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Newham Primary Care Commissioning Committee Part I – 15.00-16.00 Wednesday 5 February 2020
FO21 Plaistow Room, 4th Floor, Unex Tower, 5 Station Street, London E15 1DA
Agenda
No Time Item Action Required Page Presenter
1. Administration and updates
1.1
3.00pm
Welcome, introductions and apologies Chair
1.2 Declarations of interests Monitor Chair
1.3
a) Minutes of the previous meeting – 18December 2019
b) Chair’s Action – APMS Tranche 7 Lot10 Contract Extension
Approve
Approve
Page 2
Page 4Chair
1.4 Action log Monitor Page 6 Chair
1.5 3.10pm The Project Surgery Update Monitor Page 7 Joseph Lee
1.6 3.20pm PCN DES Draft Specifications Monitor Page 11 Leilla Shaikh
1.7 3.25pm Finance Report
Monitor Page 60 Vince Henaghan
2. Decision items
2.1 3.35pm Terms of Reference – Updated Decision Page 67 Lauren Sibbons
2.2 3.40pm Boleyn Medical Centre (Dr M Khan) – temporary list closure
Decision Page 78 Lorna Hutchinson
2.3 3.50pm The Forest Practice – temporary list closure Decision
To Follow Lorna Hutchinson
3 Any Other Business
3.1 3.55pm Proposed change of Committee
schedule Chair
Next meeting:
TBC
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Primary Care Commissioning Committee Part I meeting: 4.30pm-5.30pm Wednesday 18th December 2019
Committee rooms, 4th Floor, Unex Tower, 5 Station Street, E15 1DA
Minutes
Voting members present:
Phil Horwell (Chair) Lay Member
Ellie Robinson Lay Member
Steve Collins Executive Director of Finance, WEL CCGs
Fiona Smith Board Nurse, NCCG
Jenny Mazarelo Director of Primary Care (Interim), WEL CCGs
Non-voting members present:
Nadeem Faruq GP Board Member, NCCG
Fiona Hackland Head of Commissioning, Public Health – Adults, LBN
In Attendance:
Yusuf Olow Interim Committee Officer, NCCG (minutes)
Lorna Hutchinson Assistant Head of Primary Care, NEL Primary Care Team
Lauren Sibbons Head of Primary Care, Newham CCG
Apologies:
Chetan Vyas Director of Quality & Safety, WEL CCGs
Leonardo Greco Healthwatch Newham
Greg Cairns Director of Primary Care Strategy, Londonwide LMC
Zulfiqar Ali Cabinet Member for Health and Adult Social Care, LBN
No Item
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1.1 Welcome, introduction, apologies for absence and declarations of interest
The Chair welcomed everyone to the meeting and noted the apologies above.
1.3 Minutes of the meeting held on 30th October 2019
The Committee agreed that the minutes of 30th October 2019 were a fair and accurate account of the meeting.
Minutes of the meeting held on 27th November 2019
The Committee agreed that the minutes of 27th November 2019 were a fair and accurate account of the meeting.
1.4 Action log
PCCC111 Strategic Estates Plan
This action was not due.
PCCC122 Newham Health Report
J Mazarelo clarified that the Newham Health Report would be presented by Leonardo Greco at the next meeting he attends. The Chair requested that should L Greco be unable to attend that a paper be tabled regardless. The Chair expressed concern that this report, offered by Newham Healthwatch to the Committee in August and deferred again in October remained outstanding. The Committee requested that the report be presented to the next meeting without further delay
Action: L Greco to be advised that the outstanding report is expected at the next meeting
2. Any Other Business
2.1 The Chair requested that an update be given in relation to the Project Surgery and how the situation had changed, whether for better or for worse, suggesting that it would be useful for the Committee.J Mazarelo agreed to follow up on the request.
Action: JM to seek an update from The Project Surgery
2.2 Next meeting:
NEL Primary Care Commissioning Committees in Common
Monday 13th January 2020
2.00pm-4.00pm, Old Town Hall, 29 The Broadway, Stratford, E15 4BQ
Newham CCG Primary Care Commissioning Committee
Wednesday 5th February 2020
2.30pm-3.30pm Plaistow room 4th Floor, Unex Tower, 5 Station Street, London E15 1DA
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Chair’s Action
Primary Care Commissioning Committee (PRCO)
a) Newham CCG’s Constitution gives the Chair of a meeting of its Governing Structure the authority totake a decision normally reserved for that body by virtue of the following paragraphs within itsConstitution:
5.1.3 The provisions of these standing orders shall apply where relevant to the operation ofthe Practice Member Council, Board, the Board’s Committees and Sub-Committees and allCommittees and Sub-Committees unless stated otherwise in the Committee or Sub-Committee’s terms of reference
4.6. Chair's ruling
4.6.1. The decision of the Chair of the Board on questions of order, relevancy and regularityand their interpretation of the Constitution, standing orders, Scheme of Reservation andDelegation and prime financial policies at the meeting, shall be final.
