primary care commissioning committee (pccc)...2017/07/27 · 4.4 30/03/2017, item 7.3, primary care...

Primary Care Commissioning Committee (PCCC)

Meeting to be held at 10.30am on Thursday, 27 July 2017 in the Board Room, Sanger House, Brockworth, Gloucester GL3 4FE

No. Item Lead Recommendation

1. Apologies for Absence

Chair

2. Declarations of Interest

Chair

3. Minutes of the Meeting held on 25 May 2017

Chair Approval

4. Matters Arising

Chair

5. Presentation on progress re Beeches Green Premises Development

Andrew Hughes and Tim Scruton

Information

6. Primary Care Premises Report Andrew Hughes Information

7. Application for contractual practice mergers from London Medical Practice, Heathville Medical Practice, Barnwood Medical Practice and Saintbridge Surgery

Jeanette Giles Approval

8. Delegated Primary Care Commissioning Financial Report

Cath Leech Information

9. Primary Care Quality Report Marion Andrews-Evans

Information

10. Any Other Business (AOB)

Chair

Date and time of next meeting: Thursday 28th September 2017 at 10.30 am in the Board Room at Sanger House.

of 8 Primary Care Commissioning Committee Minutes 25th May 2017

Agenda Item 3


Minutes of the Meeting held on Thursday 25 May 2017 in the Board Room, Sanger House, Gloucester GL3 4FE

1 Apologies for Absence

1.1 Apologies were received from Alan Elkin (AE).

2 Declarations of Interest

2.1 AS declared a general interest as a GP but more specifically with agenda item, 5 as his practice, Heathville Medical Practice, was a potential merger.

Present:

Jo Davies (Chair) JD Lay Member – Patient and Public Engagement

Colin Greaves CG Lay Member - Governance

Mary Hutton MH Accountable Officer

Cath Leech CL Chief Finance Officer

Marion Andrews-Evans MAE Executive Nurse and Quality Lead

Julie Clatworthy JC Registered Nurse

Dr Andy Seymour (Non-Voting)

AS Clinical Chair

In attendance:

Helen Goodey HG Director of Primary Care and Locality Development

Helen Edwards HE Associate Director of Primary Care and Locality Development

Alan Potter AP Associate Director of Corporate Governance

Becky Parish BP Associate Director, Engagement and Experience

Chris Graves CsG Healthwatch Representative

Joanna White JWh Programme Director for Primary Care

Jeanette Giles JG Head of Primary Care Contracting

Ryan Brunsdon RB Board Administrator


2.2 JD declared that the meeting was quorate and that she felt that AS should not be excluded from any discussions as he was a non-voting member.

3 Minutes of the Meeting held on Thursday 30 March 2017

3.1 The minutes were approved as an accurate record.

4 Matters Arising

4.1

28/01/2016, Item 9.1, Any Other Business – JD advised that the Primary Care Commissioning Committee self-assessment progress review was due for the September meeting. Item to remain open.

4.2 24/11/2016, Item 5.22, Premises Workstream Progress Report – HG advised that the Primary Care Premises Workstream Progress Report would be discussed during the confidential PCCC session. Item Closed.

4.3

HG clarified that it was national process for NHS England (NHSE) and PropCo to have capital and revenue sign off in relation to Estates and Technology Transformation Funds (ETTF). MH confirmed that this had not been delegated to CCG.

4.4 30/03/2017, Item 7.3, Primary Care Strategy Workforce Update - JD advised that the comprehensive plan and strategy for the nursing workforce was required for the July meeting of PCCC. Item to remain open.

4.5 30/03/2017, Item 10.5, Delegated Primary Care Budgets – CL confirmed that RB had recirculated the Premises Timeline, which included revenue consequences to the committee members on 12th May 2017. Item Closed.

4.6 30/03/2017, Item 11.8, Primary Care Quality Report - GP attendance at safeguarding roadshows – HG confirmed that information on the number of GPs who had attended safeguarding roadshows was included within the agenda at item 8. Item Closed.


5 Draft Standard Operating Procedure for applications for contractual mergers

5.1

JG introduced the Draft SOP for applications for contractual mergers which had been developed to standardise the process for consideration of contractual merger requests. The paper was taken as read.

5.2 JG highlighted that the SOP outlined the principles and steps required by practices and the CCG when an application for a contractual merger is received, in accordance with the NHSE policy.

5.3 JG reported that the CCG should consider costs and value for money as a contract merger could result in higher costs per head of population. JG noted further considerations to be: premises reimbursement, procurement and competition.

5.4 JG advised that it was important for practices to undertake due diligence with Practices they are potentially merging with.

5.5 JG noted that practices were responsible for their own engagement with their patients and the population. JG further noted that the CCG would be responsible for engagement with stakeholders and the list of stakeholders was included within the report.

5.6 JG informed members that once applications had been received and reviewed, a report would be prepared for the Primary Care Operational Group (PCOG) for assessment and recommendations which would then be taken to PCCC for decision. HG added that PCCC would be receiving requests from July 2017 onwards.

5.7 CsG queried whether GP practices would be given advice or a portfolio in relation to patient and public engagement and involvement. BP assured the Committee that the SOP stated advice and support would be given by the CCG with regards to how they could communicate and consult through Patient Participation Groups (PPGs).

5.8 CG highlighted concerns that patient choice would be reduced or limited due to mergers and that this was not explicit enough within the SOP. JG assured members that papers brought to PCOG and


PCCC would be clear in highlighting what patient choice would be available.

5.9 CG questioned whether the submission of application to merge highlighted at point 3.3 of the report would be communicated to NHSE. JG confirmed that NHSE would also be contacted.

5.10 JD queried what the impact to PCCC would be and the timescales of the potential mergers. HG advised that there were potentially 8 practices looking to complete merges by April 2018. HG noted that some mergers would need to be completed quicker than others.

5.11 CsG expressed concerns that patients often view practices merging as a negative as they may not have had the appropriate reassurances outlining the positives of mergers. BP confirmed that work had been undertaken with PPGs regarding a potential merger, and information had been made available to advise them on the importance of merging. BP noted that PPG matters would be added to the CCG website which would provide PPGs the opportunity to blog and network.

5.12 RESOLUTION: The Committee approved the SOP for applications for contractual mergers

6 General Practice Forward View – NHSE Feedback from March 2017 Submission and Updated CCG Plan

6.1

HE introduced the General Practice Forward View paper which was taken as read. HE noted that this version of the paper took into account all comments received from NHSE following submission of an earlier version on 10th March 2017.

6.2 HE reported that all categories outlined within the paper were rated as green, with the exception of the “Workforce” category which was rated as amber. HE assured that the amber rating was consistent with other CCGs across the South Central region.

6.3 HE noted that changes for each section of the document had been made and were reflected within the summary. The changes were covered within the; Workforce, Access, Infrastructure, Workload, Organisational Form and Engagement sections.


6.4 HG informed the Committee that during the quarterly review with NHSE, it had been reported that the CCG General Practice Forward View was the best that they had seen. HG also informed that NHSE had nominated CCG to present to the national group on the progress made with the General Practice Forward View.

6.5 HE added that the CCG had been nominated for the Healthcare Transformation Awards in the Fostering Commissioner and Provider Collaboration Category for the work done with the GP Forward View and place based work.

6.6 CG requested that the second heading on page 28 of the report should be rectified to highlight that the plan was an oversight of Gloucestershire‟s Sustainability and Transformation Plan, not the CCG‟s. HE agreed with the change and advised the Committee this would be made in advance of the request for final approval by the Governing Body prior submission NHSE.

6.7

AS queried whether the amber rating in relation to workforce was the same throughout the country. HE agreed to obtain this information.

6.8 RESOLUTION: The Committee recommended the General Practice Forward View for approval by the Governing Body

7 Delegated Primary Care Commissioning Financial Report

7.1 CL introduced the Delegated Primary Care Commissioning Financial Report as at March 31st 2017 which outlined the financial position on delegated primary care co-commissioning budgets. The report was taken as read.

7.2 CL highlighted that the report showed a break even position for the year 2016/17.

7.3 CL indicated that the main variances of the financial position were included within 2.3 of the report.

7.4 RESOLUTION: The Committee noted the Delegated Primary Care Commissioning Financial Report.


8 Primary Care Quality Report

8.1

MAE introduced the Primary Care Quality Report which provided assurance to the Committee that quality and patient safety issues were given the appropriate priority and that there were clear actions to address them. The report was taken as read.

8.2 MAE reported that Section 2 of the report on workforce, education, training and community education provider networks (CEPN) would have been included within the GP Forward View at agenda item 6.

8.3 MAE informed the Committee that the changes in gluten-free prescribing had resulted in savings of around £28,500 per month. MAE noted that there was an appeal system in place for gluten-free prescribing and confirmed that there had been 3 successful appeals.

8.4 MAE referred to the work around Oral Nutritional Supplements, known as SIP feeds , and noted that Dieticians were working with practices to talk to patients about the implementation of a „food first‟ approach as an alternative to SIP feeds where appropriate. MAE reported that there was excessive use of SIP feeds in care homes and work was being done to reduce consumption.

8.5 MAE advised the Committee that the number of Prescribing Support Pharmacists (PSPs) had reduced and that these roles were being developed into technician roles. MAE noted that many PSP‟s had converted to clinical pharmacists.

8.6 MH requested that the final number of recruited pharmacists be made available. MAE confirmed that recruitment was still being undertaken and that the final number would be made available once recruitment had finished.

8.7 MAE informed the Committee that a training passport was being developed for the STP footprint to enable statutory and mandatory training to be transferred across organisational boundaries. It was noted that this would help standardise training.

8.8 MAE described the Red Bag project highlighting that a patient moving from a care home to an acute or community hospital, would take a red bag with them which would contain personal and


relevant possessions providing the hospital with information about that patient, which should assist with a faster discharge. MAE noted that the pilot was being led by the manager of Millbrook Lodge Nursing Home.

8.9 MAE highlighted that two significant events had been recorded on the National Reporting Learning System (NRLS) and that there was a focus on supporting practices on identifying and reporting serious incidents.

8.10 BP reported that there continued to be low response rates for the Friends and Family Tests (FFT‟s) for GP practices in Gloucestershire. It was noted that only 41 practices submitted data in February 2017.

8.11 MAE advised that the Gloucestershire Safeguarding Adult Board (GSAB) held four half day roadshows which were attended by six GPs and these roadshows focused on self-neglect and modern slavery. MAE reported that 150 attendees, including 73 GP‟s and 55 Practice Nurses, had attended safeguarding adult level 2 training.

8.12 MAE reported that there had been nine cases of MRSA attributed to the community reported during 2016/17 and 177 cases of C. difficile with a threshold of 157 for 2016/17. MAE advised that new threshold of 257 for E.Coli would be implemented for 2017/18.

8.13 MAE informed the Committee that any GP practice who had merged or moved buildings would have a re-inspection by CQC. MAE further noted that all practices that received a “requires improvement” rating would also be re-inspected by CQC.

8.14 JD queried the timescales for the proposals of lowering C.difficile and E.Coli cases. MAE reported that an analysis of the data was being looked at and a clearer plan would be available in the next few months. MAE assured that work on E.Coli had already started with the implementation of a catheter passport.

8.15 CsG highlighted that Healthwatch Gloucestershire had written to Healthwatch England regarding NHSE not sharing details of complaints noting that this was starting to become a national issue amongst patient organisations.


8.16 RESOLUTION: The Committee noted the Primary Care Quality Report.

9 Any Other Business (AOB)

9.1 There was no other business.

The meeting closed at 11:27am.

