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Priory Avenue Dispersal Review

December 2018

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1. Introduction

1.1 Background

Priory Avenue Surgery closed on 30th June 2018 following the termination of the APMS

contract with One Medical Group which had been in place since 1st October 2016. The

contract was terminated by mutual agreement following longstanding performance

concerns including adverse CQC ratings. The CCG had previously provided significant

financial and clinical support however sustainable improvements had not been delivered

and the provider was unable to recruit the substantive staff required to make the service

viable going forward.

The CCG’s Primary Care Commissioning Committee agreed in December 2017 that the

practice’s list size and premises were not large enough to continue to provide modern

primary care in the long term and that the list should therefore be dispersed through a

managed process which would ensure a smooth transition for patients. It was initially

agreed that all patients would be allocated to one practice (Balmore Park Surgery), although

would still retain the option to register elsewhere, however this could not be achieved and

so it was decided to disperse patients between local practices with special arrangements

put in place to manage the anticipated large influx of patients into Balmore Park and Emmer

Green surgeries. In all 6,089 patients moved to other practices through a two-stage process

whereby patients were originally given options to register elsewhere and then remaining

patients were allocated remotely by the CCG. At 1st July 2018, the day after closure, all

known patients had been registered with another practice.

The nature of the contractual position meant that this process had to be conducted very

quickly and without detailed initial public engagement. Whilst such a situation is unusual,

there are likely to be learning points for the CCG with respect to any further dispersals and

the purpose of this review is to ensure that these are drawn out and acted upon in future.

1.2 Scope of the review

The Terms of Reference for the review are included at Annex A. The aims of the review

were as follows:

To assess whether the dispersal has achieved the CCG’s commissioning intentions

with regard to this practice. These were agreed by the Primary Care

Commissioning Committee and are summarised as follows:

o Smooth transition of patients to a stable and high quality provider(s)

o Provision to be integrated with local general practice.

o Patient choice to be maintained.

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o Agreed approach to result in acceptable levels of risk for the CCG.

o Intention to commission cost-effective provision in the medium-term,

recognising there is likely to be a continued need for significant financial

assistance in the short-term.

o Local practices to be treated equitably in any process to identify alternative provision.

To identify learning points for any future dispersal of a patient list. To identify any ongoing implications of the dispersal and consider any action

required to address this.

The review focussed on the dispersal process and as such did not consider the management

of the previous APMS contract or the decision to close Priory Avenue Surgery.

1.3 Review process

The review was based around two stakeholder meetings held in October 2018. Both were

chaired by Wendy Bower, Lay Member (Patient Experience). The first meeting focussed on

CCG and receiving practices’ processes whilst the second focussed on patient experience.

Emmer Green Surgery and representatives of South Reading locality did not attend the

meetings but this report has been shared with them. The minutes of the meetings have

been included at Annex C and D.

A small number of written submissions from group members were received and discussed

at the meetings. In addition, Healthwatch Reading submitted an updated summary report

after the second meeting, which has been included at Annex E and considered as part of this

report. Healthwatch Reading also submitted copies of comments made on a closed social

media group which have been reviewed but are not reproduced here.

1.4 Reporting

This report will be presented to the CCG’s Primary Care Commissioning Committee meeting

in public on 9th January 2018

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2. Summary of dispersal process

A full timeline is included at Annex B. This covers the decision-making process through to

the final surgery closure. Key stages in the dispersal were as follows:

2.1 Patient communication

As there had been insufficient time to undertake patient engagement, a key focus was

ensuring that all patients received an individual communication setting out the details and

timing of the closure, their options for re-registration and what to do next. 6,089 patients

were sent one of two letters which were dispatched on 21st May 2018. The first letter, sent

to 4,824 patients eligible for registration at Balmore Park and/or Emmer Green surgeries,

included a form to be returned to the CCG stating a preference for registration at either of

these surgeries together with standard registration paperwork. Details of other practices

which patients could approach for registration were also included. The second letter, sent

to 1,265 patients not eligible for registration at Balmore Park or Emmer Green surgeries as

they lived outside of catchment, listed details of other practices patients could approach. In

both cases the letter stated that if patients took no action by 13th June 2018 they would

automatically be allocated to another practice.

All letters were sent out by Primary Care Support England on behalf of the CCG. The CCG

could not have sent letters itself as we do not hold patient address details.

Eligibility for registration depends on whether a patient lives within a practice’s defined

practice boundary. The boundaries are stated within GP contracts and can only be changed

with CCG agreement. It was not possible to tailor letters to individual addresses and as such

some patients may have approached practices that they could not register with.

2.2 Remote registration / self-selected registration

3,335 patients responded to Letter 1 expressing a preference for either Emmer Green or

Balmore Park surgeries. Forms were date stamped and logged before being sent onto the

practices in question for processing. Practices then contacted patients directly to confirm

registration. 2,881 patients were registered with Balmore Park through this process and

474 with Emmer Green. 366 patients registered with other practices during this period,

primarily Melrose Surgery (24 patients), the Reading Walk-in Centre (109 patients),

Chatham Street Surgery (80 patients) and the University Medical Practice (41 patients). In

total 3721 (61%) of patients took action to re-register during this period. Sonning Common

Practice also reported that they took on a significant number of patients in this period

however the numbers of patients was not obtained.

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Support to patients was provided through PALS and through information in the surgery

supported by the Patient Participation Group running drop-in sessions and producing a ‘live’

FAQs document with input from Healthwatch Reading who also advised patients at the

surgery during this period. A total of 315 patient enquiries were received between May

and September 2018. The queries received were; 54 questions about the form, 27 said that

they did not receive the letter, 15 people had moved out of the area, 3 people were on

holiday and missed the process, 17 callers had sent in forms but had not received a reply

yet. In the second part of the process, PALS advised a total of 70 people where they had

been allocated. The majority of patients received a response in 2-3 days. Of the calls

received 52 had been resolved by the time that PALS went back to them. The other 77 calls

were regarding a range of enquiries regarding patients’ different circumstances.

Two public meetings were held, on 29th May and 6th June 2018. 21 people attended these

events which were supported by Healthwatch Reading and the Priory Avenue Patient

Participation Group.

Peppard Road Surgery’s list was closed at the time and as such some patients living South of

the River Thames who had previously been able to register with a Caversham surgery no

longer had that option. The CCG received correspondence from approximately 20 patients

in this position all of which were reviewed for exceptionality. In most cases the concerns

were around accessibility/mobility, however it was not felt to be appropriate to seek to

make an exception in any of these cases as patients with limited mobility may be more likely

to require home visits in future which practices would struggle to provide to patients living

outside of the boundary. In any case the CCG does not have jurisdiction to require a

practice to register a patient outside of their boundary except where there are no

alternative practices available which was not the case in this scenario.

2.3 Allocation

At the end of the remote registration/self-selection period, 2,151 patients remained on the

Priory Avenue list without a pending registration with Balmore Park or Emmer Green

Surgery. These patients were allocated based on postcode.

