increase of £0.053m on the previous finance report. The CCG recently approved three claims for reimbursement to support locum costs being incurred during maternity leave. Locum costs are difficult to predict and will continue to be monitored for the remainder of the year. To mitigate the risk the CCG took direct control for the management of locum reimbursement from November 2016. Previously NHSE had administered this process on behalf of the CCG.

4.1.6 The CCG has also funded a service for vulnerable and hard to reach patients from

within the existing budgets; this is a re-provision of the ‘Options’ contract. It has also been possible to support a weekend extended hours service from within the primary care allocation.

4.2 Prescribing

4.2.1 The current prescribing forecast is based upon Prescribing Monitoring Document (PMD) data to the end of November 2016.

4.2.2 The prescribing budget at Month 10 is £31.787 million. This is a reduction on the previously reported budget of £31.997 million as a result of £0.210 million being removed from the budget and taken as a QIPP achievement. The latest PMD data, to November 2016, indicated an increase in forecast spend of £141k, and this, combined with a smaller increase in the cost of dressings (which are charged directly to the CCG

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by NWOS) has resulted in an increase in full year forecast spend of £169k compared to the previous month. This is summarised at Appendix 2.

4.2.3 As the PMD forecast is now based on eight months data it can be assumed to be reasonably robust; and this figure is also consistent with PMD reports from previous months (with the exception of M9, which showed an unexpected £206k reduction in FOT, which has now moved back).

4.2.4 At Month 7 the final £0.127 million prescribing reserve was released, and the £1m prescribing reserve set aside at the beginning of the year has now been released in full. There are therefore now no remaining reserves to fund any potential increase in 2016/17 expenditure. There are still some risks associated with the prescribing forecast as this is a high value and volatile area of spend, and this area continues to be carefully monitored.

4.2.5 Work continues to implement the Medicines Management work-plan which focuses on waste and cost reduction.

4.3 Local Enhanced Services

4.3.1 The CCG commissions a number of Local Enhanced Services (LESs) from GP practices. These are: anti-coagulation, joint and muscle injections, phlebotomy, and DMARDS (rheumatology). The total budget for these services is £0.345m, and claims received to month 10 totalled £0.225m. However claims are generally at least one month in arrears, and total expenditure for the year is expected to result in an underspend of £0.006m. Appendix 2 provides a breakdown of this projection.

4.3.2 A verification exercise is currently being undertaken on a sample of LES claims; with at least one claim from every claimant practice being verified against supporting data from the practices to ensure that the services have been delivered.

4.4 Risks

4.4.1 There are a number of recurring risks that have been identified since the CCG took responsibility for delegated commissioning of primary medical services in April 2015.

4.4.2 The table below provides details of those budgets which contain the greatest degree of risk and which potentially are most likely to cause a shift in the current financial projection:

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5. Summary

5.1 Primary care budgets will continue to be reviewed and risk assessed in the context of the overall financial position as the year progresses and the committee will be kept informed of any changes to the position.

Managerial Lead – Clare Barrow, Deputy Chief Finance Officer

Contact Name: Paul Brennan, Primary Care Project Accountant, [email protected], 0151 244 4139

Background Documents: NHS England – Outcome of 2016/17 GMS Contract Negotiations. Gateway Reference 04839 NHS England – Implementing the 2016/17 GP Contract. Changes to Personal Medical Services

and Alternative Provider Medical Services. Gateway Reference 05111 NHS England – 2016/17 to 2020/21 Financial Allocations Appendices: Appendix 1 – Delegated Primary Care Budgets Appendix 2 – Medicines Management and Local Enhanced Service Budgets

Expenditure Type Risk Mitigation

PrescribingA high value and volatile area of spend which can fluctuate significantly during the year.

The CCG continues to monitor monthly expenditure based on information received

from the PPA.

Premises

CHP and NHSPS costs - the current forecast outturn contains the latest charges identified by both CHP and NHSPS. However, these are potentially subject to change.

The CCG continues to monitor the cost of GP practices occupying CHP and NHSPS buildings.

Locum costsIncrease in locum costs to support sickness,

maternity, paternity and adoption cover. The total cost to the CCG is difficult to forecast.

Since November '16 the CCG has taken responsiblity for approving the

reimbursement of locum claims. . Previously this had been the responsibility of NHSE. This

will enable more accurate and timely reporting of locum costs.

Direct Enhanced Services

Budgets have been set based on historical information and it is anticipated that activity will

increase year-on-year.

Identify any practices that commence/cease offering enhanced services and adjust the

forecast accordingly at the earliest opportunity.

QOF

Budgets have been set based on historical information. Any increase in the number of points

practices achieve would have an impact on the current forecast.

The Primary Care Contracting Team will review performance based on the information

declared by practices on the CQRS system.

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NHS KNOWSLEY CCG Appendix 1

Annual Budget Forecast Outturn VarianceContract Value 20,726,084 20,077,146 (648,938)Fairness in Primary Care 1,372,787 449,842 (922,945)GMS 4,712,923 4,850,954 138,031GMS Correction Factor 74,160 59,198 (14,962)Out of Hours 452,940 452,896 (44)PMS+ 14,113,274 14,264,256 150,982Enhanced Services 771,492 653,959 (117,533)Dementia 123,555 0 (123,555)Extended Hours 221,559 225,357 3,798LD Health Checks 57,613 48,266 (9,347)Out of Area Referrals 719 (180) (899)Rota Virus 0 2,822 2,822Unplanned Admissions 359,769 368,931 9,162Violent Patients 8,277 8,763 486GPIT 406,000 405,996 (4)GPIT 406,000 405,996 (4)Other 333,449 557,963 224,514Extended Hour - Weekend (AVS) 0 208,626 208,626Locum - Adoption/Maternity/Paternity 32,703 88,917 56,214Locum - Sickness 1,376 12,732 11,356Professional Fees 46,844 58,259 11,415Seniority 252,526 189,429 (63,097)Subscriptions 0 0 0Premises 4,538,858 4,555,223 16,365Actual Rent 53,130 44,352 (8,778)Clinical Waste 94,655 74,088 (20,567)Cost Rent 71,051 70,279 (772)Notional Rent 292,741 369,899 77,158Premises CHP/NHSPS 3,881,824 3,885,531 3,707Rates 129,344 96,879 (32,465)Water Rates 16,113 14,195 (1,918)QOF 2,262,717 2,250,997 (11,720)QOF Achievement 678,815 709,874 31,059QOF Aspiration 1,583,902 1,541,123 (42,779)Grand Total 29,038,600 28,501,284 (537,316)

DELEGATED PRIMARY CARE BUDGETS

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NHS KNOWSLEY CCG Appendix 2FINANCE REPORT - PRIMARY CARE COMMITTEE

Annual Budget Forecast Outturn VariancePrescribing 31,786,706 31,955,832 169,126Prescribing 31,786,706 31,955,832 169,126

Annual Budget Forecast Outturn VarianceLocal Enhanced Services 344,741 338,483 (6,258)Anti-Coagulation Practice Service 164,528 124,046 (40,482)Joint and Muscle Injections 10,000 87,599 77,599Phlebotomy Practice Service 65,378 57,513 (7,865)DMARDS/Rheumatology Service 104,835 69,325 (35,510)

LOCAL ENHANCED SERVICES

PRESCRIBING

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Report title: Antimicrobial Resistance (AMR) Strategy and Action Plan

Report presented by: Mark Pilling – Interim Head of Medicines Management

Purpose of the report: The updated briefing report describes the local action plans to reduce the spread of Antimicrobial Resistance and to implement sustainable good practice.

Recommendations:


The Primary Care Committee is asked to note the content of the report and approve the updated Action Plan to reduce the spread of Antimicrobial Resistance.

Delegated Powers:


N/A



2. Safe x

3. High quality x

4. Cost effective x


6. Closer to home

7. Affordable x

[one page only]

Page 1 of 14

PRIMARY CARE COMMITTEE – 2ND MARCH 2017

ANTIMICROBIAL RESISTANCE (AMR) STRATEGY AND ACTION PLAN BRIEFING REPORT

Executive Summary Antimicrobial Resistance (AMR) develops and spreads through the inappropriate and/or over-use of antimicrobial therapy and poor infection prevention control practices and poses a significant threat to global health. Work is already being undertaken internationally, nationally and locally which is contributing to the containment of AMR. The key to tackling the problem of AMR lies at the frontlines of healthcare, targeting prescribers and the public alike.

A local AMR Action Plan, sitting under the Knowsley Healthcare Associated Infections Group is being implemented using the recommendations from the Cheshire and Mersey AMR Strategy. The work and progress to date is detailed within the report with an updated RAG rated Action Plan.

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1. Purpose of the briefing 1.1 To outline the health and care implications of Antimicrobial Resistance as set out in

the UK Five Year Antimicrobial Resistance Strategy and by the Chief Medical Officer’s Annual Report (2011-13).

1.2 To describe the key issues for Knowsley and the approach being taken by Knowsley

Clinical Commissioning Group and partners to tackle antimicrobial prescribing locally and reduce the impact of antimicrobial resistance on the morbidity and mortality of the Knowsley population.

1.4 To ask the Primary Care Committee to note the content of the report and to approve

the RAG rated Action Plan. 2. Background 2.1. Antimicrobial Resistance (AMR) develops and spreads through the inappropriate

and/or over-use of antimicrobial therapy and poor infection prevention control practices. As antimicrobials continue to become ineffective, there has been a significant increase in the development of infections that cannot be treated. Examples include Carbapenemase Producing Enterobacteriaceae (CPE) and Vancomycin Resistant Enterococci (VRE), which can asymptomatically colonise the guts of individuals.

2.2 Globally, about 700,000 people die every year from drug resistant strains of common

infections, and this number is likely to be an underestimate due to poor reporting and surveillance. [The Review on Antimicrobial Resistance, Jim O’Neil (May 2016)].

2.3 The National Risk Register estimates that ‘the numbers of infections complicated by

AMR are expected to increase markedly over the next 20 years. If a widespread outbreak were to occur, we could expect around 200,000 people to be affected by a bacterial blood infection that could not be treated effectively with existing drugs, and around 80,000 of these people might die. High numbers of deaths could also be expected from other forms of antimicrobial resistant infection.’1

2.4 Work is already being undertaken internationally, nationally and locally which is

contributing to the containment of AMR. It is imperative that work is continued and driven at the local level. The key to tackling the problem of AMR lies at the frontlines of healthcare, targeting prescribers and the public alike.

3. Key Issues 3.1 Knowsley has historically experienced high levels of prescribing antibiotics when

compared locally (figure one) and the gap is not narrowing despite a focus on the issue over a number of years

3.2 Work has already commenced to address high prescribing rates which are described

later, including asking practices to audit and review their prescribing of antibiotics as part of the 2016-17 prescribing element of the CCG’s Quality premium.

1 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419549/20150331_2015-NRR-WA_Final.pdf

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3.3 A local AMR Action Plan (Appendix 1) is being implemented using the recommendations from the Cheshire and Mersey Strategy. The CCG’s Healthcare Associated Infections (HCAI) Group has received an initial draft and will identify which actions, in addition to the work already being undertaken, are best done locally. There are also actions which will be best done as part of a wider health economy, such as work with local trusts.

4. Implications for the CCG 4.1 It is important that the CCG, as a relatively high user of antibiotics across the local

health economy continues to takes appropriate actions in-line with the national AMR Strategy, and current and planned actions are described below in section 5.

4.2 AMR is also within the STP and LDS priorities, and is therefore on-going and will be a priority area for HCAI and Medicines Management Teams (MMTs), to deliver. There may be some human resource and therefore financial implications to developing this work. For example, the creation of a GP Antimicrobial Stewardship role and Community microbiologist. These roles are not envisaged to be full time (1-2 programmed activities per week each) and could be shared across CCGs potentially.

4.3 Other potential costs are the extension of Antimicrobial Pharmacists role (which is

already in place at both St Helens and Knowsley and Aintree Acute Trusts), public facing media campaigns and AMR awareness, stewardship and training across community settings which are all progressing.

4.4 STP submissions have requested additional transformational funding to support widespread education and training, community microbiological support and primary care support. If this funding is not available then there may be a need to propose funding from the CCG.

4.5 Apart from the work of the STP, the CCG and KMBC are developing their local

schemes and campaigns to promote appropriate use of antibiotics by clinical staff, and working on local campaigns, audits, peer review and training to assist with improving the public’s understanding of antimicrobial stewardship.

5. Actions being taken by the CCG 5.1 Work to address the high levels of prescribing has been a key focus for Knowsley

CCG and partners over the last eighteen months and work to date includes:

5.1.1 Antibiotic Prescribing review by the CCG’s Medicines Management Sub-Committee to review information on prescribing trends every 6 months;

5.1.2 Antibiotic prescribing is part of practice based peer view process enabling

practitioner reflection while prescribing; 5.1.3 Audits of adherence to the Pan Mersey Antibiotic Formulary across primary

and secondary care are being undertaken within the context of the Primary Care Quality Premium. The prescribing guidance includes an aim to reducing the risk of HCAI, taking into account local resistance pattern;

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5.1.4 In collaboration with KMBC, an Antimicrobial Resistance Pack including tools and advice to address overuse of antibiotics was disseminated to all prescribers in December 2015 and again in November 2016;

5.1.5 A comprehensive public and professionals facing Antibiotic Awareness Week

which took place the week commencing November 14th 2016, with a communications plan led by KMBC which included widespread distribution of public messages, promotion of the Antibiotic Guardian campaign (endeavouring to encourage pledges around self care and promotion of key messages), and practical tools to support clinical staff;

5.1.6 The Public Health England pilot awareness campaign was launched

on Monday 13th February across the Granada TV region. The Campaign Briefing Note for Healthcare Professionals is attached as Appendix 1. This was disseminated to practices and local pharmacies by the CCG and Local Pharmaceutical Committee;

5.1.7 Practices and Pharmacies should have received a campaign kit which contains posters and leaflets. In addition the briefing refers to an engagement tool for prescribers and includes:

(a) TARGET (Treat Antibiotics Responsibly = Guidance, Education, Tools) leaflet – a downloadable leaflet;

(b) Back-up prescriptions – allowing prescribers to provide a note to their patient to explain why they are not prescribing antibiotics ;

(c) The Antibiotic Guardian campaign which encourages healthcare professionals to pledge to take an action to protect against antibiotic resistance. http://antibioticguardian.com;

5.1.8 GP Practices are being encouraged to use Back-up prescriptions as well the

Target Antibiotic Toolkit and suite of educational resources to support prescriber and patient education and GP appraisals. www.rcgp.org.uk/TARGETantibiotics;

5.1.9 CCG Practice Prescribing Leads have been asked to take on Antibiotic

Stewardship at practice level and pledge to be an Antibiotic Guardian www.antibioticguardian.com/;

5.1.10 All Practices have received copies of the local Pan Mersey APC Antibiotic

Prescribing Guidelines. http://www.panmerseyapc.nhs.uk/formulary.html; 5.1.11 CCG Medicines management team have worked with practices to audit and

review the prescribing of antibiotics; 5.1.12 Adoption and monitoring of national CQUIN relating to Antimicrobial

Resistance with all local providers; 6. Summary

6.1 The development and spread of AMR poses a very high risk to the health and

wellbeing of the nation. Within the local action plan;

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http://antibioticguardian.com/

http://www.rcgp.org.uk/TARGETantibiotics

http://www.panmerseyapc.nhs.uk/formulary.html

6.2 A local AMR Action Plan, sitting under the Knowsley Healthcare Associated Infections Group is being implemented using the recommendations from the Cheshire and Mersey Strategy. The work and progress to date is detailed within the report with an updated RAG rated Action Plan.

Clinical Lead – Dr Adit Jain, Clinical Lead for Prescribing Knowsley CCG Managerial Lead – Mark Pilling, Interim Head of Medicines Management, Knowsley CCG

16th February 2017

Background Documents: None. Appendices: Appendix 1: Knowsley CCG Antimicrobial Resistance Action Plan Appendix 2: Antimicrobial Resistance (AMR) pilot Granada region campaign .

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Appendix 1 Knowsley CCG Antimicrobial Resistance Strategy Action Plan

Area for Development

(Senior Responsible Manager)

Evidence Required Progress and Evidence to date

Completed / Further

Actions (Red/ Amber Green)

Further findings/evidence from the practice- Date of

Completion

1. Ensure every Trust, Community Trust, [including non-medical prescribers] has an AMR action plan (Mark Pilling)

Obtain reassurances that every trust has an AMR action plan

Obtain reassurances that every trust has an Antimicrobial Stewardship Committee

In respect of providers the local Community Trust (5BP) undertakes and provides audits to the CCG of Antibiotic Prescribing. Antibiotic Stewardship is on the agenda of Drug and Therapeutics Committees of both local Acute Trusts with actions identified. Individual prescriber concerns at Trust level are fedback.

