The professional voice of general practice in EnfieldLondonwide LMCs is the brand name of Londonwide Local Medical Committees LimitedRegistered and office address: Tavistock House North, Tavistock Square, London WC1H 9HX. T. 020 7387 2034/7418 F. 020 7383 7442E. info@lmc.org.uk www.lmc.org.ukRegistered in England No. 6391298. Londonwide Local Medical Committees Limited is registered as a Company Limited by GuaranteeChief Executive: Dr Michelle Drage

ENFIELD LOCAL MEDICAL COMMITTEE LIAISON MEETING

Monday 24 February 2014

LMC Pre-Meet 1:30pm2:00pm-3:30pm

Seminar Meeting Room, Forest Primary Care Centre, 308a Hertford Road, Edmonton N9 7HD

AGENDA

1.0 Welcome and Apologies

2.0 Declarations of InterestMembers to declare any conflicts of interest in connection with any items on the agenda or in the light of subsequent debate

3.0 Minutes and Matters Arising3.1 Minutes from the Part 2 LMC meeting on Monday 11 November 2013 (pages 2 – 4)3.2 Matters Arising not elsewhere on the agenda

4.0 CCG Update, including:4.1 Financial update (pages 5 – 7)4.2 Enhanced Services update

5.0 Public Health5.1 Locally Commissioned Services (formerly enhanced services) update5.2 Payments including health checks update (page 8)

6.0 Items for discussion6.1 Mobilisation of UCL Project: Clinical Teaching Fellowships update (pages 9 – 13)6.2 Primary Care Strategy (pages 14 – 15)6.3 Network funding and development6.4 Prescribing budget (page 16)

7.0 Date of Next Meeting:Monday 28 April 2014, Seminar Meeting Room, Forest Primary Care Centre, 308a Hertford Road,Edmonton N9 7HD

8.0 Any Other Business

1

Enfield Local Medical Committee MeetingPART TWO

Minutes from the meeting held at 2pm on 11 November 2013in West Lodge Park Hotel, Cockfosters Road, Hadley Road, EN4 0PY

Present: LMC Members:Dr Neil AminDr Hardeep BhupalDr Katy BlustonDr Tim FennDr Sarit GhoshDr Richard HarrisDr Sinnappoo KarthikesalingamDr Manish KumarDr Muhammad RazakDr Tathagata SadhuDr Pavan SardanaDr Ujjal SarkarMrs Uttara SarkarDr Ramesh SharmaDr Jonathan Warren

CCG Representatives: Dr Alpesh PatelMr Peter Lathlean

Guests: Glenn Stuart, Public HealthJo Stronach-Lenz, Public Health

In Attendance: Ms Helen Musson, Assistant Director of Primary Care Strategy,Londonwide LMCsDr Julie Sharman, Medical Director, Londonwide LMCsMs Debbie Griver, Committee Liaison Executive, Londonwide LMCs

1.0 Welcome and ApologiesApologies were received from Dr Olanrewaju Durojaiye, Dr MohammedAbedi, Ms Christine Williams, Ms Liz Wise, Mr Ray James and Mr GregCairns.

Dr Kumar welcomed Dr Razak and Dr Bhupal who have been co-opted ontothe Enfield LMC.

2.0 Declarations of Interest2.1 There were no new declarations of interest.

3.0 Minutes and matters arising not listed elsewhere on the agenda3.1 The Minutes of the meeting on 19 August 2013 were confirmed as an

accurate record.

4.0 CCG Update4.1 It was reported that CCG finances are looking strong and the CCG is on

target to meet the control total. The CCG had plans in place to achieve £12million QIPP savings. It was indicated that there was a risk for 2014/15 ascurrent reports were that the contracts with secondary care would overspendat approximately £8-12 million.

Item 3.1

2

It was noted that there would be a new allocation formula for the CCG budgetthat would be published on 17 December 2013 for 2014/15 and 2015 16. Itwas expected that Enfield CCG would receive further investment as a resultof these allocation changes.