It had been agreed for capacity reasons the Balmore Park and Emmer Green Surgeries

would take on a maximum of 3,000 and 1,500 patients respectively. Whilst the number of

eligible patients was higher than this it was anticipated that some would not choose these

practices and/or that some patients would since have died or moved away as a full list clean

had not been carried out prior to the dispersal. In the event both practices took on slightly

more patients than they had originally agreed to; 3,012 went to Balmore Park and 1,656 to

Emmer Green.

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Other surgeries receiving significant numbers of allocations were as follows: Melrose

Surgery (341), the Reading Walk-in Centre (253), Chatham Street Surgery (146) and the

University Medical Practice (39). 12 patients were allocated to Sonning Common Surgery in

Oxfordshire.

2.3 Transfer of notes

Notes were transferred to patients’ new practices primarily electronically using GP2GP

transfer. As part of GP2GP it is normal for some elements of notes and/or supporting

documents to be requested by manual transfer; the CCG arranged for NHSE to provide some

hands-on support within the surgery to support this process and other aspects of closedown

including the bagging up of hard copy notes which, in accordance with standard processes,

were transferred by PCSE.

2.4 Vulnerable patients

The CCG worked with the outgoing provider on the identification of vulnerable patients with

a view to ensuring that additional support was provided to these patients where required.

This included one of the CCG’s GP clinical leads spending time in the practice helping to

generate a list of patients.

2.5 Post-registration support

Financial assistance was provided to practices receiving significant numbers of patients

(increased list size of 3% or more) in the form of a one-off payment per patient of £35

where the overall increase exceeded 5% (Balmore Park and Emmer Green surgeries) and

£17.50 where the increase was 3-5% (Melrose Surgery, Chatham Street Surgery, Reading

Walk-in Centre). This was in addition to standard payments for newly registered patients

under GP contracts. A guarantee of QOF income and an adjustment to the Quality CES was

also agreed for Balmore Park and Emmer Green surgeries. The percentage increases in list

size resulting from the dispersal compared to April figures were as follows, this does not

however take account of patient movement since or residual growth during Quarter 1.

Practice % change from dispersal at 1st July

Balmore Park Surgery 18.14%

Emmer Green Surgery 16.82%

Melrose Surgery 3.52%

Walk-in Centre 4.29%

Chatham Street Surgery 2.09%

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GPs were given details of how to report clinical concerns around the previous care of any

patients that they have taken on. So far the CCG has received mainly general feedback

regarding work required for patients taken on.

Continued support is available to patients through the Patient Advice and Liaison Service

however call levels have been minimal.

The CCG will continue to monitor list size change in the area to ascertain whether most

patients remain with the practice they were re-registered to or if there has been much

subsequent patient movement particularly now that Balmore Park and Emmer Green

surgeries have fully re-opened their lists (during the dispersal period it was agreed they

would not take on patients who already had a Reading GP to avoid de-stabilising the

process).

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3. Issues identified and learning points

The following table sets out the issues identified by the review for each of the stages of the

dispersal and the agreed learning points to be taken into account in any future dispersal.

Dispersal stage Issues identified Approach to be taken in any future dispersal

Patient communications

Core Priory Avenue PPG members felt that the early CCG briefings did not make it sufficiently clear that if discussions with Balmore Park were not concluded successfully the only Plan B would be a dispersal which would mean the closure of the practice. They also indicated that they found it difficult to receive briefings in confidence that they could not share with the wider membership.

The nature of the briefings given reflected the confidential nature of the contractual position and the tight time constraints due to risk of contract failure. It would have been difficult to do anything differently although perhaps further sense checking of what had been understood could have helped. Ideally any future dispersal should be managed over a longer period, ideally six months to include preparation time and patient engagement although it is recommended that the process itself is still undertaken over 1-2 months maximum to avoid uncertainty and unmanaged ‘drifting’ of patients.

The timescales for the dispersal did not allow time for general patient engagement around the closure. The focus was therefore on advising individual patients and communicating with stakeholders.

The communications plan for any further dispersal should consider engagement required around the option being taken and how the process is run (any engagement around dispersal as opposed to other options for a practice should have occurred prior to a dispersal being agreed). Dispersals are usually undertaken where there is no other suitable option and so this will affect the nature of any engagement. Communication with individual

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patients around their options will be a key priority for any dispersal process.

Patient letters were only received on the same day that the issue broke in the press and came over several days despite being posted at the same time. The CCG encountered significant issues in working with PCSE in particular unclear leadership and a complicated process for obtaining quotes. There was also a late issue whereby PCSE were unable to produce SAEs; these therefore had to be printed locally and couriered to them. These issues are being flagged with PCSE in a letter from the CCG’s GP Chair. The CCG worked closely with the local press to delay coverage but were unable to delay in beyond the day on which the first letters were received. It was difficult that people had different letters depending on where they lived however this was felt to be unavoidable in this scenario.

The CCG had to use PCSE to send letters as they hold the patient data required; CCGs are not allowed to hold this but for any future dispersal other options should be further considered including using patient details generated by the outgoing practice which was not felt to be appropriate in this situation.

The CCG would work proactively with the local press in any future dispersal as they did this time.

The complexities of the letter sending process together with the overall time constraints due to the nature of the contractual position reduced the amount of time patients had to respond thereby increasing the chance of patients being away, not having time to seek advice on their letters etc.

In any future dispersal it is recommended that patients are given one month to respond.

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Attendance at public meetings was low; some participants in the review suggested this was due to the venue/timing. It may however also reflect the generally low levels of concerns expressed around the closure.

Accessible public meetings to be arranged at the outset of any future dispersal process.

The documentation sent to patients was very long particularly for those who could remotely register at Balmore Park and Emmer Green Surgeries.

Future dispersals to consider how the documentation can be simplified e.g. by enabling online registration through Footfall rather than having to send out registration forms, including a more user friendly guide at the front. Healthwatch Reading indicated they would have been able to make more suggestions if they had had more time to review the letter and supporting documentation.

There was a delay in PALS responding to calls often of 2-3 days which may have raised patient anxiety.

Need to consider temporarily increasing PALS capacity for any future dispersal. In so doing should be guided by response rates above. Also should update answerphone message to specifically refer to the dispersal and say when patients can expect to get a response.

PPG and other support was helpful in advising patients but had not been specifically planned into the process.

In a future dispersal it would be helpful for the CCG to engage the PPG and Healthwatch more proactively with regard to providing sessions / advice on site and other ways of supporting patients including comparative documents and patient guidance where appropriate.

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Social media was not used or updated to support patients. The information provided was felt to be very ‘fixed’ e.g. there was no ongoing update on registrations to date, updated FAQs etc (other than those provided by PPG).

Social media to be considered as part of communications plan for any future dispersal together with regular website updates.

Communications for existing patients of receiving surgeries was not organised except where practices did this themselves.

CCG to consider communication with existing patients of receiving practices as part of development of communications plan for any future dispersal.

Remote registration/self –selected registration

The remote registration process placed a significant burden on CCG and practice administrative teams. The phasing of this workload was difficult to predict and varied between practices and the CCG was reliant on practices processing registrations quickly so as to ensure that the residual allocations list was up to date. There were some initial operational issues such as the order in which documents were stapled together but these were resolved relatively quickly.