Local CCG’s are working with Trusts such that they have Antimicrobial Stewardship Committees. It will also be important to see that every Trust and CCG has an Antimicrobial Pharmacist and ensure that they are provided with sufficient protected time to fulfil this role. The CCGs Healthcare Acquired Infections Working (HCAI) undertakes an Antimicrobial Stewardship function

Completed - at 31.1.2017 CCG and Trusts reporting on Antibiotic Stewardship to their organisations at least three times a rear.

Continue to request prescribing data and assurances from Trusts and report these to the CCG’s Medicines Management Subcommittee at least every 4 months

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2. Implement Back-Up Prescribing for the treatment of upper respiratory tract infections Audit post implementation (read code 8BPO) (Mark Pilling)

Implement Back-Up Prescribing via Practitioner-Centred Approach or Patient-Centred Approach

Consider implementation in Accident and Emergency Departments, Walk-In Centres, Out Of Hours and with Non-Medical Practitioners.

In collaboration with KMBC, an Antimicrobial Resistance Pack including tools and advice to address overuse of antibiotics was disseminated to all prescribers along with promotion of Back-Up antibiotic prescribing information to primary care prescribers including GPs and nurses issue at the end of 2015. Audits post implementation will continue 2016-17

Consider implementation in Accident and Emergency Departments, Walk-In Centres, Out Of Hours and with Non-Medical Practitioners by 1st April 2017

Re-audit deferred prescribing of antibiotics –audit to be undertaken in each GP practice by 30.9.2017

3. Pharmacy engagement (Mark Pilling)

Ensure consistent messages are given by all prescribers and all pharmacists.

Pharmacies should support the AMR strategy as appropriate

Community Pharmacies in Knowsley have been provided with copies of the Pan Mersey APC Management of Common Infections Guidelines and advice on prescriptions for antidiarrheals in cases of C.Difficile

Completed 15.12.2016

19 local pharmacies are designated Healthy Living Pharmacies and have received accredited training in health promotion. As one of six campaigns to be run in 2017 the pharmacies will be promoting sound antibiotic usage throughout February 2017.

4. Ensure AMR awareness, stewardship and training is delivered to all prescribers, non-medical prescribers and health care workers (Mark Pilling)

Target all prescribers (medical, non-medical, pharmacists) and consider including AMR in yearly mandatory training

There are many training national resources available to

A Practice Prescribing Leads meeting with Public Health England presenting and an ‘antibiotic expert GP’ on 25th October 2016. All Practices have received copies of the local Pan Mersey APC Antibiotic Prescribing Guidelines.

AMR is part of mandatory training in local Acute Trusts.

GP Practices have been asked to

by 30.9.2017

To consider sustainability of improvement with regular reminders, MMT audit, and feedback with education. Medicines Management Subcommittee to receive reports on AMR Action Plan and practice antibiotic prescribing data by 30.9.2017

Consider session within CCG PLT

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2 http://ecdc.europa.eu/en/EAAD/Pages/Home.aspx 3 http://www.who.int/mediacentre/events/2015/world-antibiotic-awareness-week/event/en/

support training aimed to address and meet the PHE Antimicrobial prescribing and stewardship competencies

use the RCGP’s Target Antibiotic Toolkit and suite of educational resources to support prescriber and patient education and GP appraisals.

Education and updates are offered to practice nurses through practice nurse education forum.

e.g. September 2017

Non-Medical Prescribing data and reports, including use of antibiotics to be reported to Medicines Management Subcommittee at least annually

5. Support public facing media campaigns to aid and inform about Antimicrobial Resistance (Mark Pilling)

Local Authorities and CCGs should consider local engagement with any national or international AMR campaigns and plan local activities to promote the initiative

Dates where AMR can be promoted locally are:

1. European Antibiotic Awareness Day in mid-November2

2. The World Health Organisation’s World Antibiotic Awareness Week in mid-November3

A comprehensive public and professionals facing Antibiotic Awareness Week (commencing November 14th) and communications plan which included widespread distribution of public messages, promotion of the Antibiotic Guardian campaign and practical tools to support clinical staff was led by KMBC in November 2016.

Commenced 15.2.2017

Within the Granada TV region a campaign will run in February and March 2017 to target women of child bearing age (in their role in families) and older people in order to educate and address expectations of antibiotic prescribing. The pilot will be evaluated. Local communications will align with these media messages.

Consider on-going public engagement with AMR campaigns locally and nationally.

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6. Implementation of AMR and Stewardship education at the primary and secondary school level (Mark Pilling CCG) (Sarah McNulty)

It is recommended that the free ‘e-Bug’ resource produced by PHE is utilised in all schools to encourage a generational change in the attitude to the use of antibiotics

http://www.e-bug.eu/

By 30.4.2017

A collaborative approach with Public Health and KMBC to be agreed

7. Identify a dedicated Community Microbiologist function to support AMR Stewardship (Mark Pilling) (Sarah McNulty KMBC)

Ensure protected sessions are available and consider whether these can be enhanced to a more proactive and accessible clinical advisor service for GPs and other antibiotic prescribers in the community

By 30.4.2017

For review

8. Identify an Antibiotic Stewardship Lead GP (Mark Pilling)

Establish whether this role exists already

If not, consideration should be given to how this resource can be identified and secured

There is not currently an Antibiotic Stewardship GP but some of the responsibilities are within the CCG’s Clinical Lead Role for prescribing. Practice Prescribing Leads to be asked to assume Antibiotic Stewardship for their practice.


For on-going review.

9. Ensure that every secondary care trust is implementing PHE Start Smart - Then Focus toolkit (best practice recommendations) (Mark Pilling)

Obtain reassurances that every trust has implemented the tool kit, including a ward-focused antimicrobial team

There is adoption and monitoring of national CQUIN relating to Antimicrobial Resistance with all local providers. The CCG recognises that a comprehensive AMR action plan that covers primary and secondary care is crucial for assurance and on-going monitoring of local AMR activities. Local CCG’s are

Trusts to provide AMR Reports by 31.5.2017

Request 6 monthly updates report to be presented at Medicines Management SubCommittee

Page 10 of 14

http://www.e-bug.eu/

working with Trusts such that they have Antimicrobial Stewardship Committees. It will also be important to see that every Trust and CCG has an Antimicrobial Pharmacist and ensure that they are provided with sufficient protected time to fulfil this role.

10. Ensure that every GP Practice is implementing TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) (best practice recommendations) (Mark Pilling)

Obtain reassurances that every GP Practice has implemented the tool kit

GP Practices have been asked to use the RCGP’s Target Antibiotic Toolkit and suite of educational resources to support prescriber and patient education and GP appraisals.

Practices continue to audit and review their prescribing of antibiotics as part of the 2016-17 prescribing element of the CCG’s Quality premium.

CCG reporting on Antibiotic Stewardship to MMSC – 3 times per year

Continue to request prescribing data and report these to the CCG’s Medicines Management SubCommittee every 4 months.

11. Ensure every Trust and CCG has an Antimicrobial Pharmacist and ensure that they are provided with sufficient protected time to fulfil this role (Mark Pilling)

Obtain reassurances that every trust has a dedicated Antimicrobial Pharmacist

The CCG is advised that both local Trusts have at least one Antimicrobial Pharmacist with sufficient protected time to fulfil this role.


Request reports of Antimicrobial Pharmacist activity, and outcomes and assurances from Trusts and report these to the CCG’s Medicines Management SubCommittee every 6 months.

12. Ascertain assurances that community antibiotic formularies are confluent with secondary care antibiotic formularies

Primary and secondary care formularies should dovetail.

Obtain reassurances that Community

The Pan Mersey CCGs and Local Acute and community Trusts are fully committed to the Antibiotic Formulary – Pan Mersey APC – Antimicrobial Guide for Primary Care and CCGs have


Within reporting to MMSC there will be on-going review of prescribing data to confirm good adherence to confluent prescribing between CCG, Community and Hospital Trusts.

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and obtain assurances that community antibiotic formularies are used by primary care prescribers (Mark Pilling)

Antibiotic Formularies exist and include information regarding AMR

representation on secondary care decision making committees for Antibiotic choices in secondary care. CCG Audits GP and NMP prescribing, reporting to MMSC

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Campaign Briefing Note For Healthcare Professionals

Version 10.5 Last updated: 2 Feb 2017 Campaign name Antimicrobial Resistance (AMR) pilot Granada region campaign Activity dates 13 February – 7 April 2017 (TBC) Topline In February 2017 Public Health England (PHE) will be launching a pilot awareness campaign across the Granada

TV region to support national efforts to reduce inappropriate prescriptions for antibiotics. Policy objective Overuse and misuse of antibiotics is creating antibiotic resistant strains of bacteria against which only a few or

even none of our current antibiotics work. The race is on to develop new antibiotics to kill these resistant strains but, if we don’t win that race, we could face a future in which antibiotics no longer work. That could mean a return to the pre-antibiotic age, where people with compromised immune systems may not recover from common infections and deaths in childbirth or from infected wounds or pneumonia were commonplace.

The inappropriate use of antibiotics will drive antibiotic resistance which means antibiotics will become less likely to work in the future. The Government has announced an ambition to halve inappropriate prescribing of antibiotics by 2020 1

Aim, key message and evaluation

The public have little understanding of the concept of antibiotic resistance and what it means for them. The focus of this campaign will be on tackling this lack of understanding and reducing patient pressure on prescribers for antibiotics thereby, reducing inappropriate prescribing.

The key aims of the pilot are to: • Alert the public to the issue of antibiotic resistance – only using them as prescribed by their healthcare professional. • Reduce public expectation for antibiotics – i.e. encourage patients to stop asking for antibiotics

inappropriately • Support healthcare professional (HCP) change– by increasing understanding amongst patients

about why they might not be given antibiotics and by boosting awareness of/ support for alternatives to prescriptions

The public facing campaign messaging will be informed by user testing to ensure its effectiveness to change behaviours. The messaging will stress that taking antibiotics when you don’t need them means they are less likely to work for you in the future.

Pre and post campaign evaluation will aim to assess:

• Reach • Understanding of key messages • Attitudes towards antibiotics • Expectation for antibiotics • Changes in prescribing rate

Who is the campaign pilot aimed at?

The campaign is aimed at individuals most likely to use antibiotics in the Granada TV region: • Women aged 20-45 who tend to have primary responsibility for family health • Older men and women aged 50+, who have recurrent conditions and high levels of contact with GPs.2

Key facts, the issue and the importance of running a pilot campaign

• The World Health Organisation (WHO) is concerned that we are heading for a post-antibiotic era where common infections and minor injuries which have been treatable for decades can once again kill.3

• Whilst antibiotics are vital for treating many infections, there is evidence that antibiotics are being taken for viral infections such as colds or flu where they are not effective.4

• Patients have little knowledge about how long common infections usually last. • The costs of antimicrobial resistance (AMR) are enormous, both in financial terms and in lives lost and

disability years. By 2050, deaths attributable to AMR could be as high as 10 million a year alongside a reduction of 2% to 3.5% in Gross Domestic Product (GDP).5

• It is estimated it could cost the world up to 100 trillion USD by 2050.6

• Despite the severity of the problem, public understanding of the issue is low: there is not a wide understanding of the difference between viral infections (which are not treatable with antibiotics) and bacterial infections). 40% of people surveyed thought that viral infections could be treated with antibiotics (Ipsos Mori 2014). This lack of understanding may be driving negative behaviours around antibiotics, including inappropriate pressure on prescribers to prescribe them, patients not completing a full course and sharing antibiotics with others.

Why the Granada Region? • PHE is ensuring we have a well co-ordinated approach on the human health aspects of our AMR strategy

nationally and locally. PHE’s improvements to surveillance and reporting of antibiotic prescribing and resistance and the availability of data has helped to facilitate local action plans and interventions.

• In Q2 in 2016, the North West had the highest levels of antibiotics prescribed, both overall and per head in the UK – with over 1.2 million prescribed equating to 169 items per 1000 residents (15% of the total population in England).

• The highest combined GP and hospital prescribing is in Merseyside (30.4 DDD per 1,000 inhabitants).7

• An antibiotic consumption by Clinical Commissioning Group’s (CCG’s) map8 was plotted and identified the Granada TV region within the North West as being the TV region which the highest number of CCGs with

Appendix 2

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How does this campaign support other AMR work?

Other AMR public engagement to improve clinical practice and promote wider understanding of the need to reduce inappropriate prescribing9 has included:

• TARGET (Treat Antibiotics Responsibly = Guidance, Education, Tools) leaflet – a downloadable leaflet

on prescriber’s ICT system explaining when antibiotics should and should not be prescribed http://www.rcgp.org.uk/clinical-and-research/toolkits/target-antibiotics-toolkit/patient-information-leaflets.aspx

• Back-up prescriptions – allowing prescribers to provide a note to their patient to explain why they are not prescribing antibiotics https://www.nice.org.uk/guidance/ng15

• Behavioural Insights Trial – run by the team at PHE to explore whether messaging can influence patient expectation and demands for antibiotics https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/405031/Behaviour_Change_f or_Antibiotic_Prescribing_-_FINAL.pdf

• The Antibiotic Guardian campaign which encourages the public, students and educators, farmers, the veterinary and medical communities, professional organisations and healthcare professionals to pledge to take an action to protect against antibiotic resistance. http://antibioticguardian.com

• The European Antibiotic Awareness Day (EAAD) a Europe-wide initiative led by the European Centre for Disease Prevention and Control (ECDC). http://ecdc.europa.eu/en/eaad/Pages/Home.aspx

Evaluation of these efforts has shown some success and antibiotic prescribing rates are reducing, although there is variation in this across England. A key area for focus now is public engagement, as we need to reduce the

What activities

are taking

place?

A number of channels (tbc) will be used to raise awareness for the duration of the campaign these are likely to include television and radio, digital and social media. Out-of-home-advertising which will include posters at bus stops, direct mail and PR activity could take place at various times during the campaign.

Getting involved Brief colleagues and cascade information The Chief Medical Officer is supporting the launch of this campaign.

She has committed to the strengthening of resources available to support health professionals, their patients, and the public, so that everyone understands the value and importance of antibiotics, the shared responsibility for reducing AMR, and the need to protect the public and future generations. 11

Healthcare practitioners (HCPs) including GP practices, pharmacists, dentists and others with responsibility for prescribing antibiotics, or engaging with patients who are asking for antibiotics are encouraged to:

• Act by taking a look at the campaign toolkit • Circulate information to relevant colleagues • Display toolkit assets like posters, digital content and leaflets so information is accessible by patients. • Share the campaign on websites and intranets, social media and internal and external newsletters

Campaign resources The PHE marketing team will provide free campaign resources for any healthcare practitioners engaging with patients who are asking for antibiotics including (but not limited to) GP practices, pharmacists, dentists and those with responsibility for prescribing antibiotics. The resources will be delivered automatically to all GPs and community pharmacies in the Granada TV region and available to order for all other healthcare professionals. It will contain assets that partners can use to promote the message to patients. These will include leaflets, posters, briefing sheets, access to waiting rooms screens and an engagement tool for prescribers.

To be notified when the toolkit is available, and pre-order free campaign resources sign up at https://campaignresources.phe.gov.uk/resources/campaigns/58

Note: Contents of the toolkit will be confirmed over the next month. Once available, toolkit content and assets will be strictly embargoed until the official campaign launch and restricted only for use in the Granada TV region pilot area.

For queries Email: [email protected]

1 Government response to the Review on Antimicrobial Resistance, September 2016 2 Define research with 55+, mothers of young children and individuals with risk criteria (for example, regular antibiotics users or users who have previously purchased antibiotics over the counter in a foreign country); Solutions research with mothers aged 11 and under.

3 WHO factsheet, April 2015 http://www.who.int/mediacentre/factsheets/fs194/en/ 4 NHS Choices, http://www.nhs.uk/Conditions/Antibiotics-penicillins/Pages/Introduction.aspx 5 Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations - The Review on Antimicrobial Resistance Chaired by Jim O’Neill (December 2014) https://amr-review.org/ 6 Tackling drug-resistant infections globally: final report and recommendations; The Review on Antimicrobial Resistance – chaired by Jim O’Neill (May 2016) 7 https://www.gov.uk/government/news/new-report-reveals-increase-in-use-of-antibiotics-linked-to-rising-levels-of-antibiotic-resistance 8 Antibiotic consumption by the Clinical Commissioning Group’s (CCG) map https://drive.google.com/open?id=1FscuXvQR1bNJ3mmHEwRgsBN43t8&usp=sharing and https://fingertips.phe.org.uk/profile/amr-local-indicators 9 https://www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018 10 Prescribers include GPs, hospital doctors, dentists and some nurses, pharmacists, physiotherapists, optometrists, chiropodists and podiatrists 11 Annual Report of the Chief Medical Officer, Volume Two, 2011, Infections and the rise of antimicrobial resistance. Department of Health, 2011 (Published March 2013) https://www.gov.uk/government/publications/chief-medical-officer-annual-report-volume-2

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http://www.rcgp.org.uk/clinical-and-research/toolkits/target-antibiotics-toolkit/patient-information-leaflets.aspx

http://www.rcgp.org.uk/clinical-and-research/toolkits/target-antibiotics-toolkit/patient-information-leaflets.aspx

https://www.nice.org.uk/guidance/ng15

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/405031/Behaviour_Change_for_Antibiotic_Prescribing_-_FINAL.pdf




http://antibioticguardian.com/

http://ecdc.europa.eu/en/eaad/Pages/Home.aspx

https://campaignresources.phe.gov.uk/resources/campaigns/58


http://www.who.int/mediacentre/factsheets/fs194/en/

http://www.nhs.uk/Conditions/Antibiotics-penicillins/Pages/Introduction.aspx

https://amr-review.org/

https://www.gov.uk/government/news/new-report-reveals-increase-in-use-of-antibiotics-linked-to-rising-levels-of-antibiotic-resistance

https://drive.google.com/open?id=1FscuXvQR1bNJ3mmHEwRgsBN43t8&amp%3Busp=sharing

https://www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018

https://www.gov.uk/government/publications/chief-medical-officer-annual-report-volume-2





Report title: Medicines Management Work Plan Update


Purpose of the report: To provide a progress report against the Medicines Management Work Plan and issues in respect of Sodium Oxybate

Recommendations:


The Primary Care Committee is asked to note the current progress in delivering the Work and to support recommendations for an evaluation of current and future prescribing of Sodium Oxybate.