5.0 Enfield Primary Care Strategy5.1 There was no further update since the last meeting.

5.2Patient Experience TrackerThe patient experience tracker was developed in March in order to providepractices with tablet computers to encourage patient participation andfeedback within practices. The opportunity has been offered to all practiceswith 33 practices expressing an interest in taking part. It was noted thatPractice Managers and PPG Members had been involved in developing thesurvey.

Concern was expressed about what data will be shared outside the practiceonce it was collected and how it will be used outside the practice. MrLathlean stated that the Practice would continue to own the data collectedfrom patients but the CCG would receive an overview of some of the data onhow many questions patients are completing the questionnaire and in whichquestions they are answering. This data was being collected in order toevaluate the success of the project. The CCG wished to support betterservices for patients by providing this tool to practices and the data collectedwill not be shared with NHS England.

It was noted that the questions are only in English which will be an issue inEnfield. It was also suggested that the questions need to be validated asthey could be interpreted in various ways. Mr Lathlean explained that theinformation is for the practice to inform their services based on patientfeedback and in-house changes to the survey could be made.

It was noted that the data collected via the tracker may be part of NHSEngland’s criteria for all practices to take part and submit the data as aperformance measurement tool of practices in 2016.

6.0 Enhanced Services Update6.1 There was no update.

7.0 Network Development7.1 Londonwide LMCs had offered to help PA Consulting with their work on

network development but have not had a response as yet. It was noted thatit had been suggested that there was an open meeting to discusscollaborative working.

It was noted that Barnet had secured funding for their network groups butEnfield CCG needed to understand how the rationale to secure funding fornetwork groups had been achieved.

8.0 Mental Health Services Update8.1 This item was postponed to the next meeting.

It was noted that all Practices should have received an email regarding aMental Health audit which they needed to complete and return.

3

9.0 Risk Profiling DES and funding streams

Dr Alpesh Patel agreed to follow up on the issue that was raised aboutpractices still having to achieve the identified of the same numbers of patientswithin a shorter period of time to achieve payment and would report back.

AlpeshPatel

10.0 Public Health Update – Health check Payments

All payments are now flowing to practices with quarters one and two paid andIT solutions being considered and implemented to resolve these problems. Itwas noted that if Members have any payment issues they can contact MrGlenn Stuart.

It was reported that there is a proposal to put the price of the Health checksservice up to take into account the new ordering system that will beimplemented whereby practices will send their receipts to CCG who will beinvoiced by Public Health. There is anticipation that the service will be £35 in2014/15.

It was agreed to add an email contact, Mr Glenn Stuart, for paymentproblems into the LMC newsletter.

CLE

11.0 Date of next meeting – 24 February 2014

4

Finance Report- Month 9 Introduction The purpose of this report is to provide the Enfield Clinical Commissioning Group (CCG) Governing Body with information on the financial position of NHS Enfield CCG and its prospective position for the full year. This report covers the financial position for Month 9 2013/14, including the QIPP position. Financial Position – Month 9 2013/14 and forecast for year Summary The Revenue Resource Limit for the year after adjustments from the opening position is £337.850m, of which £254.480m is allocated YTD to Month 9. The month 9 cumulative results show an underspend of £19k. This position is primarily due to over-performance on the UCLH contract and non- contractual activity being offset by acute reserves. Our assumptions are that these trends will continue and therefore the projection to the end of the year shows a small underspend of £26k. There are, however, a number of significant risks to be managed if this position is to be achieved. Acute Secondary Care, which in previous years has created significant pressures for Enfield and many other locations within the NHS, is less volatile financially across the CCG’s two main providers due to the agreement of block contracts. However underlying activity levels are generally increasing. The overall budget allocation for Acute and Integrated Care in the financial year is currently assessed as adequate to cover significant pressures in respect of the Payment by Results contracts with University College London Hospitals, Great Ormond Street Hospital and the Royal National Orthopaedic Hospital. Similarly whilst there are also some less significant adverse variances on Out of Sector agreements, it is anticipated these will remain within the overall budget allocation enabling the CCG to maintain the forecast of breakeven for the financial year. There remain a number of risks to delivering this breakeven position, including activity on contracts that are paid through Payments By Results (PbR) tariffs, for example the UCLH position mentioned above; additional investment in certain services (e.g. Improving Access to Psychological Therapies), the impact of Specialised Commissioning allocation transfers to NHS England and a change to the NHSE position on balances carried forward. As stated in our previous reports, Specialised Commissioning figures have been under review, with the latest position from NHS England indicating Enfield has a shortfall of £5.7m rather than the expected neutral position. None of the £5.7m has been adjusted in the CCGs acute SLAs and therefore means there is a cost pressure against the CCG to this value.