The remote registration process was felt to be helpful overall and to reduce the pressure on the receiving practices who would otherwise have been inundated with patients looking to register. It is therefore recommended that it is replicated for any further dispersal on a similar scale. It would however have been helpful for the administrative teams to meet to plan the process and agree some of the detailed operational processes. This would include arrangements for more clearly highlighting patients who are part of the same family as there were some issues with forms being split up and/or registrations being sought for children with no adult attached. Also exploring opportunities for mutual support where the timing of registration requests varied between organisations.

There was sometimes a time lag between patients sending in

In a future dispersal there should be further discussion of the registration

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their registration forms and receiving confirmation of registration.

process and agreement around how practices will manage this and then clearer communications around response times so that patients are not concerned if they do not hear anything back for some time. The risk that some patients would have sought to register and then be allocated because their registration was not complete did not transpire to be a widespread problem; all practices worked hard to progress registrations quickly.

The CCG received some reports of delays or issues where patients sought to register with another practice e.g. one practice that was insisting on photocopies of documentation being brought in.

These issues were not widespread and were followed up at the time but again for any future dispersal it would be helpful to further agree registration processes and timings with the practices concerned.

The remote registration process and the ‘first come first served’ approach could have required more careful administration if it had not been possible to accommodate all patients’ choices. New arrangements would have been put in place at the time had either practice neared their maximum capacity through this process.

This issue does require further consideration as registrations were typically dealt with in batches received on particular days; a future dispersal process may need clearer arrangements for managing forms received on the same day and dealing with a situation where a particular practice is over-subscribed.

Allocation Obtaining lists for allocation process relied on PCSE; again whilst team members were helpful there was a lack of clear leadership to escalate issues to and uncertainty around timescales.

The CCG has no option but to use PCSE for this work however a schedule of data extracts required should be agreed upfront with clear timescales set out.

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Allocation process relied on local manipulation of data – this was time consuming and diverted capacity from other aspects of the dispersal.

CCG to consider data handling capacity for any future dispersal so this has been identified upfront. Also to ensure access to postcode data.

The CCG had to ask Balmore Park and Emmer Green surgeries to slightly exceed the numbers they had agreed to take as there remained patients at the allocation stage who could only register with one of them.

It was difficult to exactly predict the demand for registration at these surgeries but patient numbers agreed with practices for any future dispersal should probably allow more spare capacity if possible.

There was a 3% discrepancy between the original patient list and the list for allocation likely to be due to patients having returned letters to PCSE because they had moved away and/or list cleaning by the provider prior to closure although this could not be verified. Registrations with non-Berkshire practices are also unknown.

Agreeing above list of data extracts with PCSE in advance would ensure more exact tracking of patients through the process. To include accessing information about registrations with non-Berkshire West practices.

Following the dispersal it was identified that sixty patients were still showing on PCSE systems as registered to Priory Avenue. A list of these patients has now been obtained and all but two are duplicate listings for patients who have been registered elsewhere. This is likely to be a process issue and is now being followed up with the practices concerned.

Further discussion of registration processes prior to any future dispersal (see above) should reduce the risk of this re-occurring.

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Transfer of notes

100 sets of notes are known not to have transferred to receiving practices (work is underway to obtain these from the EMIS back-up) and a further 130 to have missing Docman documents which it has not been possible to recover. There were also issues with the quality of some of the documentation sent through by the outgoing practice where this was requested alongside GP2GP transfer despite NHSE having provided support to this on behalf of the CCG. These issues have all been flagged with the Nurse Director as CCG quality lead and the receiving practices concerned have taken appropriate action.

It has also been complex to manage hospital correspondence with messages about the closure not always being disseminated to all departments and some lack of clarity over when Priory Avenue would be removed as a practice on the spine. The CCG continues to receive some hard copy letters mainly from non-local providers which it sends back to the trusts in question.

The outgoing provider was slow to arrange a diversion of post despite this having been agreed in advance. This has been followed up and is now in place.

Similar support should be provided to the outgoing provider around closedown in any future dispersal to ensure that hard copy documents are printed as required and sent across to new providers. IT leads should proactively arrange access to EMIS back-ups and to the Docman server for any practices taking on large numbers of patients in case this is required.

The CCG should also work closely with IT leads from early on to agree arrangements for electronic correspondence and changes to the spine. In addition earlier communication with providers than was possible within the timescales for this dispersal would also improve the flow of patient communications following surgery closure; in particular it is important to ensure that messages are disseminated within the provider organisations contacted.

Vulnerable patients

The CCG was reliant on the outgoing provider to identify vulnerable patients requiring support with the process and additional support post-transfer.

In any future dispersal it is recommended that there is more proactive engagement with other services as well as the outgoing provider in order to identify

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This did not go as smoothly as planned despite support from the CCG’s GP Chair in part due to intelligence being lost as many staff transferred to other roles prior to the surgery closure. It was not always evident from patient records whether they fell into one of the categories identified as vulnerable. The onus was also on the outgoing provider to contact and advise these patients and the practices they were going to and this did not always happen effectively. Receiving practices have subsequently provided assurance regarding support given to such patients post-transfer.

vulnerable patients and track them through the transition. This could include liaising with safeguarding leads, DNs and others directly and considering who else could provide support and advice to these patients should the outgoing provider not be in a position to do so. These discussions would also support smooth transitions for patients under the care of other services as well as the practice e.g. patients on the DN caseload.

Post-registration support

Sonning Common practice has subsequently highlighted that they did not receive any transitional support. The number of patients formally allocated to them was 12 but others sought registration themselves as part of the initial phase of the process.

The CCG engaged with Oxfordshire CCG during the process however in future dispersals it is recommended that there should be earlier engagement with the commissioners of any neighbouring practices outside of the CCG area in order to ensure consistency of approach.

Healthwatch Reading has recommended that the CCG undertake a survey in due course to obtain further information on patient experience of existing and transferred patients at practices that have taken on high numbers of Priory Avenue patients.

CCG to consider this further as would inform any future dispersal process. Also to consider appropriate level of monitoring of any subsequent changes in patient lists.

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4. Review of commissioning intentions

The review meetings considered whether each of the CCG’s commissioning intentions had

been met. A summary of this discussion is included below.

Smooth transition of patients to a stable and high quality provider(s)

All patients previously registered at Priory Avenue Surgery who still require registration

within Berkshire West have been able to register with a practice of their choice unless they

choose to be allocated. All practices to which patients were allocated are rated Good or

Outstanding by the CQC. The majority of patients have been registered with Balmore Park

or Emmer Green surgeries both of which perform well on all key performance indicators.

Provision to be integrated with local general practice.