Delegated Powers:


N/A



2. Safe x

3. High quality x

4. Cost effective x


6. Closer to home

7. Affordable x

[one page only]

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PRIMARY CARE COMMITTEE – 2ND MARCH 2017

MEDICINES MANAGEMENT WORK PLAN UPDATE

Executive Summary The report describes the continued progress and impact of the Medicines Management Work Plan for 2016-17. The report also describes recent Controlled Drug and safety assurances for prescribing. The identified actions within this report continue to demonstrate that regular review with improvements to policies, systems and procedures assure that prescriptions remain appropriate, safe and clinically and cost-effective. The Committee is asked to note the good progress and quality improvements of the Work Plan for 2016-17 and to support recommendations for an evaluation of current and future prescribing of Sodium Oxybate for narcolepsy with cataplexy.

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1. Purpose of the briefing 1.1 The purpose of the report is to provide the Committee with the continued progress of the

Medicines Management Work Plan for 2016-17 quality improvements achieved and the delivery of a £1.6m QIPP target in 2016-17. The report also describes recent Controlled Drug and safety assurances.

1.2 The Committee is asked to note the impact of the Work Plan 2016-17 and progress with

Controlled Drug and safety assurances, cost-efficiency and further quality improvements achieved to date for 2016-17.

1.3 The Committee is also asked to support recommendations for an evaluation of current and

future prescribing of Sodium Oxybate for narcolepsy with cataplexy. 2. Background 2.1 The Medicines Management Work Plan 2016-17 aims to optimise the use of medicines for

maximum patient benefit and provide best value to the NHS. The Work Plan was implemented with measurable improvements to the quality of prescribing, reduced medicines waste and increased prescribing efficiency.

2.2 There is a continuous programme of work to review and address prescribing safety issues,

improve prescribing quality and reduce avoidable medicines waste. The MMT ensures practices have safe and effective systems for prescribing. The Medicines Management Sub-Committee receives regular reports on the management of medicines safety, Controlled Drug Prescribing and clinical and cost effectiveness.

2.3 Specific cost pressures on prescribing continue to arise from our ageing population, new

treatments and recommendations from specialists for GPs to commence treatment and participate in shared care of specialist and often expensive medication.

3. Key Issues 3.1 The MMT Work Plan requires continuous safety and quality audits conducted in all

practices with additional input into practices requiring assistance. The report also describes the actions being undertaken to achieve financial balance for prescribing.

3.2 Practice specific waste medicine reductions are continuing in 2016-17 with estimated

avoidable waste believed to be in excess of £1.5M per year. A public engagement exercise has identified patients concerns about the volume of medicines at home that they did not request.

3.3 There continues to be issues with regards to inappropriate ordering of repeat medications

on behalf of patients by third parties including community pharmacies. There are proposed actions in respect of commercial third party ordering described in section 4 to be undertaken within pilot practices to determine impact should the pilot be rolled out and undertaken at scale.

3.4 Medicines Management Sub-Committee received the quarterly Controlled Drugs Report in

February 2017. Prescribing data, ePact, shows that there is a concern with some prescriber’s understanding of buprenorphine patches and the number of days each patch application should be applied by the patients. Different brands and strengths of buprenorphine patches have different durations of applications which are either 3, 4 or 7 days. In Knowsley a high proportion of buprenorphine patches are prescribed at a quantity equating to changing the patch every 3 days; however the majority of what is prescribed is

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to change patches every 4 or 7 days. This equates to patients receiving more than 30 days’ supply (maximum 30 days’ supply is good practice), and therefore potentially, excessive quantities can be issued each month.

3.5 It is good practice to prescribe a maximum of 30 days’ supply of controlled drugs. Where it

is found prescribers have prescribed more than 30 days’ these have been highlighted and discussed if it’s appropriate. In some cases the decision has been made to continue with more than 30 days’ supply but measures have been taken to ensure closer monitoring to prevent possible excess supplies. In other practices, patients have had their prescribed CD quantities changed to 28 days.

3.6 Good practice in prescribing buprenorphine patches therefore was covered in the

Medicines Management Newsletter in December 2016 and at practice based meetings in November 2016.

3.7 Sodium Oxybate is as oral treatment for Narcolepsy (with Catoplexy) prescribed by

Specialists only, usually via Sleep Disorder Centres. In respect of local prescribing recommendations, Appendix 1, the Pan Mersey Area Prescribing Committee has reviewed the existing red statement and many, but not all CCGs appear to support continuation of the Red statement i.e. Specialist prescribing only. This was also discussed at Medicines Management Sub-Committee in February 2017. MMSC did not feel there was sufficient information about individual patient benefits for the current significant investment alongside further investment should more patients be prescribed Sodium Oxybate.

3.8 The prescribing cost is significant for a small number of patients and the data provided by

the Sleep Centre for the existing cohort of patients in 2015-16 Aintree recharged £61,766. For the first 6 months of 2016-17 the cost was £39,000 for 4 patients. This medication is PbR excluded and therefore additionally charged to the CCG (High Cost Drugs Budget). The CCG will be required to approve or disapprove the ’red’ recommendation which is currently under review (every 2 years). The CCG need to consider patients already receiving treatment and consider if we support the red statement. If we don’t support for the 4 existing patients the CCG would be required to look at other options e.g. prior approval by the CCG for each new patient. There may need to be more explicit criteria to be met e.g. 20 episodes of sleep in one day before commissioning and financial decision are made. The CCG will work with the local sleep experts to get more information about benefits for the existing Knowsley patients.

4. Actions taken by the CCG 4.1 The work areas highlighted in the Medicines Management Work Plan for 2016-2017 are

aligned with CCG priorities and reflected in the prescribing element of the Primary Care Quality Premium (PCQP) 2016-17. The prescribing element of the PCQP for 2016-17 recognises the influential role of Practice based Clinical Leads for Prescribing, in making improvements to prescribing quality, reducing risk of harm to patient’s from medication and reducing unnecessary prescribing expenditure.

4.2 The CCG has committed to implement a plan to improve current systems for third party

ordering of repeat prescriptions. It is envisaged that there will be a per practice policy that requires the majority of patients to order their own repeat medications direct from their GP practice. However, any patients who are currently managed by third parties and are considered to be vulnerable, will, with patient and their GP’s agreement, continue to have their regular medications ordered by a third party on their behalf. A pilot of a robust system and process will be undertaken alongside a communication plan with all stakeholders within several practices with evaluation starting in July 2017. A number of practices have registered their interest in participating in a pilot.

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4.3 Drug errors and incidents are managed in accordance with the CCG’s Incident and Near

Miss Reporting and Risk and Serious Untoward Incident Reporting Policies. Commissioned services monitor their levels of incidents and near misses and escalate any concerns to the CCG as commissioners of the service. Reporting of errors by independent contractors and in particular GP Practices are encouraged and frequently facilitated by the MMT. It is a GP practices’ responsibility to ensure MHRA alerts are acted upon. Failure to act on alerts will be highlighted to MMSC and then potentially escalated to the Chief Executive, the Primary Care Committee and the Governing Body.

4.3.1 The reporting and re-call of medicines which are known or suspected to be defective

must be carefully and promptly controlled, documented and carried out to ensure that patients are not put at risk. Whilst this responsibility lies with the person responsible e.g. in practices and Trusts the CCG will need to have assurances.

4.3.2 The CCG Medicines Management Team holds records for the implementation of

MHRA medicine and device alerts and CCG led medicines safety audits.

4.3.3 The medicines safety audits undertaken and completed and reported to all Practices in the last 18 months and the planned safety work for 2017-18 is:

(a) Table 1. Medicines safety work since May 2015 and the planned safety work

for 2017-18.

Medicines Safety and Audit work undertaken Date undertaken

High risk of abuse medication audit May-15 Repeat prescription audit May-15 Drug misuse audit (CD's) Jun-15 Sodium Valproate in pregnancy Sep-15 Red drug Audit Oct-15 Domepridone Re-audit Nov-15 Medication monitoring (high risk meds) Nov-15 Warfarin Audit (Re-audit) Mar-16 Midazolam MHRA safety check May-16 Simvastatin MHRA alert May-16 Citalopram MHRA alert May-16

Overuse of inhaled Beta-agonists December 16 and Jan- 2017

Planned Safety Work 2017-18 Implementation of Medicines Alerts on receipt, including and Pan Mersey APC recommendations for safer prescribing

Continuous

Review of Aspirin prescribed with Anticoagulants Apr-17

Jun-17 Prescribing Safety Indicators from the Kings Fund, RCGP and PINCER Trial Prescribing Safety Indicators from the Kings Fund, RCGP

Sep-17

Re audit of Oral diclofenac and other less safe Oral NSAIDs Nov-17

Re-Audit Risky drugs September to March 2017

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Audit of medicines known to cause AKI September to March 2017

Buprenorphine patches (duration of use) September to March 2017

Co-prescribing of multiple laxatives September to March 2017

Pregabalin and risk of addiction / dependence.

September to March 2017

4.4 The CCG Medicines Management Team holds records for medicines incidents reported to

the CCG e.g. by patients, clinicians, practices and Trusts. This information is held on a database that enables categorisation of the incident, actions taken, target dates for actions, evidence and timelines for the incidents, and identify whether the incident is open or closed. The incidents identified by the MMT or to the CCG in the last quarter to December 2016 are to be found in Appendix 2.

4.5 The MMT’s most frequent activity following a medicines safety incident is to support and

facilitate fact finding, the root cause analysis and to ensure that a significant event audit form is completed e.g. by the practice and ask that this can be shared with the CCG so that learning can then be shared e.g. via the MMT Newsletter. Serious Untoward Incidents (SUIs) are reported centrally to the local Commissioning Support Unit to instigate a formal process of investigation, led by the relevant CCG and for relevant learning to be shared.

4.6 Practice and Commissioned Service prescribing budgets are being set with the application

of a fair shares methodology. The weighting being used has an extra weighting for care home patients (care & nursing homes). There is a process for management both high cost drugs and expensive patients frequently influenced by secondary care initiated prescribing.

5. Evidence and Engagement 5.1 Practice Prescribing Meetings continue with target cost growth and QIPP Target shared

with and described to GP Practice Prescribing Leads in all practices. All Practices are aware of their individual QIPP targets and the challenge to achieve a cost growth target of 2.5% or less and the majority of practices are well within the target of 2.5% or less.

5.2 The Table and Chart below illustrate monthly progress for accumulative savings against

target to end of January 2016. Current delivery of £1.6M QIPP savings is therefore ahead of target and actual efficiency savings by 31st March 2017 are estimated to far exceed the £1.6M target and be close to or exceed £1.95M as illustrated in Table 1 and Chart 1.

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Table 1: Accumulated QIPP Target and Actual Accumulated Saving at 30.1.2017

Accumulative TargetAprilMayJuneJulyAugustSeptOctNovDecJanFebMar

£488,138.12£662,197.36

£20,499.52£61,498.55

£122,997.10£204,995.16£307,492.74£430,489.84

Accumulative Saving£46,215.51£109,603.99£204,211.29£337,466.40

£573,986.45£737,982.58£922,478.23

£1,897,950.69

£1,127,473.39£1,352,968.07£1,598,962.26

£860,830.67£1,063,739.11£1,271,597.87£1,500,187.28£1,688,956.36

Chart 1: Accumulated QIPP Target and Actual Accumulated Saving at (January 2017)

5.3 Prescribing cost growth at the end of December 2016 was -2.0% a significant improvement on the 4.63% in December 2015. There is a consistent downward trend in cost growth for Knowsley since November 2015.

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5.4 Prescription volume growth has decreased to 2%, slightly above the Pan Mersey CCG’s current average of 1.94% growth, with the cost per item remaining at £7.40 per item.

5.5 The OptimiseRx software, integrated within the EMIS GP Clinical system, has also

increased cost effectiveness with an actual return of £0.193 million between April and the end of December 2016, and a projected annual return on investment increasing to £0.34 million. This is greater than previously anticipated and better than the previously commissioned ScriptSwitch software.

5.6 The medicines management team are currently the planning the details for Work Plan for

2017-18 to include a comprehensive range of quality and cost improvements. The Work Plan will identify QIPP opportunities that will reduce unnecessary prescribing costs. The MMT are currently working with the community respiratory service to identify patients who need to be referred into the asthma service to have their inhaler treatments optimised. There are a significant number of patients who will benefit from inhaler review and compliance support. The MMT will be medicines management team are identifying those patients who are highest risk (i.e. no inhaled corticosteroid but more than twelve relievers in a twelve month period) and working with practices to refer these patients into the service.

5.7 The number of practices registering their interest in the pilot is increasing quickly and many

practices seem keen to participate and be involved in this pilot. The CCG will look to implement the pilot on a phased roll out to cover practices in all localities before assessing the impact of the work. It is proposed the pilot is a phased roll out to ensure that the relevant resources, i.e. the medicines management team, are available for each practice during the implementation phase to reduce the number of issues that may arise.

6. Summary 6.1 This report describes recent actions and achievement for 2016-17 following the

implementation of the Medicines Management Work Plan to achieve safe, high quality and cost-effective prescribing with the minimum of waste. The identified actions within this report continue to demonstrate that regular review will help ensure that prescriptions remain appropriate to the condition of the patient, are safe and effective.

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Clinical Lead – Dr Adit Jain Managerial Lead – Mark Pilling

Signatory details: Mark Pilling, [email protected]

Telephone: 0151 676 5604 Background Documents: None. Appendices: Appendix 1 – Pan Mersey APC – Prescribing Policy Statement – Sodium Oxybate Oral Solution Appendix 2 – Medicines Related Incidents identified in the last quarter to December 2016

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Appendix 1

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Appendix 2 - Medicines Related Incidents identified in the last quarter to December 2016 Date (recorded)

Emis No Type of Incident

Issue Action ( and if SAE/Incident form completed Y/N)

Current Status

28/11/16 Unknown Patient Record

Patient started on Apixaban (NOAC) Aug 16 and told to stop Aspirin. GP ended the course, however a few days later it was restarted by another GP (presumably from an old repeat slip) and the patient had been taking both.

The patient was then seen by secondary care Nov 16 that advised them to cease taking Aspirin, still has not been moved to past drugs, therefore I have stopped the course today.

Closed

16/11/16 Patient Record

Drug history undertaken on admission. Using summary care record- dose of Phyllocontin reported as 450mg BD. Pharmacist asked for dose to be changed from 225mg BD to 450mg BD as per SCR. Dose changed and subsequent aminophylline level when checked was 40.8. Aminophylline stopped and dose reduced to 225mg BD on discharge. Community pharmacy contacted to see if patient had any blister packs prepared. Aminophylline dose confirmed as 225mg BD. On further questioning- community pharmacy confirmed that they had been giving the patient 225mg BD in her blister pack since at least March 2015 but that the GP records had never been updated.

The surgery has already amended directions on 16-Nov-2016 to Phyllocontin 225mg MR one to be taken twice a day. I have spoken to the practice manager Angela McKenna and she is going to report Phyllocontin as significant event and get in touch with hospital regarding gerontology discharge.

Closed

11/11/16 4661 Prescription Possible medication prescribing error - patient receiving apixaban via GP and warfarin Via INR clinic

This is on-going and being investigated by KMBC Safeguarding, patient now RIP. Hospital did not advise GP to stop warfarin Community Pharmacy also issued both warfarin and NOAC. On at least one day pat had warfarin NOAC and Clexane.

Open

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Date (recorded) Emis No Type of Incident

Issue Action ( and if SAE/Incident form completed Y/N)

Current Status

27/10/16 Unknown Prescription Near Miss - Patient used to take (Amitriptyline 25mg - Take 2 at night) but was increased Jun/July to (Amitriptyline 50mg - Take ONE at night and Amitriptyline 25mg - Take ONE at night). Dr P did end the course when the new script was issued, but Dr S restarted (presumably from an old repeat slip).