Item 4.1

5

The CCG has recently been informed of a change by NHS England in the treatment of legacy provisions, particularly regarding the provision of retrospective continuing care payments. This has resulted in a cost pressure to the CCG of £2.9m in this financial year. Both the above issues are being discussed with NHSE and also with NCL CCGs in the context of utilisation of the NCL Risk Share Fund. It has been assumed at this stage that these unexpected cost pressures will be covered non-recurrently by risk share monies. Results The results are shown below together with comments as follows: - 1. The total expenditure for the 9 months was £254,461k, which was consistent with budget

allocations, enabling the CCG to show a small underspend of £19k. 2. As the Governing Body is aware, the activity run rate with our main providers will be a key factor in the next year. Based on month 8 data, the North Middlesex underlying run rate is projected to be £5.4m over plan, although the data quality continues to be questionable. Similarly BCF is over plan by £2.9m. We continue to work with the CSU to gain a better understanding of the trends. As stated elsewhere in this report the contractual block contracts contain this problem in 2013/14 but represent the greatest financial risk for next year. 3. UCLH contract negotiations have now been concluded. We are reporting a significant overspend for the year to date of £2,950k projecting this as a trend to increase to £3,830k by the year end due to a range of issues including Specialised Commissioning and Maternity Service charging. A range of challenges have been raised which may reduce the forecast. 4. The agreement with Royal Free is based on a ‘cap and collar’ contract with a collar of £200k. Lower than forecast activity volumes suggest that the ‘collar’ underspend position will materialise as the out-turn position. 5. Additional adverse variance risks are to an extent mitigated by funds remaining in unallocated reserve to cover final agreed contracts and over-activity of PbR contracts for the year. The implications of higher ‘run rates’ capped within block contracts into 2014/15 are challenging. 6. The position on non-acute budgets is showing an over-spending of £251k with overspends on Programme Corporate Costs, Mental Health Services and Community Services being partly offset by underspends on Continuing Care and Primary Care. 7. Running Costs remain within budget. QIPP The Enfield QIPP target is now £12.4m following removal of £2.9m of unidentified QIPP. This has been funded through non-recurrent funds but still presents a risk to 2014/15 and work continues to identify schemes and savings to mitigate this. The current YTD position, at month 8, which is the latest available, shows an adverse performance of £327k, which can be attributed to the following: £264k – Primary Care Medicines Management – At present the PC Medicines management QIPP is under performing by approximately £264k. This is partly due to a higher number of dispensing days YTD compared to the previous year. It is also noted that individual schemes have seen delays or savings below anticipated. The Head of Prescribing has provided a plan to the

6

Transformation Programme Group on how to mitigate the adverse performance and an update on progress will be provided. The above performance is based on assuming block contract QIPPs are achieved. If the run rate of QIPP projects is assessed the CCG would be reporting a deficit versus plan of £2,248k after 8 months. Payment Performance December performance showed NHS bills increasing to exceed the 95% target at 98.8% (82.9% cumulative) by value, and by number it has increased to 98.0% (86.7% cumulative). Non-NHS bills are still below target by number at 79.4% (88.0% cumulative), but above by value at 98.9% (96.4% cumulative). Cash Management The cash position remains satisfactory and is consistent with the CCG’s forecast of a balanced position. The relatively healthy cash balance at the end of month 9 is likely to be utilised as the Secondary Care providers ensure invoicing is comprehensively completed for the year end deadlines. Running Costs The CCG management costs are showing a small favourable variance at month 9, offset by a similar overspend in respect of the CSU. The CCG is projecting a full year position consistent with budget, and should benefit from reduced use of interim staff. Performance against the £25 running costs allowance is within the Resource Limit. As stated previously the methodology used for calculating Running Costs is similar to most other London CCGs although there are differing interpretations of, for example, programme costs that are generally, but not always considered clinical rather than inside the £25. It is important to note that there has not been detailed definitive guidance although London CCG CFOs have produced draft guidance which is hoped will be incorporated into the NHS Accounts Manual for 2013/14.