Date and Time of next meeting: Thursday 27 July 2017

Minutes Approved by Gloucestershire Clinical Commissioning Group Primary Care Commissioning Committee: Signed (Chair):____________________ Date:_____________

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Primary Care Commissioning Committee (PCCC) Matters Arising – July 2017

Item Description Response

Action with Due Date Status

28/01/2016 Item 9.1

Any Other Business

CG suggested that a self-assessment was undertaken to reflect on the role as a Committee in order to improve on processes and identify areas for development where further training was required. 30.03.17 13.2 – CG suggested that this be revisited again in 6 months to review progress.

AE 28 Sept 17

Due Sept

30/03/2017 Item 7.3

Primary Care Strategy Workforce Update

JC commended the practice workforce work and asked if an equally comprehensive plan and strategy could be developed for the Nursing workforce. HG agreed that a comprehensive plan was required and this would be brought to a future PCCC meeting to include information on the full Nurse development programme.

HG 27 July 17 Due July

25/05/2017 Item 8.6

Primary Care Quality Report

MH requested that the final number of recruited pharmacists be made available. MAE confirmed that recruitment was still being undertaken and that the final number would be made available once recruitment had finished.

MAE

Agenda Item 4

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Agenda Item 6


Meeting Date Thursday 27th July 2017

Title Primary Care Premises Report

Summary The primary care premises development workstream is made of a number of key components;

Ensuring the delivery of the committed premises developments to practical completion;

Progressing the priorities identified in the Primary Care Infrastructure Plan (PCIP), including proactively working to kick start development opportunities and supporting business case development;

Ensuring local practices take full advantage of national funding initiatives such as the Estates and Technology Transformation Fund (ETTF);

Working with other key delivery partners particularly NHS Propco where joint responsibility for business case development exists;

Managing local improvement grant processes; and

Ensuring the CCG operates within Premises Directions and uses these regulations appropriately.

Whilst individual proposals are presented to the PCCC for decision, members of the meeting are keen to have regular workstream reports, which will be provided at every other meeting – three reports per year. The included detailed report sets out key progress for all areas of work up to the 30th June 2017.

Risk Issues: Original Risk Residual Risk

There will be insufficient suitable primary care premises to meet core quality standards, to deliver the range of service required for the future model of primary care and be able to provide services for the expected increased population.

Financial Impact The premise workstream includes a number of financial elements and these are detailed in the report where applicable

Legal Issues The CCG applies NHS Premises Directions to rights

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(including NHS Constitution)

and responsibilities of the practice and the CCG. In terms of the NHS Constitution the author considers ‘You have the right to expect your NHS to assess the health requirements of your community and to commission and put in place the services to meet those needs as considered necessary’ and ‘You have the right to be cared for in a clean, safe, secure and suitable environment’ as the most pertinent NHS Constitution rights applicable to this scheme.

Impact on Health Inequalities

No health inequalities assessment has been completed for this report.

Impact on equality and Diversity

No equality and diversity impact assessment has been completed for this report.

Impact on Sustainable Development

The Building Research Establishments Environmental Assessment Method (BREEAM) is the national standard for assessing the sustainability of new construction developments. It aims to differentiate between developments with higher environmental performance by providing a sustainability ratings across 9 indicators (management, health and wellbeing, energy, transport, water, materials, wastes, land use and technology and pollution)There are 6 performance levels (unclassified, pass, good, very good, excellent and outstanding). There is a national government requirement that generally for new public buildings, the rating should be excellent. The NHS oversees compliance with this, although the NHS stipulates this applies to schemes that cost over £2m to complete.

Patient and Public Involvement

The Primary Care Infrastructure Plan se s out a clear engagement and involvement approach and provides a recommended checklist. All business case proposals will included patient engagement feedback

Recommendation Members of the committee are asked to comment on and note the contents of this report.

Author Andrew Hughes

Designation Associate Director, Commissioning

Sponsoring Director Helen Goodey Director of Locality Development and Primary Care

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Agenda Item 6

Primary Care Commissioning Committee Thursday 27th July 2017

Premises Development workstream progress report April 1st 2017 to

June 30th 2017

Theme

Item

Progress

Committed/ legacy

schemes

(please note Longlevens

and Devereux Centre now completed and now

business as usual)

Sevenposts

The practice expects work to start on site at the beginning of August 2017. Subject to the plan remaining on schedule, the building should be completed by summer 2018, with an expectation that Seven Posts and Greyholme Surgeries would close shortly after this – no later than by autumn 2018.

In line with Premises Directions 2013 and previous approvals, the CCG is reimbursing £119,476 of total professional fees and currently the CCG reimbursed £95,552 with £23,924 remaining.

Churchdown

Construction has started and the new surgery is planned to be open in March 2018. The CCG has providing additional fee support (for monitoring surveyor and legal fees) and has reimbursed £22,521 of a maximum of £42,500. In line with Premises Directions 2013, the CCG has also agreed to reimburse an estimated £23,773 of £36,020 when Stamp Duty Land Tax is paid by the practice in due course

Stow Surgery

In March 2016, The Primary Care Commissioning Committee confirmed their continued support for the previously agreed scheme. However, it was noted that this was subject to a Value for Money report being issued by the District Valuer. Final technical sign-off was delegated to the

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Chair of the Committee and the Accountable Officer to confirm the level of rent to reimburse to the The CCG has been waiting to receive confirmation from the developer that the scheme can be delivered within the financial envelope of £144k excluding VAT per annum It should be noted this is the maximum level of reimbursement deemed value for money by the District Valuer. Once confirmation is received, the District Valuer will be able to issue their Value for Money report. This means final technical sign off the scheme (previously delegated to Chair of PCCC and Accountable officer) In line with previous agreement, the CCG is also supporting the practice with £74k to contribute to legal, commercial and project management costs. From the CCG perspective there is nothing further for the organisation to do at this stage. Members should note that any perceived delay is essentially due to requirement to finalise a number of technical, legal and commercial aspects associated with the scheme. The CCG is hopeful these can all be completed soon and mean that the Practice and their developer can move forward to deliver practical completion.

Glevum surgery

Following additional investment by the CCG, building work for the refurbishment of existing surgery and construction of significant extension continues. The extension is expected to be completed and open by the end of March 2018. The practice will then relocate from the original part of the building to the new extension so that the total refurbishment of the existing

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building can commence. This part of the project is planned to be completed by the end of August 2018

Kingsway

All NHS approvals in place and planning permission granted. Practice currently procuring construction partner. The practice is anticipating that building work will commence in September 2017 with completion and opening of the new facility in the Autumn of 2018.

Stoke Road surgery

Refurbishment and extension of surgery has overrun and due to be completed during July 2017

PCIP/ new proposals (Including

reference to ETTF

funding)

Beeches Green

In line with agreed arrangements between NHS Propco, following a quotation tender, the CCG appointed GVA to support the three practices to develop their business case and work with NHS Propco to redevelop the existing Beeches Green site to able to accommodate around 26,000 patients. Work on the business case continues. The focus has been on determining requirements of the three surgeries in the context of the shared building. Wider requirements (mainly GCS and 2G) are now beginning to be progressed. However, no significant requirements are anticipated. It should be noted that the business case is being planned for completion in time for either the November 2017 or January 2018 PCCC (including IM&T specification and patient engagement finding) Subject to CCG approval, the CCG will need to work with NHS Propco to obtain NHS capital through NHS England, unless NHS Propco seek a 3rd party developer to lead practical completion on their behalf.

Cheltenham Town Centre

The business case was being progressed by 5 practices, their advisor and the third party developer. An initial feasibility

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assessment is expected to be completed by early July 2017 Two of the practices (Yorkleigh and Underwood) have now withdrawn from the scheme. This leaves Berkeley Place, Crescent Bakery and Royal Crescent surgeries At the time of writing this report (3rd July 2017), future arrangements were being discussed and finalised with a view to continuing to complete a business case setting out revised requirements for around 24,000 patients.

Avenue & St Peters,

Cirencester

Both practices remain in the early stages of their business case and the assumption is that both practices will co-locate into a single site in Cirencester town. The practices have met with the CCG to discuss key elements required and have identified a potential site.

Phoenix, Cirencester

The practice is progressing a business case for the development of a new surgery aligned with the Chesterton Housing development. The practice remains in negotiation with the relevant site owners. It is currently anticipated that the business case will be completed before the end of the calendar year, although practical completion of the building will be linked to the progress of the Chesterton housing development.

Brockworth & Hucclecote

Both practices remain committed to a single GP led development. A potential site has been identified in Perrybrook housing development in Brockworth (albeit, a larger site than indicated in the development and moved from central position to Western position of site so that the needs of both practices are met). However, there has been limited progress with the development

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agent. Both practices and the CCG still need to consider plan ‘b’ options, including two separate developments. The practices have also recently commissioned professional support from GVA to progress their plans.

Cinderford Health Centre

The practices have appointed a specialist development company to help them to take this forward. The company is currently working with the two practices to explore options in the local area and once potential sites have been identified the practices will engage with their patients, to ensure that their opinions and views are taken into account in making decisions for the future. It is anticipated that the business case will be completed ready for either the November 2017 or January 2018 PCCC.

Coleford Health Centre

No significant progress made. It is assumed that any business case development will not start until the Autumn of 2017

Minchinhampton

The practice has now confirmed this will be a GP Led development and is currently progressing their business case. The CCG development Team is also supporting the development of IM&T requirements and preparing patient engagement plans. The current assumption is that the business case will be ready for consideration at the November 2016 PCCC.

Romney House, Tetbury

Proposal remains the top priority for the CCG. The CCG Development Team has been working closely with the practice to try and identify potential sites, which is the current barrier preventing progression of business case.

Regent Street, Stonehouse

The team will review the timelines of large scale housing planned for the area to ensure that progress aligns with the West of Stonehouse housing development.

Gloucester City Health Centre

No significant progress has been made over last three months. The replacement/

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redevelopment of Gloucester City Health Centre remain a key priority. However, there a number of constraints currently preventing the practice from taking a scheme forward. However, opportunities remain in respect of the approved Local Development Order (LDO) for the redevelopment the Quayside and Blackfriars in Gloucester City Centre has and the principle of the primary care centre. This is being progress through the STP wide ‘One Gloucestershire’ Estates workstream.

Improvement Grants

(including ETTF)

Beeches Green (L84039)

Description - Improvement Grant to convert existing space for patient confidentiality. Cost – 66% IG based on a total project cost of £5,000 (including VAT), i.e. up to £3,300. Funding Source - CCG funded as agreed in Core Leadership Meeting of 19th December 2016. Update - The works have been completed. We are in the process of establishing the portion of the total invoice that related to the work that was the subject of the IG and will need NHS PS to re-invoice the practice for that work. At that point the CCG will be able to reimburse the practice their 66% IG award.

Brunston & Lydbrook (L84071)

Description - Improvement Grant to provide additional clinical capacity and

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improve access, lighting and fire precautions. Cost – 66% IG based on a total project cost of £65,000 (including VAT), i.e. up to £42,900. Funding Source - CCG funded as agreed in Core Leadership Meeting of 19th December 2016. Update – A contract has been appointed as a result of a tender process and work has begun.

Culverhay (L84027)

Description - Improvement Grant to provide additional clinical and training capacity. Reconfigure existing space to enhance patient confidentiality & disability access. Cost – 66% IG based on a total project cost of £320,500 (including VAT), i.e. up to £211,530. Funding Source - This proposal was originally submitted to the 2016/17 Estates & Technology Transformation Fund. The proposal was reclassified as a Minor Improvement Grant but as the total cost of the project was over £180k, the project is being administered by NHSE unlike the Lydney & Springbank projects. Update – NHSE have recently sent an update that the total projected cost of the proposed project has increased significantly, circa 65%. NHSE are in the process of ascertain the

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reasons for the increased costs compared with the original application before deciding to proceed with the application via NHSE’s Change of Costs Procedure.