I have confirmed with the patient that there is only 75mg in her blister pack and the pharmacy have not dispensed both. I then confirmed with the pharmacy, and they said they always send the script back. However they have claimed for both in Sept according to EPS tracker and again presumably would have continued to do so. I moved the old dose back into past drugs, added a consultation and informed the pharmacy that under no circumstances to give 2 scripts for 25mg without consulting us.

Closed

27/09/16 63 Patient Record

Patient has been issued both Seretide and Fostair within 2 days of each other but no documentation as to why. They are both now active on their medication list. Pt was originally switched from Seretide to Fostair in Nov 15 as per GP agreement and moved the Seretide to past drug with the note next to it that it had been switched to Fostair. Dr M re-authorised the course 23.09.16 and issued this medication at the same time as requested by C on 22.09.16. on 23.09.16 C then requested the Seretide which you then recommenced from past drug on 26.09.16.

There was no documented reason why the patient would have been issued both. GP was asked to investigate and review the patient.

Closed

12/09/16 Unknown Prescription Wrong dose of levomepromazine prescribed to patient.

Prescribing Lead advised that the GP who done it is going to write up as a Significant Event Analysis and present at the next practice meeting

Closed

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Report title: Evaluation of a Patient Group Direction for the supply of Varenicline (Champix®) tablets


Purpose of the report: The Committee is asked to note the content of the report, the positive outcomes from the evaluation and the proposal to consolidate the scheme.

Recommendations:


It is recommended that the Primary Care Committee approves the proposal to continue to fund the scheme as part of current stop smoking interventions in Knowsley

Delegated Powers:


N/A



2. Safe x

3. High quality x

4. Cost effective x


6. Closer to home

7. Affordable x

[one page only]

Page 1 of 13


EVALUATION OF A PATIENT GROUP DIRECTION FOR THE SUPPLY OF VARENICLINE (CHAMPIX ®) TABLETS

Executive Summary

In December 2014, the Cheshire and Merseyside Public Health Network (Champs) developed a Patient Group Direction (PGD) for Varenicline (Champix) to support the provision of the drug directly to clients by pharmacists with the aim of improving access for patients. A proposal to commission pharmacies in Knowsley to dispense Varenicline under Patient Group Direction as a pilot was approved by the CCG in December 2015. It was recommended the evaluation of the pilot should consider the impact of the scheme on Varenicline cost, effectiveness of the scheme in improving access to Varenicline in Knowsley and impact on quit rate. The Knowsley evaluation showed that the scheme has contributed to improving access to Varenicline and resulted in 15.2% of smokers attempting to quit using Varenicline which was higher than 14.4% in 2015/16. Nationally between 2014/15 and 2015/16 the proportion of client using Varenicline to help them quit had remained at 25%. 4-week quit rate associated with Varenicline was 66.5% which was higher than any other quit method – this was an improvement on the rate of 53% in 2015/16. The quit rate after 12-week follow up was 34.0% which was the 2nd highest after the 12-week quit rate associated with unlicensed nicotine replacement products (mainly electronic cigarettes). Compliance with stop smoking interventions, as measured by loss to follow-up (LFU) rate has also improved. The LFU rate was 6.9% compared with 15.2% in the period preceding the pilot (i.e. April 2015 to February 2016). The rate was the lowest among all the quit methods. At the inception of the pilot it was estimated the scheme would cost the CCG between £68,632.20 and £107,616.60 a year to fund Varenicline. The evidence from the evaluation suggests it would cost the CCG £33,000.00 a year to fund the Varenicline supply under the PGD if it is implemented across all pharmacies in Knowsley. It is recommended that the scheme becomes part of usual stop smoking offer.

Page 2 of 13

1. Purpose of the report 1.1 To brief the Primary Care Committee on the outcome of the Varenicline PGD Service Pilot. 1.2 To seek the Primary Care Committee approval to support funding Varenicline dispensing

under a Patient Group Direction (PGD) as part of the usual stop smoking offers in Knowsley.

2. Recommendations 2.1 Based on the positive outcomes associated with the scheme it is recommended the Primary

Care Committee approves the proposal to continue to fund the scheme as part of current stop smoking interventions in Knowsley.

3. Background 3.1 In December 2014, the Cheshire and Merseyside Public Health Network (Champs)

developed a Patient Group Direction (PGD) for Varenicline (Champix) to support the provision of the drug directly to clients by pharmacists with the aim of improving access for patients. A proposal to commission pharmacies in Knowsley to dispense Varenicline under Patient Group Direction as a 6-month pilot was approved by the Knowsley CCG in December 2015. The pilot started on 1st March 2016 but there was insufficient data to support a robust evaluation hence it was extended for another six months.

3.2 It was recommended the evaluation of the pilot should consider the impact of the scheme

on Varenicline cost, effectiveness of the scheme in improving access to Varenicline in Knowsley and impact on quit rate.

3.3 The evaluation aimed to address these recommendations to inform the decision on whether

or not to continue with the scheme as a component of the stop smoking offer and roll it out to all pharmacies in Knowsley. This report highlights the main finding from the evaluation.

4. The evaluation 4.1 The pilot

4.1.1 There are two levels of smoking cessation support in Knowsley:

(a) Intermediate Service provided by community pharmacies; (b) Specialist Service provided by City Health Care Partnership.

4.1.2 Pharmacists who were interested in providing the service signed the PGD and their respective pharmacy managers signed a service contract which set out the payment schedule and terms and conditions as contained in the Local Authority Public Health Contract. Table 1 shows the distribution of the participating pharmacies by electoral ward.

4.1.3 Participating pharmacists received referrals from stop smoking advisors for

Varenicline to be issued to clients. 4.1.4 Up to 6 packs of Varenicline were issued at fortnightly intervals over 12 weeks in line

with the PGD. Records of number packs given out were entered on the ServicePack database. Invoices were generated on monthly basis for payments to be made.

Page 3 of 13

4.1.5 The pilot started on 1st March 2016 with 16 pharmacists in 12 out of 31 Knowsley pharmacies signing up to deliver the service. Data for this report covers 1st March to 31st December 2016 except for the financial data which covered up to 31st January 2017.

4.1.6 The CCG funded the cost of Varenicline while Knowsley Council funded the service

cost. 4.1.7 Appendix 1 contains supplementary information provides further data for reference. Table 1: Distribution of participating pharmacies by electoral ward

Electoral Ward Number of pharmacies

Halewood North Ward 1

Page Moss Ward 3

Prescot North Ward 1

Roby Ward 1

St. Gabriel’s Ward 1

St. Michaels Ward 2

Stockbridge Ward 2

Whitefield Ward 1

Total 12

4.2 Cost of the scheme

4.2.1 Each pack of Varenicline cost £27.30. Pharmacies were paid a consultation fee of £10.00 for initial assessment of client and £5.00 for subsequent visits.

4.2.2 In all 368 Varenicline packs were issued by pharmacists to 159 clients over the

period costing a total of £10,046.40. The highest monthly expenditure was £1,774.50 in October 2016 while the lowest expenditure was in March 2016. The lowest figure for March was due to the slow uptake of the scheme.

4.2.3 The service cost paid by Knowsley Council over the period was £10,670.00 over the

period.

4.2.4 The total cost of the scheme of the 11-month period was £20,716.40.

4.3 4-week quit rate and compliance

4.3.1 Overall 4-week quit rate among clients using Varenicline was higher than the rate among those using any other methods. The 4-week quit rate was 66.5% among those using Varenicline (81.5% for Intermediate Service and 64.0% for Specialist Service) compared with 53.0% in 2015/16.

Page 4 of 13

4.3.2 In all, 15.2% of clients used Varenicline as the method of quit (based on completed case data submitted to Health and Social Care Information Centre) which represent an improvement from the 2015/16 rate of 14.4%. The increase could have been higher if the scheme were implemented across more pharmacies.

Table 2: Combined 4-week quit performance

Method Used For Quit Total number of clients

4-week quitters

Number lost to follow up (LFU)

4-week Quit rate

LFU rate

Champix only 188 125 13 66.5% 6.9%

Combination Licensed NRT 402 148 71 36.8% 17.7%

Licensed Medication & Unlicensed NRT

7 2 4 28.6% 57.1%

Single Licensed NRT 589 316 69 53.7% 11.7%

Support Only 474 246 39 51.9% 8.2%

Unlicensed NRT 10 6 1 60.0% 10.0%

Unknown 452 98 204 21.7% 45.1%

Total 2,122 941 401 44.3% 18.9%

4.3.3 Lost to follow-up (LFU) rate was used as an indicator for compliance with the

treatment. The LFU rate of 6.9% (18.5% for intermediate service; 5.0% for Specialist Service) compared with 15.2% in the period preceding the pilot (i.e. April 2015 to February 2016). The LFU rate associated with Varenicline use was the lowest among all the quit methods (Table 2). The improved compliance has contributed to improvement in the quit rate associated with Varenicline.

4.4 Long term abstinence

4.4.1 Overall 12-week quit rate associated with Varenicline use was the 2nd highest (34.0%) with those using unlicensed NRT (mainly electronic cigarettes) having the highest 12-week quit rate of 40.0% (Table 5).


Method Used For Quit Total number of clients

12-week quitters

LFU 12-week quit rate

LFU rate

Champix 188 64 46 34.0% 24.5%



7 1 5 14.3% 71.4%


Support Only 474 129 79 27.2% 16.7%

Unlicensed NRT 10 4 2 40.0% 20.0%

Unknown 452 17 381 3.8% 84.3%

Total 2122 416 838 19.6% 39.5%

Page 5 of 13

5. Recommendation 5.1 Based on the positive outcomes associated with the scheme it is recommended the Primary

Care Commission approves the proposal to continue funding Varenicline cost under the PGD as part of the usual stop smoking offer in Knowsley.

6. Proposals 6.1 It is proposed to embed the offer of Varenicline using a PGD into the existing stop smoking

offer and extend the scheme to all pharmacies willing to participate in it across Knowsley. 6.2 A decision to continue with the scheme would be communicated to all pharmacies and the

Local Pharmaceutical Committee. GPs were informed about the pilot and the continuation of the service and its extension to other pharmacies would be dully communicated to GPs.

6.3 The list of participating pharmacies would be updated and given to the Specialist Stop

Smoking Service provider to help them refer clients to the pharmacists. 6.4 To embed the service within the existing contractual arrangement with pharmacies the

existing service contract would be varied to include the PGD service. 7. Impact on Services to the Population 7.1 Varenicline use has been associated with higher quit rate nationally. Increasing access to

the drug would improve quit rates in Knowsley and improve the health of the population. 7.2 Tackling smoking is a key priority for many local Sustainability and Transformation Plans

(STPs). Smoking cost Knowsley economy £50.3m each year with £7.3m of the cost spent by Knowsley CCG on treating smoking-related health problems and £5.1m being spent on current and ex-smokers who require social care in later life as a result of smoking-related illnesses.1 Improving quit rate and long-term smoking abstinence would contribute toward reduction in health and social care cost.

8. Resource Implications 8.1 Financial

8.1.1 The scheme cost £10,046.40 in Varenicline cost over 11 month. Excluding expenditure in March 2016 from the total, the average monthly Varenicline cost was £977.34. Based on this average monthly spend, it would have cost £11,728.08 annually for the 12 pharmacies to continue to provide the service or £30,297.54 if it is rolled out to all 31 pharmacies in Knowsley. It was assumed that over the next 5 years demand would increase by 10%. This would increase the cost to £33,327.29 per year for all 31 pharmacies to provide Varenicline using the PGD.

8.2 Human Resources 8.2.1 None

1 ASH Ready Reckoner v5.7 (30 Jan 2017)

Page 6 of 13

8.3 Technology

8.3.1 Knowsley Council is in the process of procuring a new pharmacy database. This would support data reporting and performance monitoring.

8.4 Physical Assets

8.4.1 None 9. Risk Assessment 9.1 The potential risk to the CCG would be financial. The cost estimate used the worst-case

scenario. Due to the declining smoking prevalence nationally and locally, numbers using stop smoking services are expected to reduce further. National data shows year-on-year reduction in Varenicline prescriptions for smoking cessation.

9.2 Given the above it is unlikely the cost would exceed £33K as pharmacies with the highest

level of patronage have already signed up and not every pharmacy would be willing to provide the service.

9.3 There is a potential that smokers may attempt to move from one pharmacy to another to

obtain multiple prescriptions for Varenicline. This problem has not occurred during the pilot. However, Knowsley Public Health Department is in the process of procuring a new pharmacy database and a key requirement would be that the database has capacity to preclude multiple registrations of clients.

10. Summary 10.1 The evaluation showed that the scheme has contributed to improving access to Varenicline

and resulted in 15.2% of smokers attempting to quit using Varenicline which was higher than 14.4% in 2015/16.

10.2 4-week quit rate associated with Varenicline was 66.5% which was an improvement on the

rate of 53% in 2015/16. The quit rate after 12-week follow up was 34.0% which was the 2nd highest after the 12-week quit rate associated with unlicensed nicotine replacement products (mainly electronic cigarettes).

10.3 Compliance with stop smoking interventions, as measured by loss to follow-up (LFU) rate

has also improved. The LFU rate was 6.9% compared with 15.2% in the period preceding the pilot (i.e. April 2015 to February 2016). The rate was the lowest among all the quit methods.

10.4 At the inception of the pilot it was estimated the scheme would cost between £68,632.20

and £107,616.60 a year to supply Varenicline. The evaluation showed it would cost £33,000.00 a year if it is implemented across all pharmacies in Knowsley.

10.5 It is recommended that the Primary Care Committee approves the proposal to continue

fund the Varenicline supply under the PGD and its roll out to all pharmacies willing to provide the service in Knowsley.

Clinical Lead – Dr Adit Jain, Clinical Lead - Prescribing

Managerial Lead – Mark Pilling, Interim Head of Medicines Management

Page 7 of 13

Signatory details: Gabriel Agboado, Public Health Programme Manager, [email protected] Telephone: 0151 443 2641

Background Documents: None. Appendices: Appendix 1 – Further data in respect of the evaluation of the Varenicline (Champix ®) PGD pilot.

Page 8 of 13


Appendix 1 - Further data in respect of the evaluation of the Varenicline (Champix ®) PGD pilot Table 1: Distribution of packs received by clients

Pack Number of clients %

Pack 1 (week 1-2) 66 41.5%

Pack 2 (week 3-4) 43 27.0%

Pack 3 (week 5-6 18 11.3%

Pack 4 (week 7-8) 9 5.7%

Pack 5 (week 9-10) 12 7.5%

Pack 6 (week 11-12) 11 6.9%

Total 159 100.0%

Figure 1: Monthly spend on Varenicline

£273.00

£600.60

£1,037.40 £928.20

£1,228.50

£464.10

£846.30

£1,774.50

£1,173.90

£819.00 £900.90

£0.00

£200.00

£400.00

£600.00

£800.00

£1,000.00

£1,200.00

£1,400.00

£1,600.00

£1,800.00

£2,000.00

Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17

Page 9 of 13

Table 2: Distribution of number of Varenicline packs issued and associated cost by GP Practice

GP Practice Number of packs Total spend

Bluebell Lane Surgery 15 £409.50

Camberley Medical Centre 13 £354.90

Colby Medical Centre 8 £218.40

Dinas Lane Medical Centre 29 £791.70

Halewood Health Centre 2 £54.60

Hillside House 9 £245.70

Longview Primary Care Centre 36 £982.80

Manor Farm Primary Care Resource Centre 51 £1,392.30

North Huyton Primary Care Resource Centre 34 £928.20

Nutgrove Villa 21 £573.30

Page Moss One Stop Shop 2 £54.60

Park House Medical Centre 7 £191.10

Prescot Medical Centre 17 £464.10

Princess Drive Medical Centre 6 £163.80

St. Laurence’s Medical Centre 5 £136.50

Stockbridge Village Health Centre 42 £1,146.60

Tarbock Medical Centre 9 £245.70

The surgery 9 £245.70

Tower Hill Primary Care Resource Centre 1 £27.30

Whiston Primary Care Resource Centre 3 £81.90

Wingate Medical Centre 1 £27.30

Out of Area GP/GP Unknown 48 £1,310.40

Total 368 £10,046.40

Page 10 of 13

Table 3: Specialist Service 4-week quit performance

Quit method (specialist) Number of clients

4-week quitter

s


-week Quit rate

LFU rate

Champix only 161 103 8 64.0% 5.0%



4 1 2 25.0% 50.0%


Support Only 462 239 35 51.7% 7.6%

Unlicensed NRT 10 6 1 60.0% 10.0%

Unknown 96 37 17 38.5% 17.7%

Total 1462 671 139 45.9% 9.5%


Quit method (both) umber of clients

4-week quitters


-week Quit rate

LFU rate

Champix only 188 125 13 66.5% 6.9%



7 2 4 28.6% 57.1%


Support Only 474 246 39 51.9% 8.2%

Unlicensed NRT 10 6 1 60.0% 10.0%

Unknown 452 98 204 21.7% 45.1%

Total 2,122 941 401 44.3% 18.9%

Page 11 of 13

Table 5: Specialist Service 12-week quit performance

Method Used For Quit Total Quitters LFU 12-week quit rate

12-week LFU rate

Champix 161 48 35 29.8% 21.7%



4 1 2 25.0% 50.0%


Support Only 462 126 70 27.3% 15.2%

Unlicensed NRT 10 4 2 40.0% 20.0%

Unknown 96 17 25 17.7% 26.0%

Total 1462 307 291 21.0% 19.9%


Method Used For Quit Total Quitters LFU 12-week quit rate

12-week LFU rate

Champix 188 64 46 34.0% 24.5%



7 1 5 14.3% 71.4%


Support Only 474 129 79 27.2% 16.7%

Unlicensed NRT 10 4 2 40.0% 20.0%

Unknown 452 17 381 3.8% 84.3%

Total 2122 416 838 19.6% 39.5%

Page 12 of 13

Figure 2: Locations of participating pharmacies

Page 13 of 13




Date of meeting: 3rd March 2017

Report title: Healthwatch Knowsley Primary Care Patient Feedback Report

Report presented by: Rosemary Sowerby, Healthwatch Knowsley

Purpose of the report: To provide an overview of current levels of patient satisfaction with Primary Care Services based on feedback received via the Healthwatch Knowsley Feedback Centre.