7

Health Checks update

All practices in Enfield were offered the health checks contract and all but 2 signed up to it.However, this is not necessarily the same as delivering and at the moment we are struggling tocollect data on what is being delivered and when – for instance in:

Q1 practices reported delivering 1815; Q2 practices reported delivering 2186; Q3 practices reported delivering only 8591.

The above includes provision by a community provider – this is intended to pick up those who areeither not registered with a GP and/or do not respond to GP invite.

We are also working with Health Intelligence to implement systems whereby we can extract dataelectronically. Once implemented and teething problems aside the intention of this is that we willbe able to extract data automatically. Something like 48 of 52 practices have signed up to this.Obviously this will give us much more useful and robust data than current practice of ringing andemailing practices every quarter.

Glenn Stewart

1 We suspect but don’t know that invoices will come in at the end of the year. We would obviously like many more to come in for Q4.

Item 5.2

8

Primary Care Strategy Programme – CCG/UCL Partners Initiative toRecruit Primary Care Teaching Fellows

MEETING: Enfield LMCDATE 24th February 2014AUTHOR: Jenny Mazarelo, Programme Manager - Primary Care StrategyCONTACT DETAILS: Jenny.Mazarelo@enfieldccg.nhs.uk (Tel: Tel: 020-3688-2156)

SUMMARY:

This report seeks to address the concerns raised with the LMC regarding the implementation of thisinitiative.

IntroductionThe proposal for this GP Workforce Development initiative was considered by North CentralLondon’s Primary Care Sub Committee of the Health and Wellbeing Board on 16th August 2012.The initiative was led by Dr Angela Lennox, the Deputy Medical Director at the time and supportedby a Project Manager, Daniel Morgan.

The proposal was developed by a small working group of GPs (Mo Abedi, Tim Fenn, Sarit Ghosh,Janet High, Angela Lennox, Alpesh Patel), UCL Medical School (Joe Rosenthal) and PCT officers(Daniel Morgan and Sean Barnett). It was anticipated that both training for existing practices andrecruitment of the Clinical Associate posts would begin in Quarter 4 of 2012/13.

The benefits of the initiative were anticipated to be: 17,472 of additional appointment capacity offered to Enfield patients; improvements in specific disease areas or clinical pathways through their service development

role working across all the practices within their locality networks; raising the profile of Enfield as a place to work for graduate GPs, and to create; greater links between undergraduate and postgraduate training and retention of skills and

experience.

In addition to the recruitment of four Academic Clinical Associate GPs (subsequently renamed asPrincipal Clinical Teaching Fellows), it was also proposed that Enfield would offer the ‘Training inPractice’ (TIP) programme for local practices to develop and support GP practices which aspire tooffer undergraduate training for students with the skills to teach undergraduate, postgraduate andfoundation students. However, this programme was not introduced as part of the initiative and it isnot clear from the audit trail of documentation what the rationale for this was.

The four full time, two-year GP posts were to provide: 5 sessions of academic time (teaching/research/service development); 4 Clinical sessions in an Enfield general practice (one year rotations); 1 Professional Development session; Individually supervised research and teaching activities within the academic Department; Formal courses related to educational theory & practice and research methods; Mentorship and support for integrating academic and clinical practice.

Item 6.1

9

However, by the time recruited commenced in September 2013, this commitment had beenamended to: 2 sessions of academic time (teaching/research/service development); 5 Clinical sessions in an Enfield general practice (one year per practice); 1 Professional Development session; 2 sessions of individually supervised research and teaching activities within the UCL academic

Department.

There appears to have been a delay in establishing a NCL/UCL Steering Group and the recruitmentof host practices and Principal Clinical Teaching Fellows (PCTF) did not then commence untilMarch and September 2013 respectively.

