london’s gp consortia development programme – …...(pbc) to the formal establishment of our...

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London’s GP consortia Development Programme – Application form

For information on the applications process please review the guidance document on

London’s GP consortia development programme – available at www.london.nhs.uk

Please provide all applications to [email protected]

You can use this template to demonstrate your evidence, but supporting documents can also

be provided.

Consortium Details:

Please complete the table below for all applications.

Consortium Name Southwark Health Commissioning (SHC)

Sector for consortium South East London

Primary PCT for consortium NHS Southwark

Local Authorities for consortium London Borough of Southwark

Lead contact for application

Name Dr Amr Zeineldine

Designation Chair, Southwark Clinical Commissioning Board

Email address [email protected]

List of practices in consortium (including

practice codes)

G85001 Forest Hill Road

G85006 Gaumont House Surgery

G85007 Lister Primary Care Centre – Dr

Ullah

G85009 St James Church Surgery

G85012 Aylesbury Partnership

G85013 Camberwell Green Practice

G85019 The Trafalgar Surgery

G85029 Falmouth Road Surgery

G85030 Concordia Parkside

G85031 DMC Chadwick Rd

G85034 Princess Street Group Practice

G85040 Queens Rd Surgery

G85042 St Giles Surgery –Dr Virji

G85050 Sir John Kirk Close Surgery

G85051 Elm Lodge Surgery

G85052 Old Kent Road Surgery

G85082 Maddock Way Surgery

G85084 Penrose Street Surgery

G85087 DMC Silverlock

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G85091 3 Zero 6 Medical Centre

G85094 Bermondsey and Lansdowne

Medical Mission

G85095 Manor Place Surgery

G85097 Grange Road Practice

G85106 Borough Medical Centre – Dr

Misra

G85112 Hambleden Clinic

G85119 Sternhall Lane Surgery

G85125 Park Medical Centre

G85132 Concordia Melbourne Grove

G85134 The Lister Health Centre – Dr Aru

G85138 Albion St. Group Practice

G85623 Parkers Row Family Practice

G85632 Villa Street Group Practice

G85642 Blackfriars Medical Practice

G85644 The Gardens (The Surgery)

G85651 Dulwich Medical Centre

G85681 Lordship Lane Surgery

G85685 Nunhead Surgery

G85692 Surrey Docks Health Centre

G85705 New Mill Street Surgery

G85707 East Dulwich Primary Care Centre

G85712 Avicenna Health Centre

G85715 The Lister Health Centre – Hurley

Group Practice

G85719 (The Surgery) Dr Lee

G85721 East Street Surgery

G85723 Lister Health Centre – Dr Hossain

G85726 St Giles Surgery – Dr Patel

Y00454 Borough Medical Centre – Dr

Sharma

Registered patient population for

consortium 319,127

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Pathfinder phase – Design, planning and preparation:

For applications to the design, planning and preparation stage please provide evidence

against the criteria listed in the table below:

Strong GP leadership and support:

A joint statement of intent from the GP practices within the consortium

Statement of Intent General Practice in Southwark welcomes and supports the proposals outlined in the Government’s White Paper Equity and Excellence: Liberating the NHS and we have made clear our intention to establish a GP Commissioning Consortium comprising all general practices within the borough to lead the commissioning of local NHS healthcare and services. Clinicians are committed to the rapid development of GP commissioning in Southwark. General Practice firmly believe that the involvement of local health professionals and patients in leading the development of service pathways that better reflect local priorities will ensure the best possible outcomes for our patients. Local General Practice wishes to engage with London’s GP Consortia development programme at the earliest opportunity and following the programme launch Southwark’s GP leads held a workshop to consider our application on 11 November 2010. We believe that our local arrangements meet the criteria for the Pathfinder phase and that our successful application will:

• Allow the acceleration of already well developed plans for our GP Commissioning Consortium

• Build upon our strong track record of GP Commissioning in collaboration with local stakeholders over the past three years

• Allow us to exploit the opportunities presented by the established integration between the Council and local health partners in Southwark and deliver against the shared and ambitious goals that local GP Commissioners have been able to shape with Kings Health Partners (KHP)

General Practice Support This application for Pathfinder status is made on behalf of all General Practices in Southwark. Since the publication of the White Paper in July 2010 mandated GP leads have worked with their GP colleagues, through established locality groups, to agree plans to form a single borough wide consortium. Having taken this decision we are now approaching the full implementation of our plans to move from effective Practice Based Commissioning (PBC) to the formal establishment of our Consortium on 2 December 2010. Southwark GPs believe that the consortium arrangements that have already been established move us beyond the ‘mobilisation’ phase outlined by the development programme and leave us well placed to become first wave Pathfinders. We have a strong and collective desire to press ahead with the commissioning of care for local residents.

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On the 13 October 2010 members of the Southwark Clinical Commissioning Board (CCB) wrote to NHS London to express our wish to become early adopters of GP Commissioning in London following consultation with our constituent practices. We now welcome the opportunity to join the Pathfinder programme and to take some delegated responsibilities for commissioning from April 2011. Both our intention to form a Southwark Consortium and this application has been discussed with and are supported by the Southwark Local Medical Committee (LMC) and Londonwide LMCs. Strong GP Leadership already working closely with the PCT General Practice in Southwark has already formed a Clinical Commissioning Board, with eight GP members, to lead GP Commissioning. This has been established for the last 15 months and has provided strong leadership in influencing commissioning in Southwark ahead of the White Paper. By 2 December 2010 the CCB and NHS Southwark will have finalised and adopted governance arrangements that support the phased transfer of agreed commissioning responsibilities to the CCB in this transition period. On 25 November the NHS Southwark Board will approve the CCB as a formal committee of the Board with arrangements for decision making made clear through its scheme of delegation. GP Commissioners have also played the lead role in designing Southwark’s Borough based Business Support Unit (BSU), as part of the South East London management cost reduction plan, and believe it is aligned to our plans as a commissioning body. GP Leads have been mandated by their colleagues to develop our Consortium. This established group of GP Commissioners have worked with their constituents to commission and redesign services over the past three years and have now led the establishment of new GP Commissioning arrangements to meet the challenges of the White Paper. Going forward an agreed selection / election process for the membership of the CCB from 2 December 2010 onwards began in late August and will be completed by the end of November 2010. This process will ensure GP members of the CCB have a clear and democratic mandate from all general practices in the borough. This process has been co-produced with the Londonwide LMCs. In our role as Commissioners, local GPs have a clear understanding of the very real financial and performance issues that we face in the local health economy; we hold a high level of ownership of these issues and are committed to ensuring the effective delivery of the QIPP plans we have developed in Southwark.