Leckhampton (L84040)

Description - Improvement Grant for a range of minor improvements including reconfiguring existing space to enhance patient confidentiality & disability access. Cost – 66% IG based on a total project cost of £8,400 (including VAT), i.e. up to £5,544. Funding Source - CCG funded as agreed in Core Leadership Meeting of 19th December 2016. Update – The proposed revised works have been completed and the CCG has reimbursed the practice subject to the terms and limit of the IG Award.

Locking Hill (L84032)

Description - Improvement Grant for a range of minor improvements including additional clinical capacity, enhanced disabled access and CQC compliance. Cost – 66% IG based on a total project cost of £20,400 (including VAT), i.e. up to £13,464. Funding Source - CCG funded as agreed in Core Leadership Meeting of 19th December 2016. Update – The proposed works have been completed and the CCG has reimbursed the practice subject to the terms and limit of the IG Award.

Lydney Description - Improvement Grant for a range of minor improvements including

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additional clinical/training capacity, enhance patient confidentiality and CQC compliance. Cost – 66% IG based on a total project cost of £55,000 (including VAT), i.e. up to £36,300. Funding Source - This proposal was originally submitted to the 2016/17 Estates & Technology Transformation Fund. The proposal was reclassified as a Minor Improvement Grant and as the total cost of the project was under £180k the funding was transferred to the CCG to administer as ‘business as usual’ in accordance with its obligations under the 2013 Premises Costs Directions. Update – The proposed revised works have been completed and the CCG has reimbursed the practice subject to the terms and limit of the IG Award.

Rendcomb (L84063)

Description - Improvement Grant for a range of minor improvements including enhanced disabled access & automated doors. Cost – 66% IG based on a total project cost of £10,200 (including VAT), i.e. up to £6,732. Funding Source - CCG funded as agreed in Core Leadership Meeting of 19th December 2016. Update - The proposed works have been completed and the CCG has reimbursed the practice subject to the terms and limit of the IG Award.

Springbank (Y05212)

Description - Improvement Grant to remodel existing space to provide additional

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clinical/training capacity and develop service provision and range. Cost – 66% IG based on a total project cost of £111,000 (including VAT), i.e. up to £73,260. Funding Source - This proposal was originally submitted to the 2016/17 Estates & Technology Transformation Fund. The proposal was reclassified as a Minor Improvement Grant and as the total cost of the project was under £180k the funding was transferred to the CCG to administer as ‘business as usual’ in accordance with its obligations under the 2013 Premises Costs Directions. Update – The required 3 tenders have been obtained under a formal tender process. However, negotiations are ongoing and a successful contractor has not been appointed. A decision on the successful contractor is expected soon along with confirmation of the expected start date for the works.

Other issues 2017/18 IG Process

The CCG is in the process of developing the process for 2017/18 Improvement Grants. A letter will be sent to practices by inviting Improvement Grant proposals for consideration and/or approval. As was the case in 2016/17, any approval will be subject to the availability of funding.

Appendix 1

Page 1 of 9

Application for Consideration of a Contractual Merger (Please add additional pages if you have insufficient room to complete fully) Name and address of the practices wishing to merge: Practice code: L84057 Practice code: L84026 Type of contract: GMS Type of contract: GMS Practice code: L84042 Practice code: L84013 Type of contract: GMS Type of contract: GMS Please complete the following: 1. Which of these contracts you would prefer to continue with (CCG final decision in this respect would be required) The Heathville Contract - L84026 2. Indicate whether you intend to operate from all current premises -Yes. a. If yes, which premises will be considered the main and which is to be considered the branch/s (if applicable): The main sites will be:

Aspen Centre (currently Barnwood, Heathville and London), Horton Road.

Saintbridge, Askwith Road. The branch site is:

Heathville’s Surgery in Tuffley.

Heathville Medical Practice Aspen Centre

Horton Road, Gloucester GL1 3PX

London Medical Practice Aspen Centre


Saintbridge Medical Practice Askwith Road, Gloucester

GL4 4SH

Barnwood Medical Practice Aspen Centre


http://www.bing.com/local?lid=YN1029x5556979568357220001&id=YN1029x5556979568357220001&q=Aspen+Medical+Centre&name=Aspen+Medical+Centre&cp=51.8659782409668%7e-2.22580909729004&ppois=51.8659782409668_-2.22580909729004_Aspen+Medical+Centre


http://www.bing.com/local?lid=YN1029x3379305211192903939&id=YN1029x3379305211192903939&q=Saintbridge+Surgery&name=Saintbridge+Surgery&cp=51.8489532470703%7e-2.22225403785706&ppois=51.8489532470703_-2.22225403785706_Saintbridge+Surgery

http://www.bing.com/local?lid=YN1029x3379305211192903939&id=YN1029x3379305211192903939&q=Saintbridge+Surgery&name=Saintbridge+Surgery&cp=51.8489532470703%7e-2.22225403785706&ppois=51.8489532470703_-2.22225403785706_Saintbridge+Surgery


Appendix 1

Page 2 of 9

3. Are there any changes to premises/hours, etc? Premises will remain extant. It is intended to increase the opening hours in line with the Extended Access Pilot - ie provide an additional service to our patients Mon - Fri 1830 to 2000, Saturdays 0900 to 1200 - which was recently secured. 4. Full details of the benefits you feel the registered patients of all practices involved will receive as a result of this proposed merger. London Medical Practice is currently operating as a single-handed practice with Dr I Jarvis retaining sole Partner responsibility and the only signatory on the Practice’s GMS contract. Despite an extensive recruitment campaign over the last eighteen months aimed at recruiting a new Partner(s), this has been unsuccessful. This leaves the Practice in an extremely vulnerable position. Merging with the other practices in this Cluster provides sustainability, resilience and the ability to maintain the GMS contract - for all practices, but particularly for London. In the main, the surgeries already have overlapping boundaries and in several cases outliers would fall within the combined/ redefined boundary (albeit Heathville’s boundary more or less encompasses all the other practices’ boundaries). Moreover, operating from three sites has the potential to provide all patients with better access to services, and access to a greater pool of healthcare professionals. The wider skill-mix will also potentially enable new service development and specialisms. This is further enhanced by the adoption of Extended Access for all patients registered with these practices. 5. Please provide as much detail as possible as to how the current registered patients from the existing practices will access a single service, including consistent provision across: • home visits; • booking appointments; • additional and enhanced services; • opening hours; • extended hours; • single IT system; and • premises facilities. It is anticipated having a single telephone system that allows patients to opt for the location they wish to visit, noting that the merger should increase the services available for the overall patient cohort, as the mix of services currently delivered by single practices will be offered across the piece. The availability of home visits would not be affected although management of this is yet to be determined under

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new processes and the Extended Access Pilot; however, a pooling of resources will ensure this service is at the least more robust than current processes - more than likely better. Existing contracts require rationalising eg we will have a single website through which to offer online access. From 5 July 2017, all practices will be operating the same clinical system (EMIS Web), which will facilitate respective staffs booking appointments in a patient’s preferred location. With the adoption of Extended Access (absorbing Extended Hours within) the opening hours will increase, to the benefit of all patients. It is common practice for partners to discuss which (new) Enhanced Services (ES) to take part in (noting that all current ES would be open to all patients) and we would see this remaining the case as the partnership widens, with decisions being based on the specification requirements, patient needs and practice income. 6. Merger of clinical systems will require lead time. Please confirm the practice has approval for the clinical system merger and has considered the lead time for the merger: All 4 practices will operate a single Clinical IT system from 5 July 17, EMIS Web. The practices have made initial contact with the CSU regarding system merger and are aware of the prospective lead time (this being a critical path). Thus, getting this application approved is paramount to initiating this process. 7. Details of the proposed merged practice boundary (please provide a map): Maps of the current practice boundary and the new boundary are attached to Appendix 1 (Supporting information). 8. Describe your engagement with patients to date and how you propose to engage with your wider patients about this proposal, communicate actual change to patients The Saintbridge and Heathville Patient Participation Groups (PPGs) have already been consulted and broadly approve. Dr Hodges from Barnwood has also attended a meeting with the Saintbridge PPG. London and Barnwood (due to their smaller size and reduced GP partner numbers) have struggled to have a self-sustaining PPG. However, the matter has been discussed in detail with a large number of patients on an informal basis, and there have been no objections in principle raised. On receipt of outline approval to merge, the practices intend to start immediately a public engagement and consultation process in partnership with the CCG engagement lead. This will include written information, notices on websites, public engagement meetings and the formation of a new combined PPG. There will also be engagement via social and local media.

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The larger merged practice will ultimately be in a stronger position and have the scale to embed patient representation into governance structures in a more systematic and robust manner. 9. Please confirm that a process of due diligence has been undertaken by each of the merging parties for each of the following areas:

Practice Name Organisational Financial Clinical (including record keeping)

Other, e.g. partnership agreements

Barnwood Completed. Initial discussion started in March 2016. Unanimous agreement to merge from partners. Executive committee formed and operating, with oversight over 7 work-streams.

Completed, Little & Company. Partners had access to this information before considering merger.

Single clinical system now in place and already moving to common operating procedures and protocols. Future operating model being developed.

Draft new single partnership agreement drawn up and being finalised. Status of owned premises being explored.

Heathville Completed. Initial discussion started in March 2016. Unanimous agreement to merge from partners. Executive committee formed and operating, with oversight over 7 work-streams.




London Completed. Initial discussion started in March 2016. Unanimous agreement to merge from partners. Executive committee formed and operating, with oversight over 7 work-streams.




Saintbridge Completed. Initial discussion started in March 2016. Unanimous agreement to merge from partners. Executive committee formed and operating, with oversight over 7 work-streams.




10. Please identify the proposed date the merger will take effect from: 1 April 2018

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Appendix 1

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Appendix 1

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Appendix 1

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Appendix 1

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Note: this application does not impose any obligation on the CCG to agree to

this request.

Please return to:

Primary Care and Localities Directorate, NHS Gloucestershire Clinical Commissioning Group, Sanger House, 5220 Valiant Court, Gloucester Business Park, Brockworth, Gloucester, GL3 4FE.

Appendix 2

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SUPPORTING INFORMATION

FOR PROPOSED MERGER OF

THE THREE ASPEN CENTRE SURGERYS

BARNWOOD MEDICAL PRACTICE HEATHVILLE MEDICAL PRACTICE

LONDON MEDICAL PRACTICE

AND

SAINTBRIDGE MEDICAL PRACTICE

Introduction 1. Barnwood Medical Practice (BP), Heathville Medical Practice (HP), London Medical Practice (LP) and Saintbridge Medical Practice (SP) are practices within the Gloucestershire Clinical Commissioning Group (GCCG) operating area. Each practice holds a GMS contract with GCCG. BP has a list size of 5,878, HP has a list size of 10,087, LP has a list size of 5,106, and SP has a list size of 8,259, as at FY 2015/16. The percentages of weighted list compared with raw list for 20155/16 for each of the practices were: BP 96.8%; HP 103.4%; LP 106.9%; and Saintbridge 94.8%. 2. BP, HP and LP operate from one location within Gloucester, called The Aspen Centre, Horton Road (although HP has a branch surgery in Tuffley) and Saintbridge operates from its site in Asquith Road - all are located within inner city Gloucester, with an approximate distance of 1.8 miles between them. 3. All practices have been in discussion regarding collaborating together and closer working for some time - they are all members of the same Cluster Group. As those discussions have progressed, the operational and cultural similarities between the practices have become clearer. Equally, it has become noticeable that they share similar medium and longer term outlooks around General Practice sustainability and resilience, and that a merger makes business and economic sense. 4. Following further discussion between Partners and a Financial Due Diligence Review of all practices in May 17, the intention to merge has been confirmed with effect from 1 April 2018. 5. In addition to the advantages that patients will see, it is envisaged that the proposed merger will greatly benefit all levels of staff (administrative and clinical) across the practices by sharing workloads, enabling efficiency (economies of scale), enhancing resilience and therefore improving and enhancing the patient experience. It is also important to emphasise that the proposed merger will not lead to the withdrawal of any services currently provided to patients, more likely lead to additional services to many - following a potential reconfiguration of how and where some services are provided. It

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will not affect patient access to the practices and will not lead to the removal of any patients under boundary regulations. Background of the Practices 6. Barnwood currently operates from the Aspen Centre, Horton Road. The Practice

originally formed in the early 1900s on Worcester Street, later moving to the previous

premises on Barnwood Road.

