part 1 a g e n d a - nhs milton keynes ccg · part 1 a g e n d a item lead enc. time 1. apologies...

NHS England and MK CCG Co-Commissioning Joint Committee Meeting 6 April 2016 at 3pm

Sherwood Drive, Board Room 2, Ground Floor

PART 1 A G E N D A

Item Lead Enc. Time 1. Apologies & Welcome

2. Declaration of Interests Chair

3. Minutes of Previous Meeting held on 3 February 2016

Chair CC16/01

4. Matters Arising Chair

5. Primary Care Contract & Procurement Update Broughton Gate/Brooklands Development Western expansion Area Neath Hill

CCG/NHSE

Verbal update

3.10

6. Milton Keynes Village – Extension proposal Red Hill Surgery – Outline Business Case

Janine Welham

CC16/02 CC16/03

3.20

7. Vulnerable Practices Scheme - update Nick Ince Verbal update

3.50

8. Data Collection – PMS Monies

Janine Welham

To follow 3.55

9. Dentistry Nicola Smith Verbal

4.05

10. Neighbourhood Update Alex Friend CC16/05

4.10

11. Memorandum Of Understanding Jill Wilkinson To follow

4.20

12. Prime Minister’s Challenge Fund a. Progress Report

MKUCS/ Programme

Team CC16/06

4.30

13. Any Other Business Chair

Dates of next meetings

14. All meetings will be held at Sherwood Drive 1 June 2pm - 4pm, Board Room 1 3 August 2pm - 4pm, Board Room 1 5 October 2pm – 4pm, Board Room 2 7 December 2pm – 4pm, Board Room 1

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accurate record of the meeting

4. Matters Arising

Item 3 – Minutes amended for 19 October Item 4 – GP Access is on the agenda Item 5 ‐ Monetary value of the Walk‐in element for Broughton Gate obtained from NHSE Item 5 – Applications for the Primary Care Transformation Fund has now been extended until the end of April 16. Item 6 – Data starting to be collated for the PMS monies, to be discussed at the next meeting. Item 7 – Themes from the previous NHSE Quality Visits circulated as information to the group Item 8 – Risk Register to be circulated with the minutes Item 8 – QoF data received from NHSE Item 8 – Neighbourhood update to be presented at the April Meeting Item 8 – Annual Practice Based Budget Report to be presented at the April Meeting

JWe AF AF

5. Primary Care Contracts & Procurement Update

Rebecca Green presented the paper for Broughton Gate/Brooklands development which covers the Eastern Expansion, the paper shows that the new premises will be for a 20,000 list size with 10 GP’s the building time line has now slipped by 3 months and is looking to open in May 2018. Milton Keynes Council requested assurance from the CCG and NHSE prior to going to cabinet in March with the business case. Also running in parallel with the Eastern Expansion Milton Keynes Council will also start work on the West Expansion with proposals of a similar building. The building in the East will include a café, pharmacy and private dentist. The CCG has not committed to any space but the council are building the premises so that it is flexible to adapt the space at a later date. Sue Fogden confirmed that there is £7m tariff allocated for the two building for both east and west, Milton Keynes Council will be the owner and landlord, The temporary building at Broughton Gate lease and planning permission will need to be extended. Rebecca confirmed that NHSE and the CCG have seen the proposed plans and commented on the space, Rebecca explained that due to the procurement for the provider we could not offer advice from a Milton Keynes practice due to conflict of interest. NHSE have given names for the council to approach for advice for medical input to the planning of the building. Matthew Webb and Dominic Cox to do a joint letter to give strategic support but not over commitment. Rebecca clarified this will be for the GP element only. Risks around both expansions to be added to the risk register to include, temporary building, liability, void costs, procurement and ensuring enough capital funding.

MW/DC

JWe

6. Primary Care Transformation Fund – Alexia Stenning

Alexia Stenning gave a verbal update and advised that the initial guidance had not yet been issued. The deadline has now slipped and the guidance should now be issued at the end of February with bids to be submitted at end of April.



Alexia and Janine have visited practices and this has also been discussed at the Premises working group. The Western and Eastern expansion will need to be included bids are to include new models of care, extensions, new premises, workforce and IT. Alexia will update at the next meeting. Sue advised that this scheme is capital and not revenue and expectations of practices could be raised and this would need to be explicit in any communication. Dominic Cox discussed what is the primary care strategy and the top priorities and how to deliver primary care at scale. The money should be then aligned around this.

AS

7. Minor Surgery – Alexia Stenning

Alexia Stenning presented a paper and requested a point of view from the committee. The proposal is to do more scoping work around both of these areas, currently 27 practices deliver minor surgery and primary outpatient clinics do not deliver procedures currently. The committee agreed that both areas could be looked into as it would support care closer. Dr Nicola Smith supports the proposal but there could be a risk of deskilling GP’s. The next steps are to discuss with the Local Medical Committee and seek more information from practices.

AS/JWe

8. GP Survey Results – Janine Welham

The latest GP survey results were presented along with November’s Friends and Family Test for Milton Keynes. It was requested that any Patient Participation Surveys for practices should be taken into account. It was agreed that the survey results to be used alongside other data sources from practices to show a dashboard to give a more of an overview of a practice and to be used as part of the Quality Visit programme. The Memorandum of Understanding that Jill Wilkinson is working on with NHSE needs to be circulated to the group.

JWi

9. Vulnerable Practices – Alexia Stenning

Alexia advised the committee on the vulnerable practices scheme and that NHSE, CCG and LMC had identified and prioritised practices, along with self‐ nominated practices. The criteria used for standardisation was used for all 27 practices. Nicholas Ince confirmed that any diagnostic element would identify why they are vulnerable and would be funded by Central Midlands NHS. Alexia confirmed that are currently five vulnerable practices identified within Milton Keynes CCG, Neath Hill it was agreed would be dealt with separately due to different issues.

10. Prime Minsters Challenge Fund – Susan Hoath Susan Hoath advised that the letter sent from NHSE and the CCG will be responded to prior to the deadline and the reports circulated where been written prior to receipt of the letter from NHSE and the CCG/ The following points



Currently working to a project plan until end May

The governance structure was discussed at the last collaboration board meeting and they are comfortable with the programme director and the clinical SRO. There has been some management changes within MKUCS

There will be a national evaluation, the children’s and rapid response will be done as per the original proposal but access will need re‐profiling.

Access is now up and running with on average 330 GP slots per week

95% of appointments used

DNA rates are especially high at weekends over 25% did not attend on Sunday even though patients are sent a text reminder with an option to cancel

Currently not run at maximum capacity this is due to the DNA rates and the project team will observe these figures for the next few weeks to see if more capacity is required or that the current level is meeting demand, the staff to fulfil this capacity is already in place

A couple of minor incidents have been flagged up but have been dealt with immediately these are a temporary residents, walk in patients as all appointments are pre‐bookable only via the registered GP practice and two patients who were booked in for a clinical need outside the service specification.

There is a communication plan that has been developed once confirmation on how long the project will continue for.

Project team has met with the five hubs to see what is working well, difficulties and what is not working.

Date of Next meeting: 6 April 2016 /BR1/3pm at Sherwood Drive

PRACTICE

ROOMS Floor PRINCIPAL USE TIMES MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

08:30-12:30Dr Whyte Acupuncture Dr Whyte Dr Whyte Dr Whyte

12:30-15:00GP / other admin Acupuncture GP / other admin GP / other admin GP / other admin

15:00-18:00Dr Whyte Acupuncture Dr Whyte Dr Whyte Dr Whyte

08:30-12:30Dr Sekharan Midwife (visiting) Dr Sekharan Dr Sekharan Dr Sekharan

12:30-15:00GP / other admin Midwife (visiting) GP / other admin GP / other admin GP / other admin

15:00-18:00Dr Sekharan Midwife (visiting) Dr Sekharan Dr Sekharan Dr Sekharan

08:30-12:30Dr Moore Dr Moore GP Registrar Dr Moore Dr Moore

12:30-15:00GP / other admin GP / other admin GP / other admin GP / other admin GP / other admin

15:00-18:00Dr Moore Dr Moore

visiting cliniciansDr Moore Dr Moore

08:30-12:30Practice Nurse MS Practice Nurse S Practice Nurse MS Practice Nurse MS Practice Nurse MS

12:30-15:00Practice Nurse MS Practice Nurse S Practice Nurse MS Practice Nurse MS Practice Nurse MS

15:00-18:00Practice Nurse MS

visiting cliniciansPractice Nurse MS Practice Nurse MS Practice Nurse MS

08:30-12:30Practice Nurse FM Practice Nurse FM Practice Nurse J Practice Nurse FM Practice Nurse J



08:30-12:30Practice Nurse FM ENT Clinic Practice Nurse FM Practice Nurse FM Practice Nurse FM



08:30-12:30Dr Lawrence Dr Lawrence Dr Lawrence Dermatology Dr Lawrence

12:30-15:00GP / other admin GP / other admin GP / other admin Dermatology GP / other admin

15:00-18:00Dr Lawrence Dr Lawrence Dr Lawrence Dermatology Dr Lawrence

Practice Nurses &

clinics

Consulting Room 7 -

GP Partner

G GP Partner (4 days

per week)

Consulting Room 6 -

Nurses & clinics

G


per week)

Consulting Room 4 -

Practice Nurses

G Practice Nurses

Room

G Practice Nurses

Room

Consulting Room 5 -

Practice Nurses

RENTALISED AREA

Consulting Room 1 -

GP Partner


per week)

Consulting Room 2 -

GP Partner


per week)

MILTON KEYNES VILLAGE PRACTICE: CURRENT ROOM UTILISATION SCHEDULE : FEBRUARY 2016

Consulting Room 3 -

GP Partner

PRACTICE

ROOMS Floor PRINCIPAL USE TIMES MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

RENTALISED AREA

Consulting Room 1 -

GP Partner


per week) 08:30-12:30Dr Egan Dr Egan

visiting cliniciansDr Egan Dr Egan


15:00-18:00Dr Egan Dr Egan Practice Nurse S Dr Egan Dr Egan

08:30-12:30Dr Rice Dr Rice Dr Rice Dr Rice community services


15:00-18:00Dr Rice Dr Rice Dr Rice Dr Rice community services

08:30-12:30Practice Nurse JD Practice Nurse JD Practice Nurse JD Practice Nurse S Podiatry

12:30-15:00Practice Nurse JD Practice Nurse JD Practice Nurse JD Practice Nurse S Podiatry

15:00-18:00Practice Nurse JD Practice Nurse JD Practice Nurse JD

visiting cliniciansPodiatry

08:30-12:30Practice Nurse G Practice Nurse G Practice Nurse G Practice Nurse K Practice Nurse K



08:30-12:30SE's Registrar

visiting cliniciansSE's Registrar SE's Registrar SE's Registrar

12:30-15:00GP / other admin Stop Smoking GP / other admin GP / other admin GP / other admin

15:00-18:00SE's Registrar Stop Smoking SE's Registrar SE's Registrar SE's Registrar

08:30-12:302nd Registrar 2nd Registrar community services 2nd Registrar 2nd Registrar

12:30-15:00GP / other admin GP / other admin community services GP / other admin GP / other admin

15:00-18:002nd Registrar 2nd Registrar community services 2nd Registrar 2nd Registrar

08:30-12:30HV Meeting Physiotherapy HV Clinic HV Clinic Physiotherapy

12:30-15:00admin etc Physiotherapy admin etc admin etc admin etc

15:00-18:00 Baby Clinic Physiotherapy HV checks Physiotherapy HV checks

Consulting Room 8 -

GP Partner


per week)