Priory Avenue patients have been registered with established local providers of primary

care. All practices in Reading are part of either the North and West Reading GP Alliance or

the Reading Primary Care Alliance both of which work with the two other local GP alliances

through the Berkshire West Primary Care Alliance to plan and develop sustainable primary

care services. Balmore Park and Emmer Green surgeries are active members of the North

and West Reading GP Alliance and are now working together as a local primary care cluster

to deliver enhanced access and other services. The other receiving practices (Melrose

Surgery, Chatham Street Surgery, the Reading Walk-in Centre and the University Medical

Practice) are also actively involved in at-scale working to improve services for patients.

Patient choice to be maintained.

All patients had a choice of registering elsewhere (either through the remote registration

process or by approaching a practice in person) or being allocated to a practice. All lists

except Peppard Road Surgery were open so patients could choose where to register

providing they were within their chosen practice’s boundary area. Balmore Park and Emmer

Green surgeries limited numbers however all preferences expressed through the remote

registration process were met. Priory Avenue patients living South of the River were no

longer able to access a service in Caversham which caused concerns amongst a small

number of patients who saw this as a reduction in choice. They did however have the option

of registering with one of a number of other practices covering their area.

Agreed approach to result in acceptable levels of risk for the CCG.

The CCG had clear grounds for selecting a dispersal approach, namely that the list size in

question was relatively small and previous providers had struggled to run a sustainable

service. The CCG was satisfied that existing providers would, with some support, be able to

accommodate Priory Avenue’s patients whilst maintaining the high quality of care currently

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provided. The CCG would ideally have looked to undertake more extensive patient

engagement however this was not possible within the timescales involved and the priority

was to mitigate the very real risk of sudden contract failure. The focus was therefore on

communicating with each individual patient about the options open to them. In summary

the approach taken was deemed most appropriate in the circumstances and the residual risk

involved was felt to be within acceptable parameters.

Intention to commission cost-effective provision in the medium-term, recognising

there is likely to be a continued need for significant financial assistance in the short-

term.

The CCG had incurred significant costs in supporting the previous provider through Section

106 arrangements. The transitional support provided to receiving practices was of a similar

magnitude to the support previously provided although final costs will depend on the extent

to which Balmore Park and Emmer Green surgeries draw upon the guarantees given to them

around QOF and enhanced services funding. These are however short-term costs and going

forward payments for Priory Avenue patients will be at standard PMS rates.

Local practices to be treated equitably in any process to identify alternative provision.

Reading practices were offered the opportunity to express an interest in taking on the list as

a whole and subsequently were engaged with regard to their willingness to take on patients

as part of a dispersal and any support required. Transitional funding was originally offered

to any Berkshire West practice that experienced a 5% increase in list size; as not many

practices qualified for this a reduced level of funding was subsequently offered to practices

experiencing a 3% increase. No concerns were expressed with regard to the approach taken

however earlier engagement with the commissioners of any nearby practices outside of the

CCG’s area might be appropriate in any future dispersal to ensure a common approach.

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5. Conclusions

The Priory Avenue dispersal was an unusual and challenging exercise, particularly because it

was carried out in a very tight timescale against a backdrop of contract breakdown and

complex relationships with the outgoing provider. The scale of the dispersal was also

unprecedented in Berkshire West.

The dispersal was largely successful in that all known patients were re-registered with

another practice by the time that Priory Avenue Surgery closed on 30th June 2018. For the

most part the registration process ran smoothly with only 5% of patients contacting either

PALS or Healthwatch Reading for additional support. All patients who responded to the

remote registration process were registered with their choice of practice as were patients

who sought to re-register themselves within the constraints of practice boundaries. The

CCG’s commissioning intentions were met as set out above.

As would be expected from an exercise of this scale and the first dispersal undertaken by

the CCG, a number of learning points have been identified which will be taken into account

in any future dispersal. Many of these relate to timing; the tight timescales for this dispersal

were unfortunate and should be avoided if possible in future. Others relate to the

complexity of some of the processes and taking opportunities to agree these more clearly

with those concerned from the outset. There are also learning points around patient

communications and a number of issues to consider in more detail in future such as

simplifying documentation and using social media and other on-line channels to provide

more evolving information and support. A further area of learning is around vulnerable

patients and ensuring all opportunities to identify and support those who may need extra

help are explored.

The CCG would like to thank all of those who worked with us during the dispersal to make

the process run as smoothly as possible, particularly the practice teams who worked swiftly

and efficiently to process large numbers of registrations in a short time and to provide

additional support to new patients. We would also like to thank Healthwatch Reading and

Priory Avenue Patient Participation Group representatives who provided direct advice to

patients about the choices available to them throughout the process. Finally we would like

to thank all of those who participated in the review process for their contribution and input

to what has been a helpful learning exercise.

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Annex A

Priory Avenue Dispersal Review Terms of Reference

1. Purpose To undertake a retrospective review of the dispersal of patients registered with Priory Avenue Surgery as a result of the APMS contract with One Medical Group being terminated with effect from 1st July 2018. The review will aim to:

Assess whether the dispersal has achieved the CCG’s commissioning intentions with regard to this practice as considered by the Primary Care Commissioning Committee at its December 2018 meeting and endorsed by North and West Reading CCG’s Governing Body and other PCCC voting members later in December 2018. These are set out in below. It should however be noted that the CCG’s preferred approach of identifying one provider to take on the list did not prove feasible and the dispersal was therefore a second option.

o Smooth transition of patients to a stable and high quality provider(s) – for Circuit

Lane services to continue to be provided from existing surgery in accordance with the primary care strategy for North and West Reading CCG, fo

o Priory Avenue services to be available from the existing surgery or from a location in close proximity.

o Provision to be integrated with local general practice. o Patient choice to be maintained. o Agreed approach to result in acceptable levels of risk for the CCG. o Intention to commission cost-effective provision in the medium-term, recognising

there is likely to be a continued need for significant financial assistance in the short-term.

o Local practices to be treated equitably in any process to identify alternative provision.

Identify learning points for any future dispersal of a patient list.

Identify any ongoing implications of the dispersal and consider any action required to address this.

2. Structure The review will be undertaken primarily through two stakeholder meetings with supporting information provided to each. The focus of the meetings will be as follows:

Meeting 1: CCG and receiving practices’ processes, issues and impact Meeting 2: Patient experience

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In addition a number of stakeholders asked to participate in the review have provided written submissions which will be reviewed at the appropriate meeting. Each meeting will consider the key relevant elements of the dispersal process with a view to identifying:

What went well

What did not go so well

What could be done differently in the event of any future dispersal The meetings will also consider the ongoing implications of the dispersal for patients, the practices concerned and the CCG and identify any further work required in response.

3. Membership The review will be chaired by Wendy Bower, Lay Member for Patient Engagement. Stakeholders invited to participate are as follows:

Balmore Park Surgery

Emmer Green Surgery

Representatives of South Reading CCG locality (with individual practices also written to directly)

Healthwatch Reading

Former members of Priory Avenue Patient Participation Group

CCG Nurse Director

CCG administrative team

NWR locality team

CCG Patient Advice and Liaison Team

CCG Primary Care Team

NHS England (in respect of support provided to CCG Primary Care Team during practice closedown)

The first meeting will consider whether any other stakeholders should be approached for a view.