4.9. Emergency powers and urgent decisions
4.9.1. The powers which the Board has reserved to itself within these Standing Orders mayin emergency or for an urgent decision to be exercised by the Chief Officer and the Chairafter having consulted at least two non-executive members. The exercise of such powers bythe Chief Officer and Chair shall be reported to the next formal meeting of the Board inpublic session for formal ratification.
And that as a matter of interpretation it is deemed that the phrase “where relevant to the operation of …Committees and Sub-Committees” is appropriate in relation to paragraphs 4.6 and 4.9
b) These paragraphs relate to;
The Executive Committee
The Audit Committee
The Remuneration Committee
The Quality Committee
The Primary Care Commissioning Committee
c) The terms of reference of the following Committees (approved by the Executive Committee), whichare not part of the Constitution, gives the Chair of these meetings the authority to take a decisionnormally reserved for that meeting with guidance on the requirement to report back on the actiontaken to the next meeting;
The Integrated Care Committee
The Acute Commissioning Committee
The Community Commissioning Committee
The Mental Health Commissioning Committee
The Children and Maternity Commissioning Committee
The Urgent Care Working Group
The Information Management and Technology Committee
The Finance Committee
The Medicines Management Committee
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1. Decision taken normally within the terms of reference of the Committee
Approval to extend an APMS contract end date from 31 March 2020 to 30 June 2020.
2. Reason decision cannot await consideration at next meeting
A delay in issuing outcome letters to bidders from 7 October to 3 December 2019 hasadversely impacted on the mobilisation period that should have commenced on 23 October2019. Both the current incumbent and new provider are in agreement that commencing thenew contract on 1 July 2020, rather than 1 April 2020 will allow for a smoother transition,including engagement with patients and staff affected by a TUPE transfer.
3. Date of next meeting where decision will be reported to the Committee: 29 January 2020
Signed…………………………………… Date:
Chair of the Primary Care Commissioning Committee
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Action
referenceMeeting date Action Owner Deadline Update
PCCC111 31/10/2018
Strategic Estates Plan
Strategic Estates Plan approved by PCCC on 31.10.18 on an annual
review cycle S Collins 30.06.20
No annual update to the Newham SEP required. WEL SEP
development underway which will incorporate Integrated Care
System plans and be shared with PCCC when complete.
Item 1.4: 5 February 2020 Primary Care Commissioning Committee - Action Log Part I
Highlighted items represent a recommendation to remove from register
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Primary Care Commissioning Committee Part I meeting: 15.00-16.00 Wednesday 5 February 2020 FO21 Plaistow Room, 4th Floor Unex Tower, 5-7 Station Street, London E15 1DA
Title Update of Subcontracting of Primary Medical Services – The Project Surgery
Agenda item 1.5
Author Joseph Lee, Senior Transformation Manager, WEL CCGs
Presented by Joseph Lee, Senior Transformation Manager, WEL CCGs
Contact for further information
Joseph Lee, Senior Transformation Manager, WEL CCGs,
020 3688 2227
This paper is for ☐ Decision ☐ Monitor ☐ Discussion ☒ For Information
Action required The Committee is requested to note the contents of the report regarding The Project Surgery’s subcontracting of its core service delivery to MD International Limited, trading as Docly.
Executive summary
The Project Surgery comprises of a sole Personal Medical Services (PMS) contract holder. The practice is located in Plaistow with a registered population of 5,052 patients with a Good CQC rating.
The contract holder’s previous request to partially sub contract primary medical services provision to a third party provider due to maternity leave within the practice, was approved by the Committee on 30 October 2019 and an update requested at a future meeting.
The update provides high level data on the usage so far, including utilisation and waiting times, and the practice and patient experience of the service.
Supporting papers None
Next Steps/ Onward Reporting
No planned further presentation or reporting.
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Where has the paper been already presented?
Previously presented to Primary Care Committee on 30 October 2019
How does this fit with NHS Newham CCG strategic Priorities?