GP Registrar Room

1

G GP Registrar

Treatment Room 1 G Juliane's Room

Treatment Room 2

Patient Activity

Room (non clinical)

G Baby clinics, health

education &

physiotherapy

Consulting Room 9 -

GP Partner


per week)

GP Registrar Room

2

G GP Registrar

G Kate's Room

PRACTICE ROOMS Floor PRINCIPAL USE TIMES MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

08:30-12:30 new GP new GP new GP new GP new GP

12:30-15:00 GP / other admin GP / other admin GP / other admin GP / other admin GP / other admin





08:30-12:30 new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee


15:00-18:00new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee

08:30-12:30 new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee


15:00-18:00new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee new Registrar/Trainee

08:30-12:30 new NP / PN new NP / PN new NP / PN new NP / PN new NP / PN






08:30-12:30 SE's Registrar visiting clinicians SE's Registrar SE's Registrar SE's Registrar

12:30-15:00 GP / other admin Stop Smoking GP / other admin GP / other admin GP / other admin

15:00-18:00 SE's Registrar Stop Smoking SE's Registrar SE's Registrar SE's Registrar

08:30-12:30 2nd Registrar 2nd Registrar community services 2nd Registrar 2nd Registrar

12:30-15:00 GP / other admin GP / other admin community services GP / other admin GP / other admin

15:00-18:00 2nd Registrar 2nd Registrar community services 2nd Registrar 2nd Registrar

08:30-12:30 HV Meeting Physiotherapy HV Clinic HV Clinic Physiotherapy

12:30-15:00 admin etc Physiotherapy admin etc admin etc admin etc

15:00-18:00

Baby Clinic Physiotherapy HV checks Physiotherapy HV checks

new Nurse

Practitioner /

Practice Nurse

Current GP Registrar

Room 2

REPROVIDED &

ENLARGED PATIENT

ACTIVITY ROOM

G Current Patient

Activity Room

relocates -inc baby

clinics, health ed &

physiotherapy

REPROVIDED CR

FROM CURRENT

REGISTRAR ROOM 1

G Current GP Registrar

Room 1

A larger

range of

procedures,

including

cryotherapy.

Note: The Practice can offer this facility, and their minor-prodedures service, to patients from other surgeries under

additional service agreements. The GPs are planning to sign up to the next level of this enhanced service for minor

procedures etc. The suite can also be available for use by visiting clinicians when required.

G

NEW CONSULTING

ROOM B

G new GP Partner /

Salaried GP or

equivalent

NEW CONSULTING

ROOM E

G

NEW CONSULTING

ROOM F

G new Nurse

Practitioner /

Practice Nurse

G new GP Registrar /

Trainee (4th

placement for

Practice)

G new GP Registrar /

Trainee (3rd

placement for

Practice)

RENTALISED AREA

NEW TREATMENT

ROOM SUITE

(INC

PREP/RECOVERY/CD

U)

Minor Procedures

Room (with prep /

recovery room, clean

& dirty utility).

REPROVIDED CR

FROM CURRENT

REGISTRAR ROOM 2

G

NEW CONSULTING

ROOM D

MILTON KEYNES VILLAGE PRACTICE: PROPOSED EXTENDED PREMISES UTILISATION SCHEDULE : FEBRUARY 2016

NEW CONSULTING

ROOM A

G new GP Partner /

Salaried GP or

equivalent

NEW CONSULTING

ROOM C

PRACTICE ROOMS Floor PRINCIPAL USE TIMES MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

A larger

range of

procedures,

including

cryotherapy.

Note: The Practice can offer this facility, and their minor-prodedures service, to patients from other surgeries under

additional service agreements. The GPs are planning to sign up to the next level of this enhanced service for minor

procedures etc. The suite can also be available for use by visiting clinicians when required.

G

RENTALISED AREA

NEW TREATMENT

ROOM SUITE

(INC

PREP/RECOVERY/CD

U)

Minor Procedures

Room (with prep /

recovery room, clean

& dirty utility).

08:30-12:30 Dr Whyte Acupuncture Dr Whyte Dr Whyte Dr Whyte

12:30-15:00 GP / other admin Acupuncture GP / other admin GP / other admin GP / other admin

15:00-18:00 Dr Whyte Acupuncture Dr Whyte Dr Whyte Dr Whyte

08:30-12:30 Dr Sekharan Midwife (visiting) Dr Sekharan Dr Sekharan Dr Sekharan

12:30-15:00 GP / other admin Midwife (visiting) GP / other admin GP / other admin GP / other admin

15:00-18:00 Dr Sekharan Midwife (visiting) Dr Sekharan Dr Sekharan Dr Sekharan

08:30-12:30 Dr Moore Dr Moore GP Registrar Dr Moore Dr Moore


15:00-18:00 Dr Moore Dr Moore visiting clinicians Dr Moore Dr Moore

08:30-12:30 Practice Nurse MS Practice Nurse S Practice Nurse MS Practice Nurse MS Practice Nurse MS

12:30-15:00 Practice Nurse MS Practice Nurse S Practice Nurse MS Practice Nurse MS Practice Nurse MS

15:00-18:00 Practice Nurse MS visiting clinicians Practice Nurse MS Practice Nurse MS Practice Nurse MS

08:30-12:30 Practice Nurse FM Practice Nurse FM Practice Nurse J Practice Nurse FM Practice Nurse J



08:30-12:30 Practice Nurse FM ENT Clinic Practice Nurse FM Practice Nurse FM Practice Nurse FM



08:30-12:30 Dr Lawrence Dr Lawrence Dr Lawrence Dermatology Dr Lawrence

12:30-15:00 GP / other admin GP / other admin GP / other admin Dermatology GP / other admin

15:00-18:00 Dr Lawrence Dr Lawrence Dr Lawrence Dermatology Dr Lawrence

08:30-12:30 Dr Egan Dr Egan visiting clinicians Dr Egan Dr Egan


15:00-18:00 Dr Egan Dr Egan Practice Nurse S Dr Egan Dr Egan

08:30-12:30 Dr Rice Dr Rice Dr Rice Dr Rice community services


15:00-18:00 Dr Rice Dr Rice Dr Rice Dr Rice community services

08:30-12:30 Practice Nurse JD Practice Nurse JD Practice Nurse JD Practice Nurse S Podiatry

12:30-15:00 Practice Nurse JD Practice Nurse JD Practice Nurse JD Practice Nurse S Podiatry

15:00-18:00 Practice Nurse JD Practice Nurse JD Practice Nurse JD visiting clinicians Podiatry

08:30-12:30 Practice Nurse G Practice Nurse G Practice Nurse G Practice Nurse K Practice Nurse K



ADDITIONAL SESSION

SUGGESTIONS

G

G

Nurse-led Treatment

Room 2

G

Consulting Room 7 -

GP Partner

G

Consulting Room 1 -

GP Partner

dedicated clinics for asthma, diabetes, weight management & COPD, as well as for baby clinics, immunisations & child health plus physio, podiatry & OT services,

also teaching, training, records updating & scanning, family planning & parenting classes.

Consulting Room 3 -

GP Partner


per week)

Kate's Room


per week)


per week)

Consulting Room 2 -

GP Partner

Consulting Room 9 -

GP Partner

Consulting Room 5 -

Practice Nurses

G Practice Nurses

Room

Consulting Room 6 -

Nurses & clinics

G Practice Nurses &

clinics

GP Partner (4 days

per week)

GP Partner (4 days

per week)

Consulting Room 8 -

GP Partner

Nurse-led Treatment

Room 1

G Juliane's Room

GP Partner (4 days

per week)

Consulting Room 4 -

Practice Nurses

G Practice Nurses

Room

Revision

Date

Drawn Note

P134 MK VIllage Surgery Feas 1.pln

01

Proposed Alterations & Extensions toMilton Keynes Village PracticeGriffith Gate, MK, Bucks

Primary Health Investment PropertiesClient

Project Title

Drawing Title

Drawing Status

DateDrawn By Checked By (File copy only)

Job No. Drawing No. Revision

Scale at A1

This Drawing To Be Read In Conjunction With Other Relevant Consultants and SpecialistsDrawings And Specifications

P134

Existing Plans

1 Millers YardRoman Way

Market HarboroughLeicestershire

LE16 7PW

t : 01858 464986 brp-architects.com

brp (arch) ltd accept no responsibility for work notundertaken fully in accordance with the contents of this drawing

and related specifications.

© COPYRIGHT brp (arch) ltd

16.8 m2

17.2 m2

17.4 m2

17.4 m2

17.1 m2 17.1 m2

17.3 m2

3.3 m2 3.8 m2

0 m2

2 m2

3.7 m2

1.2 m2

16.9 m2

4.2 m2

14.9 m2

2.6 m2

43.3 m2

10.2 m2

17.1 m2 17.4 m2

10.7 m2

65.2 m2

5.9 m2

37.8 m2

Existing Gross Floor Area 466.7 m2

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

TreatmentRoom

Clea-ner

DisWC

Reception

Elecs

Patient ActivityClinic

Waiting Room

Store

Dis WC/ BC

LobbyAdministration

Dentist

Pharmacy

ConsultingRoom

Staff WC

3.3 m2

17 m2

1.7 m2

8.7 m2

5.8 m2

24.6 m2 20.9 m2

14.7 m2

25.5 m2

1.8 m2

3.6 m2

17.1 m2

3.7 m2

4.2 m2

11.3 m2

Exiting Gross Floor Area 214.8 m2

Training /Meeting Room Admin

Lift Motor/ Store

Wc

Health Visitor

Store

SecretariesStaff Change Comms /

ArchivePracticeManager

PlantRoom

CommonRoom

WC Shower

Preliminary

03.02.16APS

~

First Floor Plan

Ground Floor Plan Scale (m)

0 2 3 4 51 10

1:100 @ A1

Plans have been developed from as-built floor plans taken fromthe Health & Safety file held on site and need to be verified byextensive site checks.

permissible extent of extensions determined by acquisition linetaken off As-Built Site and Location Plan drawing No K219-L002-AB as extracted from the Health & Safety file held on site withoutknowledge of any easements, restrictions impositions or the likethat need to be clarified in due course

Revision

Date

Drawn Note

P134 MK VIllage Surgery Feas 2.pln

03

Proposed Alterations & Extensions toMilton Keynes Village PracticeGriffith Gate, MK, Bucks

Primary Health Investment PropertiesClient

Project Title

Drawing Title

Drawing Status

DateDrawn By Checked By (File copy only)

Job No. Drawing No. Revision

Scale at A1

This Drawing To Be Read In Conjunction With Other Relevant Consultants and SpecialistsDrawings And Specifications

P134

Feasibility Plans (2)

1 Millers YardRoman Way

Market HarboroughLeicestershire

LE16 7PW

t : 01858 464986 brp-architects.com

brp (arch) ltd accept no responsibility for work notundertaken fully in accordance with the contents of this drawing

and related specifications.