There have been a few partners coming and going in the intervening years, and the nursing and administrative staff has expanded with the growing complexities of NHS General Practice. The Aspen Centre has been in use since August 2014 and has transformed the way that the practice operates and plans for the future. As well as providing GMS services to the registered patient list, Barnwood also provides cover for the Charlton Lane Centre (the older persons mental health inpatient facility for the county) and to Great Western Court (local authority run bed-based rehabilitation facility). The former senior partner Dr Brooke retired in October 2016, and unfortunately a

suitable replacement doctor has yet to be been identified.

The Practice has a long history as a training practice, with 2 former partners serving as

training programme directors for Gloucestershire. One of the 3 partners is currently a

trainer, and another intends to become a trainer in the next 2 years.

Barnwood specialises in training ST2 and ST3 GP trainees doctors, and since this year

Physician Associate (PA) students.

7. Heathville currently operates from the Aspen Centre, Horton Road. The Practice

is long established having started in the 1950s on London Road before moving to 5

Heathville Road in the 1960s.

There have been a few partners coming and going in the intervening years, and the nursing and administrative staff has expanded with the growing complexities of NHS General Practice. There is a long established branch surgery in Warwick Ave, Tuffley, which was originally the house of one of the partners. It has recently been refurbished and expanded to make it fit for modern healthcare purposes. The long-standing partnership model has changed in recent years and there are now no full time partners remaining at Heathville with a fair amount of medical care being provided by salaried doctors. It is also is a training practice and currently trains ST2 and ST3 trainee doctors. 8. London currently operates from the Aspen Centre, Horton Road. The Practice was started in 1948 by Dr Fyfe, initially practicing from a number of addresses on London Road, most recently number 97 for the past 25 years or so. There have been a few partners coming and going in the intervening years, and the nursing and administrative staff has expanded with the growing complexities of NHS General Practice. Two partners left in the early part of 2017, leaving Dr Jarvis as a

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single-handed doctor with a list of over 5000 patients; he manages this with an experienced advanced nurse practitioner, a new nurse practitioner, and some locums, although has a salaried doctor joining the team for one day per week in July and hopefully others to follow. London is a training practice specialising in training Foundation Year 2 (F2) doctors in Primary Care. 9. Saintbridge currently operates from Asquith Road . The practice was started in the 1960s by Dr Seddon who ran the surgery as a single-handed GP from Cotswold Road. He was later joined by Dr Cookson and they moved the premises to Askwith Road in the 1970s. There have been a few partners coming and going in the intervening years, and the nursing and administrative staff has expanded with the growing complexities of NHS General Practice. The building was flooded in 2007 shortly after having been refurbished and work had to take place over several months dry the building out and refurbish it again. In addition to many other advantages for merging, this has the added value of providing an immediate Business Continuity opportunity, should the building become flooded again, although it is hoped not with its improved flood defence mechanism (early warning protocol, water gates installed and silt cleared from balancing ponds). Saintbridge is a training practice specialising in training Foundation Year 2 (F2) doctors in Primary Care.

Practice Area - Barnwood Medical Practice

10. The boundary area has remained extant for some time.

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Practice Area - Heathville Medical Practice

11. The boundary area has remained extant for some time, is larger than most and covers Gloucester City and much of it surrounds Practice Area - London Medical Practice

Appendix 2

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12. The boundary area has remained extant for some time. Practice Area - Saintbridge Medical Practice

13. The boundary area has remained extant for some time.

Combined Practice Area

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14. The combined practice boundary will essentially be the same as the Heathville boundary as it currently stands. This is because the boundaries of the three other practices fall within the Heathville boundary. Staffing - Barnwood Medical Practice

15. Number of GPs

Name Gender Session Cover

Partners

Dr J Moreno Male 9

Dr R Hodges Male 8

Dr S Meade Female 6

Salaried GP

Dr KS Raj Male 5

GP Registrars and F2

Dr L Cooper Male 6

15a. Number of Hours of Nursing Time

Name Gender Weekly Cover

Practice Nurse

Samira Limbada Female 18

Sharon Cain Female 10

Helen Chandran Female 24.5

Healthcare Assistants

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Kay Confaloni Female 20

Cally Turner Female 12

Phlebotomist

15b. Number of sessions/clinical hours per week GP - 28 sessions per week (includes pre-booked clinics and extras; excludes Registrars and F2s). Nursing - 84.5 hrs per week (excludes Healthcare Assistants). 15c. Number of Other Practice Staff

Role No. of Staff Weekly Cover

Practice Manager 1 PT

Secretary 1 PT

Reception 6 PT

IT Manager 1 FT

QOF Admin/Records Mgmt 2 PT

Summarising/Occ Health 1 FT

Apprentice - -

15d. Staff Issues The former senior partner Dr Brooke retired in October 2016. A recruitment effort to

replace her has not proved successful and efforts remain ongoing. A new practice nurse has recently been recruited. Staffing - Heathville Medical Practice

16. Number of GPs


Partners

Dr R Watkins Male 4

Dr N Gilbert Male 6

Dr A Seymour Male 2

Dr R Khalid Female 6

Dr H Khalid Male 6

Salaried GP

Dr J Orme Female 6

Dr W Peek Female 5

Dr A VandenBroek Female 5

Dr H Bland Female 6

Dr R Kanan Female 6


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Dr K Patel Female 7

Dr J Jones Female 6



Practice Nurse

Mrs T Williams Female 20hrs

Mrs K Voyce Female 25hrs

Mrs C Gough Female 37hrs


Mrs H Cook Female 25hrs

Mrs L Phillips Female 35hrs

Phlebotomist

16b. Number of sessions/clinical hours per week

GP - 52 sessions per week (includes pre-booked clinics and extras; excludes Registrars and F2s). Nursing - 82 hrs per week (excludes Healthcare Assistants).

16c. Number of Other Practice Staff


Practice Manager 1 FT

Secretary 2 PT

Reception 10 PT

IT Manager - -

QOF Admin/Records Mgmt 2 PT

Summarising/Occ Health - -

Apprentice - -

16d. Staff Issues It has been increasingly difficult to both recruit and retain partners, in particular with the current situation being that the majority of medical cover is now provided by salaried doctors. Staffing - London Medical Practice

17. Number of GPs


Partners

Iain Jarvis Male 8

Nurse Practitioners

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Sarah Ron Female 9

Jane Szymanski Female 6

Salaried GP

Emma LeRoux Female 2


Hannah Jackson (F2) to end July

Female 8

Kim Ashton (ST2) from August

Female 7



Practice Nurse

Lisa Stoddart Female 6

Rachel Wright Female 4


Kim Peacey Female 8

Phlebotomist

17b. Number of sessions/clinical hours per week GP + NP - 23 sessions per week (includes pre-booked clinics and extras, and Nurse Practitioners). Nursing - 54 hrs per week (excludes Healthcare Assistants).



Practice Manager 1 (on mat leave) FT

Secretary 1 PT

Reception 5 PT

IT Manager

QOF Admin/Records Mgmt 3 FT

Summarising/Occ Health

Apprentice 1 FT

17d. Staff Issues Recruitment of senior clinicians has proven to be a challenge over the past year or so, and especially the past 4 months. The Practice is keen on training both clinical and non-clinical roles, in which recruitment has been good, and thus there is a stable non-clinical team. The clinical team, although lacking in GPs, is building and becoming increasingly stable as it does.

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Staffing - Saintbridge Medical Practice

18 Number of GPs


Partners

Jhumpa Sarkar Female 8

Sam Kuok Female 8

Andreas Marksteiner Male 8

Wali Islam Male 8

Salaried GP

Sam Holdcroft Female 4


3 x F2 Doctors 3 month rotations 13.5



Practice Nurse

Jacqui Curwen – may retire in April 18 or may stay on

Female 19

Donna Griffin Female 26

Bev Thorp

Female 20

Debbie Sibley – starts Dec 17 – to be Jacqui’s replacement

Female 20

Lynsey Garrott

Female 16


Karen Wilkins

Sarah Bee 35

Phlebotomist

18b. Number of clinical hours per week

GP - 36 sessions per week (includes pre-booked clinics and extras; excludes Registrars and F2s). Nursing - 82 hrs per week - at present (excludes Healthcare Assistants).



Finance Manager

Secretary 2 PT

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Reception 11 PT

Clinical Admin Manager 1 FT

QoF Admin/Records Management/Summarising

4-5 PT

Apprentice - -

18d. Staff Issues No significant issues. Aiming to build a strong practice nurse team and to engage in succession planning even if there are greater numbers for a period of time. IT - All Practices 19. As of 5 July 2017, all 4 practices are operating EMIS Web. Care Quality Commission - Barnwood Medical Practice 20. Overall rating GOOD (July 2016). Report can be viewed here. http://www.cqc.org.uk/location/1-1525040907 Care Quality Commission - Heathville Medical Practice 21. Overall rating GOOD (October 2015), Report can be viewed here.

http://www.cqc.org.uk/location/1-1482438584

Care Quality Commission - London Medical Practice 22. Overall rating GOOD (November 2016), Report can be viewed here.

http://www.cqc.org.uk/location/1-1447352540 Care Quality Commission - Saintbridge Medical Practice 23. Overall rating GOOD (May 2016), Report can be viewed here. http://www.cqc.org.uk/location/1-569342236 Clinical Governance - All Practices 24. All Practices currently have weekly meetings where clinical governance issues and patient cases are discussed. Clinical meetings to discuss safeguarding, palliative and complex cases are conducted quarterly. Practices also have monthly education and training sessions (e.g. annual CPR and basic life-support). Integrated within each practice is a process or recording and reviewing significant events, and complaints where apposite, which are also discussed at these meetings. Merging into a single practice will greatly enhance our ability to organise and deliver high quality staff training and clinical education though better organisation and greater









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use of the Aspen Centre's training and conferencing facilities. We also expect to make more efficient use of our Clinician's enhanced skills in certain clinical areas such as minor surgery, diabetes, respiratory, frailty and women's health by reducing clinician time spent on low-value and repetitive tasks that can be devolved. Training Practice 25. Barnwood has a long history as a training practice, with 2 former partners serving as training programme directors for Gloucestershire. One of the 3 partners (Dr J Moreno) is currently a trainer, and another (Dr S Meade) intends to become a trainer in the next 2 years. Barnwood specialises in training ST2 and ST3 GP trainees doctors, and since this year Physician Associate (PA) students.