Recommendations:



Note the content of the report.

Delegated Powers:


N/A


N/A



2. Safe x

3. High quality x

4. Cost effective


6. Closer to home x

7. Affordable

[one page only]

Service User Experience Report

Primary Care Services

February 2017

Healthwatch Knowsley Experience Report February 2017 Page 2 of 16


Contents About this report ..................................................................................................................................................4 1

Snapshot ............................................................................................................................................................5 2

Key Themes ........................................................................................................................................................6 3

Ratings ..............................................................................................................................................................7 4

Overall Tracker ....................................................................................................................................................9 5

Recommendations .............................................................................................................................................. 15 6

Healthwatch Knowsley ......................................................................................................................................... 15 7

Healthwatch Knowsley Feedback Centre .................................................................................................................... 16 8

Contact Us ....................................................................................................................................................... 16 9


About this report

This report details experiences of GP services shared by community members from Knowsley for the December 2016 – February 2017. The

comments have been collected and analysed using the Healthwatch Knowsley Feedback Centre.

All the patient experience comments are the actual words of the people who shared them and have not been changed in any way.

The report will be shared with:

NHS Knowsley CCG Primary Care Committee

And will be made available to the following if required.

Knowsley Metropolitan Borough Council

Care Quality Commission

Healthwatch England

NHS England

Service Providers


Snapshot


Key Themes


Following our Stakeholder consultation that recommended a focus on access to Primary Care

Services Healthwatch Knowsley are coming to the final stage of a focussed project on this issue.

A full detailed report will be published by the end of Quarter Four 2016-17. Therefore this

report provides an overview of the main issues that are highlighted in the reported period for

this committee and we will share the final report at the next meeting.

Ratings


Overall Tracker

GPs 06/16 07/16 08/16 09/16 10/16 11/16 12/16 01/17 02/17 03/17

Total Comments Received

Last month

Average YTD

Current Average YTD Change

Camberley Medical Centre (Aston Healthcare) 1.00 1.75 3.00 3.33 9 1.92 1.92

Cedar Cross Medical Centre 4.50 3.50 4.11 17 4.00 4.00

Colby Medical Centre (Bluebell Medical Centre) 2.33 5.00 4 2.33 3.67

Cornerways Medical Centre (North Huyton Primary Care Resource Centre) 3.83 4.26 4.00 4.14 1.50 3.00 4.00 37 3.55 3.46

Deysbrook Lane Medical Centre 5.00 2 5.00 5.00

Dinas Lane Medical Centre 4.25 3.71 4.00 3.67 4.00 3.50 5.00 29 3.93 3.86

Dovecot Health Centre 5.00 1 5.00 5.00

Dr Kinloch and Dr Moran (The Halewood Centre) 3.50 3.60 4.00 11 3.70 3.70

Dr Maassarani and Partners (Towerhill Primary Care Resource Centre) 4.50 2.90 4.00 2.00 5.00 15 3.35 3.35

Gateacre Brow Practice 3.00 1 4.35 4.35

Gresford Medical Centre (Aston Healthcare Limited) 4.50 2 4.50 4.50

Hillside House Surgery (Dr Pervez Sadiq) 4.83 3.00 5.00 4.50 10 4.33 4.33

Hunts Cross Health Centre 3.00 4.50 4 3.00 3.00


GPs 06/16 07/16 08/16 09/16 10/16 11/16 12/16 01/17 02/17 03/17


Last month

Average YTD


Knowsley Medical Centre (Aston Healthcare) 5.00 1.00 2.00 5.00 6 3.25 3.25

Long Lane Medical Centre 3.00 1 3.00 3.00

Longview Medical Centre 3.50 3.22 4.50 5.00 18 4.06 4.06

Manor Farm Road Surgery (Aston Healthcare) 3.20 2.80 3.14 1.00 2.00 4.00 3.33 37 2.43 2.69

Millbrook Medical Centre 3.63 2.63 2.00 3.00 5.00 4.00 2.50 26 3.38 3.38

Nutgrove Villa Surgery 3.00 4.50 5.00 9 3.75 3.75

Park House Medical Centre 3.00 3.75 3.00 4.25 3.00 2.00 17 3.17 3.17

Pilch Lane Surgery (Dr M Suares' Practice) 4.00 2.50 3.67 9 3.39 3.39

Prescot Medical Centre (Dr Heath) 2.83 3.29 13 3.06 3.06

Primrose Medical Practice 4.00 1.00 2 2.50 2.50

Rainford Health Centre 2.00 1 2.00 2.00

Rainhill Village Surgery 5.00 4.00 3 5.00 4.50

Roby Medical Centre 5.00 3.50 2.00 6 3.50 3.50

Rocky Lane Medical Centre 1.00 1 1.00 1.00

Roseheath Surgery 4.00 5.00 3.00 4 4.50 4.50

St John's Surgery Ltd 3.20 5 3.20 3.20

St Laurence's Medical Centre (Dr RI King's Practice) 2.75 2.33 3.00 3.00 1.00 1.00 18 2.42 2.42


GPs 06/16 07/16 08/16 09/16 10/16 11/16 12/16 01/17 02/17 03/17


Last month

Average YTD


Stockbridge Village Medical Centre (Dr P Rigby and Partners) 4.38 4.38 5.00 3.00 3.00 2.50 37 3.95 3.95

Tarbock Medical Centre 4.14 3.50 4.33 3.00 16 3.99 3.74

The Bluebell Medical Centre (Dr Peter Ayegba) 2.37 2.46 2.63 5.00 3.00 5.00 30 3.09 3.09

The Halewood Centre (Aston Healthcare) 4.00 4.00 3.00 4 4.00 4.00

The Hollies Medical Centre 4.00 5.00 5.00 4.67 13 4.67 4.67

The MacMillan Surgery (St Chads Centre) 4.50 4.50 4.33 4.50 31 4.46 4.46

The Spinney Medical Centre 4.00 5.00 2 4.50 4.50

Trentham Medical Centre (Dr VK Tewari's Practice) 3.89 3.86 4.50 11 4.08 4.08

Unknown GP 2.25 4.50 4 2.25 2.25

Urgent Care 24 (Liverpool and Knowsley NHS Out of Hours Provider) 1.00 5.00 2 1.00 3.00

Westmoreland GP Centre (Dr Alexander-White & Partners) 4.00 1 4.00 4.00

Cross Lane Surgery 3.33 2.75 3.20 29 3.09 3.09

Whiston Primary Care Resource Centre 5.00 4.00 4 4.09 5.00

Wingate Medical Centre 2.82 2.63 4.60 5.00 4.12 4.22 74 3.76 3.83

Woolton House Medical Centre 3.00 1 3.00 3.00


GPs 06/16 07/16 08/16 09/16 10/16 11/16 12/16 01/17 02/17 03/17


Last month

Average YTD


Overall 3.64 3.26 3.37 3.84 3.46 3.05 3.96 3.77

577 3.48 3.56

GPs June July August September

October

November

December January February March

Total Comments Received Last month Average YTD


Camberley Medical Centre (Aston Healthcare) 1.00 1.75 3.00 3.33 9 1.92 1.92

Cedar Cross Medical Centre 4.50 3.50 4.11 17 4.00 4.00

Colby Medical Centre (Bluebell Medical Centre) 2.33 5.00 4 2.33 3.67

Cornerways Medical Centre (North Huyton Primary Care Resource Centre) 3.83 4.26 4.00 4.14 1.50 3.00 4.00 37 3.55 3.46

Deysbrook Lane Medical Centre 5.00 2 5.00 5.00

Dinas Lane Medical Centre 4.25 3.71 4.00 3.67 4.00 3.50 5.00 29 3.93 3.86

Dovecot Health Centre 5.00 1 5.00 5.00

Dr Kinloch and Dr Moran (The Halewood Centre) 3.50 3.60 4.00 11 3.70 3.70

Dr Maassarani and Partners (Towerhill Primary Care Resource Centre) 4.50 2.90 4.00 2.00 5.00 15 3.35 3.35

Gateacre Brow Practice 3.00 1 4.35 4.35

Gresford Medical Centre (Aston Healthcare Limited) 4.50 2 4.50 4.50

Hillside House Surgery (Dr Pervez Sadiq) 4.83 3.00 5.00 4.50 10 4.33 4.33

Hunts Cross Health Centre 3.00 4.50 4 3.00 3.00

Knowsley Medical Centre (Aston Healthcare) 5.00 1.00 2.00 5.00 6 3.25 3.25


Long Lane Medical Centre 3.00 1 3.00 3.00

Longview Medical Centre 3.50 3.22 4.50 5.00 18 4.06 4.06

Manor Farm Road Surgery (Aston Healthcare) 3.20 2.80 3.14 1.00 2.00 4.00 3.33 37 2.43 2.69

Millbrook Medical Centre 3.63 2.63 2.00 3.00 5.00 4.00 2.50 26 3.38 3.38

Nutgrove Villa Surgery 3.00 4.50 5.00 9 3.75 3.75

Park House Medical Centre 3.00 3.75 3.00 4.25 3.00 2.00 17 3.17 3.17

Pilch Lane Surgery (Dr M Suares' Practice) 4.00 2.50 3.67 9 3.39 3.39

Prescot Medical Centre (Dr Heath) 2.83 3.29 13 3.06 3.06

Primrose Medical Practice 4.00 1.00 2 2.50 2.50

Rainford Health Centre 2.00 1 2.00 2.00

Rainhill Village Surgery 5.00 4.00 3 5.00 4.50

Roby Medical Centre 5.00 3.50 2.00 6 3.50 3.50

Rocky Lane Medical Centre 1.00 1 1.00 1.00

Roseheath Surgery 4.00 5.00 3.00 4 4.50 4.50

St John's Surgery Ltd 3.20 5 3.20 3.20

St Laurence's Medical Centre (Dr RI King's Practice) 2.75 2.33 3.00 3.00 1.00 1.00 18 2.42 2.42

Stockbridge Village Medical Centre (Dr P Rigby and Partners) 4.38 4.38 5.00 3.00 3.00 2.50 37 3.95 3.95

Tarbock Medical Centre 4.14 3.50 4.33 3.00 16 3.99 3.74

The Bluebell Medical Centre (Dr Peter Ayegba) 2.37 2.46 2.63 5.00 3.00 5.00 30 3.09 3.09

The Halewood Centre (Aston Healthcare) 4.00 4.00 3.00 4 4.00 4.00

The Hollies Medical Centre 4.00 5.00 5.00 4.67 13 4.67 4.67

The MacMillan Surgery (St Chads Centre) 4.50 4.50 4.33 4.50 31 4.46 4.46


The Spinney Medical Centre 4.00 5.00 2 4.50 4.50

Trentham Medical Centre (Dr VK Tewari's Practice) 3.89 3.86 4.50 11 4.08 4.08

Unknown GP 2.25 4.50 4 2.25 2.25

Urgent Care 24 (Liverpool and Knowsley NHS Out of Hours Provider) 1.00 5.00 2 1.00 3.00

Westmoreland GP Centre (Dr Alexander-White & Partners) 4.00 1 4.00 4.00

Cross Lane Surgery 3.33 2.75 3.20 29 3.09 3.09

Whiston Primary Care Resource Centre 5.00 4.00 4 4.09 5.00

Wingate Medical Centre 2.82 2.63 4.60 5.00 4.12 4.22 74 3.76 3.83

Woolton House Medical Centre 3.00 1 3.00 3.00


Recommendations

Healthwatch Knowsley will continue to work with the CCG to triangulate the patient experience that we receive provided by other sources.

Healthwatch Knowsley

What is Healthwatch?

Healthwatch is the independent consumer champion created to gather and represent the views of the public on Health and Adult Social Care. We play a part at both a local and national level to make sure that peoples experiences of Health and Adult Social Care are taken into account by both service providers and commissioners.

How do we make a difference?

We are part of, and answerable to the community

We improve local health and adult social care services through community feedback

We provide information about the care choices the community have

We talk and listen to people from every part of the community

We hold services to account for the care they provide Why do we do it?

Healthwatch Knowsley has been developed to give the people of Knowsley a stronger voice in influencing and challenging how health and adult social care services are provided within our region.

What we are responsible for

Enabling people to share their views and concerns about health and adult social care services in Knowsley

Helping build a picture of where services are doing well and where they can be improved

Providing authoritative, evidence based feedback to organisations responsible for commissioning or delivering local health and adult social care services

Working with Clinical Commissioning Groups and social care providers amongst others to help make sure that services are designed to meet local people’s needs.

Our Values


Inclusive – we put communities first, working with children, young people and adults

Influential – we are responsive, setting the agenda and making change happen

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MEDICINES MANAGEMENT SUB-COMMITTEE

KEY ISSUES

1st February 2017

Sodium Oxybate

• Sodium Oxybate is a treatment option for narcolepsy with cataplexy in adults and is initiated and prescribed by specialist commissioned sleep services.

• The Sub-Committee discussed the APC red statement in place for Sodium Oxybate. The prescribing cost is significant for a small number of patients and the data provided by the Sleep Centre is not assumed to be a good investment. The CCG need to consider 4 patients already receiving treatment and consider if the 4 existing patients require specialist review. For new patients proposed for Sodium Oxybate the CCG may be required to look at other options e.g. prior approval by the CCG for each new patient.

• It was agreed there is a need to identify costs aspects before commissioning/financial decision are made and that the CCG would work with specialists to get more information about the existing 4 patients.

Medicines Management Sub-Committee Risks

• The Sub-Committee reviewed the risks O9 and O20 which are considered to be moderate risks.

Medicines Management Strategic Plan Update

• Progress has been made against the 3 year plan with more clinical education sessions in place for Prescribing Leads, a monthly newsletter, a comprehensive programme of antibiotic stewardship, recruitment of permanent Medicines Management staff and continued development of Practice Pharmacists to undertake a clinical assurance role.

Medicines Management Work Plan Update

• The Standard Operating Procedure (SOP) for repeat prescription ordering by Care Homes in Knowsley has been produced and approved by the Primary Care Committee. The SOP will now be disseminated to Care Homes via the Council and GP Practices.

• A draft implementation plan is in progress for robust repeat ordering and prescribing systems which will be piloted in 2-3 practices and will be discussed at the next Repeat Ordering Working Group.

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• Budget setting for the next financial year is to be done this month.

• The Prescribing Element of the Quality Premium for 2017-18 will include: Prescribing Leads role, Medicines Safety, Clinical Effectiveness, Cost Effectiveness and Efficiency and Waste Reduction.

Controlled Drug Monitoring Report

• The report on controlled drug monitoring updated the Sub-Committee on any issues or common themes and is completed on a quarterly basis on the previous quarters data. Common trends/outliers are picked up and reported to prescribers and shared via newsletter and discussed at practice based meetings. There were no significant concerns for CD Prescribing.

ADHD Shared Care Framework Proposals

• The framework looks to combine adults and paediatrics as Alder Hey are still retaining patients who should have already transitioned. Knowsley GPs do not routinely prescribe ADHD medication.

• Knowsley already commission an adult ADHD service but with limited on-going capacity

for prescribing. The CCG may need to consider looking at existing commissioning arrangements to enable shared care for these patients.

Medicines Safety and Incidents Report

• The MMT undertakes a number of medicines related safety functions including: management of prescribing related incidents, implementation of MHRA alerts, periodically re-auditing previous safety alerts and share important alerts via the Medicines Management monthly newsletter. The report also identified the activities undertaken by the MMT including the review of prescribing incidents in the quarter ending December 2016.