© COPYRIGHT brp (arch) ltd

93.8 m2

20.8 m2

36.8 m2

7.4 m2

10.7 m2

17.2 m2

17.4 m2

17.4 m2

17.1 m2 17.1 m2

17.3 m2

3.3 m2 3.8 m2

0 m2

2 m2

3.7 m2

1.2 m2

16.9 m2

4.2 m2

14.9 m2

2.6 m2

7.5 m210.2 m2

20 m2

16.1 m2

16 m2

16 m2

5.9 m2

8.4 m2

15 m216 m2

16 m216 m2

18.6 m2

3.1 m2

16 m2

17.1 m2

Proposed Gross Floor Area 802.2 m2

Existing Gross Floor Area 466.7 m2

40 m2

3.8 m2

2.1 m2

16.8 m2

17.1 m2

2.2 m2

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

TreatmentRoom

Clea-ner

DisWC

Reception

Elecs

Waiting Room

Store

Dis WC/ BC

LobbyAdministration

Dentist

Pharmacy

ConsultingRoom

Staff WC

ConsultingRoom

ConsultingRoom

ConsultingRoom

ConsultingRoom

Non-ClinicalInterview

MinorProcedures

Change

DirtyUtility

Recovery

ConsultingRoom

ConsultingRoom

ConsultingRoom

HealthVisitors

ConsultingRoom

Rooflight

Records

CleanUtility /ClinicalStore

Down

Health PromotionRoom

Store

WC

St

Staff Only

Staff Only

Staff Only

Staff Only

Staff Only

Sta

ff O

nly

3.3 m2

17 m2

1.7 m2

8.7 m2

5.8 m2

25.5 m2

1.8 m2

3.6 m2

17.1 m2

3.7 m2

4.2 m2

11.3 m2

1.8 m2

1.4 m2

10.7 m216 m229.5 m2

Exiting Gross Floor Area 214.8 m2

Proposed Gross Floor Area 214.8 m2

Training /Meeting Room

Lift Motor/ Store

Wc

Store

SecretariesStaff Change Comms /

ArchivePracticeManager

PlantRoom

CommonRoom

WC Store

St

St

Kitchen

Down

AdministrationPractice

New replacementAcoustic

Sliding Partition

Preliminary1:100 @ A1

03.02.16APS

~

First Floor Plan

Ground Floor Plan Scale (m)

0 2 3 4 51 10

Plans have been developed from as-built floor plans taken fromthe Health & Safety file held on site and need to be verified byextensive site checks.

permissible extent of extensions determined by acquisition linetaken off As-Built Site and Location Plan drawing No K219-L002-AB as extracted from the Health & Safety file held on site withoutknowledge of any easements, restrictions impositions or the likethat need to be clarified in due course

1

Outline Business Case for procurement and developmentof primary medical care premises.

Development Title: Red House Surgery Bletchley

Outline Business Case & Supporting Information

March 2016

Final

2

Contents Page

1.0 Sponsoring NHS Organisation

2.0 Source of Capital

3.0 Title of Scheme

4.0 Capital Value

5.0 Contact Details

6.0 Scheme Summary / Description

7.0 Strategic Case

8.0 Economic Case

9.0 Site Appraisal

10.0 Project Plan

11.0 Key Risks / SWOT Analysis

12.0 Further Supporting Information

13.0 Option Appraisal

14.0 Summary & Conclusion

Appendices

Appendix A – Schedule of AccommodationAppendix B – Plans of existing premisesAppendix C – NHS England CMR Letter

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1.0 Sponsoring NHS Organisation

NHS England Midlands & East (Central Midlands)3rd Floor Charter House,ParkwayWelwyn Garden CityHertfordshireAL8 6JL

Contact – Sue Fogden MRICS LLB (Hons) / Annley [email protected] / [email protected]

1.1 Interested Commissioning Organisation

NHS Milton Keynes Clinical Commissioning GroupPlace Sherwood,Sherwood DriveMilton KeynesBuckinghamshireMK3 6RT

Alexia Stenning – Assistant Director of Primary CareJanine Welhan – Primary Care Development [email protected]@miltonkeynes.nhs.uk

1.2 GP Practice Details

Red House Practice241 QueenswayBletchleyMK2 2EH

Jane Hanlon – Practice Manager / Dr Paul Staten – Lead [email protected]@miltonkeynes.nhs.uk

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2.0 Source of Capital

The Red House Practice initially bid for funding under the Primary Care Infrastructure Fund in February 2015.The bid was to purchase the adjacent property to allow the practice to extend services and alleviate theobvious space issues. The PID was initially supported by the PCIF scheme, however, it was established that asthe purchase and refurbishment was unlikely to happen in the 12 month time period allowed under thisscheme that the scheme should be deferred while still supported. As a result NHSE and CCG have advisedthe practice to draw up an Outline Business Case outlining options for development. The route for fundingwill be via the Primary Care Transformation Fund and also utilising any S106 money available from the LocalAuthority. This OBC will therefore be used as a Project Inception Document (PID) for the PCTF.

This OBC will set out options for capital requirements plus revenue implications for both a GP developmentand a 3rd party development.

The full extent of revenue and capital implications are shown in table 8, however, at this stage these areindicative as there is no firm commitment on sites in the area and no discussions have taken place with theDistrict Valuer in terms of Current Market Rent.

3.0 Title of the scheme

The scheme title is Red House Surgery Development.

4.0 Capital Value / Cost

The capital value of the scheme has been calculated by using inputs of construction cost plus site andprofessional fee costs. All taxes have also been applied to provide an outline capital cost of £4.7m. We noteagain that this is provisional and subject to confirmation as set out in section 2.

5.0 Contact Details

NHS Milton Keynes Clinical Commissioning GroupPlace Sherwood,Sherwood DriveMilton KeynesBuckinghamshireMK3 6RT

Alexia Stenning – Assistant Director of Primary [email protected]

GP Practice DetailsRed House Practice241 QueenswayBletchleyMK2 2EHJane Hanlon – Practice [email protected]

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6.0 Scheme Summary / Description

1.3 Background and supporting Information

Table 1Red House Practice Number Full

TimePartTime WTEs

Number of Partners 5 4 1 3.32Number of Registrars 0Number of Salaried GPs 5 1 4 4Number of Practice Nurses 4 1 3 3.32Number of Healthcare support workers 4 2 2 2Number of Administration Staff 19 13Number of Staff 36 25.64

5 year patient growth for Red House Practice

Table 2Year Patients2011 121832012 132262013 134112014 136942015 13881

Note - The practice have seen growth of over 12% in 5 years.

Services Provided Table 3

Service No of Sessions FrequencyGP’s 62 WeeklyGPRGMS Nursing [inc HCA] 37 WeeklyHealth Visiting (HSCC) Only held when available

space.Maternity 3 WeeklyMinor Surgery Registered When required and

scheduledFamily Planning * 1 WeeklyTravel Clinic * Incorporated in nurse timeCounselling No longer available due to

lack of space.Psychotherapy No Longer available due to

lack of spaceCommunity Nurses Office space within building

but unable to provide clinicsdue to space.

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Child Immunisation * 1 WeeklyChronic Disease Management * Incorporated in nurse/gp

timeLeg Ulcers * Incorporated in nurse time WeeklyHealth Checks Incorporated in HCA time WeeklyExtended Hours 7 hours per week WeeklyFour New DES Incorporated in GP/nurse

timeWeekly

Influenza/Pneumococcal 2 Saturdays a year and alsoincorporated in nurse time

Learning Disabilities * Incorporated in nurse timeAlcohol Reduction * Incorporated in nurse/GP

time

Demographic of population and patientsTable 4

Age Range Male Female Total0 to 5 465 476 9416 to 15 710 729 143916 to 25 671 711 138226 to 35 898 943 184136 to 45 881 855 173646 to 55 965 987 195256 to 65 834 871 170566 to 75 683 818 150176 to 85 369 458 82786 to 95 66 176 24296 to 105 6 13 19

Totals 6548 7037 13585

Red House Practice

Male patients 2015 = 6548 Female patients 2015 = 7037

7.0 Strategic Case

7.1 Local Strategy – Local Developments and Growth

The Red House Surgery Bletchley has resorted to closing its patient list due to the pressures placed on it byregional growth. The current list is just short of 14,000 patients and has seen growth of 12% in the past 5years or 1,400 new patients in that time. The Milton Keyes area grew by over 20% between 2003 and 2013

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compared to an England average of 8.9% over the same period. Furthermore Milton Keynes and Bletchleyare area of significant housing growth due to good links to London. Recent planning approvals are containedin Table 5 below:

Table 5Development Residential Units NotesFairfield / Stony Stratford 2220 North West AreaWhitehouse 4330 North WestOxley Park East 1410 1200 completeKingsmead South 410 In progressTattenhoe Park 1260 Western ExpansionNewton Leys 350 CommencedEaton Leys 1900 subject to planning

Total Units 11,880

By using a standard residential calculator of 2.4 people per dwelling, the increase in patient population in theBletchley region is circa 29,000 up 2031 and 19000 by 2024/25. The illustrations below give an idea if theimpact on population with graph one relating to Fairfield and Whitehouse and graph 2 relating to Oxley Park,Kingsmead South and Tattenhoe Park.

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Other developments in Newton Leys and Eaton Leys have not been profiled by the local authority in terms ofimpact on local services, however, it should be noted that the Local Authority planning to receive more than£150m in S106 / CIL for these developments. It should also be noted that there are a further 15,000 newhomes planned for central and eastern Milton Keynes (Reference 150423 Delivery Pack Milton KeynesInfrastructure Coordination Delivery Service).

The Red House Practice has no room to expand to cater for this significant growth in population. There iscurrently insufficient room for the GP’s at the practice and practice nurses, HCA and phlebotomists sharefacilities which in turn restrict access and appointments. The Respiratory nurse has to hold clinics when GP’sare on leave as there is not enough space to cater for them during peak times. The current accommodationextends to 428.58 sqm which equates to approximately 27.92 patients per sqm. This is more than double theprovision in SFA 2004/5 and reflects the need for new premises for this practice.

A 14,000 patient practice should have accommodation of circa 1446sqm to accommodate the growingdemands of patients, the move to offer additional services in the primary care setting and to cater forpopulation growth in the region. An initial draft schedule of accommodation is contained in Appendix 1 andis calculated using the HBN11-01 planning tool based on patient contacts and also adds an element ofgrowth due to the housing developments commencing in the immediate area. The initial findings of HBN11-01 indicated the building is significantly undersized being only 32% of the 1446sqm suggested in thecalculations.

The practice patient reach is extensive (see Fig 1 below) and as such the population growth to the south,east and west of Bletchley will impact in some way on the practice ability to grow.

Fig 1

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7.2 CCG Strategy

Milton Keynes CCG 5 Year Strategy states:

As the primary organisation within Milton Keynes for commissioning health services to meet all therequirements of patients, the CCG will work collaboratively to ensure that it can meet the needs of the localpopulation whilst living within its delegated resource limit. Improving the health of the local population is keyto this aim, and is being delivered through the implementation of locally agreed individual commissioningstrategies for Urgent Care3, Mental Health4, Older People5, Dementia6, Children & Young People7. ATransforming Primary & Integrated Strategy8 is also being developed, which lays out the ambition tocommission a greater proportion of activity in community and home settings in order to rebalance the healtheconomy and the Primary Care Development Strategy9 which underpins how the CCG can support NHSEngland in the delivery of high quality of services in primary care.

Some of the main issues within Milton Keynes are:

Population growth of over 19% between 2012 and 2026 Increase in average life expectancy Increase in annual birth rate of 40% since 2001. Over 85’s increase of 95% by 2026 Over 60’s population set to grow by 15% between 2011 and 2016.

The CCGs vision is to provide greater scope of services and increase access within primary care. In order toachieve this vision one of the primary enablers is property and its suitability to deliver the changes needed.The CCGs Primary Care Strategy 2013 states:

Primary Care Estate and premises

The CQC has a mandate for ensuring that essential standards of quality and safety are met. However, theCCG will encourage practices to offer premises that:-

Deliver care in the right place with the right access Provide the patient with an environment that is fit for purpose Ensures easy access with clear sign posting Meets all statutory and mandatory requirements including compliance with all relevant disability,

fire, health and safety legislation Embraces sustainability agenda

The CCG will undertake an assessment of the current estate suitability for primary care in Milton Keynes. Thestrategic direction is towards larger practices, able to provide a range of general medical services, enhancedservices and community based healthcare.