Strategic Priorities • To commission a Newham-based integrated health and care system which
delivers high quality services for the residents of Newham, in accordance withstatutory requirements
• To commission and develop GP services that are modern, accessible and fitfor the future in caring for our residents
Enabling Priorities • Ensuring we maintain our performance across the key business areas
Outcomes • We will improve access to, and, the quality of, Primary Care• We will clearly be able to demonstrate how we have improved outcomes for
our residents
Commissioning Priorities • To implement the five-year framework for GP contract reform to implement
The NHS Long Term Plan.
Risk BAF.05– Failure to effectively monitor the quality, performance and activity ofcommissioned services, with a focus on ensuring the delivery of better clinicaloutcomes.
BAF.07.01 Failure to effectively deliver a primary care strategy that isadequately resourced to service Newham residents
Equality impact There is no anticipated adverse impact to patients. The proposal enables an element of current service provision to be sub-contracted resulting in no loss of face to face access for patients. The approval enabled an increase in clinical capacity in the short term to negate negative impact for patients wishing to access the service.
Stakeholder engagement
Presented at Practice PPG in September 2019
Further patient engagement has been conducted upon roll out
Financial Implications
Newham CCG faces a significant financial challenge in 2019/20 and is undertaking a range of measures to ensure sustainability. This paper presents issues that may have financial consequences. These are yet to be fully determined but if not already embedded in budgets or reserve provision, a further Board decision would be required to release any additional expenditure commitment.
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1. Introduction and background
1.1
1.2
1.3
1.4
The Project Surgery has a registered patient population of 5,052 (as at 1 October 2019) and five GPs (headcount) delivering twenty one clinical sessions a week. The practice currently offers online consultations, telephone consultations and face-to-face appointments for its patients.
The practice contacted the CCG to request approval to sub-contract 20 clinical hours of its primary medical service provision, with effect from 1 November 2019, as a result of three Salaried GPs about to go on maternity leave.
The request was to subcontract to MD International Limited, trading as Docly, who are a CQC registered provider of digital consultations. This request was approved by Primary Care Commissioning Committee on 30 October 2020.
The approval was made with a request that an update be provided to the Committee regarding the usage of the service including patient and practice feedback.
2. Sub-Contracting Update
2.1
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
2.1.6
2.1.7
The sub-contracting of in hours services to Docly is delivered through an online consultation platform which requires patients to register and submit an online consultation form to be reviewed.
Whilst the practice did have access to the CCG’s commissioned online consultation platform, the need to subcontract the GP led review of these forms meant that Docly’s in house software had to be utilised.
The practice has reported that there was some initial hesitation from patients regarding the additional platform, however once they had signed up they seemed extremely happy with the service that they received.
To date the practice has had 367 patients register for the service and 240 consultations or cases submitted. Of these, 98% of patients have submitted only 1 case which would suggest that the platform is predominantly accessed by patients without complex co-morbidities or long term conditions.
The practice have not made the use of Docly mandatory within the practice and therefore traditional access routes and telephone triage remain available for patients.
In relation to patient feedback the service has collected 80 unique sets of patient data and reported that 86% of patients would recommend the service. The practice has reported one complaint has been received as a result of the service, as the patient wanted a face to face appointment prior to triage, this has since been resolved.
The practice has reported that 80% (192) of cases have been submitted in hours with 20% (48) submitted out of hours. The average response time is 2.7 hours and the median is 1 hour.
Of the 240 cases submitted, 24% (58) resulted in a face to face appointment being offered, with the remaining 182 being concluded remotely, freeing up clinical and administrative time. It should be noted that this is in line with previous evaluations that the CCG has conducted on commissioned online consultation products.
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2.1.8
In summary the practice are extremely satisfied with the additional capacity the service provides and the quality of the consultations provided by Docly.
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Primary Care Commissioning Committee Part I – 15:00 – 16:00 Wednesday 5 February 2020
FO21 Plaistow Room, Unex Tower, Station Street, London E15 1DA
Title Primary Care Network Draft Enhanced Service Specifications
Agenda item 1.6
Author Leilla Shaikh, WEL CCGs, Deputy Director of Primary Care (Interim)
Presented by Leilla Shaikh, WEL CCGs, Deputy Director of Primary Care (Interim)
Contact for further information
Leilla Shaikh, WEL CCGs, Deputy Director of Primary Care (Interim)
E: [email protected] / T: 020-3688-2334
This paper is for ☐ Decision ☐ Monitor ☐ Discussion x For Information
Action required The Committee is asked to note the response from WEL CCGs to the draft Primary Care Network Directed Enhanced Service Specifications published in December for consultation.