4. Reporting A full written report will be taken to the Primary Care Commissioning Committee who will be asked to endorse any further action identified.

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Annex B

Timeline of events

Date Summary

13/12/17 PCCC received a Part B paper recommending termination of the APMS contract in place with One Medical Group to provide services from Priory Avenue Surgery following a further CQC visit in October 2017 which showed that the improvements made following the previous visit in January 2017 had not been sustained and significant risks remained in respect of staffing, capacity, clinical leadership, management of clinical correspondence, governance, repeat prescribing and medications reviews. Paper set out a number of key commissioning principles and recommended that a preferred local provider be selected to take on the patient list in its entirety through a managed dispersal process (with patients retaining the choice to move to other practices). Paper recognised that the preferred provider would require financial assistance and proposed continued S96 funding for the first 18 months together a list size guarantee and further assurances around QOF and enhanced services performance. Paper was for discussed but it was intended to make a decision on a teleconference to be arranged in January 2018.

19/12/17 Due to continued concerns regarding sustainability of the service and likely enforcement action by CQC prompting One Medical Group to indicate they were also looking for an early exit from the contract, a paper was taken to NWR Governing Body including the above paper but adding an additional recommendation that Balmore Park Surgery be identified as the preferred provider for Priory Avenue, subject to due diligence, public engagement around the closure of the site and discussions around transition arrangements. Balmore Park Surgery was reported to be a high performing practice with a Good CQC rating and the only provider that had expressed an interest in taking over the patient list. The recommendations were endorsed by the Governing Body including PCCC voting members. The only voting PCCC member for NWR CCG who did not also sit on the Governing Body (Saby Chetcuti) approved the approach remotely on 23/12/17.

04/01/18 Priory Avenue PPG briefed in confidence regarding above discussions.

25/01/18 Notice of termination by mutual agreement issued to One Medical Group with effective date to be confirmed.

January – March 2018

Discussions with Balmore Park Surgery regarding takeover of list. Balmore Park advised CCG at end of March that they were not willing to proceed and asked to discuss arrangements for a standard dispersal.

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14/03/18 Above decisions ratified by PCCC (Part B). Update paper provided which stated that agreement had yet to be reached with Balmore Park and should this not prove possible the CCG would revert to a standard dispersal.

April 2018 Discussions with Balmore Park and Emmer Green Surgery regarding proposed dispersal approach including financial support and managed registration process. Engagement with other affected practices. PPG members informed in confidence on 24th April 2018 of intention to close surgery and disperse list. Engagement with Healthwatch and development of letters and supporting information for patients – PPG also supported this. Equality Impact Assessment completed and actions identified around supporting vulnerable patients to re-register.

04/05/18 Confirmation of termination date issued to One Medical Group (30th June 2018).

09/05/18 PCCC voting members formally agreed by teleconference the termination and dispersal proposed in the March paper based on updated version of the paper including more information about the rationale for the dispersal (size of list compared to GPFV expectations, lack of success in recruiting substantive clinical staff and premises constraints). Paper noted due to deteriorating situation at the practice and high risk of contract failure 30th June 2018 had now been confirmed as the termination date. Also noted that whilst there had been discussions with the PPG and Healthwatch there was not now enough time to undertake formal engagement and as such the process would now focus on communicating options to each individual patient. The paper also set out the dispersal process to be followed including a CCG-supported remote registration process for Balmore Park and Emmer Green surgeries and sought agreement to financial support to be provide to these surgeries and to others experience an increase in list size of >5% as a result of the closure. All recommendations were endorsed by the Committee. NHSE informed of decision.

Early May 2018

Stakeholder communication including Councillors, MPs and other services (BHFT, RBFT etc).

21/05/18 Letters sent to Priory Avenue patients by PCSE. Two letters used – one for patients within the Emmer Green and Balmore Park catchments (4,824 patients) outlining the remote registration process for those practices plus other choices, second letter for patients outside of catchment areas (1,265 patients) setting out list of practices they could approach for registration.

29/05/18 and 06/06/18

Information events held for Priory Avenue patients. In addition PPG ran drop-in advice sessions at the surgery during this period.

13/06/18 Deadline for return of remote registration forms and re-registration by patients. Prior to that CCG received forms, removed patients from allocations list and sent paperwork on to practices for registration. Practices sought to register as quickly as possible to avoid duplication with allocations list. 3,355 patients had registered

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with Balmore Park or Emmer Green and 366 at other practices by this point (61%).

15/06/18 List of patients remaining registered extracted by PCSE and reconciled against registration forms sent to Balmore Park and Emmer Green surgeries. Provisional allocations list developed.

From 18/06/18

NHSE (on behalf of CCG due to staff leave) provided on-site support to practice around closedown including support in extracting information from clinical system to be forwarded to receiving practices to supplement information provided by electronic transfer.

22/06/18 Allocations lists sent to receiving practices.

25/06/18 Allocations letters sent to patients (2,151).

30/06/18 Priory Avenue Surgery closed.

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Annex C

Priory Avenue Dispersal Review Meeting

18 October 2018 at 10:00 – 11:30

57-59 Bath Road, Reading, RG30 2BA

MINUTES

MEMBERS PRESENT

Wendy Bower Lay Member for Patient Engagement WB

Helen Clark Director of Primary Care HC

Eiliis McCarthy Practice Manager, Balmore Park Surgery EMc

Emma Sanford PA to CO/Business Manager (in part) EM

Terry Pascucci PALS Officer TP

Debbie Simmons Nurse Director DS

Lydia Benedek-Koteles Primary Care Administrator LBK

Apologies:

Dr Isabel Cook Senior Partner, Emmer Green Surgery

Carole Coles-Ranson Practice Manager, Emmer Green

Dr Graham Paige Senior Partner, Balmore Park Surgery

Maureen McCartney Ops Director – North and West Reading

Dr Bu Thava /Dr Kajal Patel South Reading Locality representatives

1.

Background of review

LBK listed the attendees for the meeting and apologies and those deputising were noted as above.

HC gave explained the background for the review, which were to look back at whether the CCG’s

commissioning intentions in this matter had been achieved, to identify any learning points for any

future dispersal and to identify any ongoing implications of the dispersal and consider any action

required to address these.

2.

Terms of Reference for the review

It was noted that the date needed changing and DS was to be added to the membership.

LBK to action.

This was a retrospective review of the dispersal of Priory Avenue. HC discussed the paper to the group,

listing the aims of the meeting in the paper. The Terms of Reference were agreed by those present.

3. Dispersal timeline

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HC presented the paper to the attendees and recapped on the numbers. 6,089 patients had been

dispersed of whom 4,668 had been registered by either Balmore Park or Emmer Green surgeries (3,355

through the initial remote registration process and further 1,313 by allocation). Other surgeries had

taken 1,204 patients (366 by registration and 838 by allocation). Balmore Park’s list had increased by

18.14%, Emmer Green’s by 16.82%. Other surgeries with a significant increase in list size were Melrose

Surgery (3.54%), the Walk-in Centre (7.62%) and Chatham St (3.44%). It was noted that there was a 3%

difference between the original list extracted for the purposes of sending the letters and the number of

patients who had re-registered or were allocated at the end of the process; this may be in part due to

patients re-registering outside of the area or to list cleaning undertaken by the provider. At October

2018 sixty patients are also still showing as being registered with Priory Avenue Surgery and a list of

these patients has been requested to be reconciled against the allocations list. NHSE has advised that

dispersals such as this typically result in some ‘ghost’ patients being identified.