As a result of this study several schemes have been developed and others are in planning. Furthermore theRed House redevelopment has been supported by the CCG as a priority in the south of the region asreported in the Joint Premises Meeting December 2015 item 7:

“Kieran Leigh gave an update on behalf of Sue Fogden, the National team has given approval to proceed onthe larger value schemes (fees only, no commitment to on-going revenue or capital), the OBCS must be fullycompleted by 31 March 2016, currently MKCCG has one scheme the Red House surgery.”

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The meeting was further advised that:

“Future PID schemes will focus on a longer term vision and any potential projects will need to be movedforward. It was agreed that a working group is required on premises strategy and to look at the following:-

Where we are currentlyWhat is required/what is the outcomeHow to process this for services for the future population

7.3 National Strategy

NHS England’s Five Year Forward view sets out key objectives to change the way healthcare is delivered inEngland. At the core is:

1. Improved seven day access to effective care2. Increased capacity for primary care services out of hospital3. Commitment to a wider range of services as set out in the CCG’s commissioning intentions to reduce

unplanned admissions to hospital4. Increased training capacity

Following its publication, several guidance papers have been produced by NHS England to assist them indrawing up strategies to meet the needs of the changing NHS in their regions. It is important to note thatone size will not fit all and many of the objectives will be tailored to meet the regional needs rather than anotional national requirement. The significant patient and population growth in this region of England isobviously one of the main driving factors for change. While accommodating the growth through premisesdevelopments the CCG can also influence and introduce change to the way health is delivered. Modern wellequipped premises will result in provision for greater access, wider services and joint working within theregion.

The Red House scheme will address the key areas of the Five Year plan as follows:

Goal 1 - Improving seven day access to effective care

The Red House Practice is leading in primary care within Bletchley and is working with Milton Keynes CCGand NHS England to deliver effective care to patients in the locality seven days a week.

They are participating in the Prime Minister’s Challenge Fund scheme along with 21 other practicesregionally to extend hours and provide 7 day effective care to patients. Unfortunately due to buildingconstraints Red House is unable to become the hub for these services and the premises are not suitable.

A new development would facilitate:

1. Extended hours as part of the regional practice network2. Acting as a hub to assist in the triage of patients regionally to reduce admissions to hospital.3. Provide 7 day effective care through the network for high use and high risk groups (over

65’s)4. Provide MIU services regionally to high risk groups to reduce admissions to hospital.

Milton Keynes CCG 5 Year Strategy

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Services beyond core GMS will be delivered through a collaborative working approach. Like minded practiceswill federate to deliver an enhanced range services that move care close to home. Primary care at scale (todeliver 7days a week, 8am to 8pm) will be delivered through an integrated approach such as currently existsin MKUCS where our practices are currently members. GP as case manager / consultant at top of pyramidcalling on others including nurse practitioners, Extended Scope Practitioners, mental health, social care.Single point of access to ensure coordinated response to health and social care needs.

Goal 2 - Increased capacity for primary care services out of hospital

The poor space and condition of the premises portrays an unprofessional NHS service to 14000 patients inthe locality. It has been recognised that the overall healthcare experience delivered from these premises issignificantly below the accepted standard both regionally and nationally. The new facility would be betterlocated for the core patients and the growth areas in Bletchley and also better suited to offer additionalservices to meet strategic goals. All of these issues would be addressed with a new development.

The current schedule of accommodation and patient contact data suggests a modern health care facility of1446sqm to comply with HTM11-01 should be provided for the current 14,000 patients registered at the RedHouse practice and a factor has been added to accommodate not only the increase population growth butalso the aging population, increase in services and increase health education and training. The currentpremises extend to circa 428sqm which indicates the current provision is already circa 70% undersizedwithout population growth projections. This obviously has an impact on the services delivered and theopportunity to extend services for the future. The practices are committed to extending services in the newdevelopment and are regionally recognised as innovative, forward thinking and adaptable. Some of theinitiatives they would like to provide are:

Having the capability and flexible space to provide other multiple Locality based services counselling,Physiotherapy, Chiropody.

Accommodation for specialist nurses - dementia, mental health, Parkinson's, epilepsy, MS, tobecome the hub of services on the region.

Aspire to provide 8am to 8pm 7 days per week with right facilities and putting in models of care tofacilitate this.

Diagnostics space for ultra sound scanning for early intervention. Community hub for health and wellbeing promotion and education

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Provision of equitable access and quality care.

The practice wants to become a focal point for the community, where they can organise the patient health,wellbeing and social care requirements. They can also integrate the voluntary sector into the model of carefor patients.

How will this scheme achieve this?

The practice is currently constrained by space and has been looking at providing a wide variety of LES’ andPCOCs locally. However, they are not able to participate in the majority of these because of our lack of sparerooms. They do have visiting specialist dermatology nurses, a clinical psychologist attends at present to seepatients, the HVs use a room to see patients and they have a visiting community pharmacist who assists thepractice on a regular basis. They have been asked to hold memory clinics and act as a hub for a sexualhealth outreach clinic but cannot due to lack of rooms. They would like to host outreach clinics but areunable to. The practice would also like to host federation and training meetings but have no facilities to hostthese events.

A new development would create a regional hub for additional services and also for meeting and conferencefacilities for the wider Milton Keynes region.

Milton Keynes – Five Year Strategic Plan

The development meets the key points contained in Milton Keynes CCGs Primary Care Strategic Plan asfollows:

Adopting new ways of working.A recent report “Primary Care: Today and tomorrow - Improving general practice by working differently”identifies some possible solutions to the challenges of increased scale and scope of practice along with anincreased emphasis on standards and scrutiny. These include:

The GP as a generalist working with others to deliver more care in the community and acting as thecare navigator

Adoption of GP led triage systems to improve the effectiveness of consultations The development of new primary care access models including polyclinics, extended hours and

practice federations Developing integrated care models across health and social care and across primary, community and

secondary care Shared decision making and self-management Developing a focus on customer care Using more complex nursing skill mixes Pharmacist led care Productive general practice Single accountable care providers Multidisciplinary team working Primary care led specialist clinics Home based self-management of conditions such as rheumatoid arthritis Innovative use of technology for monitoring and communication Financial incentives

These models will be explored through the period of this strategy.

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Goal 3 - Commitment to a wider range of services as set out in your commissioningintentions to reduce unplanned admissions to hospital

There is no room in the practices to provide health & wellbeing or health promotion activities and there is aninability to deal with local emergencies or unplanned care. The development of new premises would allowthe local NHS to address these issues as follows:

Unplanned Care:

Better staffing which would facilitate implementation of wrapping care around the communityneeds.

Closer liaison with ‘Out of Hours’ providers Closer liaison with Acute Trust Access to a pharmacist and other community health providers Better able to achieve local Admission Avoidance strategies Better able to provide minor injury care Better able to provide “Extended Hours” appointments

Planned care:

Better able to reduce referrals and improve on appropriate referrals to Secondary Care clinics byusing “in-house” sub-specialists MSK Services with OPD Rheumatology clinics (e.g. Dermatology GPspecialists, and have trained nurse practitioners in diabetes, COPD and gynae and contraceptiveservices). They would also like to be central place for Phlebotomy, ECG and Diabetes Clinic to takeplace

Reduce out-patient follow-up using specialist nurses/GPs Direct physiotherapy access for musculoskeletal/chronic neurological problems Integration with and hosting of Community Teams. The practice is already working on this with the

Integrated Care Planning and hope to be at the level of Whole Systems Integrated Care imminently. Integration with social services Patient education: courses, leaflets, patient library, IT access, motivational interviewing, dietary

advice, exercise classes. Enhanced minor surgery with infection control compliant suite Engage fully with Mental Health initiatives – Primary Care Mental Health Workers and in-house

counselling Smoking cessation classes and support

Every Patient Counts 2014/15 and 2016/17 - High quality care. We will be driven by quality in all we do.No longer can we accept minimum standards as good enough – our patients rightly expect the bestpossible service.One of our key aims is to enable general practice, community pharmacy and other primary care servicesto play a much stronger role, at the heart of a more integrated system of community-based services, inimproving health outcomes. It is clear from the Call to Action that there is a widespread appetite fordeveloping new models of primary care that provide more proactive, holistic and responsive services forlocal communities, particularly for frail older people and those with complex health needs; play astronger role in preventing ill-health; involve patients and carers more fully in managing their health; andensure consistently high quality of care. NHS England and CCGs have a joint responsibility to drive up allaspects of quality in primary care services.

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There is a growing consensus that this will mean enabling general practice to work at greater scale and incloser collaboration with other health and care organisations, whilst retaining personal continuity of careand strong links with local communities.

Goal 4 - Increased training capacity

One of the major challenges facing general practice is recruitment and retention of GPs. The Centre forWorkforce Intelligence was commissioned by the DOH in March 2013 to look into the workforce of GPs inEngland and project the situation up to 2030. Some of the main findings and bullet points are as follows:

Key findings:

Growth in the GP workforce has not kept pace with the increase in the number of medicalconsultants or population growth. The number of GPs rose by 23 per cent on a full-time equivalent(FTE) basis to 32,075 (excluding registrars, retainers and locums) between 1995 and 2013. Bycontrast, the number of consultants in other medical specialties more than doubled over the sameperiod to 39,094 (FTE).

On a per capita basis, the number of GPs per 100,000 people in England has fallen to 59.6 GPs per100,000. The CfWI expects the GP per capita ratio to return to its 2009 peak of 61.5 GPs per 100,000by around 2015.

Boosting the number of GP trainees is proving difficult. Although fill rates have been high and therehas been a modest increase in applications for GP training in the last two years, the number ofaccepted offers to GP training posts in 2013-14 remained below its 2010-11 peak.

The GP workforce is getting younger and more female. By 2030 the average age of GPs will be lowerthan now, and the number of GPs in their 30s is set to increase by around 6,700.

One of the findings was that trained GPs are more likely to settle in the area they trained in rather thanmigrate to other areas. This sends a strong message to local CCGs that increase in training capacity has adirect link to the reinforcement of the GP workforce.

How does this scheme do this?

The Red House Practice are very keen to become a training practice and are actively looking in to the trainingof GPs to become a Trainers in the foreseeable future. They feel this is likely to be possible with additionalrooms but in our present premises it would probably not be feasible.

The patient profile and size of this practice means that they are well suited to become a teaching practiceand be at the vanguard of providing the next generation of GP’s in the region.

Government Pledge

The UK Government made a pre-election pledge for 5000 new GP family doctors by 2020. This has sincebeen amended to net increase, and also includes nurse practitioners; however, the challenge still remainsespecially when it is advised that it takes 10 years to train a GP. Additional and specialist space is required fortraining of GPs with first-hand experience with patients. The new scheme at Bletchley would be suppliedwith training rooms, resource library, video conference and recording facilities and CPD rooms. The currentfacility cannot offer training facilities as the restricted space is used for core GMS activities.

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Goal 5 – Current capacity within primary careHow does this scheme do this?

Projections for population growth in Milton Keynes show that by 2025/6 there will be an additional 19,000people living in the Bletchley region and an additional 50,000 in Milton Keynes. This represents 19% growthfrom 2016 to 2022. An analysis of the practices within Bletchley is shown below in table 6. The sizes havebeen calculated using a factor of 0.09 per patient as set out in SPA 2004/5 Red Book. While HTM11-01 is themore recent guidance the SPA provides a quick snap shot for analytical purposes.