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Executive summary
The report asks the Committee to note the joint response from WEL CCGs, based on feedback from commissioners, local authorities and General Practice colleagues on the draft Primary Care Network Direct Enhanced Service Specifications.
WEL CCGs welcomed the opportunity to give feedback on the specifications, in order to ensure that the final versions would support local initiatives and need.
Supporting papers Appendix A: Draft PCN DES Specifications
Next Steps/ Onward Reporting
Await publication of the final specifications from NHSE
Where has the paper been already
presented?
An overview of the draft specifications was shared at the NEL Primary CareCommissioning Committees in Common
NHSE have hosted webinars to encourage discussion and feedback on thedraft specifications
How does this fit with NHS Newham
CCG strategic Priorities?
Strategic Priorities
• To commission a Newham-based integrated health and care system whichdelivers high quality services for the residents of Newham, in accordance withstatutory requirements
• To commission and develop GP services that are modern, accessible and fitfor the future in caring for our residents
7 Outcomes
• We will have a borough based Integrated Care System that is utilised,understood and valued by our residents
• We will ensure we plan, design, and commission accessible high qualityservices for our residents with our residents
• We will improve access to, and, the quality of, Primary Care• We will clearly be able to demonstrate how we have improved outcomes for
our residents• We will support our entire CCG workforce to deliver what we need to for our
residents• We will promote equality as a commissioner of health services and as an
employer
Risk Failure of NHSE to secure sign up to the new specifications could slow thedevelopment of PCNs
Equality impact This report relates to all Newham residents in the ten protected characteristics that are covered by the Equality Act 2010 and our Equality Duties.
Stakeholder engagement
NHSE have carried out extensive engagement through webinars and social media. Locally we have encouraged stakeholders (General Practice, Local Authorities,
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Community Services) to share feedback to contribute to the joint response.
Financial Implications
Directed Enhanced Services are commissioned and funded by NHS England, so there are no local financial implications. However resource from local teams will be needed to support implementation of the services.
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1. Introduction and background
1.1
1.2
The GP contract framework sets out seven national services specifications that will be added to the Network DES. Draft outline requirements, including proposed network dashboard metrics, for the first five services have now been made available to enable opportunities for stakeholders to review and comment.
The deadline for comments was 15 January 2020. This report gives a brief overview of the specifications, and the response from WEL CCGs to the draft specifications. The final version of the specifications will be published in early 2020 as part of the wider GP contract package for 2020/21. The final versions will include further detail for each requirement, followed by guidance for implementation.
2.
2.1
2.1.1
2.1.2
2.1.3
2.2
2.2.1
Draft PCN DES Specifications
The five national PCN specifications, which will be implemented in a phased approach between 20/21 and 23/24 are:
Structured medication review and optimizations
Enhanced Care in Care Homes
Anticipatory Care
Personalised Care
Early Cancer Diagnosis
Funding has not been allocated directly for delivery of these service specifications. PCNs are expected to use the additional workforce from the roles reimbursement scheme, and additional clinical leadership from GPs to deliver these schemes. CCGs and ICSs will be asked to support PCNs and their community providers to institute shared workforce models to help maximise collaboration.
It is recognised that, for some of the specifications, a locally commissioned service may already exist which covers some or all of the proposed requirements set out in the document. As these proposals are in draft, CCGs are advised that they should not, therefore, take final decisions about existing locally commissioned services until the final Network Contract DES for 2020/21 is published.
Our feedback to NHSE is detailed below.
Clinical Leadership
Across the WEL CCGs, significant work has taken place in partnership with key stakeholders to develop our system plans to improve outcomes relating to care homes, anticipatory care, personalised care, cancer and medicines optimisation. Borough based plans are clinically led, factor local need, as well as system resource and capacity. Any new specifications should encourage PCNs to work as part of their local system to develop the requirements, and to use the existing leadership and management infrastructure in place to support local service and development. PCNs should not be mandated to nominate additional clinical leadership time, as this reduces the amount of time available for patient care.
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2.2.2
2.2.3
2.2.4
2.2.5
Population Health
There are significant variations in population demographics across WEL CCGs. PCNs with a higher number of complex patients cannot be expected to deliver the same outcomes with the same resource as those with a lower number of patients requiring anticipatory care. If the specifications are to address population health inequality, this needs to be factored into the resource. In our experience of commission MDTs, PCNs need flexibility in identifying patient groups that would most benefit from anticipatory care based on their demographics. For example where a PCN has a high proportion of children they may want to develop anticipatory care plans and MDTs linked to the needs of this patient group. PCNs across a borough or ICS should be encouraged to utilise the same tools so that data and information can be shared to support collaboration and sharing of best practice.