A vision for the consortium

A vision for the health of people in Southwark Our vision is to commission services to enable the population of Southwark to achieve excellent health outcomes A vision for the consortium As a consortium of local clinicians we will aim:

• To commission locally responsive services and will prioritise engagement with local people

• To work effectively with all our partners, including Southwark Council and KHP

• To secure the engagement and effective contribution of all Southwark practices in

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the commissioning process

• To address existing and future financial challenges for the local health economy through the effective redesign and integration of care pathways

In establishing our Consortium and taking early delegated responsibility for key areas of commissioning spend will seek to align behaviours within general practice with the financial and consequences of those decisions. Southwark’s general practice is also clear that the next the landscape for commissioning will continue to involve over the period of the development programme and we will welcome the opportunity to work in news ways and in collaboration with other Consortia over time.

A plan for how the consortium will work with its constituent GP practices

Well developed Consortium structures for working with constituent practices Our Consortium plans for working with constituent practices are well developed. They seek to maximise the engagement of every practice team within the borough and are aligned to the locality based commissioning that underpins our QIPP and Polysystem plans for the transformation of health and health services locally. Every practice in the Consortium is a member of a locality group and each group currently has mandated GPs that lead that group and sit on the CCB. The interaction of the locality groups and the CCB provides the main mechanism for communication and co-ordination of the Consortium. Locality groups meet on a monthly basis. GP Commissioning Leadership Going forward the CCB will comprise two mandated (through our selection / election process) GP leads from four localities that make up the borough. Each GP Lead has a formal Job description that they have agreed to perform, and are performance managed against by the CCB Chair, that requires them in broad terms to perform three key roles:

• To be the key link between the CCB and all the practices within the locality they represent ensuring that practices are aware of and are able to inform commissioning across the borough.

• To be active members of the CCB as the lead commissioning group for Southwark

• To be the lead for a portfolio of commissioning responsibilities (e.g. Urgent Care) across Southwark.

General Practice ‘Buy-in’ The Southwark GP Commissioning Consortium has been organised around the establishment of four Southwark localities to ensure that GP Commissioning in the borough is cohesive, inclusive, representative and sensitive to the different needs that are found in these localities. The four localities were defined through full and formal consultation with local stakeholders and residents and are as follows:

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• Borough and Walworth (North West)

• Bermondsey and Rotherhithe (North East)

• Peckham (Central)

• Dulwich (South) Each area comprises 11 to 16 local practices and each serve between 65,000 and 90,000 registered patients. The localities are coterminous with Southwark’s Polysystems or networks of care. In 2009 clinical leads worked with NHS Southwark to undertake a borough wide consultation with local people and stakeholders upon the future of health and health services in the Borough – Transforming Southwark’s NHS. The consultation engaged more than 3,000 local residents and confirmed a high level of support for commissioning plans to redesign services that would be ‘closer to home’ and based upon the needs of each locality. In that consultation residents confirmed that they recognised these localities as the areas where they live and conduct their lives and access health services. As a result GP Commissioners have sought to organise the Consortium according to these localities both as a means to plan and implement commissioning change in response to local need and to facilitate the engagement of local general practice in the consortium. In preparation for this way of working NHS Southwark facilitated locality workshops in the second half of 2009/10 with attendance from every practice within each locality to agree these arrangements and to confirm local priorities. These workshops were repeated this year with local residents from each locality and our practices to allow an opportunity for GP Commissioners to engage with their residents on local priorities and Southwark’s QIPP plans. Governance arrangements In addition to the formal interaction between the CCB and its constituent practices, described by the CCB Terms of Reference and outlined above, practices have also developed and agreed a governance agreement that describes the relationship between General Practices, the CCB and the PCT as they relate to GP Commissioning. The governance agreement was developed as part of Southwark’s approach to Practice Based Commissioning and will be amended to reflect new arrangements for the Consortium following its December 2010 launch. The governance agreement outlines the rights and responsibilities of practices engaged in GP Commissioning and has been signed by all practices. The agreement also outlines the outcomes based incentive scheme for GP Commissioning that rewards practices for their involvement and work. The nature of the agreement allows practices to engage in commissioning activities at a variety of levels from ‘Participation’ (e.g. in audits and adherence to agreed pathways) through to ‘Leadership’ (e.g. of borough wide service redesign). This arrangement is designed to secure the widest possible engagement of general practice across the borough. Monitoring outcomes and collective incentive Local arrangements for GP Commissioning have sought to define what success looks like in terms of engagement and working with practices and we have established mechanisms by which to test this and ensure that we understand and address issues as they arise on an ongoing basis. This occurs through two processes:

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• A monthly electronic survey - of all practices asking practices for feedback on

the degree of their involvement and impact

• A six monthly audit of practice contribution - to commissioning and adherence to the governance agreement. This process determines the level of incentive ‘reward’ to be paid to practices

In addition GP leads for each locality are provided with details of the performance of their constituent practices in terms of pathway adherence or the undertaking of agreed areas of work in order that they can address issues with practices as and when they arise. Finally, GP Commissioning in Southwark is and will continue to be based upon collective responsibility – the success of practices in changing behaviour and outcomes is monitored and rewarded on the basis of collective performance which has been successful in encouraging the collaboration of practices and working on a population basis.