Table 6

Practice List Size NIA HTM11-01 SPA2004 size

Capacity Notes

Red House Surgery 13,800 428 1242 -814 ConvertedParkside Surgery 10,200 720 918 -198 Purpose BuiltWhaddon 11,600 718 1044 -326 Purpose BuiltBedford Street 4200 234 378 -144 Purpose BuiltWestfield Road 5800 295 522 -227 Purpose BuiltDrayton Road 2902 136 261 -125 Converted

Balance -1834sqm

The table indicates a current under provision of circa 1834sqm of space when compared with HTM11-01 andSPA2004/05 Red Book allowances. Further analysis shows that there is current under provision for circa21,000 patients in the region. Given the timescale for this scheme is 2 years it could easily be extrapolatedthat the capacity issues along with population growth equates to a requirement for 40,000 patient places by2019. The Red House scheme will provide a net 1200sqm of this space and therefore plug the capacity gapfor the short to medium term.

Notes:1. Patient list numbers accurate to 20142. NIA figures obtained from Milton Keynes Planning Dept Document.3. The table only includes practices in Bletchley and not Milton Keynes as a whole.

It is clearly demonstrated that there is currently a capacity issue in primary care within the immediateregion. This does NOT allow for the significant population growth in the region as it’s based on 2014 patientlist numbers and is not projected.

8.0 Economic & Commercial Case

8.1 Current Premises Costs

The current Red House Surgery is part owned and part leased premises. The practice extended into the firstfloor above the adjacent pharmacy to allow them to convert previously admin space into consulting space.See appendix 2 for existing plans. The costs for the current premises as valued in April 2015 by NHS Englandindicated a current market rent of £59,000.00 for the premises which breaks down as £133.50 per sqm NIAplus £150 per parking space. Table 7 below provides a further breakdown of costs associated with thebuilding.

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Table 7

Property Current Rent Per Sqm

Red House Surgery £59,000.00 £133.50

Business Rates (Estimate) £39,750.00 £60.96Water Rates £1765.00 £4.12

Current total cost £100,515.00 £198.58

8.2 Proposed Premises Cost Options

At this stage the costs indicated are preliminary and no discussions have taken place with the district valuersin terms of rental tone or build costs for the scheme. Apollo has drawn up a schedule of accommodationusing the principles of HBN11-01 and guidance note 1183, however, a more accurate assessment can becarried out when approval is given to proceed. This schedule is contained in Appendix A and identifies ascheme of circa 1426sqm.This figure accounts for future growth in the region and also the capacity issues asreported in section 7 above. The development and funding route for this scheme is not fully established atthis stage, therefore a series of options are set out below providing the capital costs and revenue costs forthe proposed routes to development. The figure of 1426sqm is gross and we have assumed a net figure of1200sqm for illustration only. In addition, following advice from NHS England we have provided a range ofcosts for rental subject to discussion following approval.

Finally, NHS England and the CCG have advised of Section 106 contributions totalling £1.7m available fromlocal housing developments in the region. The Western Expansion is circa £1.2m and Eastern Expansion£500k. Further S106 contributions can be explored for the Eaton Leys site / development when that schemeis considered for planning in June / July 2016. The S106 contributions have been built into the cost modelsbelow for illustration.

8.2.1 Third Party Development

The 3rd party development and procurement route means that the CCG or GPs will not be required to capitalfund the scheme and also not be required to part with any funds in the preparation of feasibility studies,business cases or planning of the scheme. The developer takes all of the risk and funds the developmentscheme from commencement to completion in line with the Premises Cost Directions 2014. All necessarycapital will be raised by the developer who have completed over £200m of schemes in the UK over the past20 years. The Developers in-house team will identify and secure the site, procure the construction works andhand over a state-of-the-art facility for the GP partners to lease for 25 years. The rent attributed to thedevelopment is paid by the NHS via the GMS Rent Reimbursement contract through the Premises CostDirections 2014. Table 8 below gives an indication of the one off and re-occurring costs that could beexpected on this development, however, it is worth noting that major components of the overall scheme arenot known at this stage so this is purely for illustration. For clarity the illustration is based on 1426sqm coreGMS as the enhanced space will be funded separately.

Following advice from NHSE this OBC provides a rental range for the scheme and this is subject to furtherdiscussion and negotiation with the NHS and DVS.

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Table 8Description Current Costs Future Costs NotesCurrent property costs

A As Table 7 £100,515.00 Sub standard

Re-occurring CostsB Rent on new

development(1200sqm NIA Est)

£222,000.00 to £240,000.00 Based on 1200sqm coreGMS NIA

C VAT on rent £44,400.00 to £48,000.00 Based on 20%D Rates £88,800.00 to £96,000.00 Estimate

E Total Annual Cost £355,200.00 to £384,800.00 Estimation

F Section 106 £1,700,000.00 Providing £68k rent over25 year lease.

G Increase fundingrequired (E-A) plus Fover 25 years.

£186,685.00 to £216,285.00 Subject to DV input andsite purchase cost.

One off costsH Solicitors for GPs £15,000.00 EstimateI Professional Advisor

(Monitor)£12,000.00 Estimate

J Stamp Duty Land Taxfor Lease

£34,200.00 Estimate

K IT Costs £40,000.00 EstimateTotal one off costs £101,200.00

Summary Table 8Description Total Annual Increase Notes

A RevenueImplication

£355,200.00 to £384,800.00 £186,685.00 to £216,285.00 Estimate

B One off Capital £101,200.00 0.00 Estimate

Notes:

1. The intended lease is over a period of 25 years.2. The GMS element of the rent will be determined at Outline Business Case3. The pharmacy lease will be negotiated following PID OBC approval4. Any enhanced spaces will be discussed further with the CCG and Tenant for funding support.5. Section 106 contributions to be paid to CCG to support the re-occurring rent on the scheme.

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8.2.2 – Capital Funding / GP Development

Under the current Primary Care Transformation Fund it is unclear how capital can be apportioned to GP newpremises developments. The current Premises Cost Directions 2014 only allow capital to be provided toextension or refurbishment schemes in return for rent abatement on any new space provided. The capital isusually provided on a 66% basis with the remaining 34% to be provided by the GP contractor. Table 9 belowprovides a breakdown of capital costs for a scheme of this nature.

Table 9Description Current Costs Future Costs NotesCurrent property costs

A As Table 2 £100,515.00

C Construction Costs £2,709,400.00D Land Costs £800,000.00E Consultants / Advice £400,000.00 Including Legal costsF VAT £620,000.00G SDLT £121,000.00H IT Costs £40,000.00I Professional Advisor £10,000.00

Total Costs £4,700,400.00 Estimate

S106 Contributions £1,700,000.00

Capital Requirement £3,000,400.00 Estimate

The illustration above indicates a capital requirement on £4.7m for a new scheme, however, with S106contribution in a lump sum this reduces to £3.04m. On the current premises cost directions apportionmentthis would require a capital investment of £1.983m and the GP investment of £1.021m. The current CMR onthe existing premises is £59,000.00 and this may not support the GP’s going forward if they are required tofund capital of £1.02m.

8.2.3 – Capital Contribution to Revenue Scheme

Apollo has presented proposals to NHS England where capital can be injected into a scheme to abate therent. The analysis has been carried out based on value rather than on capital cost and this can be a costeffective way of offsetting day one cost. The abatement period could still apply and then at the agreedperiod the rent would revert to CMR. In this case the Section 106 contribution of £1.7m could be applied tothe scheme in value terms to off-set a portion of the development over an agreed abatement period. Thiswould have to be modelled with the agreed CMR and site purchase inputs to come to an agreed position.

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9.0 Site Appraisal

A long list of sites has been drawn up for further investigation, these are:

Site Search – Long List

1. Red House Surgery – Possibe Redevelopment of existing site – 0.30 acres2. Denmark Street Car Park plus adjoining property – 0.30 acres3. The Saplings Sure Start and Knowles Nursery – 0.30 acres4. Maybrook House – 0.1 acres5. Bletchley Library – 0.40 acres6. Police & Fire Station – 0.75 acres7. Denbigh Rd / Third Avenue – 1 acre8. Watling Street / Gallagher Site – TBC9. Stoke Road – 0.7 acres

Following further investigation and discussion the existing surgery site was discounted due to size along withsites 2, 3, 4 and 5. The remaining sites have been investigated further as follows:

Site 6 Police & Fire Station Site – This site is well located and there is a growing strategy by the police andfire service to relocate out of town. The main police station is within Milton Keynes and they havecentralised custody suites there. Further discussions would have to take place with the heads of estates atboth organisations to establish a willingness to relocate.

1

2

3

4

56

7

8

9

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Site 7 – Denbigh Rd / Third Avenue – No further discussions have taken place, however, we have establishedownership and will progress discussions.

Site 8 – Watling Street / Gallagher – Discussions have taken place regarding the Eaton Leys site whichincorporates Watling Street frontage. The Watling Street site opposite Dobbies Garden Centre appears to bean Ancient Monument site and therefore unsuitable for development. However, Gallagher has suggestedthat they can open up a site off the A4146 for a new medical centre for Red House. The actual specifics areyet to be agreed, however, the location and accessibility for the patient catchment area appears suitable.

Site 9 – Stoke Rd – This is a council owned site that has been identified as surplus to requirements. Enquireshave been made with the local authority and we are awaiting feedback.

Further sites are being investigated and a site appraisal will be undertaken to identify the final site forselection.

10.0 Project Plan

Securing the site is the main focus for the delivery of the Red House scheme. The project plan at this stage ishypothetical subject to:

1. Securing a site under option or conditional contract2. Agreeing a suitable rent to support a scheme3. NHS and CCG support and timely decision making.

In terms of timescale the project team anticipate the following:

Table 10

Activity DateOBC Submission 20th March 2016Premises Working Group Meeting 23rd March 2016Co Commissioning Joint Committee 6th April 2016Detailed OBC Submission (Post DV Discussion) May 2016OBC Approval June 2016Planning Submission Oct 2016Planning Approval Dec 2016FBC Submission Feb 2016FBC Approval March 2017Construction Procurement April 2017Site commencement July 2017Practical Completion July 2018Go Live July 2018

The project plan will be subject to NHS approvals, district valuer negotiations, local authority planning andlegal negotiations with the practices over lease terms.

21

11.0 Key Risks / SWOT Analysis

Using the analysis tool below to detail the practice strengths, weaknesses, opportunities and any perceivedthreats:

Strengths: Should include anything positive about the practice that enhances patientcare e.g. specialist interest.

Weaknesses: These can range from poor parking facilities to inadequate computertechnology.

Opportunities: Such as untapped resources e.g. becoming a training practice.

Threats: Anything which may be seen to affect the practice list or the practice’sability to progress/develop.

These areas should also include external influences beyond the control of the Practice, e.g. closure ofproviders unit, and any likely impact on the Practice in the future such as local developments or Practicechanges.

Table 11

Strengths Cohesive open practice providing holistic careFull engagement and cooperation with LA and CCG and NHSE.

Consistently low prescribers remaining under budget Training Practice aspiration but unable due to space restraints. Cohesive work force with low turnover Open to new ways of working Embrace technology and IT – often early adopters and prepared to trial

alternative appointment models Greater flexibility increases patient choice and appointment availability.

Better management and control and value for money for the NHS.Weaknesses Insufficient consulting rooms – no GP or Trainer has their own room and

no Sluice Rooms and inadequate infection control. Desperate lack of storage Insufficient space to store notes – spread all over the building and

despite best efforts confidentiality could be compromised. No Health Promotion Room Parking poor and access. Poor on-site disabled parking Poor facilities to host students either Final Year Medical or Work

Experience Poor staff facilities and limited training or education rooms.