Lead Officer – Mark Pilling, Interim Head of Medicines Management

Chair – Dr Sue Benbow, Secondary Care Doctor

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NOTES OF THE FINANCE & PERFORMANCE COMMITTEE held on Wednesday, 21st December 2016

in the Boardroom, Nutgrove Villa

Present Apology

MEMBERS Lorraine Hannon F&P Committee Chair/Lay Member –

Audit & Governance

Dianne Johnson Accountable Officer Dr Andrew Pryce CCG Chair Dr Ronnie Thong GP/Clinical Lead – Mental Health Dr Simon Perritt GP/Clinical Lead – Unplanned Care Paul Brickwood Chief Finance Officer Iain Stoddart Chief Finance Officer Clare Barrow Deputy Chief Finance Officer Ian Stewardson Director of Strategy & Performance Craig Porter Director of Commissioning & Service

Transformation

IN ATTENDANCE Ian Campbell Associate Director - Contracting Dawn Boyer Head of Governance Lorraine Frodsham Note Taker Action 1. Welcome and Introductions The Chair welcomed everyone to the meeting.

2. Apologies for Absence Apologies for absence were received from Dr Perritt, Dr Thong,

Dianne Johnson and Clare Barrow.

3. Declarations of Interest Ian Stewardson declared an interest as he is currently on

secondment to the CCG and his substantive role is as an employee of a local provider, St Helens & Knowsley Teaching Hospitals NHS Trust.

4. Minutes of the Meeting Held on 26th October 2016 Dr Pryce pointed out one small typo on page 6 of the minutes.

With this amendment the minutes were agreed as a true and accurate record.

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5. Review of Action Log/Matters Arising Paper on Shared Contracting Team – this is on the agenda.

Item closed. Front sheet on all reports on the agenda to contain section on the implications of the risk to the CCG – Dawn Boyer has advised that this is ‘work in progress’ and will be taken to the Integrated Governance Committee for approval. Item to remain on the log. Exploration of information provided on benchmarking of planned care – Ian Campbell has provided this information. Item closed. Report on IAPT Service and the intervention of the Intensive Support Team – Craig Porter will give a verbal update as part of the Contract Performance report. Item closed. Amendments to risk S9 and S10 – these had been done. Item closed.

6. Financial Performance to Month 8 Paul Brickwood said that at this moment in time, whilst there are

financial challenges and risks, the CCG is still on track to deliver the 1% planned surplus of £2.78 million whilst still retaining the 1% non-recurrent ring-fenced funds. This would in effect show as a 2% surplus in the CCG’s accounts. Significant areas of overspend are acute hospital contracts which is expected to total £0.542 million by year-end after activity reserves are applied and Continuing Health Care where the forecast year-end overspend at month 8 is £1.158 million, largely due to the national Funded Nursing Care rate increase. However, there is a forecast full-year underspend on the overall Primary Care budget of £0.619 million and the forecast underspend on Prescribing is £0.153 million at month 8. The QIPP target was revised to £12.6 million at month 6 to take account of additional pressures. At month 8 the CCG has delivered £10.8 million of the target. Paul Brickwood said that in future the CCG needs to be careful how it handles any surplus above 1% because there is no guarantee that the CCG would keep this. Dr Pryce said he was of the opinion that if a surplus of more than 1% was achieved then this was automatically credited back to the CCG in the following year but Paul Brickwood said the planning guidance did not suggest this. Discussion took place on how the CCG may lose any surplus above 1% to assist other CCGs in deficit. It was hoped that guidance issued in February would bring clarity around this issue.

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Iain Stoddart said that early indications were that in quarter 3 wider NHS finances are likely to deteriorate and the Governing Body and Finance & Performance Committee need to be minded of the local implications and to determine what approach the CCG takes regarding levels of surplus. The Finance & Performance Committee noted the content of this report.

7. Contract Performance – Month 7 Ian Campbell said that acute contracts are now past the half-way

point of the financial year and are currently overspending by £1.8 million, which equates to almost 2.3% overspend against the plan. St.Helens & Knowsley Hospitals Trust is showing a £1.288 million over performance against plan, Spire Liverpool is £259,000 over plan and the Royal Liverpool £335,000 over plan. Provider key activity which are not on track were IAPT recovery rate (currently running at 38.9% against a target of 50%), and A&E 4 hour maximum waiting times (currently 89.22% against a target of 95%) and the Category A Ambulance response times targets. Craig Porter said that in terms of IAPT recovery rate, Gail Briers had assured that the target will be hit. It appears as though the target was achieved in the last two weeks of November, just not the whole month. The CCG is, however, going to re-issue the performance notice. The Intensive Support Team has completed a piece of work and John Edwards had now drafted an action plan and a meeting is planned with the provider. The action plan will form part of the performance notice. Ian Stewardson commented that the Spire contract was a small contract so it would not take much for this to show an over-spend position. He said that pressures arising with local acute providers, particularly in Orthopaedics, may have resulted in more referrals to Spire, hence the over-performance. Paul Brickwood queried the over-performance at Liverpool Women’s and asked if this was linked to gynaecology or maternity. Ian Campbell said it actually related to births. The Chair queried when the CCG would know if failure in the targets relating to IAPT and A&E would affect payments made in relation to quality premium targets. Ian Campbell said this would be two months after the end of the financial year. Regarding ambulance performance, the Chair queried the arrangements for addressing the performance issue. Ian Campbell advised that Blackpool CCG hosted the contract with

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Liverpool CCG being the representative for the Mersey area. Iain Stoddart said the CCG can still initiate debate direct with the NW Ambulance Trust if necessary. The Chair asked if there was any more information relating to A&E waiting times. Craig Porter said he attends the Mid Mersey A&E Board and Ian Stewardson attends the North Mersey one and an event is due to be held on 9th January to look at key issues. These Boards meet monthly and there are a number of plans and workstreams in place. He said that he had recently produced a document detailing who attends which external meetings from the CCG and he agreed to share this with the Chair. The Chair queried whether there had been any impact on the suicide rates following the introduction of initiatives by Merseycare in relation to zero tolerance. Craig Porter advised that the group looking at suicide prevention was due to meet soon and would need to look at training of nurses. Ian Stewardson said that the 5BP Trust had attended a Quality Committee meeting to talk about their zero tolerance approach. Craig Porter said the vast majority of these incidents would trigger a SUI and these get looked at in terms of lessons learned etc. The Chair asked for further information on the percentage of in-patient admissions that have been gate-kept by the Assessment/Home Treatment Team and Craig Porter agreed to provide this. Action : Map of who attends which external meetings to be supplied to the Chair. Action : Information to be provided to the Chair regarding percentage of in-patient admissions that have been gate-kept by the Assessment/Home Treatment Team. The Finance & Performance Committee noted the content of this report.

CP

CP

8. Planning Update Ian Stewardson provided this verbal update and informed that the

CCG was working on the submissions which were due this week. A draft is to be submitted to NHS England on Monday and he said that in essence the CCG was expecting any activity growth to be managed within the overall STP financial envelope, consistent with wider STP assumptions. Feedback from NHS England is that our CCG has less ‘red flags’ when compared to others in Cheshire & Merseyside.

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Ian Stoddart said that drafts have been submitted through the course of the week following comments received back from NHS England. It was fair to say that the position is challenging and finely balanced to develop a plan that delivers the financial duties expected of the CCG in the context of rising demand on services. Craig Porter said that the CCG was in receipt of information on the commissioning intentions and cost pressures faced by Knowsley MBC. This was currently in draft form and out to consultation. He suggested that the CCG’s operational plan needs to take account of these issues as any decommissioning of Council services may impact on the CCG. Iain Stoddart said the CCG needs to know in which financial year the service reductions will occur. The Finance & Performance Committee noted this verbal update.

9. Shared Contracting Team Paul Brickwood explained that the reason this report had been

brought to the Committee was the delay in the Committee receiving Business Intelligence (BI) reports. The Committee had asked for an explanation and reasons for such delays. The Shared Contracting Team (SCT) which was set up in November 2015 had started to receive notices of drop-off of support from the Midlands & Lancashire Commissioning Support Unit (MLCSU), the Data Management Information Centre (DMIC) and a Knowsley CCG Performance Officer. This caused an extra burden on the SCT. Despite this unexpected increase in the SCT workload, the team managed to solve the problems they were facing. Paul Brickwood said that debate was now taking place about how far things should be brought together to work across more than one organisation and he said that nationally this had been the direction of approach. The report provided detail on the issues faced by the team and how these had been addressed. He said that one of the clear issues identified was the need to link the team into commissioning and the need for this to happen going forward. The proposal is to continue to share the team and Paul Brickwood said that would be his recommendation going forward, particularly as the two CCGs (Knowsley and St.Helens) share a Chief Finance Officer.

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Craig Porter said the commissioning team would be speaking to the contracting team as soon as possible and there was a definite need to collaborate more effectively. Iain Stoddart asked if there were still issues with the DMIC preventing the SCT having access to Knowsley CCG data. Ian Campbell said the Data Handling Agreement had resolved this problem. The BI Team could also not access Knowsley data before the sign off of this document, so this issue had also been resolved. The Finance & Performance Committee noted the content of this report.

10. Finance & Performance Committee Risks Dawn Boyer presented this report which provided details of the

risks which are the responsibility of the Committee for review and consideration regarding the level of assurance given to the Governing Body. There are 23 risks attributed to the Finance & Performance Committee, of which 2 are currently rated extreme, 7 high, 12 moderate and 2 low. The report provided details of these. Dawn Boyer said that in addition a number of reports on the agenda aim to provide assurance in relation to these risks. In terms of implications for the CCG, a risk summary and assessment of assurance level has been completed for each of the risks and initial assessment indicates four risks where only limited assurance is available and these were detailed in the report and had already been discussed previously in the meeting. The Finance & Performance Committee noted the content of this report.

11. Business Meeting Update Craig Porter said that a presentation had been given on NHS

Right Care. Commissioning Value Packs had been used at the last planning round and will need to form part of the CCG Operational Plan for 2017/19. The NHS Right Care initiative is mandatory for CCGs to take forward, with stakeholder engagement and working with providers key to moving it forward. The 5 Boroughs Partnership Trust has developed a project to transform delivery of podiatry services in order to meet the increased demand.

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Consideration was given to the establishment of a minor eye conditions service and a community eye service in Knowsley. This was agreed in principle with the business case proposal being further explored. The referral quality project has stated and training for all Practices is underway. A full multi-disciplinary team meeting has been piloted and roll-out is underway across Knowsley. A data sharing workshop is to be convened and staff engagement and consultation is to be undertaken by the 5BP Trust. The Finance & Performance Committee noted the content of this update.

12. Section 75 Operational Management Group Minutes The minutes from the meeting held on 12th October 2016 were

received by the Committee. The Finance & Performance Committee noted the content of these minutes.

13. Minutes of the Contract Review Boards

The minutes were presented to the Committee for receipt. Craig Porter asked if future minutes from the StHK Contract Review Board could show that Ian Campbell represents both Knowsley and St.Helens CCGs in his role as Associate Director Contracting. Action : Minute taker of StHK Contract Review Board to record Ian Campbell’s role as Associate Director Contracting as being for both Knowsley and St.Helens CCGs in future. The Finance & Performance Committee noted the content of these minutes.

IC

14. Date and Time of Next Meeting

21st February 2017 at 1.00 p.m. in the Boardroom, Nutgrove Vila.

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Typewritten Text


Andrea.Kelly

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Notes of the PCQP Kirkby Locality assurance meeting held on Friday 18th November 2016

at St Chad’s Health Centre

Present Apology MEMBERS

Lorraine Hannon CCG Governing Body Lay Member (Chair) Kendra Waring CCG Primary Care Programme Manager Lysa Morton Dr Maassarani & Partners Sharon Owen Dr Maassarani & Partners Pauline Darracott Dr Maassarani & Partners Dr K F Thong Macmillan Surgery Leanne McPadden Macmillan Surgery Dr S Greenlee Millbrook MC Kay Convey St Laurence’s MC Dr V K Tewari Trentham MC Bhavna Prada Trentham MC Dr J O’Donnell Wingate MC Kelly Atkins Wingate MC

In Attendance

Rob Foster CCG Project Manager – Referral Quality Neil Rotherham CCG Primary Care Quality Officer Fiona McFall CCG Meds Mgt Team Pharmacist

1 Welcome and Apologies for Absence

Lorraine welcomed everyone to the meeting and all present introduced themselves. There were no apologies.

2 Declarations of interest

All GP practice representatives present declared an interest as providers of primary care services in Knowsley. No further declarations were made.

3 Terms of Reference

Neil briefly described the changes that had been made to the TORs from 2015-16 and the TORs were agreed by all present.

4 PCQP elements discussion/feedback

General Practice Quality Standards Neil described the requirements of this element and explained that development of the quality framework was at a very early stage.

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Dr O’Donnell confirmed that a quality workshop had taken place at the CMG meeting in August, where practices were given the opportunity to express their views on what quality in general practice will look like. Further engagement between the CCG and member practices will take place in the New Year. Kendra explained that the CCG was in the process of developing a dashboard to support this area of work. Referral Quality Rob updated the group on progress to date with the Referral Quality project. One practice (Dinas Lane MC) went live on 10 Nov 16 and has piloted the system for a week. Some changes have been made as a result of the pilot (e.g. some services have been excluded) and other practices will now start to be trained and go live. A project team has been set up to implement the referral quality system and a clinical group is also being set up. This group will advise on future development of the system. Rob explained the proposed approach for the remainder of 2016/17, which will involve 2 elements:

• Engagement – the vast majority of practices will have already engaged in initial discussions at the recent PTE and will be required to engage with the project team and those providers involved in delivering the project to enable the implementation of the system in their practice.

• Utilisation – once training has taken place and practices have gone live all practice staff involved in the referral process will need to start using the system. There will be no utilisation targets as such, but the CCG will want to see a month on month increase for the rest of the financial year.

Rob reiterated that this was a proposed approach and it would be confirmed in due course. He explained that specific practice criteria and targets would be considered for 2017/18 and the clinical group would help to shape these. The system will include a triage element but this won’t be introduced until all practices have gone live. Dr O’Donnell asked about the timescale for rolling out the system across all practices. Rob confirmed that the ideal would be to have all practices live by the end of the first week in December but that all practices would need to be live by Christmas. Lorraine asked Rob to confirm what support would be available for practices and whether a dedicated e-mail address could be set up. Accenda, the system provider, will have help desk support

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available, including trainer support and there will also be support from the CCG project team, but there isn’t currently a dedicated e-mail address. This is something that could be set up though. Prescribing Fiona updated the meeting on progress towards achievement of the prescribing element. All practices are engaging via the practice-based meetings and education events. Most practices are within target for managing prescribing cost growth and there are extenuating circumstances for those who aren’t. Fiona reminded practices that there is an appeals process at the end of the year if practices fall outside the 2.5% target. The first round of audits, due in by 31 Oct 16, have been completed and a couple of themes have been identified, namely course length issues and monitoring of patients on antibiotics. All practices have changes to make as a result of the audits. Practices doing discharge medication audits will need to submit their evidence to the Meds Mgt team by 1 Dec 16. Accountable GP for Over 75s This is the 3rd year that this element has been included in the PCQP and Neil reminded practices of their contractual responsibilities for this group of patients compared to the requirements of the PCQP specification, particularly the requirement that all practices must make a reduction in non-elective activity for all patients aged 75 and over. Emergency admissions data for Q1 and Q2 had been shared prior to the meeting and practices whose admissions appear to be increasing will be requested to review the plans they have in place for managing this group of patients. If necessary, remedial plans will also be requested.

5 Any other business

There was no other business.

NEXT MEETING

Friday 20th January 2017 (12.30pm), 2nd Floor meeting room, St Chad’s Health Centre.

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Notes of the PCQP Halewood Locality assurance meeting held on Friday 25th November 2016

at Dr Kinloch’s practice, The Halewood Centre


Lorraine Hannon CCG Governing Body Lay Member (Chair) Kendra Waring CCG Primary Care Programme Manager Dr J Benton Aston Healthcare Jayne Birkett Hollies MC Dr B Moran Dr Kinloch & Partners Lysa Morton Roseheath Surgery

In Attendance

Rob Foster CCG Project Manager – Referral Quality Neil Rotherham CCG Primary Care Quality Officer Paul Gunson CCG Meds Mgt Team Senior Pharmacist


Lorraine welcomed everyone to the meeting and all present introduced themselves. There were no apologies.




Neil briefly described the changes that had been made to the TORs from 2015-16. Lorraine highlighted section 3.1 of the TORs and encouraged practices to use the meeting as an opportunity to share best practice. The TORs were agreed by all present.


General Practice Quality Standards Neil described the requirements of this element and explained that development of the quality framework was at a very early stage. A quality workshop had taken place at the CMG meeting in August, where practices were given the opportunity to express their views on what quality in general practice will look like. Further engagement between the CCG and member practices will take place in the New Year.