Recruitment and Evaluation of Host General PracticesThe choice of general practices to host PCTFs was initially based on three key themes to ensurethat maximum benefit was gained by the population of Enfield, the CCG and the PCTFs.

a) Culture and aspirationThe PCTF was not a free ‘pair-of-hands’, but one which would facilitate the host practice to achieveits aspirations of improving the accessibility and quality of primary care; in return the PCTF was togain valuable clinical and primary care experience. In particular, the initiative was to attractpractices which had no experience of delivering undergraduate or postgraduate medical education.

b) Practice requirementsThe practice size was not a factor, its culture and aspirations were deemed more important and thefollowing GP practice attributes were sought: A willingness to collaborate with other local practices around clinical and educational

developments. Sufficient physical space to accommodate academic clinical associate and to undertake medical

student teaching – although this does not need to be a fixed space. Ability to provide clinical mentoring to Clinical Associate. An agreement to support the Clinical Associate in research and development projects in line with

local clinical strategy. Minimal or no previous experience of delivering undergraduate or postgraduate medical

education. Payment of Clinical Associate’s medical indemnity subscription.

c) OutcomesSince additional capacity was to be provided and the funding was public money, these were: A commitment to develop one or more specific new services in line with Enfield’s Primary Care

Strategy Implementation Plan and/or QIPP activity. A commitment to improve access to primary care services. A commitment to develop/expand undergraduate teaching activity within the practice.

The information for interested GP practices originally stated:“In particular we are looking to attract practices which have no experience of deliveringundergraduate or postgraduate medical education.”

and was then amended to, due to lack of response to the first round of Host practice recruitment:“In particular we are looking to attract practices which have minimal or no experience ofdelivering undergraduate or postgraduate medical education and have an interest in providingundergraduate medical education.”

10

It was originally agreed by the Steering Group that expressions of interest would be sought from GPpractices and that eight Host practices would be chosen from these (four practices for year 1 andfour practices for year 2). As the response was better than anticipated once the criteria for havingno experience of medical education was removed, the thirty-one practices who expressed aninterest in being a Host were asked to complete an application form. Application forms weresubsequently reviewed by Angela Lennox, Melvyn Jones and Joe Rosenthal.

Nine of these were shortlisted for further consideration and although there had not been anintention to evaluate practices who expressed an interest by conducting an on-site evaluation, itwas agreed by the Steering Group that practices would be visited by a clinical evaluator (AngelaLennox, Joe Rosenthal or Melvyn Smith) and managerial evaluator (Rathai Thevananth and LucyStewart).

11

Specific Concerns Raised with the LMC

1. The practices selected are only in two sections of Enfield – 2 teaching practices withinhalf a mile of each other and 2 practices in the south east of the borough.

The host practices cover three of the four localities in Enfield these are as follows:

Practice LocalityWhite Lodge North WestCarlton House North WestBounces Road South EastGillan House South West

2. This project was initially meant to send the CTFs to practices that are not alreadyproviding training. It would be helpful to explore why the rules to apply changed.

Project documentation does demonstrate that the original ethos of the project was to placePCTFs in non-training practices, however due to a lack of interest to the initial advert it wasagreed that the opportunity to be a Host practice should be opened up to all practices to ensuresufficient interest and appropriate representation across the borough.

3. Given this understanding of a key aim of the project, the fact that 2 of the 4 practices areteaching practices has left local GPs wondering how this can be justified.

Since the offer of applying to be a host practice was open to all practices following the initial lackof interest, a large proportion of the final applications were from teaching practices. Once thewritten applications were received they were anonymised and scored by impartial parties,including LMC representation.

The top six practices were originally selected however, as here was no representation in theSouth East this was then extended to the top nine practices which included the two practicesfrom the South East (one of the nine was a cohort of three practices).

Of these nine practices, seven were teaching practices. Both the non- teaching practices, GillanHouse and Bounces Road were selected as Host practices. Whilst the other practicesdemonstrated strong potential as host practices they were all larger teaching practices, with theexception of the cohort of three practices, which did include a teaching practice.

4. Two of the practices that have been selected are already two of the largest teachingpractices in the area. This means that already well-resourced practices are being givenadditional resources.