22

Opportunities Having the capability and flexible space to provide other multiple Localitybased services – counselling, Physiotherapy, Chiropody.Aspire to provide 8am to 8pm 7 days per week with right facilities

Triage or minor injuries unit could be developed to take pressure offhospital.

Diagnostics space for ultra sound scanning for early intervention. Community hub for health and wellbeing promotion and education. Can plug the capacity gap locally by developing a Bletchley Hub. Become the local training hub for new GP’s with state of the art digital

training technologies.

Threats Patient numbers continue to rise, with possible significant growth in next10 years due to LDP.

List closure due to increase in patients, lack of available space andseasonal fluctuations.

Patient expectations on premises quality and facilities have risen andpatient contacts increased.

Morale of staff, and patients is difficult to maintain in poor and restrictedaccommodation.

Appointment of new staff is difficult when showing them sub-standardpremises.

Arrival of private providers to Bletchley Town Centre CCG monitoring and scoring of premises and services which are restricted

due to premises.

12.0 Further supporting information:

A number of National Guidelines and Department of Health Initiatives directly impact on the provision ofcare to patients in Primary Care. Notable amongst these are:

“Our health, our care, our say: a new direction for community services” DoH 2006 “Our NHS, our future” by Prof Lord Darzi for the DoH in 2007 The Quality, Innovation, Productivity and Prevention (QIPP) programme for the DoH “Primary Care Federations – Putting Patients First” RCGP 2008 “Healthy lives, healthy people: our strategy for public health in England” DoH 2010 The NHS Premises Assurance Model (PAM) DoH January 2013 Update The NHS Constitution DoH March 2012 Five Year Forward View NHS England 2014

Amongst the recommendations from these national initiatives are the following common themes:

Improved access to GP services 8am to 8pm and 7 day a week access. Better use of primary care facilities to allow some health care to be provided in primary rather than

the multi-speciality Community Provider Greater patient and carer involvement in decisions about care Greater emphasis on health promotion Tailored services to address local need A reduction in health inequalities, especially for minority or marginalised communities Improved management of chronic and enduring illnesses

23

13.0Option Appraisal

In order to establish the need for a new development, we have conducted an option appraisal based on:

1. Do nothing2. Do Something3. Re-develop

It is important that we outline the background leading up to the current position also:

Background:

Current patient list is just short of 14,000 and has seen a 12% growth in the past 5 years. Planned growth inthe immediate area and patient catchment area is circa 29,000 people by 2031 and 19,000 by 2026. There isa current capacity issue in the region of c1800sqm when HTM11-01 principles are applied. The practice hasresorted to closing their list and reducing services to ensure patients are not compromised and to delivercore GMS services only. Red House is one of the largest practices in the region and needs to expand to meetthe demands of a growing population and a drive to deliver additional services from the primary care sector.The option appraisal below provides some information on considerations to date.

Do Nothing

Red House Practice population has grown faster than the general population of Bletchley due to propertydevelopment and expansion together with the wide the catchment area. The practice has attempted to keeppace with growing population by means of extensions, improvements and even taking on adjacent premisesunder lease. However, the present utilisation is over 80% and with a population growth of 19% in the localitythis results in a possible increase in patients of 19,000 by 2026. Therefore to ensure that patient care is notcompromised, doing nothing is not an option in respect of this growing problem.

Given the annual rise of circa 3% the practice has had to close patient lists in 2015 due to lack of space. TheNHS strategy of extended services in the primary care sector and extended hours are constrained by theunsuitability of the current premises. The huge growth in local population will put extensive pressure onservices locally.

It is acknowledged that demand for primary care services had risen sharply over the past 5 years. This ispartially due to lack of confidence in out of hours, improvements in treatments available for chronic diseasesuch as COPD, coronary heart problems, arthritis etc. but in the main due to the significant shift in servicesbeing delivered from the primary care setting. This strategy suggested by Lord Darzi was intended to reducethe stresses in the acute sector, however, locally we are still seeing inappropriate use of emergency servicesin secondary care. Rather than removing demand it has created an additional layer of patient expectationcontinues to grow. In order to service this demand the space and facilities need to be capable of coping withgrowing numbers and enhanced services.

In conclusion, doing nothing to improve the current and future increases in demand for primary care in thiscatchment area could have severe consequences in the region as a whole. This could also impact on theacute sector as more patients will be forced to Hospital A&E and secondary care due to the lack of availableappointments in the primary care setting. Section XX above has identified a capacity issue within the regionthat needs to be addressed in the short term and this development could start to plug this gap.

24

Do Something

The need for a redevelopment has been identified by the practice for many years and meetings with NHSEngland Area Team, the CCG and LMC have sought to drive forward the proposal and support for a newpremises for Red House Surgery. The practice has remodelled the existing premises to maximise the clinicalspace available for services. They have also taken space from the adjacent pharmacy to re-provide some ofthe lost admin areas. However, the opportunities to extend or remodel are no longer available and as such anew location is required to meet the current and future needs of the local primary care network.

Re-development

When you consider the main drivers for change locally and nationally, it becomes apparent that a newfacility for the Red House surgery is the only viable option:

1. Extensive population growth exceeding 3% annually and rising due to localdevelopments.

2. Lack of available space in current premises, 70% too small to deliver services to thealmost 14,000 patients listed.

3. Lack of alternative providers in the region and a distinct lack of capacity of circa1800sqm or 21,000 patient places. This is the current position with no allowance forgrowth in the region.

A new development for the Red House surgery is the only option available to protect the short and long termprimary care services to the local population. The new scheme can also be developed to offer additionalservices in line with the 5 year forward view and create a local hub for Bletchley for training, out of hospitalservices and extended hours.

14.0 Summary & Conclusion

This Outline Business case provides a case for change and an opportunity to invest to protect primary careprovision within a large region of Milton Keynes. The Red House Practice is hamstrung by their existingpremises, unable to extend the building to extend services or offer training. They are considered aninnovative practice regionally and are supported by the NHS and CCG in the work they do. NHS Choices ratesthe practice 5 stars throughout and 96% of patients ranked their services good to very good.

The extraordinary population growth in the practice catchment area is a call to action. Previous sections ofthis report have identified a potential increase in population of 29,000 by 2031. In addition the currentprovision in the region indicates a net shortage of 1800sqm of space or 21,000 patient places. Combined thisequates to a possible shortfall of 40,000 patient places by 2031.

There is an opportunity to take a scheme forward to not only cater for the increase population but also toreact to the local and national strategies:

Increased capacity for primary care services out of hospital Commitment to a wider range of services as set out in CCG’s commissioning intentions to reduce

unplanned admissions to hospital Improving seven day access to effective care Increased training capacity. Improved IT infrastructure to improve access.

25

A new scheme in this region of Milton Keynes could be a hub for the region and the wider population. Thereis funding available from the Primary Care Transformation Fund (PCTF) and Section 106 contributions thatwill ease the long term funding requirements of the CCG.

This scheme has obtained Primary Care Infrastructure Fund support in 2015 and has been encouraged toprogress a scheme to OBC and apply for further support for PCTF to take the scheme forward and towardsdevelopment.

To summarise, a moderate increase in revenue or a capital contribution can deliver a scheme that can helpsupport and protect services in the region for the next 40 years.

26

Appendix A

Schedule of Accommodation

27

Red House SurgerySchedule of Accomodation No. Design

Area (sq.m.)Total Area

(sq.m.)Level

Based on 18,000 patientsClinical Activity

Red HouseConsulting Room 10 16.0 160.0GP trainee room 2 16.0 32.0NurseTreatment Room 4 16.0 64.0Nurse Consulting 1 16.0 16.0HCA Rooms 3 12.0 36.0Primary Care Mental Health / Dementia Nurse 1 16.0 16.0Dirty Utility 4 8.0 32.0Clean Utility 4 8.0 32.0Spec WC 2 5.0 10.0

Clinical SpacesMinor Ops 1 18.0 18.0Prep Room 1 3.0 3.0Recovery Room 1 12.0 12.0Clean Utility 1 8.0 8.0Dirty Utility 1 8.0 8.0Spec WC 0 5.0 0.0Visiting Clinician Space 1 16.0 16.0

Clinical SupportLobby 1 10.0 10.0Reception 1 15.0 15.0Interview 1 12.0 12.0Kichenette 1 8.0 8.0

Administration

Office 1 - Telephony 1 20.0 20.0Office 2 - Secretary 1 25.0 25.0Office 3 - Presciptions / Appointments / Referrals 1 40.0 40.0Office 4 -Practice Manager 1 12.0 12.0Office 5 - Assistant Managers 1 10.0 10.0Records 1 30.0 30.0

Public Areas

Waiting Area 1 100.0 100.0Children's Play Area 2 5.0 10.0Patient Wheelchair Toilet - Large 2 5.0 10.0Patient WCs (female) 2 3.5 7.0Patient WCs (Male) 2 3.5 7.0Parent Room 2 8.0 16.0Baby change 2 8.0 16.0

Other SupportConference Room / Meeting / Health Education 3 25.0 75.0Staff Toilets 4 3.3 13.2Staff Dis (Inc. Shower) 1 6.0 6.0Domestic Services Room (DSR) 2 4.0 8.0Storage (SML) 8 4.0 32.0Storage (LG) 4 8.0 32.0Staff Room 1 25.0 25.0Library 1 15.0 15.0Staff Kitchen 1 15.0 15.0Staff Lockers 2 10.0 20.0Comms Room 1 12.0 12.0Disposal hold 1 10.0 10.0Plant Room 1 16.0 16.0Electrical switch room 1 3.0 3.0

GMS Core Total (NIA) 1093.2

Net Allowance 1093.2Planning Allowance 6% 65.6

1158.8TotalEngineering Allowance 2% 23.2

1182.0Circulation Allowance 20% 236.4Total 1418.4

Communications Allowance 2% 28.4

Total for Primary Care Centre (GIA) 1446.7

Pharmacy (GIA) 150.0Building Total (GIA) 1596.7

28

Appendix BExisting Plans

30

Appendix CNHS England Notional Rent (CMR)

Agenda Item 10

CC16/05

Joint Committee – Neighbourhood meetings update Page 1 of 4 V0.1 NHS Classified/NHS Unclassified/NHS Confidential

Subject: Neighbourhood meetings – update Meeting: Co-Commissioning Joint Committee and Finance Committee Date of Meeting: April 2016 Report of: Alex Friend – Primary Care Quality Co-Ordinator Is this document Commercially Sensitive Y/N Has this proposal been approved by Finance Y/N

1. INTRODUCTION During the inception of Milton Keynes Clinical Commissioning Group (CCG) it was deemed necessary to split the town in to 4 geographical, so called, Neighbourhoods. This was a commissioner led model allowing a two-way discussion between the CCG and a more manageable number of GP practices. Each Neighbourhood has an elected Neighbourhood Lead which is one of the GPs from within that Neighbourhood. This update paper offers the committee an over view on the work that has been done via the Neighbourhood meetings within Milton Keynes CCG.