Action - HC to add the numbers from the spreadsheet onto the timeline

4.

Submissions received

Dr Ahmed, Melrose Surgery had raised an issue regarding continuity of DN care for a complex patient

for whom a more detailed handover would have been helpful. This issue was considered under

vulnerable patients, below. It was noted that all South Reading practices had been approached for

comment but no further responses had been received. As neither Dr Kajal Patel nor Dr Bu Thava had

been able to attend this meeting it was agreed to share key findings with them in order for them to

make any further comment on behalf of South Reading practices. Similarly the key findings will also be

shared with Emmer Green Surgery should they wish to make further comment prior to the report being

produced. Action: HC

Additional comments were received from Francis Brown and Geoffrey Milligan. It was agreed that

these would be considered at the next meeting.

5.

Key areas for review at this meeting

WB asked if anyone wanted to add anything to the list; no other areas were highlighted.

PCSE involvement – initial letters and allocations PCSE were used to supply patient registration data (which only they have) and to send letters to

patients at the start of the process and at the allocation stage. This was out of scope of the national

SLA and so at cost to the CCG.

Issues:

There was a delay in sending out the letters on both occasions with difficulties in obtaining firm

quotes/generating PO numbers for these. Whilst the CCG worked to delay press coverage as long

as possible the delay on the first letters meant some patients found out about the closure through

the press before they had received their letter.

PCSE were unable to provide SAEs as the CCG does not have a business reply service in place and it

was not possible to arrange this due to Royal Mail lead-in times. SAEs had to be printed locally

and couriered to PCSE.

There was a lack of leadership within PCSE with critical processes and critical timelines being

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managed by a very junior team and no clear routes of escalation.

Due to lack of confidence in PCSE their involvement was kept to a minimum with the patient

allocation process being managed locally (by CCG staff seconded to NWR Alliance). It would have

been helpful to have been able to ask PCSE to manage the data handling involved as this is not

something CCG teams would usually do and diverted resource away from dealing with other

aspects of the dispersal.

Actions/Learning points

Feedback to be included in broader letter to PCSE currently being written by CCG GP Chair.

Action: HC

Consideration to be given to other arrangements for sending out letters in the event of any

future dispersal.

Remote registration process Practice feedback about the remote registration process was generally positive and it was felt that it

would have been difficult to manage a dispersal of this scale without this. All patients who returned

the remote registration form received their choice of practice. The meeting identified the high level of

commitment and additional effort put in to this process by administrative staff at practices and at the

CCG without which it would not have been possible to complete this task within the timescales

required.

Issues:

Significant administrative workload for CCG and receiving practices in a short space of time.

Created workload for CCG reception teams with many patients choosing to drop forms off.

Still significant workload for practices receiving queries by telephone and at reception.

Two-stage process increased potential for discrepancies and made it difficult to track every

patient.

Phasing of responses difficult to predict. Balmore Park received highest volumes early on.

Initial problems with ordering of paperwork sent to practices – resolved quickly

Issues with forms from families being sent to practices separately and/or where families had

chosen different practices (including children different from parents).

Too much paperwork required – letters to patients were very long and complex and despite

review of letters by Healthwatch and others, some patients struggled to know how to respond

due to volume of paperwork.

Actions/Learning points

It would have been helpful for the practice and CCG administrative teams to have met and

jointly agreed processes.

Documentation should be simplified in any future dispersal.

In future should give consideration to online registration e.g. through Footfall.

Vulnerable patients One Medical Group were tasked with identifying vulnerable patients and contacting them proactively

to guide them through the process, providing additional information/handover to receiving practices

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where appropriate.

Issues:

Above process did not happen as comprehensively as the CCG would have envisaged despite

support from Dr Andy Ciecierski. Coding issues meant clinical system searches yielded small

numbers, primarily carers. OMG lost key staff in transition period who would have been best-

placed to know patients who might require additional support. Receiving practices have done a

significant amount of work to support vulnerable patients who have moved to them and to

ensure appropriate arrangements are in place to enable them to access care.

Actions/Learning points:

In any future dispersal the commissioner should have more proactive discussions with other

services and with the safeguarding team to identify vulnerable patients as this process has

shown that the outgoing provider may not be able/willing to do this to maximum effect.

Allocation process including data handling This was covered above.

Patient registration Covered above

Transfer of notes The majority of notes transferred electronically via GP2GP with OMG providing additional printed

information as prompted. An NHSE member of staff worked in the surgery prior to the closure to

support this process.

Issues:

EM reported that 100 sets of notes did not come over with GP2GP and 130 notes had

incomplete or missing Docman information. Pembroke Surgery and Abbey Medical Centre had

reported similar issues for one patient each. There was also an issue with the readability of

some of the printed out summaries some of which were poorly photocopied with missing

information. The CCG is supporting Balmore Park and Emmer Green surgeries to access EMIS

back-ups. Docman information is not however now available as the server has been de-

commissioned.

Actions/Learning points:

Once a practice closes the Docman server should not be de-commissioned for a period of 6-12

months. As this time commissioner support should also be provided in the last days the

practice is operating to support the transfer of patient information.

Communications with other services The CCG informed RBFT, BHFT and Reading Borough Council of the closure of the surgery. OMG agreed

to re-direct mail to Bath Road.

Issues:

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Mail was not re-directed as agreed with OMG. This has now been rectified.

CCG to review who in each organisation is informed of such a change as there was subsequent

contact from RBFT which suggested not all teams had been made aware.

There is a time lag between a surgery closing and its removal from the spine as an option for

clinical correspondence to be sent to. This area needs further review for any future dispersal.

Impact on receiving practices – Balmore Park, Emmer Green, South Reading practices EM explained the huge impact placed on her practice, which involved trying to deliver a normal day-to-

day service throughout the dispersal process and described the impact on the reception team, clinical

workload and training requirements. As stated above no further information had been received from

other practices.

The CCG reminded the meeting that GPs have been asked to complete the clinical concerns form

should they have concerns about the care provided by any individual clinicians. To date the response

has been minimal. Action: EM to remind GPs.

Impact on CCG and GPFV strategy

It was noted that the dispersal has significantly changed the primary care provider landscape in

Caversham and that the CCG will need to revisit its plans for the locality, particularly in the context of

anticipated housing development and the potential retirement of GPs at Peppard Road Surgery.

6.

Summary of findings and plans for next meeting

WB will chair the next meeting which will focus on patients’ experience of the dispersal. Summary minutes of this first meeting will be produced and shared. TP to feedback headlines from PALS for the next meeting.

16.

AOB

No other business was noted.