Agreement from the consortium to work within current legislation and operating plans

Consortium Agreement The consortium has made a clear commitment to work within current legislation and operating plans and will, through its constitution and governance arrangements with the PCT / Sector, establish this formally. The consortium will build upon the agreement it has already secured with all Southwark practices to operate in this way through the current governance agreement outlined above and this will be re-launched as the Constitution for the formally established Consortium in December 2010. The terms of that governance agreement have been agreed with the Southwark LMC and have been signed by all practices. This level of agreement in Southwark has not been limited to the signing of a document. It has also been articulated in the production of locality based commissioning plans that outline the contribution of local practices to the Strategic and Operating Plans for Southwark. In the past those plans have been approved by the PCT and will, from 2011/12 onwards be approved by the CCB. A proposed process for decision making within the consortium, including identification of

who will hold accountability within the consortium

Clinical Commissioning Board Decision making and accountability for decisions within the Consortium will be held by the CCB. The CCB has met in shadow form for the past 15 months and will formally become a committee of the Board from the 1 December 2010 onwards. In shadow form the CCB has become, over time, the lead commissioning group for Southwark and will now formally undertake that role. The CCB contributed to the planning process for the NHS Southwark Strategic Plan for 2009/10 to 2014/15 and has led the formal review of NHS Southwark’s commissioning intentions following the application of the Secretary of State’s tests for Strategic Planning alignment with the view of GP Commissioners over Summer 2010. The CCB is now the lead commissioning group leading the development of NHS Southwark’s contribution to the South East

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London Sector QIPP Plan. The CCB has comprised eight GP Commissioning leads representing the localities of the borough and the PCT’s senior management team, including the Chief Executive. The CCB has been chaired by one of the GP leads and decision making has been through the consensus of that group. A formal Committee of the Board As a Committee of the Board the GP Commissioning Leads will be formally appointed by General Practice in Southwark through a Selection / Election process agreed locally and undertaken independently of the PCT. The CCB will continue to be chaired by a lead GP Commissioner elected by the GP members of the CCB. The membership will expand to include a non-executive director of the PCT, a LINks representative and a representative of the Local Medical Committee, all of whom will attend the Board without voting rights. Where a decision cannot be agreed by consensus the Terms of Reference for the Board will afford voting rights to those elected GP members with a casting vote for the Chair. The terms of reference will reflect the delegated authority from the PCT Board that remains accountable during the transition period. The CCB will replace all existing PCT sub-committees with responsibility for strategic and operational aspects of commissioning (The Strategic Commissioning Committee and the Executive Commissioning Committee). The CCB will work alongside the remaining committees of the PCT Board for Audit, Integrated Governance and Finance and Performance. Decisions of the CCB will be binding for members of the Consortium, currently through the application of the Governance Agreement.

A plan for engaging with clinicians and other Allied Health Professionals on joint working

Commitment to clinical engagement In establishing plans for the consortium, GP Commissioners have given emphasis to engagement with clinicians across the full range of disciplines and organisations that make up the local health economy. GP leads have also been heavily involved in the transfer of Southwark Provider Services and have engaged with those community teams. Involvement of the General Practice team Plans for GP Commissioning have always made clear that the Consortium is a body for general practice, rather than purely GP, Commissioning. Locality arrangements seek to involve the full general practice team and locality management groups include Practice Managers and nurses in lead roles. Clinicians in neighbouring boroughs Over the last six months GP Commissioning leads have also placed importance upon the development of partnership working with colleagues in Lambeth GP Commissioning groups recognising shared priorities in a number of areas. The CCB has made clear its intention to work in close partnership with Lambeth GPs during the Pathfinder phase and will seek to establish more formal arrangements over time. In order to facilitate this direction of travel GP leads from both boroughs meet on a monthly basis to share and agree joint priorities.

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Kings Health Partners (KHP) Southwark GPs have also given high priority to engaging with secondary care clinicians and have agreed a programme of engagement work with Kings Health Partners (KHP) to ensure the development of shared work programmes with acute and mental health clinicians locally. GP Commissioning leads have established a steering group for this work with KHP which is jointly chaired by the CCB Chair and the Director of Clinical Strategy at KHP, Professor John Moxham. This has led to the development of a shared work programme to deliver agreed priorities, GP leadership on each of the AHSC Clinical Academic Groups (CAGs) and the agreement to develop an Integrated Care Pilot (ICP). Engagement with KHP has been given high priority and two Lambeth and Southwark engagement events, attended by over 80 clinicians from primary and secondary care have been held to agree and shape plans to deliver priorities since July 2010. KHP have also written to NHS London to formally support our application. Primary Care Contractors Finally the Consortium has recognised the importance of building upon existing and high quality relationships with other independent contractors and community services providers in the borough. The CCB will prioritise the development of an engagement plan with community pharmacists, dentists and optometrists over the final quarter of 2010/11. This plan will build upon the planned development of networks of primary and community care professionals in each of the four localities to support the delivery of local Polysystem plans.