2. AGENDA ITEMS

The below list shows the areas that have been discussed throughout 2015-2016 across all Neighbourhood meetings

Practice Based Budgets (including a number of audits) Prime Ministers Challenge Fund Public Health cardiovascular disease profiles C-diff root cause analysis, Quality Team Multi-Disciplinary Teams project Dementia diagnosis rates Influenza uptake data Prescribing/medicine management update Heart Failure data

Agenda Item 10

CC16/05


End of Life pathway changes Mental Health pathway changes Diabetes pathway changes The High Impact Team Rescue Medications Drug charts and District Nursing Nutrition and Dietetic updates Bronchiolitis Pathway update Caring for Children Closer to Home project Out of Area patients Antimicrobial resistance Care Quality Commission (CQC) proposed fee increase Referral Management Service and Primary Care Outpatient Clinics developments Working more closely with the hospital to improve communications

3. PRACTICE BASED BUDGETS

The Neighbourhood meetings (and clinical leads) have been used during 2015-2016 as the catalyst for potential pathway changes that benefit patients. Actions in relation to the Practice Based Budgets (PBB) that were discussed within the Neighbourhood meetings during 2015-2016 are therefore listed below. ID Neighbourhood Action OutcomesW1 West Breast referral audit against the NICE breast

referral guidance Consultants attended meeting have suggested that a primary care audit needs to be done with ‘reasons for referral’, ‘investigation’, ‘outcome’ included.

W2 West Potential coding change between 2013/2014 and 2014/2015 data for emergency admission HRG Chapter L-Urinary tract and male reproductive system

No coding change

W3 West Catheter audit - urethral categorisation of bladder with in the emergency admissions

Has led to contractual challenges with CNWL and some quality challenges with MKUHFT

W4 West Brainstorm reasons for gradual increase in number and cost of Pathology tests

February 2016

W5 West Audit how many of the HRG Chapter L‐Urinary tract and male reproductive system emergency admissions were readmissions within 30 days

Only 2 cases in 12 months. There is already a process in place to challenge these with MKHFT

S1 South Audit colorectal 1st OPA Potential for open access colonoscopy, discussion needed with hospital. Apparently already open access at Blakelands and at Saxon, GPs awareness

Agenda Item 10

CC16/05


Invite gastroenterology consultant to educate GPs on knowledge gaps, need to discuss which areas (e.g. bile acid malabsorption , pancreatic insufficiency) On the agenda for a PLT event

S2 South Emergency admissions for 'diseases of childhood neonates', zero length of stays

February 2016

S3 South Audit the care provided to patients prior to emergency admission HRG Chapter D-respiratory for Nov and Dec 2015

Pending

N1 North ONGOING ATTEMPT TO GAIN COMMITMENT FROM PRACTICES FOR A DERMA AUDIT For dermatology 1st OPA 2WW identify how many have been discharged after the 1st appointment Compare the number of dermatology 1st OPA for January-March 2014 (PCOC not live) and January-March 2015 (PCOC live) to verify whether the total number of dermatology referrals has changed - for North the same number of referrals went to providers in each period (149) Divide the PCOC referrals by the practice population and x1000 - the rates per 1000 population vary quite a lot between practices Audit dermatology referrals for Nasiri and Muthuveloe for 2014/2015 (59 of) After meeting on 11/8/15 all practices agreed to run audit

What sort of Cases/Diagnoses could have been managed in-house? There were 16 cases out of 207, Diagnoses included:

Seborrhoec dermatitis Stasis Dermatitis Acne Rosacea x 2 Facial Eczema Contact Dermatitis Hypopigmented patches Psoriasis Scars/Keloids Simple Sebaceous Cysts Simple Dermatofibromas Venous Eczema

Some could have been seen at a PCOC rather than a hospital clinic, but main problem is that PCOCs are for diagnosis only, not treatment. Some may not have needed referral at all. Appropriate pre-referral work-ups / treatments not always tried.

When can Dermatology referrals NOT be managed in-house:

Due to EXTENT and SEVERITY of rash or lesion.

LOCATION of lesion – face, eyelid, neck Need to EXCLUDE malignant melanoma

or SCC Need BIOPSY to confirm diagnosis Lesion RESOLVED

E1 East Further work required on 'discharged after 1st appointment' information presented in meeting on 8/7/2015 Obtain latest benchmarking figure from Anne Gray for 'discharge after 1st appointment' Show information for each of the 8 specialities Show information for each GP Show information for all neighbourhoods (against East)

No significant issue found

E2 East Audit for the 'discharged after 1st OPA' in respiratory

Not carried forward

Agenda Item 10

CC16/05


E3 East Need to understand the conditions behind the increase in 'digestive' emergency admissions

Minimal feedback from Practices

E4 East Need to visit The Grove regarding the emergency admission data for quarter 1 of 2015/2016. Need to show graph for 2 year comparison for emergency admissions

Meeting held. Feedback taken on board

E5 East Emergency admission rates per 1000/patients Ashfield were outlying. Patient level info issues, no feedback as yet

E6 East Rerun graph relating to AF004 QoF code (anti coag for AF patients). Present to GPs and advise feedback for next meeting on how the low numbers are being addressed.

Awaiting meeting with Public Health

4. ATTENDANCE AT NEIGHBOURHOOD MEETINGS

Via the minutes of each meeting the attendance trends for each Neighbourhood meeting have been collated below. North - throughout 2015-2016 two practices have consistently been absent from the meetings, Kingfisher and Neath Hill. Other practices attend regularly and with both Practice Manager and GP representation. East – throughout 2015-2016 Broughton Gate have attended irregularly. Walnut Tree has not attended at all. The Grove and Fishermead are regular attenders but there is no clinical representation. GP attendance at this meeting is generally low which makes it difficult when clinical discussions need to be held. South – throughout 2015-2016 Drayton Rd have been occasional attenders and when they do there is no clinical representation. Overall the South has good clinical representation and some interesting discussions have been held. West – throughout 2015-2016 the meeting has been very well attended by both clinical leads and Practice Managers.


GP Access Fund Milton Keynes

INTERIM REPORT MARCH 2016

1. BACKGROUND

Formerly known as the Prime Minister’s Challenge Fund, the GPAF is an NHS England funded programme to pilot new way of working to increase capacity in and improve access to primary care services. The original funding agreement to 31 March 2016 has recently been extended to lengthen the pilot period for new services and allow more effective data collection and evaluation. NHS England and Milton Keynes CCG act as joint commissioners for the pilot services and will lead the commissioning of sustainable services as a legacy of the Access Fund programme. Twenty‐two of the twenty‐seven practices in Milton Keynes are already involved in the programme, with the remaining five able to access some of the services offered and encouraged to participate in planning sustainable service options. The Milton Keynes Programme aims to:

Extend access to primary care through additional capacity in the evenings (providing 7am to 8pm in total) and at weekends with a single bookable entry point. It will link all primary care patient record systems electronically including the extended access service.

Offer general practice improved direct access to extended specialist services for children and young people and older vulnerable and complex patients. Direct referral systems will be developed for access to the specialist teams and expand the development of an adult ‘virtual ward’ as an alternative to hospital based care.

Facilitate the development of stronger collaborative working across primary care in Milton Keynes.

The programme is hosted by Milton Keynes Urgent Care Services and is led by a Collaboration Board chaired by Dr Jolly Zachariah and made up of key stakeholder organisations. It consists of four main project areas:

GP Access – pre‐bookable primary care consultations operating early mornings, evenings and

weekends from 5 hubs and shared across all 22 collaboration practices;

Children’s Services – ‘same or next day’ follow up appointments with specialist children’s

nurses accessed through primary care and supporting parents of children with common

childhood illnesses;

Rapid Response – supporting the existing Rapid Response community team with a medication

optimisation service;

Building collaboration – facilitating the development of sustainable vehicles for working at scale

and sharing services across primary care.

The current Programme Leadership is provided by Dr Thao Nguyen (Clinical Director and SRO) and

Susan Hoath (Programme Director) who have overseen significant progress in the programme since

December 2015. They have attended and reported to previous Co‐Commissioning Committees and

present this paper as an update on the programme as a whole and an interim report on the current

position.


2. GP ACCESS WORKSTREAM

Current Offer

The GP Access workstream is now offering up to 400 appointments per week, around 60% of the

originally profiled clinic capacity. We have identified clinical rooms to expand this to 100% (670 per

week) and some additional GP recruitment is in place to support these sessions, if required.

However, it is important to note that the current clinic capacity is being well used but not fully booked

and spot checks through‐out the week indicate that there are rarely occasions when there is no

appointment available within the following 3 days. We are releasing some new sessions (to extend

capacity in Bletchley through the week and on two sites at weekends) and will continue to monitor

uptake to balance capacity and demand.

All five hub sites are delivering services (in varying patterns) with a minimum of one GP clinic 07:00 to

08:00 every weekday and two GP clinics on weekday evenings and weekends. The five hubs (H) are:

The Grove, Eaglestone

Central Milton Keynes Medical Centre, Bradwell Common

Parkside Health Centre, Bletchley

Wolverton Health Centre, Wolverton

Broughton Gate Health Centre, Broughton

The service went live in three phases:

Phase One: five hub sites seeing their own patients (to test booking and clinical software)

Phase Two: five hubs seeing their own and each other’s patients (to test cross booking)

Phase Three: five hubs seeing patients from across all 22 practices.

GP Appointments Delivered

Period Total available appointments

% booked Total DNAs % DNAs (of booked)

Phase 1: 21‐Sep to 13‐Dec 1607 97.76 133 8.47

Phase 2: 14‐Dec to 13‐Jan 291 93.47 37 13.60

Phase 3: 04‐Jan to 27‐Mar 3213 94.21 493 16.29

Overall: 5123 95.26 663 13.59

HCA (Phlebotomy) Appointments Delivered

Period Total available appointments

% booked Total DNAs % DNAs (of booked)

Phase 1: 21‐Sep to 13‐Dec 2336 94.95 195 8.79

Phase 2: 14‐Dec to 13‐Jan 406 80.54 41 12.54

Phase 3: 04‐Jan to 27‐Mar 3709 90.81 535 15.88

Overall: 5123 95.26 663 13.59


Uptake by practice and hub site

Having had the advantage of early access to the scheme, the hub practices have inevitably benefitted

most from the service so far, however all practices have accessed the service in some form, with others

able to use it to substantially support access difficulties. The table below shows the (unweighted)

patterns of access for Phase 3 of the project.

Overall (4 Jan 2016 ‐ 27 Mar 2016)

Registered Practice

Patient Count

Pats seen @

other sites

%Pats Atten

ding other site

Hub Site

% of Booked

% List Size (oct‐15)

BG

CMK

Grove

Park

Wolv

Bedford Street Surgery 22 22 100% 8 4 1 2 7 0.60% 4.99%

Broughton Gate Health Centre (H) 870 1 0% 869 1 0 0 0 23.91% 3.95%

CMK Medical Centre (H) 520 99 19% 59 421 10 1 29 14.29% 7.42%

Cobbs Garden Surgery 0 0 0 0 0 0 0 0.00% 3.60%

Drayton Road Surgery 6 6 100% 3 1 0 0 2 0.16% 1.23%

Fishermead Medical Centre 37 37 100% 22 8 3 1 3 1.02% 2.75%

Hilltops Medical Centre 504 504 100% 180 121 52 8 143 13.85% 6.80%

Newport Pagnell Medical Centre 102 102 100% 56 4 3 1 38 2.80% 8.11%

Parkside Medical Centre (H) 147 116 79% 83 16 8 31 9 4.04% 4.43%

Purbeck Health Centre 87 87 100% 7 3 2 0 75 2.39% 2.89%

Red House Surgery 3 3 100% 1 1 0 0 1 0.08% 5.89%

Sovereign Medical Centre 1 1 100% 0 0 0 0 1 0.03% 4.72%

Stonedean Practice 1 1 100% 0 0 0 0 1 0.03% 2.98%

Stony Medical Centre 12 12 100% 4 2 0 0 6 0.33% 4.87%

The Grove Surgery (H) 83 6 7% 6 0 77 0 0 2.28% 2.84%

Walnut Tree Health Centre 35 35 100% 24 6 2 1 2 0.96% 4.49%

Water Eaton Health Centre 2 2 100% 1 0 1 0 0 0.05% 2.73%

Watling Vale Medical Centre 124 124 100% 81 14 2 0 27 3.41% 5.52%

Westcroft Medical Centre 7 7 100% 1 1 0 0 5 0.19% 5.77%

Westfield Road Surgery 18 18 100% 9 0 2 1 6 0.49% 2.44%

Whaddon Medical Centre 43 43 100% 11 2 9 2 19 1.18% 5.07%

Wolverton Health Centre (H) 1005 7 1% 3 3 1 0 998 27.62% 6.51%

Updated Patient Records* 10 10 7 3 0 0 0 0.27%

Totals 3639 1243 1435 611 173 48 1372

% of Patients from other sites 34% 39% 31% 55% 35% 27%

*These are patients that have changed their Registered GP Practice since attending the session, but before this information was extracted from SystmOne, to a non‐collaboration practice. (H) Hub sites


Regular communication goes out to all practices to encourage use of the service when needed. We are

currently doing an interim evaluation of Practices minimally using the service, experience of practice

staff and clinicians.