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Annex D

Priory Avenue Dispersal Review Meeting 2

25 October 2018 at 13:00 – 14:00

57-59 Bath Road, Reading, RG30 2BA

MINUTES

MEMBERS PRESENT

Wendy Bower Lay Member for Patient Engagement WB

Helen Clark Director of Primary Care HC

Eiliis McCarthy Practice Manager, Balmore Park Surgery EMc

Terry Pascucci PALS Officer TP

Francis Brown Chair, Priory Avenue PPG FB

Geoffrey Million Secretary, Priory Avenue PPG GM

Pat Bunch Healthwatch Reading (deputising for Rebecca Curtayne) PB

Lydia Benedek-Koteles Primary Care Administrator LBK

Apologies:

Dr Isabel Cook Senior Partner, Emmer Green Surgery

Carole Coles-Ranson Practice Manager, Emmer Green

1.

Background of review

LBK listed the attendees for the meeting and apologies.

WB reinforced this was a confidential meeting with the main focus being on the patient experience.

HC summarised what was discussed in the first meeting, which had focussed on CCG and practice

processes.

2.

Terms of Reference for the review

HC noted the ToR had been signed off at the 1st meeting by those present.

This was a retrospective review of the dispersal of Priory Avenue. HC summarised the paper to the

group, listing the aims of thereview.

A full written report will be taken to the Primary Care Commissioning Committee, who will be asked to

endorse any further action identified.

3.

Dispersal timeline

HC presented the paper to the attendees and recapped on the numbers and the timeline. 6,089

patients had been dispersed of whom 4,668 had been registered by either Balmore Park or Emmer

Green surgeries (3,355 through the initial remote registration process and further 1,313 by allocation).

Other surgeries had taken 1,204 patients (366 by registration and 838 by allocation). Balmore Park’s

list had increased by 18.14%, Emmer Green’s by 16.82%. Other surgeries with a significant increase in

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list size were Melrose Surgery (3.54%), the Walk-in Centre (7.62%) and Chatham St (3.44%). It was

noted that there was a 3% difference between the original list extracted for the purposes of sending

the letters and the number of patients who had re-registered or were allocated at the end of the

process; this may be in part due to patients re-registering outside of the area or to list cleaning

undertaken by the provider. At October 2018 sixty patients are also still showing as being registered

with Priory Avenue Surgery and a list of these patients has been requested to be reconciled against the

allocations list. NHSE has advised that dispersals such as this typically result in some ‘ghost’ patients

being identified.

Action - HC to add the numbers from the spreadsheet onto the timeline

4.

Summary of first meeting (paper to follow)

Action – HC to distribute the paper

5.

Submissions received

WB noted we were not intending to go through the papers submitted here as some of the comments

made were outside of the scope of the meeting. All submissions had however been noted. FB

mentioned the document he had submitted and wanted to understand what success looked like. HC

explained that the CCG’s commissioning intentions were set out in the ToR. GM asked if the process

was rushed and if this had an impact on patients? HC stated that the timescales for the dispersal itself

had been tight due to the nature of the contractual position with One Medical Group however detailed

planning and discussion of potential options and scenarios had taken place with both Balmore Park and

Emmer Green surgeries throughout.

6.

Summary of queries received by PALS TP introduced herself and went through the list of submissions received from PALS. There were a total

of 315 patient enquiries until the end of September, which were received by telephone and email. The

queries received were; 54 questions about the form, 27 said that they did not receive the letter, 15

people had moved out of the area, 3 people were on holiday and missed the process, 17 callers had

sent in forms but had not received a reply yet. In the second part of the process, PALS advised a total of

70 people where they had been allocated. The majority of patients received a response in 2-3 days. Of

the calls received 52 had been resolved by the time that PALS went back to them. The other 77 calls

were regarding a range of enquiries regarding patients different circumstances.

Pat discussed the number of phone calls Healthwatch had received and agreed to send HC data

regarding these calls. Pat also informed attendees about the use of social media and what information

they had gathered. HC explained we did not use social media given time scales but this was a learning

point for future reviews.

Action – PB to send WB and HC data about call queries and social media

7.

Key areas for review at this meeting

PPG engagement

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The CCG had sought to liaise with the PPG throughout the process providing briefings from January

onwards (in confidence initially) and seeking input with regard to the allocation process and patient

letters. It was noted that the PPG had provided considerable support to patients in the practice

through drop-in sessions, had attended the patient information events and had produced dynamic FAQ

documents.

Issues:

PPG members felt that the early CCG briefings did not make it sufficiently clear that if discussions

with Balmore Park were not concluded successfully the only Plan B would be a dispersal which

would mean the closure of the practice. It was felt that the PPG was only made aware of this on

24th April briefing.

For confidentiality reasons the early briefings included only active PPG members who then found it

difficult to update fellow colleagues. CCG members explained why it had not been possible to brief

more widely in the early stages.

PPG members fed back that the CCG communications material was not sufficiently dynamic – in

particular there was no use of social media.

Actions/Learning points:

CCG to reflect on briefing style and whether more information could have been shared earlier on.

At the time of the January briefing it was however anticipated that a solution would be agreed with

Balmore Park Surgery.

More dynamic communications strategy required for any future dispersal including regular updates

to websites and use of social media.

Notification of closure As there had not been time for a consultation with patients the focus was on providing individually

targeted information to set out patients’ options and support them in taking next steps. Patients were

notified of the closure through an individual letter setting out their options and action required. There

were two versions of this letter – one for patients eligible for registration at Emmer Green and Balmore

Park surgeries who were asked to return a remote registration form, a second for patients not eligible

to register at these practices who were asked to approach alternative practices directly. In both

instances patients were informed that if they did not take action within the timescale they would be

allocated to another practice.

Issues:

Due to the nature of the situation and the risk of sudden contract failure / lack of options, it was not

possible to undertake patient engagement around the agreed approach. The focus instead had to

be on communicating with each patient individually and supporting them to understand their

options.

Letters were received by patients on different days despite PCSE having given assurance that they

had been posted at the same time.

The CCG successfully delayed press coverage of the issue for some time however the closure was

reported in the press on the same day that the first letters were received.

It was suggested that it would have been helpful for the PALS voicemail message to refer specifically

to the Priory Avenue closure and to let patients know there could be a delay in responding to their

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query. Where patients didn’t get a response quickly from PALs they often contacted Healthwatch,

Priory Avenue or the receiving practices.

Balmore Park Surgery proactively contacted their existing patients to reassure them there would be

no adverse impact on services; this was felt to be good practice.

The paperwork used was felt to be much too long and complicated. It was suggested that a one

page summary of action required would have helped.

Actions/Learning points:

Documentation should be simplified in any future dispersal.

Bespoke PALS voicemail message to be put in place in any future similar situation.

Any future dispersal to consider communications arrangements for patients already registered at

receiving practices. Action: HC to find out how Emmer Green communicated with existing

patients.

Remote registration process Patients eligible for registration at Balmore Park or Emmer Green surgeries who wanted to be

registered at one of these surgeries were asked to return a form stating their preference. These forms

were logged and date stamped and passed to the practices for processing. All patients were registered

with their first choice of practice.