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Kendra explained that the CCG was in the process of developing a dashboard to support this area of work. Referral Quality Rob updated the group on progress to date with the Referral Quality project. Following the pilot at Dinas Lane MC, other practices are now starting to be trained and go live. A project team has been set up to implement the referral quality system and a clinical group is also being set up. This group will advise on future development of the system. Rob explained the proposed approach for the remainder of 2016/17, which will involve 2 elements:

• Engagement – the vast majority of practices will have already engaged in initial discussions at the recent PTE and will be required to engage with the project team and those providers involved in delivering the project to enable introduction of the system in their practice.


Rob reiterated that this was a proposed approach and it would be confirmed in due course. There will be a number of specialties excluded from the system e.g. mental health, cancer 2 week waits. Details of these will be shared with practices during their training. The system will include a triage element but this won’t be introduced until all practices have gone live. There is scope within the system for clinicians to provide free text comments if they feel that a referral should go through although it may not meet the relevant criteria. He explained that specific practice criteria and targets would be considered for 2017/18 and the clinical group would help to shape these. Robust datasets are being developed to support this. Following a request at the Kirkby meeting, setting up a dedicated e-mail address was being explored for practices to feed back queries. Contact and feedback details will be shared with all practices as part of their training. Prescribing Paul updated the meeting on progress towards achievement of the prescribing element. All practices have had the first of their practice-based meetings and most have also had their second. With regard to the education events, Paul confirmed that Roseheath and Hollies still needed to attend another of these.

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The first round of audits, due in by 31 Oct 16, have been completed and those practices doing discharge medication audits will need to submit their evidence to the Meds Mgt team by 1 Dec 16. Most of the Halewood practices have already done this. Accountable GP for Over 75s Neil explained the requirements of the PCQP specification, particularly the requirement that all practices must make a reduction in non-elective activity for all patients aged 75 and over. Emergency admissions data for Q1 and Q2 had been shared prior to the meeting and practices whose admissions appear to be increasing will be requested to review the plans they have in place for managing this group of patients. If necessary, remedial plans will also be requested. The following issues were highlighted by the practices:

• Dr Kinloch & Partners – the data suggests that the practice won’t achieve a reduction in emergency admissions, so they would rather receive no further payment for 2016/17 than have money clawed back in 2017/18. Kendra agreed to feed this back to Clare Barrow so that a decision could be made before the next payments are made in January. Action: Kendra to feed back payment issue to Clare Barrow.

• Hollies MC – Jayne reported that the community matron currently supporting Hollies MC and Dr Kinloch’s practice was moving jobs and there was no indication that she would be replaced. This will have a huge impact on this element of the PCQP for these 2 practices. Kendra agreed to discuss this with commissioning colleagues at the CCG so that it could be highlighted with 5BP.

Action: Kendra to contact CCG commissioning team re: withdrawal of community matron.

Lysa suggested that the Halewood practices could work collaboratively on this element, perhaps utilising some spare capacity within the Maassarani Group of practices’ nursing staff to implement an admission prevention team. Kendra confirmed that practices were at liberty to work together to achieve this element and suggested that they discuss it further outside the meeting. Lysa offered to share the evaluation report from a similar service that she had been involvedwith in NHS Wirral. Action: Lysa to share report from evaluation of NHS Wirral Admissions Prevention & Facilitated Discharge Service

KW KW LM

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NEXT MEETING

Friday 27th January 2017 (12.30pm), 1st Floor meeting room, The Halewood Centre.

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Notes of the PCQP West Knowsley Locality assurance meeting held on Tuesday 29th November 2016

at The Ellis Centre


Lorraine Hannon CCG Governing Body Lay Member (Chair) Kendra Waring CCG Primary Care Programme Manager Dr K Sandeep Aston Healthcare Nicola Raby Bluebell Medical Practice Sandra Kanczes-Daly Colby MC Suzanne Evans Cornerways MC Dr P Conway Dinas Lane MC Michelle Carmichael Dinas Lane MC Dr P Sadiq Hillside House Surgery Sheila Skinley Hillside House Surgery Dr S Kuruvilla Pilch Lane Surgery Dr S Choudarapu Primrose Medical Practice Dr P Rigby Dr Rigby & Partners Dr N Shah Roby MC

In Attendance

Rob Foster CCG Project Manager – Referral Quality Neil Rotherham CCG Primary Care Quality Officer Laura Robinson CCG Meds Mgt Team Pharmacist


Lorraine welcomed everyone to the meeting and all present introduced themselves. There were no apologies, although Roby MC was not represented.




Neil briefly described the changes that had been made to the TORs from 2015-16. The TORs were agreed by all present.


General Practice Quality Standards Neil described the requirements of this element and explained that

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development of the quality framework was at a very early stage. A quality workshop had taken place at the CMG meeting in August, where practices were given the opportunity to express their views on what quality in general practice will look like. Further engagement between the CCG and member practices will take place in the New Year. Kendra explained that the CCG was in the process of developing a dashboard to support this area of work. Dr Conway asked whether the framework would be agreed by the end of Mar 17 and whether practices would still receive the £1 per patient for this element if no further engagement took place. Neil confirmed that the onus was on the CCG to engage and practices could not be penalised if no further engagement took place. Referral Quality Rob updated the group on progress to date with the Referral Quality project. Following the pilot at Dinas Lane MC, other practices are now starting to be trained and go live. A project team has been set up to implement the referral quality system and a clinical group is also being set up. This group will advise on future development of the system. Rob explained the proposed approach for the remainder of 2016/17, which will involve 2 elements:



Rob reiterated that this was a proposed approach and it would be confirmed in due course. Michelle asked whether utilisation was already being recorded for those practices that have gone live. Rob confirmed that this was the case. There will be a number of specialties excluded from the system e.g. mental health, cancer 2 week waits. Details of these will be shared with practices during their training. The system will include a triage element but this won’t be introduced until all practices have gone live. There is scope within the system for clinicians to provide free text comments if they feel that a referral should go through although it may not meet the relevant criteria.

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He explained that specific practice criteria and targets would be considered for 2017/18 and the clinical group would help to shape these. Robust datasets are being developed to support this. Following a request at the Kirkby meeting, setting up a dedicated e-mail address was being explored for practices to feed back queries. Contact and feedback details will be shared with all practices as part of their training. Prescribing Laura updated the meeting on progress towards achievement of the prescribing element. All practices have had the first of their practice-based meetings and most have also had their second. With regard to the education events, Laura confirmed that Bluebell and Pilch Lane still needed to attend another of these. The first round of audits, due in by 31 Oct 16, have been completed and those practices doing discharge medication audits will need to submit their evidence to the Meds Mgt team by 1 Dec 16. Most of the West Knowsley practices have already done this. Accountable GP for Over 75s This is the 3rd year that this element has been included in the PCQP and Neil reminded practices of their contractual responsibilities for this group of patients compared to the requirements of the PCQP specification, particularly the requirement that all practices must make a reduction in non-elective activity for all patients aged 75 and over. Emergency admissions data for Q1 and Q2 had been shared prior to the meeting and practices whose admissions appear to be increasing will be requested to review the plans they have in place for managing this group of patients. If necessary, remedial plans will also be requested. Dr Conway asked if the data could be presented in graphical form to allow practices to look at trends over time. Neil agreed to request this from the CCG’s Performance team and share with practices. Action: Neil to request data in graphical form and share with practices. Discussion took place regarding factors that could affect a practice’s ability to reduce emergency admissions, such as above average numbers of care home patients and loss of community matron and district nurse support. Neil made the group aware of the request from one of the Halewood practices to have their remaining 2016/17 payments withheld as they didn’t believe that they would achieve this

NR

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element. Further information will be made available to practices before the next round of payments are due in January in case other practices wish to consider this approach. The PCQP specification includes an option for practices to appeal against their assessed payment, so practices failing to make a reduction in emergency admissions will have this option if they feel that there are reasonable grounds.


Dr Conway shared details of Dinas Lane MC’s approach to management of over 75s not resident in care home. These patients are now offered a 40 minute appointment with a GP. Even if this doesn’t result in a reduction in admissions it is addressing other needs that may have otherwise been missed. Michelle reported that the practice has created a template for recording these encounters and is happy to share it. All the fields in the template are code-able, so the practice is able to produce reports from it. Rob asked whether the practice had noticed any unexpected consequences e.g. increased prescribing costs? Dr Conway felt that it was too early to say at this stage.

NEXT MEETING

Tuesday 17th January 2017 (12.30pm), Suite 1, The Ellis Centre.

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Notes of the PCQP East Knowsley Locality assurance meeting held on Wednesday 30th November 2016

at The Ellis Centre


Sue Benbow CCG Governing Body Secondary Care Doctor (Chair)

Kendra Waring CCG Primary Care Programme Manager Dr A Hossain Aston Healthcare Dr K Kyaw Cedar Cross MC Heather Baker Cedar Cross MC Dr D Heath Cross Lane Surgery & Prescot MC Dr M Alexander Longview MC Dr R Kulandaisamy Nutgrove Villa Surgery Dr H Sukhavasi Park House MC Pam Evans Park House MC Dr N Shah Roby MC Dr R Rashid Tarbock MC Maureen Wright Tarbock MC

In Attendance

Rob Foster CCG Project Manager – Referral Quality Neil Rotherham CCG Primary Care Quality Officer Emilia Nowak CCG Meds Mgt Team Pharmacist Jenny Dickson CCG Meds Mgt Team Pharmacy Tech


Sue welcomed everyone to the meeting and all present introduced themselves. There were no apologies. Although Roby MC is part of the West Knowsley locality Dr Shah attended this meeting as she had been unable to attend the West Knowsley meeting on 29th November.




Neil briefly described the changes that had been made to the TORs from 2015-16. He highlighted section 3.1 of the TORs and encouraged practices to use the meeting as an opportunity to share best practice. The TORs were agreed by all present.

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General Practice Quality Standards Neil described the requirements of this element and explained that development of the quality framework was at a very early stage. A quality workshop had taken place at the CMG meeting in August, where practices were given the opportunity to express their views on what quality in general practice will look like. Further engagement between the CCG and member practices will take place in the New Year. Kendra explained that the CCG was in the process of developing a dashboard to support this area of work. Referral Quality Rob updated the group on progress to date with the Referral Quality project. Following the pilot at Dinas Lane MC, other practices are now starting to be trained and go live. A project team has been set up to implement the referral quality system and a clinical group is also being set up. This group will advise on future development of the system. Rob explained the proposed approach for the remainder of 2016/17, which will involve 2 elements:



Rob reiterated that this was a proposed approach and it would be confirmed in due course. Dr Heath highlighted that the CCG would not see a gradual increase in usage for her practices as all relevant staff would use the system fully as soon as it goes live. Rob confirmed that this would be fine. Dr Hossain asked whether Choose & Book would still be available as an option. Rob confirmed that Choose & Book was not being switched off, but the ideal is for everything that isn’t for an excluded speciality will go through the referral management system. Choose & Book can still be used. Rob provided details of the exclusions, which currently include

3

mental health, cancer 2 week waits, community services (not CVD, Diabetes or Respiratory) and urgent (within 48 hours) referrals. Details of exclusions will be shared with practices during their training. The system will include a triage element but this won’t be introduced until all practices have gone live. There is scope within the system for clinicians to provide free text comments if they feel that a referral should go through although it may not meet the relevant criteria. He explained that specific practice criteria and targets would be considered for 2017/18 and the clinical group would help to shape these. Robust datasets are being developed to support this. Following a request at the Kirkby meeting, setting up a dedicated e-mail address was being explored for practices to feed back queries. Contact and feedback details will be shared with all practices as part of their training. Dr Hossain requested that the CCG issues some formal correspondence to practices advising them to use the referral quality system to ensure patient safety and practice indemnity. Action: Rob to look into this. Dr Rashid raised the issue of patient information for use at the time of referral. He asked whether practices would be able to print this out rather than having to stock hard copies. Dr Heath asked whether the referral reference number could also be included in printable information. Action: Rob to confirm whether this is possible. Dr Sukhavasi asked whether the CCG-commissioned community CVD, Diabetes and Respiratory services would be the default choice for clinicians once included in the system. Rob confirmed that these services would be the first choice, but clinicians will be able to refer to another service if this is more appropriate. Prescribing Jenny updated the meeting on progress towards achievement of the prescribing element. All practices have had the first of their practice-based meetings and most have also had their second. Prescot MC and Cross Lane Surgery both have their second meetings booked in. With regard to the education events, Jenny confirmed that Nutgrove Villa Surgery still needed to attend another of these. The first round of audits, due in by 31 Oct 16, have been completed and those practices doing discharge medication audits have also submitted their evidence.

RF RF

4

Discussion took place regarding prescribing in line with Pan Mersey guidance. Emilia advised practices to follow the guidance where possible and to record any reasons where they prescribe against the guidance. Accountable GP for Over 75s Neil explained the requirements of the PCQP specification, particularly the requirement that all practices must make a reduction in non-elective activity for all patients aged 75 and over. Emergency admissions data for Q1 and Q2 had been shared prior to the meeting and practices whose admissions appear to be increasing will be requested to review the plans they have in place for managing this group of patients. If necessary, remedial plans will also be requested. Discussion took place regarding factors that could affect a practice’s ability to reduce emergency admissions, such as frequent fliers. Practices asked whether they could still get data on these patients. Neil explained that practices would need to request this from providers as the CCG was not allowed to hold patient identifiable information. Sue suggested that data showing admissions where the length of stay was zero days would also be useful. The CCG can provide this in anonymised form but if practices wanted to identify those patients that this data relates to they would need to request it from providers. Dr Shah highlighted an issue that she had experienced, where Intermediate Care had resisted a request for an intermediate care bed. Action: Kendra/Neil to feed this back to Craig Porter to request clarification on the intermediate care pathway. Neil made the group aware of the request from one of the Halewood practices to have their remaining 2016/17 payments withheld as they didn’t believe that they would achieve this element. Further information will be made available to practices before the next round of payments are due in January in case other practices wish to consider this approach. The PCQP specification includes an option for practices to appeal against their assessed payment, so practices failing to make a reduction in emergency admissions will have this option if they feel that there are reasonable grounds.

KW/NR



5

NEXT MEETING

Wednesday 25th January 2017 (12.30pm), Suite 1, The Ellis Centre.

1

Notes of the PCQP Kirkby Locality assurance meeting held on Friday 20th January 2017

at St Chad’s Health Centre

Present Lorraine Hannon CCG Governing Body Lay Member (Chair) Neil Rotherham CCG Primary Care Quality Officer Clare Sutton CCG Pharmacy Technician Lee Panter Dr Maassarani & Partners Erika Campbell Dr Maassarani & Partners Julia Perkins Macmillan Surgery Leanne McPadden Macmillan Surgery Dr A Fell St Laurence’s Medical Centre Dr V K Tewari Trentham Medical Centre Bhavna Prada Trentham Medical Centre Dr J O’Donnell Wingate Medical Centre Kelly Atkins Wingate Medical Centre


Lorraine welcomed everyone to the meeting and all present introduced themselves. Apologies had been received from Kendra Waring and Rob Foster. There was no representation from Millbrook Medical Centre.



3 Notes of previous meeting on 18th November 2016

The notes of the previous meeting were accepted as a true and accurate record.

4 Matters arising

There were no matters arising from the previous meeting.


General Practice Quality Standards Neil explained that there had been no further engagement by the CCG on this element. The dashboard is still in development and the latest version was presented to the Primary Care Committee on 19th January. It will be shared with practices once development

2

work is complete. There are no further requirements for practices in relation to PCQP funding at this stage. Referral Quality In Rob’s absence Neil provided an update on the RQ project. At the time of the meeting there was just one practice, Wingate MC, that hadn’t received training and therefore hadn’t gone live on the referral management system. This was due to the trainer failing to attend the practice. Training has been rescheduled for 23rd January. There was slight confusion over the status of Trentham MC and Bhavna confirmed that the practice had received training. However, the practice was experiencing difficulties with users’ NHSMail accounts. Neil agreed to feed this back to the RQ project team. Action: Neil to liaise with CCG RQ project team re: NHSMail issue at Trentham. The clinical triage element of the system will be introduced once all practices have gone live and had time to get used to the system. An information sharing agreement has been drafted and this will be shared with practices once approved by all parties. There has been limited feedback from practices and this has been quite mixed. All concerns raised by practices are being investigated by the project team. Dr O’Donnell requested that practice feedback is shared and stressed that any problems will need to be resolved quickly to avoid disengagement. Information reports will start to be shared with practices shortly to show system usage. No specific target figures have been set in relation to PCQP funding, so practices will just need to ensure that, where initial usage is limited, they increase utilisation month on month or, where initial usage is at 100%, maintain this level. Prescribing There was no CCG Pharmacist at the meeting, so no update on practice progress was available. However, all practices present believed that they were on target to achieve all of the various parts to this element. Accountable GP for Over 75s Neil updated the group on progress with this element. No further quarterly data was available at the time of the meeting. Quarter 3 data should be available in mid-February and will be shared with all practices. During discussions at the other locality assurance meetings in November it had been proposed that, for practices whose emergency admissions data suggested that they wouldn’t be able to achieve a reduction by the end of 16/17, no further payments

NR

3

should be made during the financial year as these may have to be clawed back at a later date. Some practices had expressed a view that, having worked hard to make significant reductions in emergency admissions in 15/16, they may be penalised for failing to do this in 16/17 despite their best efforts. Neil reported that an amendment to the specification had been proposed to allow more flexibility in dealing with these situations but the proposal had been rejected by the Primary Care Committee. Quarterly payments will continue for the remainder of 16/17 and the wording of the specification will remain the same. Practices whose emergency admissions increase will be required to make a case for retaining their funding at year-end. A panel will be set up to look at each case.