Local Authority engagement:

A joint statement of intent for developing partnership working with Local Authorities

Local Authority support Our application has been formally supported by the Local Authority. On the 23 November 2010 Southwark Council’s Cabinet considered the changes in the NHS and the implications for Southwark Council and formally confirmed their support for a Southwark GP Consortium for commissioning and this application for the Pathfinder development programme. Southwark Council's Cabinet agreed that it "welcomes the proposal from Southwark GPs to be considered as a GP consortium pathfinder and agreed to support them in this project." This decision follows a letter from Annie Shepperd, Chief Executive of Southwark Council to NHS London on 18 October 2010 that stated "I write to confirm that the Council will support this proposal by GPs in Southwark. It is a positive statement that GPs in Southwark have come together in this way, which will assist the continued close collaboration between health and local government locally and it is adding pace and commitment to the new government's agenda." Southwark Council and the GP Consortium welcome the new and enhanced opportunities to work together. We are committed to working in partnership in order to

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tackle local challenges around health and social care through a joint partnership approach. Within a new policy context we firmly believe this work will build on the existing joint health working between Southwark Council and NHS Southwark. Priority areas for joint working The Local Authority believes that the accelerated development of GP Commissioning locally will enhance the ability of local partners to address our key priority areas. Initial priority areas for joint working will be agreed at the earliest opportunity and are likely to include:

• The provision of effective urgent care responses across health and social care with particular focus given to admissions avoidance and reablement, and in particular in working to shift the balance of care in Southwark.

• The prevention agenda

• Tackling health inequalities - and improvements in public health more generally in the borough.

• Safeguarding. Consideration for how to participate in the development and shaping of local Health and

Wellbeing Boards

Current arrangements At present Southwark has a well established Southwark Health and Wellbeing Board, one of the five key partnership boards within the existing Local Strategic Partnership. The Board is chaired by Southwark Council’s lead member for Health and Social Care and its membership includes the PCT Chief Executive / Director of Adult Social Services, her deputy for adult social care and the Director of Public Health. The Board brings together representatives from local acute and mental health trusts. It also has a good level of involvement from the voluntary sector and brings together officers and staff from across the full range of local authority departments, such as environment and leisure. Clinical representation has been through senior clinical managers of the provider services and the PCT Medical Director but significantly GP Consortium members are now represented on the Board. The Board has an established programme of work that includes driving forward the Southwark Health Inequalities Strategy, the Social Care and Prevention strategy, the Healthy Weight strategy, the Physical Activity strategy, and the Carers strategy. Shaping future arrangements

While Southwark believes that it has a well functioning board at present with important strategies and programmes of work under its guidance, it recognises that there is a need to re-configure this in the light of new policy guidance and direction for health and social care.

In particular partners are already planning to revise the membership to include a stronger presence and representation from the Consortium GP leads. GP Commissioners will participate in the planned reshaping of the revised Board and its programme of work to ensure that the major health care issues for our local population become an integral part of the work programme.

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GP Commissioners will participate in agreeing the Joint Strategic Needs Assessment (JSNA) and will use it to inform their commissioning of local services. Building on our current joint NHS and social care commissioning, our aim is to build a strong partnership on joint commissioning of care for vulnerable adults and children between the Southwark GP consortium and Southwark Council.

Southwark Council and GP Consortium intend to work together to further enhance a health and wellbeing board to meet the aims of the partnership by driving through whole systems change to support health improvement in the borough.

A plan for engaging other stakeholders (please list all relevant stakeholders)

Southwark Council and the GP Consortium will be engaging with all key stakeholders in the development of this new partnership arrangement including:

• Patients, Users and Carers

• Southwark LINk

• South London and Maudsley Trust (SLaM)

• Kings College Hospital Trust and Guys and St Thomas's Hospital Trust

• Key Businesses

• Key Council Partners including its external providers (e.g. Veolia, Vangent and Liberata)

• Private Healthcare providers / contractors

• Voluntary sector

Ability to contribute to the delivery of the local QIPP agenda in the consortium’s

locality

Participation in the 2011/12 QIPP planning round at PCT and sector level, including

developing and agreeing priorities for the local population

Participation in Strategic Commissioning GP Commissioners have and will continue to take a lead role in the development of the Strategic Commissioning planning for Southwark. GP Commissioners were directly involved in the development of the current Strategic Plan and completed a formal review of those plans in the Summer confirming their support for commissioning intentions. The CCB has played a lead role in the current development of QIPP plans and will continue to lead this process as a formal committee of the Board. From December 2010 the CCB will become the lead decision making group for all relevant aspects of commissioning and the process of developing and prioritising these plans has been undertaken in that forum. QIPP Planning Over the last four months GP Commissioning leads have been directly involved in reviewing the ‘Case for Change’ developed by the PCT and the Sector, the identification of QIPP opportunities and the assessment / prioritisation of those potential areas for inclusion in the local QIPP plan.

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In considering the ‘Case for Change’ GP leads have worked with the commissioning, finance and public health teams at the PCT and the Sector to develop a clear understanding of the financial and quality challenges for the planning period. Facilitated sessions have identified and scoped the impact of a ‘do nothing scenario’ which has provided opportunity for GP leads to develop an ownership of that challenge, operate and take decisions on commissioning and decommissioning in that context, and disseminate the scale of these challenges to their groups. In August 2010 three half day workshops were held with GP Leads and members of the PCT Senior Management Team to review current QIPP / System wide sustainability plans in relation to Polysystem development and service transformation / decommissioning in planned, unplanned and community services. These sessions confirmed the alignment of those plans with the views of GPs locally. Since that time GPs have engaged with commissioners on the full range of potential QIPP initiatives across all areas of commissioning spend. In response to this ‘Case for Change’ and in light of a proposed ‘Long List’ of QIPP initiatives that had been developed further GP Lead sessions have been held in November 2010 to prioritise QIPP initiatives and to develop a ‘menu’ of initiatives that will be taken forward as Southwark’s element of the Sector QIPP Plan. In order to facilitate this process GP leads have reviewed the rationale for each of the QIPP proposals that were considered against a series of considerations:

• Likely impact on service quality (including the Patient Experience)

• Clinical evidence base

• Likelihood of success

• Financial impact on providers / other stakeholders

• Impact on health inequalities

• Engagement required In addition the GP Leads have reviewed and challenged proposed implementation plans and have made a risk assessment against each scheme. QIPP Plan development and implementation is a standing item on the CCB agenda and after December 2010 this committee of the Board will be responsible for approving the QIPP plan as it relates to Southwark commissioning budgets.