Heathville is a training practice (Dr R Khalid is a trainer) and currently trains ST2/3 doctors.

London is a training practice specialising in training Foundation Year 2 (F2) doctors in Primary Care.

Saintbridge is a training practice specialising in training Foundation Year 2 (F2) doctors in Primary Care.

All 4 practices have agreed to provide training for Physician Associate (PA) students studying at the University of Worcester and are looking to integrate the PA role into Primary Care going forward. Opening Hours - Barnwood Practice 26. The opening hours for BP are:

Day Opening Hours

Monday 8.30am – 8pm

Tuesday 8.30am – 6.30pm

Wednesday 8.30am – 6.30pm

Thursday 8.30am – 6.30pm

Friday 8.30am – 6.30pm

Barnwood currently participates in the Extended Hours DES, delivering an additional 3 hours of appointments per week by opening until 8pm on Mondays. Neither the Reception nor phone lines close at lunch time. Outside of core hours, the Practice uses NHS 111 as their Out-of-Hours provider.

Opening Hours - Heathville Practice 27. The opening hours for HP are:

Day Opening Hours

Monday 8.30am – 6.30pm



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Reception remains open at lunch time, although the phones switch to a provider for an hour. Outside of core hours, the Practice uses NHS 111 as their Out-of-Hours provider.

Opening Hours - London Practice 28. The opening hours for LP are:

Day Opening Hours






Reception remains open at lunch time. Outside of core hours, the Practice uses NHS111 as their Out-of-Hours provider. Opening Hours - Saintbridge Practice 29. The opening hours for SP are:

Day Opening Hours






Saintbridge currently participates in the Extended Hours DES, delivering an additional 4.25 hours of appointments per week by opening later on Mondays and Wednesdays. Reception remains open at lunch time, although the phones switch to a provider for an hour. Outside of core hours, the Practice uses NHS111 as their Out-of-Hours provider. Summary on Likely Opening Times 30. All 4 practices will be operating the EMIS Web system from July 2017, with an immediate focus of adopting joint operating procedures and working towards a common (shared) appointment booking system before implementation of the Extended Access pilot in the Autumn of 2017. The proposal would normalise the weekday opening hours of the main Aspen Centre Hub as 8am to 8pm, with telephone access, appointment booking, routine bookable appointments and urgent appointments available for all registered patients. Extending some coverage of urgent care past 6.30pm is expected to reduce pressure on OOH services and the Emergency Department at GRH.

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Extended Access will also result in the Aspen Centre being open on Saturday mornings 09:00 to 12:00 for pre-bookable and on-the-day appointments. The opening hours of the Saintbridge and Tuffley surgeries are expected to remain the same, although the patients will be able to utilise the Extended Access appointments at the Aspen Centre.

Service Provision - All Practices 31. The service provision for all practices can be found at Appendix 1.

Enhanced Service Provision - All Practices

32. In 2016/17, the Practice had signed up to National, Directed and Local Enhanced Services, which can be found at Appendix 2. Rationale for Merging 33. Commissioning services for Primary Care is increasingly being aimed toward practices covering a larger patient population. Equally, with the growing complexity of primary care it is becoming increasingly difficult to manage a small practice and offer a good level of care to patients. Merging will create a more resilient practice with the resources and expertise needed to manage all the demands of general practice, both administratively and clinically. In addition, technological advances will allow the organisation to adapt to the challenges of an ageing population, workforce and recruitment difficulties and new housing projects (such as the nearby Allstone Development), and as such will be inherently more resilient and sustainable. That said, the aim is to do more than simply cope and survive. The aim is to thrive, and do be able to take advantage of new opportunities to develop the services that can be offered for the benefit of patients and the wider health system, through partnership with local NHS trusts and secondary care providers. From early discussions, it is clear that the practices share a similar ethos and ambition – to exceed patient expectations in the delivery of general practice services. Moreover, the partners have already completed a financial review of each practice’s accounts through an independent accountant. This due diligence exercise was considered satisfactory by all parties, with universal agreement to proceed with a merger application. More detailed discussions about structures and services have also identified a number of areas where a merged practice will also be (in addition to patients) of benefit to staff:

Improved staff leave/absence cover allowing for continuity of patient care and a reduced reliance on temporary staff.

Improved career possibilities.

Improved learning and development opportunities.

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Improved working methods (economies of scale) - greater choice on working in different areas.

Thus, enhancing ‘curb appeal’ and making working in a larger organisation more appealing. Proposed Plans for Merger

34. Much work is currently underway on the planning and restructuring of merging 4 practices into one, although is too embryonic to detail at this juncture (noting there are 7 major work-strands - Executive, HR, Legal, Finance, Access, Joint Working and Admin/IT). The planning has already identified that services to patients will improve, such as Extended Access, a new urgent care system, additional assistance with frailty (employment of a General Old Age medicine Consultant), enhanced home visiting service and those practices not undertaking services being covered by others. The plans are also fully compliant with the objectives in recent National Policy documents such as the GP 5 Year Forward View and with the local Sustainability and Transformation Plan (STP). In fact, all national policy guidance that focuses on Primary Care is essentially dependent on practices working together, whether through federating, or mergers such as this proposed one. Thus, delivering joined-up, clinically safe Primary Care, and with the ability to work at sufficient scale to accept the transfer of funding and work from secondary care.

Locations 35. All sites will remain operational - Aspen Centre, Saintbridge Medical Practice and Heathville’s Branch Surgery in Tuffley.

Number of GPs (Partners, Salaried etc)

36. All GPs currently employed by each practice are expected to remain following the merger.

Number of Hours of Nursing time 37. There is no reduction expected in the number of nursing hours per week currently provided during the merger. Number of Other Practice Staff 38. There is no reduction expected in the number of practice staff during the merger Number of Clinical Hours Per Week (Face to Face Consultations)

39. There will be no reduction in the number of clinical hours provided following merger. Details on Extended Access and other services that a merged practice will be able to offer that single practices are unable to - eg through the use of a multi-disciplinary team – have been covered elsewhere.

List Sizes

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40. The 4 x Practices’ patient lists will be merged and all patients will be invited to remain with the single Practice. Opening Hours

41. The exact opening hours of the merged single practice is still to be confirmed. However, there will be no reduction in opening hours of the main Aspen site following merger (or the other 2 sites) - and, as previously detailed, will actually increase through Extended Access. Other Services 42. Other services such as Clinical Governance, Complaints, CQC Registered Manager, Significant Events, Palliative Care, MDT meetings (Health Visitors, Community Nurses) will continue, although leads for these services are still to be confirmed. Patient Benefit 43. The clinicians within all 4 practices are motivated by a desire to serve their patients in the best possible way, something that traditional General Practice arrangements increasingly are failing to allow - due to shortages of GPs and increased patient demand et al. A single merged partnership, will allow the creation of an internal urgent care stream (aka hot/cold split). This will both increase urgent care capacity and access (through skill mix and novel modalities of consultation), and improve continuity of care for patients with frailty and complex conditions by allowing a greater proportion of a GP's time to be available for their usual patient list. A longer standard working weekday for the organisation (through Extended Access) will allow the adoption of different and more flexible working patterns which in turn should allow greater career flexibility and help attract healthcare professionals to work in Gloucester. For example, the division of each weekday into 3 sessions of 4 hours each will negate the need for individual GPs to be subjected to excessively long and stressful long days on call. The merged practice will also be able to offer different types of working sessions to GPs whose out of practice commitments prevent them from working long days and who might otherwise be lost to the workforce. Working later in the evenings and having Saturday morning clinics increase the availability of appointments (such as for smears) that are of particular value and convenience for patients of working age. This should redress some of the imbalance caused by the necessary shift in focus to the care of the frail elderly during the working week. The proposed merger will greatly enhance the collective resilience that would allow a larger practice move towards a sustainable staffing model. The aim is to become a proactive organisation that better anticipates and adapts to the needs of our patients and local health system. The scale that the merger will provide allows such an organisation to lead the establishment of new models of care (such as the Multi-Specialty Community Provider or MCP) in the future. Essentially this involves the

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movement of traditional secondary care out into primary care where it is more responsive and accessible for patients, building on the success that has been witnessed with the GP Care delivered services at the Aspen Centre. Training Practice 44. The merged practice will continue to provide training and mentorship for newly qualified doctors with hospital experience as per current arrangements through CRS. It would continue to train F2 and ST2/3 doctors. Moreover, it is believed that merger may allow a further expansion in the capacity to train doctors. It should also enhance the development of the training of PA students and allow further engagement with nurse training more systematically as the organisation develops its skill-mix based clinical delivery model.

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Appendix 1 Service Provision - All Practices

X’ denotes undertakes the service.

Service Provision BP HP LP SP

Adult Immunisations/Vaccinations

X X X X

Antenatal Clinic X X X X

Aortic Aneurysm Screening X X X X

Asthma Clinic X X X X

Baby Clinic X X X X

Baby and Child Immunisation Clinic

X X X X

Bowel Cancer Screening X X X X

Breast Screening X X X X

Cervical Smear Tests X X X X

Chlamydia Screening X X X X

Diabetic Clinic X X X X

Family Planning X X X X

Heart Attack Aftercare X X X X

HRT Checks X X X X

Learning Disability Reviews X X

Mental Health X X X X

Minor Surgery X X X X

Near Patient Testing X X X X

Nurse led Minor Illness Clinics X X

(Non-NHS) Company and Assurance Medicals

X X X X

NHS Health Check Programme

X X X X

Sexual Health Clinic X X X X

Smoking Cessation Clinic X X X X

Travel Immunisations and Advice

X X X X

Well Woman and Well Man Clinics

X X X X

Yellow Fever Vaccination Centre

X X X X

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Appendix 2 Enhanced Service Provision - All Practices In 2016/17, the Practices had signed up to the following National, Directed and Localy Enhanced Services:

‘X’ denotes undertakes the service.

Enhanced Service Provision

BP HP LP SP

Avoiding Unplanned Admissions

X X X X

Anti-Coagulation X X X X

Complex Leg Ulcers X X X X

Diabetes X X X X

DVT X X X X

Extended Hours Access X X X X

High Risk Drugs X X X X

Immunisations X X X X

Influenza X X X X

Learning Disabilities X X X X

Minor Surgery X X X X

NHS Health Checks X X X X

Older People Care Homes X X X X

Primary Care Offer X X X X

Sexual Health X X X X

Winter Review X X X X

£1m Unplanned Care X X X X

Appendix 3

Saintbridge Surgery

Appendix 3

Barnwood Medical Practice

Appendix 3

London Medical Practice

Appendix 3

Heathville Medical Practice

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Agenda Item 7

Primary Care Commissioning Committee

Meeting Date Thursday 27 July 2017

Title Application to merge from Barnwood Medical Practice, Heathville Medical Practice, London Medical Practice and Saintbridge Surgery

Executive Summary An application for merger has been received from four practices in Gloucester City locality.


London Medical Practice is currently a single handed practice. The merger of these practices will have a positive impact on the resilience of this practice as the contract will no longer be held by a single practitioner.

Financial Impact The CCG should consider costs/value for money as this contract merger will merge four contracts and leads to an „averaging‟ effect. In this instance, following analysis there appears to be no cost pressure on the CCG if the merger is approved. However, the CCG should also bear in mind that once patients are under one contract, the Carr-Hill formula (or any future equivalent) will be applied and may increase the cost of the transferring patients based on one of the other factors such as rurality, when it may not have applied to the terminating contract. The merger will have a positive impact on the practices as they will be more efficient and resilient and therefore we would not anticipate they would require any vulnerable practice funding in the foreseeable future.