Issues:

Some members expressed the view that the process worked well because both surgeries were able

to accommodate all patients that sought registration with them.

There was concern over whether the ‘first come first served’ approach was appropriate and

whether forms were in fact dealt with in the order in which they were received.

The time lag between patients returning forms and receiving confirmation of registration was felt to

have been too long. However given the volume of registrations to be processed this was felt to be

unavoidable.

The process resulted in some complexity with patients receiving different letters.

The comments above regarding documentation relate to the need to include registration

paperwork to support the remote process. Other patients received a simpler letter.

Members were concerned about the response rate from PALS which was often 2-3 days.

Actions/Learning points:

The remote registration process avoided to some degree large numbers of patients having to attend

practices which could have resulted in blocked phone lines/reception desks. Overall it was felt to be

smoother for patients than a standard dispersal process.

Many patients chose not to return the form indicating they did not have a strong preference for a

particular surgery. This should be taken into account in deciding if a similar process is required for

any future dispersal i.e. decisions about the process should be based on a robust assessment of the

likely numbers of patients who would seek to re-register themselves.

Allocation process Generally the allocation process was felt to have gone smoothly from a patient perspective. Balmore

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Park and Emmer Green surgeries helpfully processed all of the registrations they had received through

the remote process prior to the allocations letters being sent which largely avoided any patients being

caught between the two processes.

Issues:

There was known to be a risk that some patients who had sought registration with a practice shortly

before the deadline and whose registration had not yet been processed could subsequently end up

being allocated. In this instance they could have chosen to stay with the practice they had been

allocated to or re-approach the practice where they had originally sought registration. However

this was not a widespread issue as all practices were asked to process registrations as promptly as

possible. GM did however report that the Walk-in Centre had asked some patients to attend several

times to complete registration. At one stage this had related to an issue with photocopying

documents; this had been followed up with the practice at the time.

Actions/Learning points:

It was suggested that the consistency of registration processes could be improved as practices seemed to handle registrations differently.

Following re-registration Issues: Attendees were asked if they had feedback about how patients were finding their new surgery. The

consensus was that patients were sad to see Priory Avenue close having been there for so long. It was

felt that Balmore Park was coping well with a small number of people mentioning blood tests were

slow but no other reports of concern and patients were reporting that they could get appointments and

that the phone was typically answered within 3-4 minutes. It was noted that some patients living to

the south of the river were unhappy at being unable to register with a Caversham surgery. PALS had

dealt with concerns from approximately 20 such patients.

Healthwatch had had no negative feedback from patients about their new surgeries.

Some attendees had raised concerns about the possible impact on other surgeries and it was suggested

that close monitoring of Friends and Family Test (FFT) results could provide an early indicator of any

problems. The CCG is currently working on a project to improve the level of FFT data collected.

Other issues Healthwatch asked if we could be confident that vulnerable patients had been supported. It was

confirmed that the previous meeting had identified learning points on this area as it had been difficult

to work with the outgoing provider to identify and support these patients.

8.

Next Steps

The findings from the meeting will be included in the final review report.

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Annex E

Healthwatch Reading feedback on Priory Avenue Dispersal November 18 1. We were asked by the CCG to give feedback on the draft patient letter and we did that by phone and email. We were only given a few days to do this and, in the future, we would hope to be given at least a week to make the most useful suggestions we can. We still managed to give some feedback on the letter, asking that it - reassure people that Balmore and Emmer Green would have enough capacity to take on extra patients (and the CCG final letter confirmed this in the Q&A) - make clear how people could appeal/raise concerns if they did not get their first choice of surgery (and the CCG final letter did include this) - describe how vulnerable patients would be supported to make choices and also be allocated according to need, not just a 'first come, first served' basis (the final CCG letter did not communicate this). Before the letter went out, we also expressed concern about the short timescale (23 May - 8 June 2018 initially, then extended to 13 June) for patients to reply on preferred choice of surgery (north of river) or registering with another surgery (south of river). If this situation arose in the future, we hope patients would get more time, at least one month to make decisions and act. 2. Healthwatch Reading proactively offered their support to patients and the CCG on the dispersal in various ways: - we publicised the upcoming closure and information for patients on our website on 23 May 2018, including extra information prepared by the Priory Avenue PPG of a table designed to help GPs choose their new GP surgery, which compared information such as each surgery's walking distance from Priory Avenue Surgery, their current CQC rating, and latest patient feedback from the National GP Patient Survey; - we visited Priory Avenue Surgery six times from 29 May - 6 June 2018, to offer support, information or advice to people needing help on moving on from Priory Avenue. We engaged directly with 33 people, some of whom asked us about what other local surgeries were like, and some who needed further explanation of what they needed to do. We urged all people to reply/act by the deadline if they wanted to have control over their future GP practice. We had to offer more in-depth support to one individual who was visibly upset, due to particular health needs and concern about the future, and explained how they could raise this with the CCG;

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- we monitored a Caversham community Facebook group to check how patients were reacting to the news, and what queries or information they needed, and we replied where appropriate with factual information, such as how to contact PALS. We have collated anonymous online comments (appendix 1). Latest posts show some reports of phone/appointment access issues at Balmore/Emmer Green services. We would recommend that in any similar future situation, the CCG monitor and engage with patients directly on social media as it is a quick way to get a message out to a large section of the population and also to correct any wrong information or assumptions - we attended the two CCG public meetings to also be on hand to support patients. We would recommend in the future that public meeting venues are checked with PPG/practice staff for their suitability as the venue on this occasion was quite far away and had little parking facilities and only attracted up to 18 people on the two dates it was held - we gave advice to 28 people who contacted us about the closure, from 23 May until early August (appendix 2 full list) Analysis of these concerns show: - some people living south of river felt it was unfair they couldn't transfer to Balmore park, which was much closer than other surgeries, some of these people had LTCs/disabilities - some people, including young adults living at home, were unfamiliar with the process of registering and mistakenly thought if one person in the family transferred, the rest of the family automatically would. In the future, please emphasise that all adults (define this by age) in same household must complete individual forms and that they don't have to go to the same surgery as their relatives if they don't want to. - some people were anxious about when they would hear - in the future can you put an approximate timescale on it e.g. You should hear in x weeks your choice, and also that people in the same house may hear back at different times - anxiety caused by no-one answering PALS number - in the future PALS helpline needs to be resourced better to answer calls as answerphone frustrates/worries people at the peak time of concern - one person north of the river had been sent a south of the river letter Since August 2018 we have not received any new calls from the public needing help with this issue or had any follow-up calls from people we initially advised. The CCG might find it useful to work with PPGs/surgeries to survey: - Existing Balmore Park and Emmer Green patients as some have expressed concern online about issues with phone and appointment access since taking ex-PA patients - Ex-Priory Avenue patients on how they feel their care has change since moving.

3. We recommend that the CCG implement the learning points for any

upcoming surgery closures, especially as the Caversham community is beginning

to express concern about future of Peppard Rd Surgery and the application by

Emmer Green to reduce its catchment area.