Local ownership of meeting the QIPP challenge

Ownership The consortium of local GPs holds a good level of understanding around the scale of the financial and performance challenges for commissioning over the coming planning period. These challenges are owned by the consortium members across the borough and GP Commissioners recognise the breadth and depth of the commissioning and redesign response required to address them. Driving QIPP plans locally The CCB will oversee the prioritisation and agreement of QIPP activities and will play a lead role in ensuring their implementation both as a collective decision making group and as individual leads for specific areas of the QIPP delivery plan.

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In order to address the QIPP challenge locally GP leads will take direct responsibility for the co-ordination of activities across their localities and for the borough as a whole. This will involve the direct interaction with practices and key stakeholders to ensure:

• A clear understanding of the actions being undertaken, the reasons for those actions and the required contribution of stakeholders collectively and as individual clinical teams

• Encouraging the change in clinical behaviour to support these actions

• Engagement with patients and the public upon this plan Each Clinical Lead will be responsible for a portfolio of commissioning activity and the required QIPP implementation within it. They will undertake these roles with the support of the Borough and Sector based commissioning teams and will monitor the implementation of each aspect of the plan, identifying any unplanned variance and agreeing remedial action as required. The CCB and the consortium members are already engaged in the implementation of plans. GP leads have already undertaken work in the following areas:

• Urgent Care – Admissions avoidance and the development of Primary Care led Front Doors to A&E

• Long Term Conditions – lead roles for CHD, COPD and Diabetes

• Outpatient redesign – In MSK, Dermatology, ENT, Neurology and Gynaecology

• System change – Development of proposals for a Referral Management Service (RMS) in partnership with local acute providers

• Procedures of Limited Clinical Effectiveness (PoLCE)

• Redesign of community mental health teams

• Redesign of community services In addition the Consortium is leading the design of an Integrated Care Pilot with KHP to look at new ways to align incentives across the local health economy and ensure an enhanced integration of care to address the QIPP agenda.

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Pathfinder Phase – Some delegated responsibilities:

For applications to take on some delegated responsibilities from April 2011 please provide

evidence against the criteria listed in the table below.

Some delegated responsibilities:

Clearly defined outcomes for the activities the consortium wishes to take delegated responsibility for

Our consortium realises the importance of the role local commissioners will play in every aspect of the local QIPP plan implementation. Within this context Southwark Health Commissioning wish to take delegated responsibility for key areas of commissioning spend for our population. From April 2011 the Consortium proposes to take delegated responsibility for 30% of the total commissioning spend within the borough and have agreed this level of transfer with NHS Southwark. The Consortium wish to take delegated responsibility for the three major spend areas listed below:

• Unscheduled care - A&E attendance and Non-elective admission

• Outpatient Activity – New and Follow-up outpatient activity (including GP and acute initiated activity)

• Drugs and Devices and Primary Care Prescribing GP Commissioners have contributed to the development of commissioning intentions / QIPP proposals in these areas in preparation for the coming year and believe that significant change can be achieved in the earliest stages of Southwark’s GP Commissioning. Our rationale for taking delegated responsibility in these specific areas from April 2011 is based upon the following principles:

• Scale – GP Commissioners recognise the size and immediacy of the challenges facing the health economy - these are areas of high spend and where system change will result in improved outcomes across the entire borough

• Performance – These areas are currently the main drivers of commissioning overspends in 2010/11 (circa £7m in 2010/11) and improvement in the performance of these areas will have a significant and lasting impact upon the quality of care received by our patients in terms of health outcomes and the patient experience

• Opportunity – GP commissioners have identified through benchmarking and their clinical assessment of current service delivery, significant opportunities to make improvements in both the quality and cost of care

• Experience – GP Commissioners have a high level of knowledge about the performance of these services locally and clearly defined plans for the service redesign and change they wish to see in these areas in 2011/12

• Engagement – Members of the consortium have engaged with stakeholders across primary and secondary care to agree new ways of working in areas that they believe they can have a major influence in from the outset. Specifically, GP leads have agreed changes in these areas as a priority for our joint work with Kings Health Partners

• Strategic Alignment – Change in these spend areas will require the collaboration of all local practices, an early priority for our Consortium. We aim to enhance the

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management of long term conditions locally and believe that improved outcomes will be reflected in these areas of spend and we wish to establish new ways of working through Polysystems with immediate impact in unscheduled care and outpatient activity. Finally, we have agreed that the enhanced management of unscheduled care specifically provides an early opportunity to maximise the potential of our partnership with social care.

The table below outlines the proportion of commissioning spend that would be delegated to GP Commissioners from April 2011 onwards:

Area £ Budget 2010/11

% of total budget

% of Acute budget

Emergency PbR 49m 10 18 A&E PbR 11m 2 4 Unscheduled Care (Sub Total) 61m 12 22 New Outpatient 19m 4 7 FU Outpatient 22m 5 8 Outpatient (Sub Total) 41m 9 15 Drugs & Devices 11m 2 4 P Care Prescribing 33m 7 - Prescribing (Sub Total) 44m 9 4 Total 146m 30 41

In accepting delegated responsibility for these areas GP Commissioners would seek to achieve significant improvements in the quality of care, transformation in the delivery of services and significant cost reductions through the de-commissioning or re-commissioning of care pathways. Specifically GP Commissioners will seek to move the level activity undertaken for Southwark patients to the upper quartile of national performance in outpatient and emergency activity. The specific outcomes in terms of cost reduction in 2011/12 and over the next four years to 2014/15 are outlined below. These aims are aligned to the QIPP proposals for Southwark and GP Commissioners believe they are achievable within the specified period:

Area £ k

Reduction 2011/12

% of 2011/12

budget line total

£ k Reduction

2011/15

% of 2011-15 budget line total

Emergency PbR 962 2 2,591 1 A&E PbR 104 1 348 1 Unscheduled Care (Sub Total) 1,066 2,939 New Outpatient 896 5 2,988 4 FU Outpatient 1,552 7 5,175 6 Outpatient (Sub Total) 2,448 8,163 Drugs & Devices 500 5 1,430 3 P Care Prescribing 1,063 3 2,280 2 Prescribing (Sub Total) 1,563 3,710 Total 5,077 14,812

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Our objectives in these areas are summarised below:

Non-Elective Care and A&E attendances

Southwark has relatively high levels of emergency admissions and we know that a large

proportion of A&E attendance can be more appropriately managed / avoided by better co-

ordination of the system. Over this period we will seek to move to the upper quartile of

performance in these areas and will take action to reduce the rate of emergency admissions,

re-admission and reduce length of stay. We will seek to:

• Commission providers to deliver improvements in the rate of non-elective admissions

• Integrate community and primary care services, prioritising admission-avoidance

• Redesign the front end of A&E to develop UCCs, enabling primary care to respond better to avoid admission via A&E

• Improve the management of LTC to prevent avoidable admissions

• Enhance access to primary care to avoid hospital attendance for minor illness

• Review the current configuration of Out of Hours care to secure better integration within an unscheduled care network

Outpatient Attendances

We will decommission a significant proportion of first outpatient attendances and shift activity

to lower cost settings of care, through a combination of referral management approaches

and service redesign. We will build on our successful approach in MSK, Gynaecology,

Neurology and dermatology, and in high volume specialties will offer interface services,

aimed at reducing unnecessary hospital attendances.

Follow up Outpatient Attendances: We have benchmarked our local provider performance

by specialty and have identified the potential to reduce unnecessary follow up in secondary

care. We will commission on the basis of providers achieving specified performance

improvements. We have already agreed a number of local clinical protocols to reduce

outpatient follow up following surgery, such as hip and knee replacements and will go further

over the course of 2011/12, including applying referral management approaches to internal

referrals.

Prescribing

We will strengthen our commissioning of acute prescribing and decommission the use of

drugs for indications not supported by NICE/ local commissioning policy. Moreover we will

work with the local Medicines Management Team within the BSU to ensure the

implementation of clinical and cost effective prescribing across primary and secondary care

through direct support to practices and shared care guidelines. Importantly commissioning

will ensure the:

• Implementation of NICE guidance

• Improvement of patient outcomes through efficient and coherent medicines systems

• Reduce wastage through improved concordance

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A plan for how the consortium will achieve the specified outcomes, including how they will manage the risks (specifically financial risk) associated with them

Our plans for achievement of these outcomes in each area of delegated responsibility are outlined in our proposed QIPP initiatives for 2011/12 and are summarised at high level in the table below:

Spend Area Summarised QIPP Initiatives

A&E Attendance • Primary Care led A&E front end services at the St Thomas’ and Kings A&E departments. Patients seen by primary care at reduced UCC tariff

• Increased productivity and improved access, particularly outside of core hours, in Primary Care

• Integration of the GP led walk-in centre based in Peckham to provide access to patients with urgent needs

• ‘Meet and greet’ service piloted with Kings A&E department will be mainstreamed

Emergency Admissions

• A single point of access (SPA) to ensure patients are supported in the community through integrated care planning

• The SPA to utilise a multi-disciplinary rapid response team

• Service redesign for improved community LTC management in diabetes, COPD & heart failure

• Implementation of risk-stratification systems to identify high-risk cases

• Potential for telemedicine provision to targeted ‘at risk’ patients

New Outpatient attendances

• Implementation of referral management system focusing on key specialties

• Pathways re-designed in a number of specialties to deliver at lower unit cost

• Scrutiny of C2C referrals by patient’s GP or appropriate referral management system

• Target of London upper quartile

Follow-up Outpatient attendances

• Decommissioning and activity shift programs to reduce OP follow-up rates in outlier specialties compared to London average

• Establishing contractual mechanisms for guaranteeing savings to commissioners

• Move to London average and make further progress to upper quartile going forwards

Drugs and Devices • Improved contract monitoring

• Procurement initiatives (increased productivity)

• Improved clinical effectiveness within the pathway (right drug, right place, right time)

Primary Care Prescribing

• Improved productivity – generics

• Enhanced Clinical Effectiveness – NICE implementation

• Improved cost effectiveness (Spend on ‘Specials’)

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The consortium will work with Borough and Sector commissioning teams to secure changes that combine pathway redesign, enhanced productivity and performance in primary and community care, and efficiency gains in our acute provider organisations. Plans for delivery in each area will be developed at borough, locality and practice level and will describe in detail the required contribution at each level. Where appropriate joint action will be agreed with GP commissioners in neighbouring boroughs and specifically with Lambeth practices. Current QIPP proposals include risk assessments and proposed mitigation. This will be replicated in locality and practice level planning. These risks will be monitored throughout the year and the level of mitigation required to manage risks will be assessed and agreed on a monthly basis by the CCB. Specifically financial risk will be monitored and managed through the following areas:

• Negotiation of appropriate penalties with acute contracts for the year 2011/12

• The continued association of new and enhanced GP Commissioning incentive payments with achievement of specified outcomes for 2011/12

• The identification of a specific level of contingency reserve within the overall reserve held by the PCT

A plan for the performance management of activities they wish to take delegated responsibility for

The CCB will agree performance and outcomes Metrics with the BSU and Sector teams and will receive monthly reporting against the delegated areas of responsibility. The CCB will monitor the performance of localities and individual practices against the plans agreed for these spend areas. Monitoring will undertaken on a monthly basis supported by the BSU and Sector teams. Early identification of variance against plans will be critical. GP leads will seek to identify and understand the reasons for variance and will work with the BSU to provide direct support to practices or a locality to address them – we will give emphasis to learning and education to achieve improvements. Where variance is unwarranted or agreed actions are not taken to address underperformance this will result in withholding of commissioning support funding as a last resort. GP Commissioners will also work with Sector acute contracting teams to monitor and address areas of over performance and will seek direct involvement in the development of plans to address areas of concern or decide upon the application of agreed contractual levers. The Consortium wishes to take a proactive role in the performance management of all providers in the areas of quality and the patient experience, cost effectiveness and productivity. Finally the Consortium will place greater emphasis on the clinical validation of activity undertaken and charged by acute providers in these and other areas of spend. This will require analysis at practice and patient level to ensure activity is appropriately charged and clinically appropriate / undertaken according to agreed pathways.