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Legal Issues (including NHS Constitution)

Gloucestershire CCG (GCCG) needs to act within the terms of the Delegation Agreement with NHS England dated 26 March 2015 for undertaking the functions relating to Primary Care Medical Services. A merger represents a variation to a practice‟s GMS contract and therefore requires agreement by GCCG under delegated commissioning arrangements. The PCCC approved a GCCG Standard Operating Procedure for an application to merge application in May 2017, which also sets out the prevailing guidance, legislation and regulations to be considered. This protocol has been followed in handling this application.


Assessed as low as patients will continue to have access to services at current locations, or can choose to register with another local practice.

Impact on Equality and Diversity

Assessed as low as patients will continue to have access to services at current locations or can choose to register with another local practice.

Impact on Quality and Sustainability

Increasing sustainability is one of the main reasons the practices wish to merge. By becoming one entity this will have a positive impact on the resilience of London Medical Practice.


The practices have started engagement in relation to proposed merger with their patients with advice and support from CCG Associate Director, Engagement and Experience.

Recommendation The PCCC is asked to review the application and supporting information which set out the

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proposals for the merger of four practices in Gloucester City locality:

Consider the recommendation from the Primary Care Operational Group meeting on 18 July 2017;

Make a decision regarding this request to merge contracts from Barnwood Medical Practice, Heathville Medical Practice, London Medical Practice and Saintbridge Surgery.

Author Jeanette Giles

Designation Head of Primary Care Contracting

Sponsoring Director (if not author)

Helen Goodey, Director Locality Development and Primary Care

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Agenda Item 7


Thursday 27 July 2017

Application to merge from Barnwood Medical Practice,

Heathville Medical Practice, London Medical Practice and

Saintbridge Surgery

1

Introduction and background

1.1 1.2

Gloucestershire CCG‟s Primary Care Strategy supports the vision for a safe, sustainable and high quality primary care service, provided in modern premises that are fit for purpose which requires a resilient primary care service. There is an increasing trend towards delivery of „Primary Care at Scale‟, with the traditional small GP partnership model often recognised as being too small to respond to the demographic and financial challenges facing the NHS. Our Strategy refers to GP practices and other professionals, such as clinical pharmacists, working together in closer partnership to deliver more sustainable high quality services. This should result in a number of benefits including access to a wider range of local services for patients within the local community, increased staff resilience, improved staff satisfaction, work life balance and learning opportunities, and improved financial sustainability. Two of the most fundamental issues affecting primary care both nationally and locally which threaten the sustainability of services and employment of staff, resulting in a crisis in general practice relate to:

Workforce o A large number of GP retirees within the next five years – 54%

amongst over 50 year olds (Dayan et al., 2014); o A lack of new medical students entering the profession with more

than one in ten slots for new GP trainees unfilled (BMJ Careers, 2014);

o Health Education England reporting only 40% of medical students chose general practice (Health Education England, 2014);

o A significant proportion – 33% of general practice nurses are due to retire by 2020;

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1.3

1.4

o At the same time, there has also been a shift with more GPs working as salaried employees and more GPs working part-time.

And

Funding o It is well recognised that spending on primary care as a

percentage of overall healthcare spend has been reducing year-on-year since 2005/06 (HSCIC, 2012);

o The relationship for GP practices between earnings, expenses and their resulting income needs to be sustainable in order to fulfil expenses, maintain staff and services, invest in their businesses and have sufficient remaining funds to pay their partners an appropriate income.

In April 2016, NHS England published the “General Practice Forward View” which sets out a range of measures to support general practice, i.e.:

General practice at the core, working „at scale‟ (mergers, federations, networks) but retaining „family medicine‟;

„At scale‟ organisations providing a wider range of services;

With a MDT approach, offering extended access (hours and methods);

Integrated, coordinated, care based on registered lists and delivering continuity of care;

Integrated IT and increased/better use of technology. Within our Primary Care Strategy we said we would:

Create a better work-life balance for primary care staff;

Support practices to explore how they can work closer together to provide a greater range of services for larger numbers of patients.

The CCG made a strategic commitment to „Primary Care at Scale‟ including working with practices to support them through merger conversations. Within our Primary Care Strategy we recognised Primary care operating at scale could result in:

Improved financial sustainability for practices through delivering more services along with rationalisation of some back-office functions and reduced duplication of work;

Reduced management responsibilities for partners as the load is

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1.5

spread amongst more;

Increased resilience in primary care, such as through additional staff in-house providing the ability to more easily flex to cover absence;

Improved work-life balance for primary care staff;

Increased practice staff satisfaction and learning opportunities through offering a more diverse range of services.

Whilst there are different initiatives nationally, the narrative is a repetitive one: sustainability and resilience of primary care fit for the future, which is working as part of an integrated team of multi-specialists needs to be working collaboratively at scale. Locally we will continue to value the essence of local primary care, care continuity and preservation of “family medicine”.

2. 2.1

Proposal to Merge Gloucestershire CCG has received a merger application (appendix 1) and supporting information (appendix 2) from the following four practices: Barnwood Medical Practice (L84057) (5,855 patients)

o Aspen Centre, Horton Road, Gloucester, GL1 3PX

Heathville Medical Practice (L84026) (10,237 patients) o Aspen Centre, Horton Road, Gloucester, GL1 3PX

London Medical Practice (L84042) (5,132 patients)

o Aspen Centre, Horton Road, Gloucester, GL1 3PX

Saintbridge Surgery (L84013) (8,683 patients) o Askwith Road, Saintbridge, Gloucester, GL4 4SH

All four practices hold a GMS contract and three of the practices are located in the Aspen Centre.

2.2

The location of the surgeries, and their population spread are shown below in the maps below. Map showing the four practice boundaries and practice locations

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Map showing the four practice combined population spreads

Individual practice population spreads are shown in Appendix 3.

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2.3 London Medical Practice is currently operating as a single-handed practice with Dr Jarvis retaining sole partner responsibility. The national and local shortage of GPs is impacting on the ability of Gloucestershire practices to recruit and retain staff, and despite extensive attempts to recruit a new partner over the last few months the practice has not been successful. All four of the practices are approved as GP training practices. The four practices have been in discussion regarding collaboration and closer working for some time and are currently a cluster. As discussions have progressed they have identified operational and cultural similarities and have a shared vision for general practice sustainability and resilience. All practices have recognised the increasing challenges of managing a small practice and a merger will create a more resilient practice with the resources and expertise to manage the demands of general practice, both clinically and administratively with greater opportunities for more innovation and different ways of working. More information about the Practices is provided in appendix 2 supporting information.

2.4 The surgeries already have overlapping boundaries and following the merger the same area will be covered.

2.5 Impact/benefits for patients and local population All sites will remain operational, i.e. Aspen Centre, Saintbridge Surgery and Heathville‟s branch surgery in Tuffley. Patients will have better access to services as the mix of services currently delivered by individual practices will be offered to all patients. There will also be access to a greater pool of health care professions. Wider skill-mix will also potentially enable new service development and specialisms. The cluster is a preferred bidder for developing plans to implement an extended access pilot in autumn 2017 with the aim of increasing the weekday opening hours of the main Aspen Centre Hub from 8am to 8 pm. The merger will enable the practices to better manage the increasing demands on general practice and adapt to the challenges of an ageing population and any new housing developments.

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No specific patient groups will be adversely affected through the proposed merger as there will be no requirement for patients to travel to a different site other than their most local one. As London Road is currently a single-handed practice a merger with the other practices in this cluster will provide sustainability and resilience to this practice and the other three practices.

2.6 Financial implications for CCG A Financial Analysis has been undertaken relating to the potential effect on GMS Global Sum Funding. An average 2016/17 weighting differential has been calculated for each practice subject to proposed merger and from this we have calculated the 2016/17 average notional differential for the combined list of the practices. The CCG then calculated a notional April 2017 Global Sum based on the combined actual patient population and applying the 2016/17 average notional differential for the combined list of the group of practices to get the weighted list. The CCG also assumed that all MPIGs will roll over to the new merged practice; the same applies for the Temporary Residents Adjustment. The CCG then compared the result of the notional April 2017 Global Sum calculation for the proposed merged practices to the actual April 2017 Global Sum funding the practice received. The result was a very slight reduction in projected Global Sum funding is predicted when compared against actual April 2017 Global Sum calculations, i.e. - 0.053%, (£1,338). The methodology used takes into account individual actual and weighted lists relative to the proposed merged entity. However, until the combined numbers are finalised by the Exeter (NHAIS) system at the time of merger this is our best estimate. It is assumed that best practice will be shared in the larger entity to enhance QOF and/or Enhanced Services performance that could potentially increase income. It is however noted that three of the practices are already above the CCG average of practice QOF achievement.

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3. 3.1

Alternative local provision There are a number of GP practices within the area where patients could register with if they choose to seek an alternative surgery, these are detailed and shown in the map below: Forest of Dean Locality

Newnham Surgery. Tewkesbury Locality

Newent Family Doctors;

Staunton & Corse Surgery. Gloucester Locality:

Bartongate Surgery;

Brockworth Surgery;

Cheltenham Road Surgery;

Churchdown Surgery;

College Yard & Highnam;

Gloucester City Health Centre;

Gloucester Health Access Centre;

Hadwen Medical Practice;

Hucclecote Surgery;

Kingsholm Surgery;

Longlevens Surgery;

Partners in Health;

Quedgeley Medical Centre;

Rosebank Health. Cheltenham Locality

Crescent Bakery;

Royal Well Surgery. Stroud & Berkeley Vale Locality

Frampton Surgery;

High Street Medical Centre;

Painswick Surgery;

Regent Street Surgery;

Stonehouse Health Clinic.

Map showing boundary of merged practices

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4 4.1 4.2

CCG engagement for the application to merge As per the Standard Operating Procedure (SOP) for the application to merge contracts, the practice had preliminary discussions with the GCCG Primary Care and Localities Directorate and the Patient Engagement and Experience Team. Gloucestershire CCG have engaged with:

Neighbouring practices (24 practices);

Healthwatch Gloucestershire;

NHS England;

The Local Medical Committee

4.3 The responses: Neighbouring practices College Yard & Highnam Surgery – “We cannot see any reason to oppose the proposal, and support this as being the best way to increase resilience and sustainability in general practice.” The Local Medical Committee “Having shared the letter with the LMC Executive Committee the agreement was that the LMC had no objections regarding the application for merger of the practices which we recognise as helpful to the sustainability of primary care delivery in Gloucester. So at this stage we have no concerns regarding their expression of merger and are not aware of any concerns from any other practices of the intended action to be taken.”

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NHS England Following confirmation that the practices were not considering any changes to their current surgery locations, NHSE did not make any comment. Any additional responses received before the meeting will be presented verbally at the meeting.

5. Practice engagement All practices have started engaging with their patients. In particular Saintbridge Surgery and Heathville Medical Practice Patient Participation Groups (PPGs) and broadly approve of the proposed merger. The CCG‟s Associate Director, Engagement and Experience, will be joining the practices and their patient representatives for an evening engagement event in early September. All the surgeries are publicising their merger plans via an information statement on their websites, a newsletter and posters displayed in practice. If the merger is approved the practices will continue further engagement and communication in liaison with the CCG.

6. Summary For those patients who wish to access GP services at an alternative location to the Barnwood Medical Practice, Heathville Medical Practice, London Medical Practice and Saintbridge Surgery options are available for them to register at alternative surgeries (see para. 3). The merger of these practices will increase the resilience and sustainability of this cluster and should improve the recruitment and retention of GPs and clinical staff. It is envisaged that the proposed merger will benefit all staff across the practices as workloads will be shared, efficiencies can be delivered which will enhance resilience and lead to an improved and enhanced patient experience. In particular the practices cite:

improved staff leave/absence cover (allowing for continuity of patient care and reduced reliance on temporary staff).

improved learning and development opportunities which can be shared across all locations.