Along with the delivery of undergraduate teaching, the purpose of the PCTFs practice basedtime is around increasing access which has been identified as a borough wide issue and issupported by the Access LES (until 31st March 2014) along with this project.

12

5. Given that one of the issues at stake here is the amount of support the PCTFs will require,what support will UCL be providing, and how much will UCL be funded for this support?

In terms of funding to UCL, the supervision figure we have agreed is £65,000 over two years.This is based on a figure of £8,125 per Fellow per year to cover all the project developmentcosts, recruitment, employment, supervision, accommodation and training which the medicalschool will provide. This is less than the full economic cost and overheads originally requestedby the medical school. £8125 per year is equal to the amount per year which training practicesreceive for hosting GP Registrars.

All other funds transferred to UCL will be paid out in salary costs for the PCTFs.

6. The role and value of UCL is not clear to some GPs in Enfield.

UCL have emphasised their commitment to engagement in the interests of promoting communitybased primary care education, developing a cohort of future clinical educators, working with thelocal NHS and supporting local health care development.

7. The feedback promised to all participating practices has not been received by allpractices.

Once the initial written applications were completed an email was sent to all practices thatapplied to inform them of the outcome of shortlisting.

On completion of the evaluation visits to potential Host practices, an email explaining theoutcome of the process was sent to each applicant with an offer of more detailed feedback ifrequired. This more detailed feedback was provided to those practices that requested it.

8. Some practices felt the feedback was insufficient.

The CCG is willing to provide further verbal feedback if required.

13

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15

GP Prescribing Budget Setting Methodology

BackgroundGP prescribing spend for 12-13 was £35.1m, current forecast for 13-14 is £36m.

Enfield CCG ranked 13th from highest for cost per astro pu for London CCGs/PCTs for 12-13.

GP practice prescribing budgets and comparsions are made using Astro Pu data.

Astro Pu is a weighting applied to patient numbers to adjust for age and sex. To calculate theAstro Pu value for a practice’s list the following formula is used.

Age Cost-based ASTRO(09)-PUs(Years) Male Female0-4 1.0 0.85-14 1.1 1.015-24 1.4 2.025-34 1.8 2.835-44 2.9 4.045-54 4.9 6.155-64 9.2 9.665-74 15.9 14.5>75 21.1 18.5

Astro Pu weighting for Enfield Practices range from 2.08 to 3.91, the mean is 3.10.

Practices with a higher weighting have a greater proportion of older patients.

Practices are asked annually to supply data showing the number of patients in care homes and anadditional weighting is added on to a practices’ Astro Pu figure at a local level to account for thesepatients. The Astro PU figure is obtained from the NHSBSA(PPA) data and the additional AstroPus for care homes are added on locally, this figure is called the adjusted Astro Pu.

Methodology for Budget SettingIn past 4 years the budget has been set using the Prescribing Support Unit Budget Setting Utility,based on a 50:50 historic:capitation split. A manual adjustment was used to ensure that nopractice received an uplift or reduction greater than 10% from their outurn. The Budget SettingUtility also gave an additional uplift for deprivation. The adjusted Astro Pu figure is used tocalculate the prescribing budget.

Proposed Methodology for 14-15 Budget setting.The Prescribing Support Unit Budget Setting Utility is no longer available for 14-15.

We are currently proposing to use the methodology that the budgets setting tool used, to setbudgets for 14-15. We are meeting with other CCGs on 19th Feb where budget setting is on theagenda and we may review this proposal if it becomes clear that a more evidence basedmethodology is available. “High cost drugs” are not accounted for separately in this process,although the high cost drugs spend will be taken into account when considering a practice’sperformance against budget if there has been a significant change in high cost drugs spend.

Risks/Disadvantages List size data is obtained from the NHSBSA(PPA) and is usually 2-3 months behind actual

list data, this means that if a practice has significant list size changes in the final quarter ofthe year, this may not be reflected in their budget.

Prescribing indicators are provided by NHSBSA comparing practices, the NHSBSA do nottake into account the adjusted Astro Pu figure meaning that a practice with many carehome patients can appear to be more expensive.

Paul Gouldstone 11/2/14

Item 6.4

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