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A plan for how the consortium will access the commissioning support it needs to deliver any delegated responsibilities it may take on

In order to fulfil the proposed delegated responsibilities outlined above the consortium will seek to access commissioning support from a variety of areas. Southwark Business Support Unit (BSU) GP Commissioners have worked with NHS Southwark’s Senior Management team to design the BSU structure that will undertake borough based commissioning throughout the Transition period until April 2013. The Unit’s design has sought to ensure the availability of highly skilled, senior and experienced locally based commissioners to provide direct support to the Consortium. The Consortium will work with the BSU Senior Management Team, across health and social care to ensure the availability of dedicated service redesign, finance and commissioning expertise from the outset. South East London Sector Support The Consortium will work with the BSU Director to ensure a strong working relationship with the relevant Directorates at the Sector. GP leads have tracked the development of the Sector proposals for management cost reductions and have developed a clear understanding of the level of commissioning, and in particular acute contracting, performance and information and public health support that will be available GP Commissioners in the delivery of specified outcomes in delegated areas. Current investment in GP Commissioning The consortium has agreed the ring-fencing of all current funding associated with the support of GP Commissioning and this resource will continue to be available to sustain current levels of clinical capacity to undertake commissioning activity and will allow the Consortium to retain the incentive scheme that has underpinned engagement to date, albeit in a revised form. Pathfinder Funding As a Pathfinder consortium Southwark Health Commissioning will be able to access additional resource which will be focused upon investment in commissioning support, focused upon our areas of delegated responsibility, in a number of areas:

• Additional management capacity – the Consortium would seek to either retain existing commissioning resource or buy-in short term management capacity to support the scale of service redesign and engagement required in these areas.

• Clinical capacity – the Consortium recognises that successful pathway redesign in these areas will require direct clinical involvement and GP time and capacity over and above that which is currently remunerated by current investment. This investment will be directed at widening the group of clinicians involved in commissioning work beyond the CCB members and drawing upon the full range of talent across the clinical disciplines locally

• Commissioning intelligence – the Consortium plan to make a significant investment in the enhanced provision of information and support in using that information to inform commissioning decisions and actions. Investment will be directed at additional practice based analysis of data and activity and towards

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systems that will practically provide Consortia with:

o Regular, accurate information on acute, community and mental health expenditure and activity at individual practice, GP and patient level – investment will be in both systems and training

o A cost effective way of accessing patient-level data from GP clinical systems and triangulating it with information from other data sets to understand the relationship between patient needs, practice performance and wider quality and financial outcomes.

o The ability to analyse commissioning outcomes performance at individual practice level

Established governance structures for managing delegated responsibilities, including how

the consortium reports to the PCT Board in order to meet current statutory requirements

The governance structures established for the areas of delegated responsibility will be in line with the relevant Schemes of Delegation and the Terms of Reference for committees will clearly outline these relationships. Southwark Health Commissioning will make regular reports on finance and performance in these areas to the PCT Board and the Finance and Performance Committee. This will include monitoring of financial, quality and performance aspects of care in these areas by the Operating Plan. Southwark Health Commissioning will develop a delivery plan for the achievement of specified outcomes in each area of delegated responsibility. This plan will be developed at a borough, locality and practice level and will outline the key actions to be undertaken, lead responsibility within the consortium for implementation and milestones / timescales for delivery. This plan will be assessed by the CCB and will make a recommendation to the PCT Board for approval. The CCB will establish a programme management approach to the implementation of the plan with a programme with a delivery structure developed for each of the three delegated areas. The workstreams for the programme will be led by a GP Commissioning lead and a designated member of the BSU Senior Management team who will be responsible for the delivery of area milestone and objectives. Each workstream will be supported by a multi-disciplinary team comprising GP Commissioning leads and members of the relevant Sector and Borough based commissioning units. Performance against the plan will be monitored by the current Finance and Performance Committee, a committee of the Board through assessment of regular reports produced by the CCB.

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Governance Structure extract - for the delegated areas of responsibility only:

PCT Board

Clinical Commissioning

Sub-Sub-Committee

Programme Team

(Delegated Areas)

Outpatients

Workstream

Emergency Care

Workstream

Prescribing

Workstream

Finance and Performance

Sub-Committee

Monthly reporting against

Delegated Areas

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Pathfinder Phase – All delegated responsibilities:

For applications to take on all delegated responsibilities from April 2011 please provide

evidence against the criteria listed in the table below.

All delegated responsibilities:

A draft constitution that sets out how the consortium will deliver its roles and responsibilities

No application at this stage

A plan for how the consortium will discharge its delegated commissioning responsibilities and ensure that the PCT can discharge any relevant statutory obligations it has


A plan outlining the finances for the consortium, including how it will approach financial risk and any potential actions to remedy overspend


Having the explicit support of the relevant PCT and Local Authority in assuming delegated responsibilities


A plan for how the consortium will access the commissioning support it needs to support it in delivering all delegated responsibilities


A plan for how the consortium will work with the Local Authority in commissioning for the local population, including the development of the JSNA and participating in the Health and Wellbeing Board


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Supporting information:

In order to assist NHS London in its support for GP consortia some additional information

would be helpful when applying to become a pathfinder. The optional questions outlined

below are not a required part of the applications, but answers to them would be welcomed

with all applications.