Merging into a single partnership will greatly enhance their ability to organise and deliver staff training and clinical education through better

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organisation and greater use of the Aspen Centre‟s training and conference facilities. Operating from three sites has the potential to provide all patients with better access to services and a greater pool of healthcare professionals. A merged practice (29,907 patients) will be better placed to take advantage of new opportunities to develop the services that can be offered for the benefit of patients and the wider heath system.

7. Recommendation The PCCC is asked to:

Consider the recommendation from the Primary Care Operational Group meeting of 18th July 2017;

Make a decision regarding this request to merge.

8. 8.1

Appendices Appendix 1 - merger application

App 1 Merger application aspen practices and saintbridge.docx Appendix 2 - supporting information

Supporting Info for Merger 4 Jul 17.docx

Appendix 3 – individual practice population spread

Population spread for each of the practices.docx

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Agenda Item 8



Title Delegated Primary Care Commissioning financial report as at 30th June 2017

Executive Summary At the end of June 2017, the CCG’s delegated primary care co-commissioning budgets reported an underspend of £807 and a breakeven forecast.


None

Management of Conflicts of Interest

None

Financial Impact The current position and forecast has been included within the CCG’s overall financial position.


None


None


None


None


None

Recommendation The PCCC are asked to:

Note the contents of the paper

Author Andrew Beard

Designation Deputy Chief Financial Officer


Cath Leech Chief Finance Officer

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Agenda Item 8


Thursday 27th July 2017

Delegated Primary Care Commissioning Financial Report as at 30th June 2017

1. Introduction

1.1 This paper outlines the financial position on delegated primary care co-

commissioning budgets at the end of June 2017.

2. Financial Position

2.1 The CCG reported an underspend of £807 against delegated budgets at the end of June (see table below).

2.2 While the year to date position is balanced there are several risks

becoming apparent at this early stage in the year:

The GMS contracts budget was set using a demographic increase of 0.18% each quarter (0.72% p.a.) which is line with NHSE South Central planning assumptions however Q1 of 17/18 has seen an increase of 0.28%. As GMS contract payments represent more than 60% of the total budget there could be some considerable pressure on the budget if list sizes increase further.

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Other GP Services is overspending by £102k year to date due to changes in the rules around sickness and maternity payments. To cover maternity leave, practices can now claim up to the maximum number of sessions rather than the actual vacancy; sickness payments are no longer discretionary and can be paid both earlier and at a higher amount than was previously allowed. Claims in the first quarter suggest that some practices are taking full advantage of the new rules. £153,120 was paid for maternity and sickness in the first quarter.

The national issue of CQRS payments of 2016/17 QOF achievement has not yet been resolved and most practices have been paid more than was expected. All practices have been informed that a repayment is likely although the full extent of the overpayment is not yet clear. An estimate of £100k has been forecast to be reclaimed from practices.

Enhanced Services is underspending due to lower than expected Minor Surgery claims.

2.3 The CCG has forecast a breakeven position for 2017/18 by using the

0.5% Contingency reserve to cover the expected overspend from sickness and maternity claims and to cover the Gloucester City clinical pharmacists who were identified at the start of the budget round. Headroom is shown as fully committed but the CCG is awaiting advice from NHSE on the use of this funding.

3. Recommendation(s)

3.1 The PCCC are asked to:

Note the contents of the paper.

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Agenda Item 9



Report Title Primary Care Quality Report

Executive Summary This report provides assurance to the Committee that quality and patient safety issues are given the appropriate priority and that there are clear actions to address them.

Key Issues

Failure to secure quality, safe services for the population of Gloucestershire.

Risk Issues: Original Risk (CxL) Residual Risk (CxL)

Failure to secure quality, safe services for the population of Gloucestershire

Management of Conflicts of Interest

Not applicable

Financial Impact There is no financial impact


Compliance with the NHS Constitution, NHS Outcomes Framework and recommendations from NICE and CQC.


A focus on the delivery of equitable services for the residents of Gloucestershire and which will reflect the diversity of the population served.


There are no direct health and equality implications contained within this report.


There are no direct sustainability implications contained within this report.


This report provides information about Patient and Public involvement, engagement and experience activity.

Recommendation The PCCC is asked to note the content of this report.

Author Marion Andrews-Evans

Designation Executive Nurse and Quality Lead


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Agenda Item 9


Thursday 27th July 2017

Primary Care Quality Report 1.0 Introduction

This Primary Care Quality Report focuses on three key domains. Planning for Quality, Quality Improvement and Quality Assurance and details the progress within Primary Care to date.

2.0 Planning for Quality

2.1 Workforce – Gloucestershire Clinical Commissioning Group Practice Nurse Facilitator (PNF)Team

2.1.1 The GCCG Practice Nurse Facilitator Team has been in post since April 2016. The team has recently undergone a change of staff with one PNF leaving and one commencing maternity leave. The Clinical Learning and Development Manager will now support the PNFs working in practice. This will be re-evaluated after six months. All localities will continue to have a PNF attached for support and guidance.

2.2 2.2.1

Education and Training GCCG Practice Nurse Facilitator Team are working with the University of Gloucestershire and practices to support student nurse placements. 21 practices have expressed an interest in hosting student nurses.

3.0 Quality Improvement

3.1 Medicines Optimisation

3.1.1 Berkeley Vale locality Prescription Ordering Centre (POC) This service has been operational within Berkeley Vale locality since April 2017, and is currently offered to patients at three of

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the six practices in the locality. This service allows patients direct telephone ordering access for repeat medications, rather than having to use paper requests and other non-verbal methods. The intention is to ensure that the requested products are actually required, by asking a series of questions and making an assessment of previous issues. It also gives the patient an opportunity to ask questions that otherwise would not get asked when using non-verbal ordering methods. The team also advise prescribers as they encounter recently overdue blood tests, or medication reviews. This helps to improve the safety and quality of prescribing by offering an extra check at each repeat request. Indeed, a number of overdue medication reviews and other reasons to advise the GP have been recorded, all of which will raise awareness of these items with the prescriber. A reduction of unnecessary stockpiling of medicines within patient homes will also result, as it becomes more difficult to “order everything” without consideration.

3.1.2

CCG Prescription Ordering Line (POL) GCCG is piloting a CCG-hosted version of the above service with Rosebank Health in Gloucester. The pilot, which closely follows the POC model, started in July. It has been termed the Prescription Ordering Line (POL) for the purposes of differentiation. As with the Berkeley Vale POC, patients call a dedicated phone line to order their repeat prescriptions. This connects them to a new team based at Sanger House who can process the request in the practice‟s own clinical system, for GP approval and transmission to the patient‟s nominated pharmacy. NHS Coventry & Rugby CCG originally devised the model in 2015, and has reported success across a range of quality metrics including patient experience and clinical safety. A number of other Gloucester practices are due to join Rosebank Health as part of the pilot over the next few weeks. If the pilot is deemed to be effective, the model will then be rolled out.

3.2 Collaborative Working System Wide

3.2.1 The STP Organisational Development and Workforce Strategy Group has established three thematic groups to take forward the priorities that have been identified in the June 2016 STP submission. The three thematic groups are Capacity, Capability and Culture. GCCG are working with these three groups to

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ensure Primary Care is represented.

3.2.2 The purpose of the Education Working Group is to support the objectives of the STP Capability Thematic Group to enable greater collaboration across One Gloucestershire. Specifically, the group will identify the educational priorities and opportunities that ensure the best use of educational resources, reduce inefficiencies and duplication, and strengthen the resilience within the Gloucestershire Health and Social Care footprint.

4.0 Serious Incidents

4.1 In General Practice, Serious Incidents are normally called „Significant Events‟. These should be reported via a GP e-form (https://report.nrls.nhs.uk/GP_eForm) which will automatically alert the National Reporting and Learning System and NHS England. Since the last report, NHS England has confirmed that they will be delegating Primary Care „safety‟ to CCGs. This means that we have the opportunity to help Primary Care develop transparency around significant events and expand the learning culture other providers aspire to within all healthcare settings in the county. In the first quarter of 2017/18 seven incidents were reported through the NRLS. None of these reports were about GP incidents. Categorised as either low or no harm incidents, these were the result of poor communication and the known delays in discharge summaries being sent from Gloucestershire Hospitals NHS Foundation Trust.

5.0 Patient Safety

5.1 GCG has recently met again with key providers of the healthcare community where the proposed framework for „Safety‟ was once again discussed. Over the last two months the Senior Quality and Safety Manager has visited a Practice Manager meeting and GP locality meeting. Feedback from these meetings suggests GCCG will need to do more preparatory work to build relationships and support a continuing culture of patient safety within General Practice.

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6.0

Complaints and Concerns

6.1 6.2

Primary Care Complaints Primary care complaints are managed for the most part by GP practices themselves. However, some complainants also choose to draw their complaints to the attention of NHS England. From 1 June 2017, GCCG is now receiving details of primary care complaints which have been handled by NHS England South (Central). Two complaints have been received to date. PALS All PALS contacts received by GCCG are reported to the GCCG Integrated Governance and Quality Committee. The following table has been amended in 2017/18 Q1 to identify numbers relating to GP services. These contacts with GCCG have been reviewed and where further action is needed this has been taken.

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Table 1: Contacts received by GCCG PALS

Type

Quarter 1

16/17

Quarter 2

16/17

Quarter 3

16/17

Quarter 4

16/17

Quarter 1

17/18

Advice or

Information 51 47 48 58 48 (16 PC*)

Comment 5 5 7 7 2 (1 PC)

Compliment 0 0 0 4 4

Concern 24 25 20 41 52 (17 PC)

Complaint

about GCCG 16 5 11 9 11 (1 PC)

Complaint

about provider 23 16 22 18 22 (7 PC)

Other 1 6 3 10 14 (4 PC)

Clinical

Variation

(Gluten Free) 0 0 49 11 2

Total contacts 120 104 130 158 155

*PC = Primary Care

7.0 GP Services Friends & Family Test

7.1

Friends and Family Test (FFT) gives patients the opportunity to submit feedback to providers of NHS funded care or treatment, using a simple question which asks how likely, on a scale ranging from extremely unlikely to extremely likely, they are to recommend the service to their friends and family if they needed similar care or treatment. Data on all these services is published on a monthly basis. The GP FFT dataset includes FFT responses for the latest month from GP practices. Data is submitted directly to NHS Digital‟s Calculating Quality Reporting System (CQRS) each month.

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7.2 7.3

The FFT results for GP Practices in Gloucestershire present a mixed picture. The full data for May 2017 is available on the FFT website at: https://www.england.nhs.uk/publication/friends-and-family-test-data-may-2017/ The overall results for all GP practices combined in Gloucestershire in May 2017 is 89% of respondents would recommend their GP practice to a member of their family or friend, 6% would not recommend their practice. These are the same as the all England and South Central percentages. However, it should be noted that 25 practices submitted no data in May 2017 and 20 practices submitted fewer than five responses. In most cases the response rates, in line with other areas nationally, are very low and therefore cannot be considered to be statistically significant when looking at one month‟s data in isolation.

7.4 The Primary Care Clinical Quality Review Group reviews the FFT data alongside the national GP Patient Survey data. Practice Patient Participation groups continue to be reminded to ask their practices for a copy of the FFT results and to promote FFT within their practices.