Did Not Attend (DNA) and Cancellations

DNA rates have varied widely from day to day, site to site and clinic to clinic. The average DNA for GP

clinics is 14% and for the HCA Phlebotomy service is 10.5%, however this masks extremes of 25% and

zero. Most GP clinics experience a persistent DNA rate of between 6% and 18%, with the most DNAs

occurring at Wolverton and the least at CMK. The DNA rate is generally higher on Monday mornings

and at weekends, and lower on weekday evenings.

We have sampled some patients to test their reasons for DNA and many identified difficulties with

either locating the clinic or cancelling appointments that were no longer required. We are introducing

a number of measures to improve this, including better information for patients and for receptionists

to use when booking appointments. We will continue to monitor DNAs closely.

A cancellation line is available 24/7 for patients to leave a message and cancelled appointments are

released as soon as possible. We are exploring ways to increase the frequency with which

cancellations can be checked and processed. We are also exploring ways to assist practices with DNAs

in general in order to maximise primary care appointments within practices and at Hubs thus

increasing access capacity overall.

Patient Feedback

We have been issuing feedback forms to all patients who attend the clinic and have started to receive

analysis of their responses:

The majority of patients found the service to be “very convenient” (Location 67.4 %, Day 64.4

%, Time 64.4 %)

67.1 % of patients found the booking process to be “very good”, a reflection on the patient’s

registered practice

79.2 % of patients would be either “likely” or “extremely likely” to recommend the service to

friends or family

We also asked patients to give us some further information about their reasons for using the service.

65.5% identified themselves as “full time worker” and a significant number of the free text comments

state that they chose the service to access a GP outside their working hours.

Asked what service they would have used if this had not been available, 27.5% said they would have

gone to the Walk‐In Centre, Urgent Care or A&E. 53.3 % said they would have delayed and waited to

see their own GP at another time.

We have had a small number of formal complaints. Two were regarding a specific clinician and have

been dealt with. The remainder (three) resulted from patients being booked into and attending

appointments but needing a service that we are unable to offer (eg: private medical checks). We have

reiterated to practices that there are some exclusions but rely on triage at booking to identify these


patients and make sure that they are directed to an appropriate service. We are currently scoping

primary care triage and patient navigation in order to ensure patients get the right appointment first

time thus reducing complaints, potential DNAs and increasing primary care access capacity in local

practices and at Hub sites.

Best Practice Clinical Care

We have developed best practice clinical protocols in Systmone to ensure clinical safety, appropriate

referrals, patient engagement and reduce GP workload. This has now been adopted by the Milton

Keynes Clinical Advisory Group who will use this model in future protocol developments.

3. CHILDREN’S SERVICE

The second largest workstream is delivering a bookable follow‐up service for patients with common

childhood illnesses. Clinics are available every day to give parents and carers an opportunity to

reassure themselves about children’s health and to be given more information about the child’s

condition. Appointments can already be booked by GPs, practice nurses and health visitors and urgent

Care Service. They are currently liaising with Milton Keynes Hospital and the children’s community

service in order to widen access to the service.

The service is currently offering over 100 appointments per week (30% as booked telephone calls) and

running at approximately 65% booked with the gap expected to be filled by referrals from MKH and

the community service. The DNA rate for this service is less than 5%.

An internal evaluation report has been commissioned and is due to report shortly.

The service is proving highly popular with local practices and patients (carers). We have been asked to

show‐case the model across other GP Access Fund locations (wave two) and will be submitting an

entry to the HSJ awards scheme.

4. RAPID RESPONSE

As reported in previous submissions, the Rapid Response workstream has focussed on embedding a

medication optimisation service into the existing Rapid Response team in Milton Keynes. The service

was commissioned from Milton Keynes Foundation Hospital Trust for 2015/16 but then sub‐contracted

to CNWL Trust to align it to the existing team. We are in the process of simplifying this bureaucracy

and negotiating directly with CNWL for the extension of this pilot project. We are currently awaiting

data from the medication optimisation team in order to complete an interim evaluation.

5. WORKING IN COLLABORATION

The final workstream is slightly different; not delivering patient services but facilitating the

development of opportunities for local practices to ‘work at scale’ and build on opportunities to

collaborate in the provision of local services, in order to facilitate a sustainable primary care. This

includes hosting workshops and practice development sessions and bringing existing organisations

together to explore shared objectives and build stronger relationships. There have been numerous

meetings with different parties. The Collaboration Task and Finish Group meet bi‐monthly in order to


accelerate this work stream. We are currently exploring Clinical Leadership opportunities for clinicians

in order to develop clinical leaders for a sustainable primary care. We have also recently invited the

remaining 5 non‐collaboration practices to become members of the GP Access Fund collaboration.

6. RISKS AND ISSUES

Risks and issues are now routinely updated by the project leads and monitored by the programme

management team on a weekly basis. They are also reported to each workstream Task and Finish

Group and to the monthly Collaboration Board meetings. The most recently reported priority risks

and issues list is at Appendix One.

7. EVALUATION

National Evaluation of ‘PMCF Wave Two’ is now underway and we are cooperating with the NHS

England appointed evaluation team. Reports of this evaluation will be published in the summer.

Evaluation of the GP Access workstream is underway, with regular data capture and analysis points,

and the ongoing reports from this are built into our reporting framework and sent to the Task and

Finish Groups, Collaboration Board and NHS England. Now that we have a more substantial data set

building, we have also started to evaluate patient feedback (see above) and the likely ongoing costs of

the piloted models. An early picture of the costs of the GP clinics, for example, is at Appendix Two.

Please note that this work continues and is being refined, however we are pleased to see that it would

appear that the costs on a ‘per appointment’ basis are settling within the range between ‘fully‐utilised’

(100% booked and 0% DNA) and our locally set Optimum utilisation (95% booked and 10% DNA).

The higher level of DNAs that we are experiencing pushes the cost per patient up to around £34.00,

against our target cost per appointment range of £25 ‐ £28.

The first evaluation of the Children’s service has been completed and is due to report soon. The CCG

lead commissioner (Hannah Pugliese) is involved in the process and will receive a full copy of the final

report.

The Rapid Response workstream is being evaluated by the Clinical Director who will report to the TAF

and lead commissioner (Ruth Adam).

Smaller pilot projects will have evaluation built into their process from the start. The programme

management team also expect to produce a brief evaluation of the way in which the project has run in

itself, capturing key lessons learnt for the local health economy.

8. FURTHER DEVELOPMENT

Now that the extension of the pilot period has been agreed, a number of small scale pilots are being

worked up to test other ways of building capacity in primary care. These include:

‐ Patent Advice and Navigation (PAN) systems

‐ Clinical triaging service

‐ Pharmacist service

‐ Acute Physiotherapist service


Further suggestions have been invited from all member practices.

We have also taken the opportunity to become even more inclusive, and have written to the five

practices that currently fall outside the programme, offering them the opportunity to join. They can

already access the Children’s and Rapid Response services and are included in the collaboration work

anyway, but joining would offer them access to the GP and HCA clinics and to the learning and

development of the whole programme. Of course, whether to join or not is a decision for each

practice to make, based on their circumstances; no‐one will be pressured to join.

Thao Ngyuen, Clinical Director and SRO

Susan Hoath, Programme Director

29 March 2016




APPENDIX ONE

As referred to in Section 6 Risks and Issues, these are now routinely updated by the project leads and

monitored by the programme management team. They are also reported to each workstream Task

and Finish Group and to the monthly Collaboration Board meetings.

The priority risks and issues reported to the March 2016 Collaboration Board were:

Risk / Issue Description Risk Score Mitigating Actions

A statement describing the cause, risk event

and impact / issue

Likelihood

Impact

RAG Status

Systems and processes that are in place and operating

that mitigate this risk, including assurances

Collaboration – It is a risk that we may not

achieve a sustainable Collaboration /

Federation by the end of the pilot

3 5 R

TAF established with key stake‐holders ; Workshops

scheduled for all practices ; Reporting in place within

the programme ; NHSIQ engaged to support process.

Children’s ‐ It is a risk that when MKUCS

vacate the urgent care centre, the children’s

service may not have identified alternative

accommodation for week day sessions.

2 5 A

Evening and weekend sessions are currently being

operated from the Grove Surgery. Alternative

options for week day sessions are under review which

aim to retain the service within a community setting.

An options document is being produced from which a

recommendation will be made.

Children’s ‐ It is a risk that if GPs do not

refer to the service then the team capacity

may be underutilised

2 4 A

Ongoing promotion of service including attendance

at GP neighbourhood meetings. Ongoing

advice/support with the booking process being given

by children's admin.

Rapid Response ‐ It is an issue that the

current service specification is insufficient

and will not ensure the collation of relevant

data for the evaluation

‐ 3 A

Service specification updated with supplier,

implementing required changes to service, monitoring

results.

Access ‐ It is an issue that we do not

currently have a clinical lead for nursing,

hence there is no safe governance provision

to establish nursing services.

‐ 4 A

Nurse advisor engaged and invited to TAF to help

design pathways. Clinical lead role to be pursued

prior to commencement of service pilot.

Access – It is an issue that we have yet to

resolve the management of patients that

fall outside our clinical guidelines

‐ 3 A

Exceptions identified and shared with all practices.

Collecting data on this patient group. Exploring

models for patient navigation and IT solutions.




APPENDIX TWO

Early analysis of the ‘costs’ for GP appointments within the MK Health Extra Service.

As referred to in Section 7 Evaluation, this graph depicts early work on the cost of delivery for the GP

clinic sessions. Please note that this work continues and is being refined, however we are pleased to

see that it would appear that the costs on a ‘per appointment’ basis are settling within the range

between ‘fully‐utilised’ (100% booked and 0% DNA) and our locally set Optimum utilisation (95%

booked and 10% DNA).

The higher level of DNAs that we are experiencing pushes the cost per patient up to around £34.00,

against our target cost per appointment range of £25 ‐ £28.

The three phases on the graph refer to the three phases of the service’s introduction:

Phase One: five hub sites seeing their own patients (to test booking and clinical software)

Phase Two: five hubs seeing their own and each other’s patients (to test cross booking)

Phase Three: five hubs seeing patients from across all 22 practices.

Source: SystmOne data from live service records.

S Osman, GPAF Programme Team

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