Optional questions:

What delegated commissioning responsibilities do the GP practices within the consortium currently hold (e.g. existing Practice Based Commissioning arrangements), and how effective these have been?

Under existing Practice Based Commissioning arrangements the following indicative budgets areas were devolved in 2010/11:

• Hospital budgets covered by Payment by results (PbR) including A&E and Non-Contracted Activity

• Prescribing

• Urgent care and Walk-in Centres

• Local community services

• Mental health In 2009/10 the CCB began to meet in Shadow form. Of the areas that had been devolved a decision was made to take specific lead roles in a number of redesign areas relating to reducing A&E attendances and Outpatient activity. Where GP Commissioners have been directly involved in service redesign and commissioning locally significant achievements have been made: Outpatient Activity GP led commissioning focused upon peer review to challenge individual practice referral activity and pathway redesign (including the development of new community based services) in specific specialties to reduce the level of GP initiated new outpatient activity. Each area of work was developed by an identified GP Commissioning lead and practice buy-in to new ways of working was secured through the outcomes based framework developed for the local incentive schemes. In outpatient activity a reduction in GP initiated New outpatient activity was achieved as demonstrated in the charts below whilst redesign work in specific specialties has resulted in significant reductions across the board (See Table below comparing Q1 2009/10 to Q1 2010/11):

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All GP Referrals

GP Referrals Made per 100,000 population

0

5000

10000

15000

20000

25000

2005/6 2006/7 2007/8 2008/9 2009/10

So urce: Quart er ly R et urns

Southw ark

London

England

GP Referrals in redesign areas

Speciality 2009/10 Q1 GP Referrals

2010/11 Q1 GP Referrals

% Reduction

Gynaecology 1,678 1,441 16.4 Dermatology 761 718 6.0 MSK 1,572 681 130.8 Neurology 328 291 12.7

A&E Attendances In order to reduce levels of A&E attendance GP commissioners worked with the PCT to implement an extension of opening hours in general practice, re-shaped the commissioning of the local GP Led Health centre to incorporate a process of redirection from A&E in the South of the Borough and launched a public campaign to encourage more appropriate use of local urgent care services. Whilst levels of A&E attendance have risen across the capital and in neighbouring boroughs attendance at local A&E departments for Southwark residents reduced over that period and continue to show a reduction. See Charts below for Southwark attendances at both GSTT and KCH.

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Southwark Practices – All A&E Attendances at GSTT

0

500

1000

1500

2000

2500

3000

3500

4000

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2008/09

2009/10

2010/11

Southwark Practices – Minors A&E Attendances at GSTT

0

200

400

600

800

1000

1200

1400

1600

1800

2000


2008/09

2009/10

2010/11

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Southwark Practices – A&E Attendances at KCH

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000


2009/10

2010/11

Southwark Practices – Minors A&E Attendances at KCH

0

500

1000

1500

2000

2500

3000


2009/10

2010/11

We believe we have a strong track record as GP Commissioners in achieving cost reductions and higher quality services, particularly in areas that we now wish to take delegated responsibility for.

What services and / or functions is the consortium looking to take on delegated responsibility for in the next stage of being a pathfinder, and when would it like to take them on?

In the first year of the Pathfinder phase Southwark Health Commissioning has made clear in this application its wish to take delegated responsibility for approximately 30% of the overall commissioning portfolio in financial terms. As a Pathfinder we anticipate a rapid rate of development and will seek to take on delegated responsibility for the reminder of the commissioning portfolio from April 2012.

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What are the main areas for development for the consortium, including any key issues that need to be resolved?

GP Commissioners have worked together and with the PCT Board and the Good Governance Institute to identify key areas for development as a Consortium and we welcome the development support that will be made available to Pathfinders within London’s programme. The Consortium have identified the following development areas and issues through this work:

• The need for rapid development of knowledge around the contracting processes for acute, community and mental health services and knowledge of the financial management applied to the commissioning of NHS services

• Development of enhanced leadership skills for GPs

• The introduction of proportionate governance arrangements to manage conflicts of interest both of individuals and of general practices as provider organisations

• The management of poor performance within a GP Consortia

• Development of appropriate mechanisms through which to commission services jointly with other emerging GP Consortium, particularly where those consortia are at different stages of development

• Succession planning in general and future training for ST4 GP trainees to ensure this adequately addresses the need to develop commissioning skills can do commissioning work for part of a fourth year.

The Consortium recognises that these issues are not unique to Southwark and welcome the opportunity to find ways, through the development programme to address them and share learning with other areas.

What forms of engagement and learning are most preferred by the consortium and its constituent GP practices?

The consortium welcomes the development support outlined by NHS London and believes we are well placed as Clinical Commissioning Board team to benefit from the individual and team development described in the programme. We are also committed to working with any provider of Alliance of providers to shape and design this support from January 2011 onwards The consortium and its constituent practices have a strong preference for activities that:

• Utilise established locality meetings where trust has been developed

• Provide action orientated educational opportunities within existing meetings and forums

• Facilitate learning through the Sharing and analysis of data openly

• Recognise the variety of levels of engagement that are likely to exist within any consortium of practices

• Bring together commissioners from other areas in London wide and national forums

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Additional comments:

Please provide any additional comments:

Southwark’s General Practices have worked together as a commissioning group since the beginning of 2007 when the Southwark PBC Leads Committee was established. Local GPs have a strong track record in commissioning and service redesign and in working together as a leadership team Prior to the White Paper GP Leads had already taken a decision to work as a single borough wide commissioning group and we now welcome the opportunity to accelerate our work to ensure commissioning for our patients is clinically led.

Please provide any other relevant information:

NHS Southwark’s current level of investment in Practice Based Commissioning is set at £3.00 per registered patient and agreement to ring-fence this funding locally has been agreed.

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