8.0 Patient Participation Groups (PPGs)

8.1 8.2

GCCG has established a Gloucestershire Patient Participation Group (PPG) Network. The Practice Participation (PPG) Group network held a successful meeting in April 2017. The meeting focussed on Cancer. Presentations and lively discussions were enjoyed on the topics of Macmillan Next Steps; Living With and Beyond Cancer - Diet & Exercise; Engaging patients; Holistic Needs Assessment (HNA) & Treatment Summaries; A Patient‟s Real Life Story; and the CCG Cancer Patient Reference Group (PRG).The next PPG meeting is scheduled for 28 July 2017. The agenda will include updates on Joining Up Your Information, the online prescription ordering pilot, healthy eating and the results of the 2017 GP Patient Survey. These results have been just been published on 7 July and will be reported to PCCC in more detail at the September 2017 meeting.

https://www.england.nhs.uk/publication/friends-and-family-test-data-may-2017/

https://www.england.nhs.uk/publication/friends-and-family-test-data-may-2017/

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8.3 8.4

The GCCG Engagement Team continue to be invited to attend a number of individual PPG meetings to discuss developments and to provide advice and guidance. Recent discussions have focussed on a possible merger between practices, potential closure of a branch surgery, action planning following CQC inspection and new Primary Care capital developments. The GCCG Engagement Team continue to support individual practices and PPGs providing advice and guidance as requested.

9.0 Safeguarding

9.1 Safeguarding Adult Reviews

9.1.1 „HE‟ Review has now been published on the GSAB website. This case is of a younger person (26 years) with a complex mental health diagnosis, significant in that she had a care packages in place with more than one agency. „HE‟ died as a result of sepsis (presented at Southmead Hospital), as a result of Self-Neglect, with capacity and refusing treatment for her health / medical needs.

9.1.2 GSAB successfully held 4 x half day Roadshows with themed workshops (Safeguarding in Self-Neglect and Modern Day Slavery). Six GPs attended in total, viewed as extremely positive given the time commitment required.

9.1.3

GCCG Safeguarding Team is facilitating bespoke Safeguarding Adult Level 2 Training, delivered by a GSAB Approved trainer at Primary Care Locality, within GP PLT sessions. Attendance and engagement has been excellent to date; five sessions complete and a further two more sessions are planned.

9.2 9.2.1

Serious Case Reviews „Megan‟ SCR still pending publication due to ongoing criminal proceedings. The SCR is complete with multi-agency work on the action plan in progress. NHS England has been asked to respond in relation to the process within Primary Care whereby a patient may be de-registered after a period of non-attendance.

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9.2.2 The „William‟ SCR is ongoing (3 month old child died in August 2016). Criminal processes are currently ongoing with both parents under charges. This baby was not registered with a GP. The Review is working to time with good agency engagement.

9.2.3 The Named GP will continue to raise awareness so practices can recognise signs of neglect both in adults and children.

10.0 Quality Premium (QP) Antimicrobial Resistance (AMR)

10.1 10.2 10.3

The QP 17/19 aims to reduce Gram Negative Bloodstream Infections (GNBSIs), reduce inappropriate antibiotic prescribing for Urinary Tract Infections and sustain a reduction of inappropriate antibiotic prescribing in Primary Care. GCCG is leading on a system wide “Clinical Programme” approach to Urinary Tract Infections which aims to reduce the number of GNBSIs and reduce inappropriate antibiotic prescribing for Urinary Tract Infections. GCCG has established a county wide Antimicrobial Stewardship group led by a Public Health Consultant from Gloucestershire County Council. The aim of this group is to have an organisational approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness within Gloucestershire. The inaugural meeting of this group was well attended by various organisations within Gloucestershire including GP‟s, Pharmacists, Public Health England, Veterinarians, Infection Prevention and Control leads and Dentists.

11.0 Health Care Associated Infections (HCAI)

11.1 11.1.1

MRSA There has been one MRSA blood stream infection (BSI) case attributed to the community reported to date (end June). A Post Infection Review (PIR) of each case is undertaken within 14 days as required by Public Health England. As a result of this PIR the case was attributed to a third party (no healthcare intervention that could have resulted in MRSA bacteraemia

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infection). The purpose of the PIR process is:

help identify factors that may have contributed to a MRSA BSI case;

help to identify any parts of the patient‟s care pathway which may have contributed to the infection, in order to prevent a similar occurrence;

help providers of healthcare and CCGs to identify any areas of non-optimal practice that may have contributed to the MRSA BSI;

help to identify promptly the lessons learned from the case, thereby improving practice for the future;

Identify the organisation best placed to ensure that any lessons learnt are acted on.

11.2

C Difficile

11.2.1 11.2.2 11.2.3 11.2.4 11.2.5

The C. difficile threshold for 2016/17 remained the same as 2015/16 with 157 for the wider health community. 2016/17 performance is 177 in the wider health community with 121 cases of C. diff reported as community acquired. The threshold for 2017/18 remains at 157. The threshold for 2016/17 was exceeded by 20 cases. GCCG‟s trainee Public Health Consultant is carrying out a robust analysis of cases during 2016/17 to try to explain this increase. This analysis is nearing completion and will be described in the next report. The county wide Antimicrobial Stewardship group aim to work with prescribers to reduce inappropriate prescribing of medications that increase the risk of C. difficile. All organisations in Gloucestershire including Primary Care use the Public Health England assessment tool to identify risk factors and good practice in C. difficile infection (CDI) prevention and control. The risk factors and good practice are used to formulate an action plan that helps to praise good practice and drive forward change for elements of practice that may need developing to improve patient safety. The use of this assessment tool supports a consistent approach to gathering information from CDI assessments across the whole health

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11.2.6 11.2.7 11.2.8

economy and is encouraged to support the identification of recurring themes and the reduction of healthcare associated infections. All community acquired cases are robustly reviewed by Practice Support Pharmacists and the GCCG Quality Team. Previous Public Health England analysis of cases of C. difficile within the community have found no cause for these numbers other than the normal risk factors for C. difficile (increasing age, severity of underlying diseases, non-surgical gastrointestinal procedures, anti-ulcer medications, duration of hospital stay, duration of antibiotic course, administration of multiple antibiotics). To date (end May) there have been 28 cases of C. difficile with 19 of these acquired in the community. GCCG would like it noted that there may be an increase in C.difficile infection as a result of a fire in the factory which is the only producer of Tazocin, a combination antibiotic. Tazocin is not linked to an increased risk of C. difficile infection. Antibiotics that may be prescribed instead of Tazocin may be linked to an increased risk of C. difficile infection.

11.3 11.3.1 11.3.2

E.Coli In 2015/16 there were 286 cases of E.Coli. There was no threshold set for E.Coli infections in 2016/17. 2016/17 performance is 283 community acquired cases of E.coli. The threshold for 2017/18 is 257. To date (end April) there have been 29 cases of E.Coli with 25 of these cases community acquired. All community acquired cases are to be reviewed by Practice Support Pharmacists and the GCCG Quality Team. GCCG is leading on a system wide “Clinical Programme” approach to Urinary Tract Infections which aims to reduce the number of E.coli urine infections.

12.0 Immunisation and Vaccination

12.1 Gloucestershire immunisation programmes are commissioned by NHS England and are delivered by a range of providers

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including Primary Care.

12.2. 12.2.1 12.2.2 12.2.3

Season influenza GCCG is a member of the BGSW Seasonal Flu Immunisation group. The aim of the BGSW Seasonal Flu Planning Oversight Board is to: • Ensure that the seasonal flu programme 2017/18 is

delivered effectively • Monitor the progress of the seasonal flu 2017/18 action

plan • To agree actions to maintain and improve flu vaccination

uptake • To monitor and improve uptake for clinically at risk groups,

pregnant women and children • To support and oversee the extension of the flu

programme to children in school year four (aged 8 yrs.) and school delivery for reception to year three (4-7 yrs.)

• Group to be clear on flu outbreak strategy and national flu

plan. The group has developed a work plan for 2017/18 to increase uptake of Seasonal Flu Immunisation. This work plan which includes communication to each practice regarding their individual uptake and ranking within all practices, encouraging practice flu leads to review their performance regularly throughout the flu season and identifying bottom five (for over 65 years) performing practices in each area and visit flu lead, to discuss best practice guide For the season 2017/18 PHE have commissioned Gloucestershire Care Services NHS Trust to provide a schools based seasonal influenza service. The aim is to increase the number uptake rates for children aged 5-7 years. Evidence suggests a higher uptake of influenza within a school based programme.

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13.0 Quality Assurance

13.1 CQC Inspections CQC inspectors use professional judgement, supported by objective measures and evidence, to assess services against five key questions or domains: • Are they safe? • Are they effective? • Are they caring? • Are they responsive to people‟s needs? • Are they well-led? CQC ratings help people to compare services and highlight where care is outstanding, good, requires improvement or inadequate. Each domain is rated as well as an overall rate given.

13.2 13.2.1 13.2.2 13.2.3

General practice All practices within Gloucestershire have now been inspected. The CQC inspection process will look at all practices currently rated as Good or Outstanding in a five-year rolling programme. Those practices that are currently rated with a domain or overall as Requires Improvement, will be followed as per current methodology, within six months. The Primary Care and quality teams will continue to offer support as necessary to practices that are considered to Require Improvement or Inadequate. One Gloucestershire practice has been served a warning notice under Section 29 of the Health and Social Care Act 2008. The inspection team found that the surgery had inadequate systems and processes and did not operate effectively to ensure compliance with the regulations. GCCG, NHSE and the surgery have met to discuss the report and establish a robust action plan. Monthly Quality Oversight Assurance meetings with the CCG, NHSE and the surgery have commenced with the aim to achieve a “good” rating when re inspected in six months‟ time. Significant support is being offered to the Practice manager via the GCCG Primary Care team. The GCCG Practice Nurse Facilitators are supporting the

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surgery with education and training as well as ensuring effective processes are in place regarding policies and procedures. GCCG has also offered a Clinical Pharmacist three days a week to support the practice.

13.3 13.3.1

Nursing and Residential Care Homes There are five Care Homes in Gloucestershire with a current CQC rating of Outstanding – these are (with dates of CQC report):

Hannacott, Gloucester (July 2017)

Oakhaven, Cheltenham (May 2017)

Dowty House, Cheltenham (April 2016)

The Manor House Nursing Home, Longhope (Feb 2016)

National Star College, Ullenwood (Aug 2015)

13.3.2 13.3.3 13.3.4

The Dean Neurological Centre, Ramsay Health Care UK Operations Limited The Dean is a 60-bed Nursing Unit in Gloucester for adults with neurological conditions, brain or spinal injury. Since CQC rating of 'Requires Improvement', the unit is making progress with actions for improvement, including in medicines management processes. CCG is leading multiagency work for support and training; which includes the GP Practice and Practice Pharmacist. The CQC carried out an unannounced follow-up inspection in June 2017. Pine Tree Court Care Home, Woodland Healthcare Limited Pine Tree Court is a 40-bed Older People Nursing Home in Gloucester. The CQC report published June 2017 (on inspection carried out in March 2017) gave overall rating of 'Requires Improvement'. It was placed in Special Measures because the service was rated Inadequate in two key questions over two consecutive inspections. The CQC are to inspect again within 6 months. There is a local multiagency approach for support and training. Edward House, Selwyn Care Limited This 12-bed Residential Home for people with Learning

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Disabilities is the only Care Home in Gloucestershire with a current CQC overall rating of Inadequate. There is multiagency working for supporting improvements.

primary care commissioning committee (pccc)...2017/07/27 · 4.4 30/03/2017, item 7.3, primary care...

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