NEXT MEETING

Friday 17th March 2017 (12.30pm), 2nd Floor meeting room, St Chad’s Health Centre.

1

Notes of the PCQP East Knowsley Locality assurance meeting held on Wednesday 25th January 2017

at The Ellis Centre

Present Sue Benbow CCG Governing Body Secondary Care Doctor (Chair) Kendra Waring CCG Primary Care Programme Manager Rob Foster CCG Project Manager – Referral Quality Neil Rotherham CCG Primary Care Quality Officer Emilia Nowak CCG Meds Mgt Pharmacist Dr K Sandeep Aston Healthcare Dr K Kyaw Cedar Cross Medical Centre Heather Baker Cedar Cross Medical Centre Dr D Heath Cross Lane Surgery and Prescot Medical Centre Carol Maddox Cross Lane Surgery and Prescot Medical Centre Dr M Alexander Longview Medical Centre Dr R Kulandaisamy Nutgrove Villa Surgery Dr S R Maddipati Nutgrove Villa Surgery Dr H Sukhavasi Park House Medical Centre Dr R Rashid Tarbock Medical Centre Maureen Wright Tarbock Medical Centre


Sue welcomed everyone to the meeting and all present introduced themselves. No apologies had been received and all East Knowsley practices were represented.





4 Matters arising

Request for correspondence from CCG re: use of the referral management system to ensure patient safety and practice indemnity – this had not yet been progressed, so Rob agreed to follow up with Dr Hossain to get more information and then action. Action: Rob to contact Dr Hossain to follow up.

RF

2

Patient information leaflets for referral management system – Rob confirmed that the project team was working towards an electronic version of the leaflet, but currently only a hard copy version is available. With regard to the referral reference number, this can’t currently be included in the referral form but the project team will continue to work with Accenda to develop the referral form. Intermediate Care pathway – clarification on the criteria and pathway for accessing intermediate care beds is still awaited. Action: Neil/Kendra to follow this up ASAP and share with the group.

NR/KW


General Practice Quality Standards Neil explained that there had been no further engagement by the CCG on this element. The dashboard is still in development and the latest version was presented to the Primary Care Committee on 19th January. It will be shared with practices once development work is complete. There are no further requirements for practices in relation to PCQP funding at this stage. Referral Quality Rob reported that all practices had now been trained and should therefore be live on the system. Levels of usage seem quite mixed at this stage. The triage element of the system should hopefully be introduced by mid-February. An information sharing agreement has been drafted and this will be shared with practices once approved by all parties. Triage should be carried out within 48 hours of receiving the referral. If this timescale isn’t met the referral will go through without triage. There has been limited feedback from practices and this has been quite mixed. All concerns raised by practices are being investigated by the project team. A Survey Monkey will be published shortly to allow further feedback, including from providers. All feedback should be directed to Danielle McCulloch (0151 244 3584 or [email protected]) in the first instance. The clinical working group met on 20th January to discuss next steps for the project and will be meeting monthly to move the referral management system forward. The group comprises:

• CCG Chair • CRG Chairs • CCG Clinical Leads • A nurse • LMC member

A number of practices highlighted the issue of referrals being returned to them by the booking team as they had been unable to


3

contact the patient within 2 weeks of receiving the referral. Practices then have to contact the patient and re-submit the referral, which adds to their workload. Rob confirmed the current process, which is a text, followed by a letter, followed by a phone call and then returned to the practice if no contact has been made. The group discussed whether any changes could be made to this process and suggested:

• A clear message in the leaflet that the GP has made a referral and that the team will be contacting the patient.

• Potentially lengthening the time that the booking team has for contacting the patient, which would allow further opportunities to contact them before returning the referral to the practice.

• A clear reminder in the information leaflet for patients to contact the booking team if they haven’t heard from them within 2 weeks of seeing the GP.

Other potential improvements to the system were discussed, for example a reminder for clinicians regarding any tests etc. that they would need to do before submitting a referral. Dr Sukhavasi informed the group that this had been introduced in St Helens practices via a link to Map of Medicine. Dr Rashid asked whether the booking team always look for the best option for each patient. Rob confirmed that the team has full access to the DoS and practices can still advise the team of a preferred option when making the referral. With regard to system usage, no specific target figures have been set in relation to PCQP funding, so practices will just need to ensure that, where initial usage is low, they increase utilisation month on month or, where initial usage is at 100%, maintain this level. Prescribing Emilia provided an update on the various parts of this element. Aston and Tarbock have had all 3 practice-based meetings and third meetings for the other East Knowsley practices are being arranged. Audits currently being undertaken by practices will be discussed at these meetings. Audit findings will need to be submitted to the Meds Mgt team by the end of March. Accountable GP for Over 75s Neil updated the group on progress with this element. No further quarterly data was available at the time of the meeting, but quarter 3 data should be available in mid-February. This will be shared with all practices to show progress. Neil reported that, during discussions at some of the locality assurance meetings in November, it had been proposed that, for practices whose emergency admissions data suggested that they wouldn’t be able to achieve a reduction by the end of 16/17, no

4

further payments should be made during the financial year as these may have to be clawed back at a later date. Some practices had expressed a view that, having worked hard to make significant reductions in emergency admissions in 15/16, they may be penalised for failing to do this in 16/17 despite their best efforts. Neil explained that an amendment to the specification had been proposed to allow more flexibility in dealing with these situations but the proposal had been rejected by the Primary Care Committee. Quarterly payments will therefore continue for the remainder of 16/17 and the wording of the specification will remain the same. Practices whose emergency admissions increase will be required to make a case for retaining their funding at year-end. A panel will be set up to look at each case. Neil had contacted practices whose emergency admissions were increasing and many had already provided information on the work they have been doing, together with any issues that may have caused the increase. Dr Heath reported that she had been auditing emergency admissions and had found a significant proportion (26%) where patients had been admitted to Whiston AEC with zero days stay. She questioned whether these types of admissions should be included in emergency admissions data. Other instances where there appeared to be multiple admissions for the same thing were also highlighted. Neil explained that when the data is produced by SUS it contains pseudonymised identifiers for patients included in the data and these can be matched to individual NHS numbers. The CCG cannot access patient identifiable data but will be able to share the pseudonymised identifiers with each practice, who can then request the corresponding NHS numbers from the DSCRO. That will allow practices to compare the SUS data to their own records to see whether there are any anomalies in the SUS data. Sue suggested that practices should get together at a later date to look at what could be changed or introduced to reduce admissions in future. This could potentially be facilitated by the Commissioning Team at the CCG.



NEXT MEETING

Wednesday 22nd March 2017 (12.30pm), Ellis Centre Suite 1.

1

Notes of the PCQP Halewood Locality assurance meeting held on Friday 27th January 2017

at The Halewood Centre

Present Lorraine Hannon CCG Governing Body Lay Member (Chair) Neil Rotherham CCG Primary Care Quality Officer Dr J Benton Aston Healthcare Jayne Birkett Hollies Medical Centre Dr B P Moran Dr Kinloch & Partners Pauline Darracott Roseheath Surgery


Lorraine welcomed everyone to the meeting and all present introduced themselves. Apologies had been received from Kendra Waring and Rob Foster. All of the Halewood practices were represented.





4 Matters arising

Quarterly payments – at the previous meeting Dr Moran had requested that, as the data suggested that his practice wouldn’t be able to achieve a reduction in emergency admissions by the end of 16/17, no further payments should be made during the financial year as these may have to be clawed back at a later date. This had been discussed at the CCG Primary Care Committee on 19th January, but the committee made the decision that quarterly payments would continue to be made and practices whose emergency admissions increase will be required to make a case for retaining their funding at year-end. A panel will be set up to look at each case. Withdrawal of community matron support at Hollies MC and Dr Kinloch & Partners – this issue had been fed back to the CCG commissioning team and discussions had taken place with 5BP.

2

Alternative support had been provided to the practices, although the amount of support had been reduced. NHS Wirral CCG Admissions Prevention & Facilitated Discharge Service – Lorraine has contacted Wirral CCG and we are currently awaiting the evaluation report from this service.


General Practice Quality Standards Neil explained that there had been no further engagement by the CCG on this element. The dashboard is still in development and the latest version was presented to the Primary Care Committee on 19th January. It will be shared with practices once development work is complete. There are no further requirements for practices in relation to PCQP funding at this stage. Referral Quality In Rob’s absence Neil provided an update on the RQ project. He reported that all practices had now been trained and were live on the system. Levels of usage seem quite mixed at this stage. The triage element of the system should hopefully be introduced by mid-February. An information sharing agreement has been drafted and this will be shared with practices once approved by all parties. Triage should be carried out within 48 hours of receiving the referral. If this timescale isn’t met the referral will go through without triage. Dr Moran highlighted that some triage already appeared to be taking place as some referrals were being returned with a suggestion to refer elsewhere. There has been limited feedback from practices and this has been quite mixed. All concerns raised by practices are being investigated by the project team. A Survey Monkey will be published shortly to allow further feedback, including from providers. All feedback should be directed to Danielle McCulloch (0151 244 3584 or [email protected]) in the first instance. The clinical working group met on 20th January to discuss next steps for the project and will be meeting monthly to move the referral management system forward. With regard to system usage, no specific target figures have been set in relation to PCQP funding, so practices will just need to ensure that, where initial usage is low, they increase utilisation month on month or, where initial usage is at 100%, maintain this level. Dr Moran asked why practices couldn’t refer directly into community services rather than going through the RMS. Dr Benton asked why even straightforward referrals needed to go


3

through the system. These questions will be fed back to the project team. Action: Neil to raise these questions with the project team. Prescribing There was no CCG Pharmacist at the meeting, so no update on practice progress was available. However, all practices present believed that they were on target to achieve all of the various parts to this element. Accountable GP for Over 75s Neil updated the group on progress with this element. No further quarterly data was available at the time of the meeting, but quarter 3 data should be available in mid-February. This will be shared with all practices to show progress towards the target of reducing emergency admissions for this group of patients. Neil explained that when the data is produced by SUS it contains pseudonymised identifiers for patients included in the data and these can be matched to individual NHS numbers. The CCG cannot access patient identifiable data but will be able to share the pseudonymised identifiers with each practice, who can then request the corresponding NHS numbers from the DSCRO. That will allow practices to compare the SUS data to their own records to see whether there are any anomalies in the SUS data. Neil had recently contacted practices whose emergency admissions were increasing and many had already provided information on the work they have been doing, together with any issues that may have caused the increase. Once practices have been able to compare the SUS data to their own records this may provide further weight to any case for retaining funding for this element at year-end.

NR



NEXT MEETING

Friday 24th March 2017 (12.30pm), The Halewood Centre.

1

Notes of the PCQP West Knowsley Locality assurance meeting held on Tuesday 31st January 2017

at The Blue Bell Centre

Present Lorraine Hannon CCG Governing Body Lay Member (Chair) Kendra Waring CCG Primary Care Programme Manager Neil Rotherham CCG Primary Care Quality Officer Laura Robinson CCG Meds Mgt Pharmacist Dr P Ayegba Blue Bell Medical Practice Nicola Raby Blue Bell Medical Practice Sandra Kanczes-Daly Colby Medical Centre Suzanne Evans Cornerways Medical Centre Dr A Pryce Dinas Lane Medical Centre Dr P Sadiq Hillside House Surgery Sheila Skinley Hillside House Surgery Dr S Kuruvilla Pilch Lane Surgery Dr S Choudarapu Primrose Medical Practice Dr P Rigby Dr Rigby & Partners Dr N Shah Roby Medical Centre


Lorraine welcomed everyone to the meeting and all present introduced themselves. Apologies had been received from Rob Foster. There was no representation from Aston Healthcare.





4 Matters arising

Over 75s emergency admissions data – at the previous meeting a request had been made for the data to be provided in graphical form to allow practices to look at trends over time. Neil confirmed that this had now been provided for all practices.


2

General Practice Quality Standards Neil explained that there had been no further engagement by the CCG on this element. The dashboard is still in development and the latest version was presented to the Primary Care Committee on 19th January. It will be shared with practices once development work is complete. There are no further requirements for practices in relation to PCQP funding at this stage. Referral Quality In Rob’s absence Neil provided an update on the RQ project. He reported that all practices had now been trained and were live on the system. Levels of usage seem quite mixed at this stage. The triage element of the system should hopefully be introduced by mid-February. An information sharing agreement has been drafted and this will be shared with practices once approved by all parties. Dr Pryce confirmed that the triage element will be used to ensure referrals conform to CCG policy. Practices will still have the option of Choose & Book or letter and the group discussed how this would be the sensible option for follow-ups. There has been limited feedback from practices and this has been quite mixed. All concerns raised by practices are being investigated by the project team. A Survey Monkey will be published shortly to allow further feedback, including from providers. All feedback should be directed to Danielle McCulloch (0151 244 3584 or [email protected]) in the first instance. Discussion took place regarding the issue of referrals being returned to practices by the booking team as they had been unable to contact the patient within 2 weeks of receiving the referral. Practices then have to contact the patient and re-submit the referral, which adds to their workload. Dr Pryce reported that his practice creates a Choose & Book referral at this stage, but he believed that this could also be done by the booking team. There was discussion about the current process for contacting patients and Dr Pryce highlighted the need to ensure that, where appropriate, the ‘Consent to text’ box on the referral form would need to be changed to ‘Yes’ from the default setting of ‘No’. Unless this is done patients will not receive a text from the booking team. Practices also need to indicate on the form that they have verified the patient’s phone number. Unless they do this the number will show as unverified on the form and the patient will not be contacted by phone. With regard to system usage, no specific target figures have been set in relation to PCQP funding, so practices will just need to ensure that, where initial usage is low, they increase utilisation month on month or, where initial usage is at 100%, maintain this level.


3

Prescribing Laura provided an update on the various parts of this element. All practices have had at least 2 of their practice-based meetings and most now have the third scheduled in. The third prescribing leads educational event is likely to be in February, although a date has not yet been confirmed. Laura highlighted that some good learning points had come out of the antibiotic audits. It was agreed that lessons learned could be an agenda item for future meetings. Sandra raised the issue of Doxycycline, which comes in packs of 8 although practices are advised to give 6. NICE guidance recommends 5 days. It was agreed that clinicians should use clinical judgement if they feel that 7 days treatment is more appropriate. Laura confirmed that part packs can be prescribed. Dr Choudarapu asked for advice on how to alert other practices about patients who are addicts and may be moving from practice to practice in order to acquire medication. Neil agreed to raise this with the Head of Meds Mgt to see what is already available and what could be introduced. Action: Neil to liaise with Head of Meds Mgt and feed back to a future meeting. Accountable GP for Over 75s Neil updated the group on progress with this element. No further quarterly data was available at the time of the meeting, but quarter 3 data should be available in mid-February. This will be shared with all practices to show progress. Neil reported that, during discussions at some of the locality assurance meetings in November, it had been proposed that, for practices whose emergency admissions data suggested that they wouldn’t be able to achieve a reduction by the end of 16/17, no further payments should be made during the financial year as these may have to be clawed back at a later date. Some practices had expressed a view that, having worked hard to make significant reductions in emergency admissions in 15/16, they may be penalised for failing to do this in 16/17 despite their best efforts. Neil explained that an amendment to the specification had been proposed to allow more flexibility in dealing with these situations but the proposal had been rejected by the Primary Care Committee. Quarterly payments will therefore continue for the remainder of 16/17 and the wording of the specification will remain the same. Practices whose emergency admissions increase will be required to make a case for retaining their funding at year-end. A panel will be set up to look at each case.

NR

4

Neil had recently contacted practices whose emergency admissions were increasing and many had already provided information on the work they have been doing, together with any issues that may have caused the increase. Neil explained that when the data is produced by SUS it contains pseudonymised identifiers for patients included in the data and these can be matched to individual NHS numbers. The CCG cannot access patient identifiable data but will be able to share the pseudonymised identifiers with each practice, who can then request the corresponding NHS numbers from the DSCRO. That will allow practices to compare the SUS data to their own records to see whether there are any anomalies in the SUS data. Sandra highlighted an issue relating to patients requiring blood transfusions as she believed these were being reported as emergency admissions. Dr Ayegba suggested that these could be referred to intermediate care, although the group felt that this may only be for Liverpool residents.



NEXT MEETING

Tuesday 21st March 2017 (12.30pm), Ellis Centre Suite 1.

PRIMARY CARE COMMITTEE Thursday 2 March 2017 at 1 ......• Kirkby – 18th November 2016 & 20th...

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