Workforce
If the only resource available to deliver the service specifications is the additional roles reimbursement scheme, the expected workload should only relate to this workforce. The specifications need to factor that the workforce will not be in post for a full financial year and needs to consider gaps for any delays in recruitment or staff being on leave. There is also no allowance for London weighting in the roles. From our experience in year one of the PCN DES the majority of staff recruited into the roles reimbursement scheme have little or no experience in primary care. The expectation of any specifications to be delivered by the roles reimbursement scheme, needs to reflect the capability of the skill mix. Should we wish to develop these new roles and sustain them, there needs to be training schemes available to staff. The training hub matrix mentions workforce planning, but this needs to happen at PCN level to make the most of the existing resource and to plan how best to utilise additional staff. There are no easy tools to support workforce and skillmix planning in primary care, without understand current capability it is difficult to plan future need. We need to create an environment where PCNs are not competing with each other or community providers for the same workforce, the approach should support collaboration. For example as well as PCN pharmacists carrying out medicines reviews, other pharmacists working in the community could also provide this service. HEE should ensure that funding to training hubs supports the development of the PCN workforce to deliver national specifications and local need.
Implementation
The maturity matrix sets out a developmental journey for PCNs and their Clinical Directors over the next few years. Many PCNs are just starting to understand how they can work together and with the system. Implementation of the new specifications will require further changes to ways of working for General Practice, and potentially changing the roles for new staff employed. There will be local initiatives and schemes in place that complement or overlap the proposed specifications, commissioners need to have the opportunity to engage with LMCs, PCNs and other stakeholders on the best approach based on local population need and current provision.
Structured Medications Review
In order to support a patient-centred approach that covers all patient groups and multi-
morbidities, we recommend that the spec includes the following points as recommended by
NICE:
People of any age with multi-morbidity conditions
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2.2.6
2.2.7
People prescribed fewer than 10 regular medicines but are at particular risk ofadverse events
The specification should also include a requirement for a referral pathway to PCNs from
health and social care professionals for SMRs for patients identified as needing one. There
also needs to be a consideration of domiciliary SMRs for housebound patients. Reference
needs to be made that the Structured Medication Reviews (SMR) and Enhanced Health Care
Home (EHCH) must to be integrated with other Medicines Optimisation and Pharmacy
services across health economies including CCGs Medicines Optimisation teams, Community
and Hospital Pharmacy and Local Authority Social Care services (e.g. medicines
administration support is provided through care workers). The outcome of the interventions
must be effectively communicated to Community Pharmacists and other healthcare
professionals in a timely manner.
Care Homes
Patient choice applies to residents of care homes, and should patients need to register with particular PCNs, the impact on choice would need to be considered. Residential and nursing homes are not spread out proportionately across our 3 boroughs. PCNs with a higher number of care homes would need to allocate a disproportionate amount of time to these patients in comparison to the rest of the registered list. Also some residential homes have a very small number of beds, so when planning the resource allocated to care homes, this needs to be a factor.
NHSE have acknowledged our feedback.
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Appendix 1
Network Contract Direct
Enhanced Service Draft Outline Service Specifications
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NHS England and NHS Improvement
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Version number: 1
First published: December 2019
Updated: NA
Prepared by: Primary Care Strategy and NHS Contracts Team [email protected]
Classification: Official - Draft
Publishing Approval Reference: 001238
1 19
Contents
Contents ..................................................................................................................... 2
1. Introduction .......................................................................................................... 3
2. Structured Medication Review and Medicines Optimisation ................................ 9
3. Enhanced Health in Care Homes ...................................................................... 14
4. Anticipatory Care ............................................................................................... 22
5. Personalised Care ............................................................................................. 29
6. Supporting Early Cancer Diagnosis ................................................................... 35
2 20
1. Introduction
1.1. In January 2019, NHS England and GPC England agreed Investment and
Evolution: a five-year GP contract framework which aimed to alleviate the workforce
pressures on general practice, secure enhanced investment into primary medical care,
and roll out new service models – in collaboration with community services and other
providers – to secure major improvements in proactive and preventative care for patients.
The GP contract framework, launched in January 2019, commits £978m of additional
funding through the core practice contract and £1.799bn through a new Network Contract
Direct Enhanced Service (DES) by 2023/24, as part of our wider commitment that, on
current plans, funding for primary medical and community services will increase faster
than the rest of the rising NHS budget over the next five years. By 2023/24 spending on
these services will rise by over £4.5 billion in real terms – £7.1 billion in additional
cash investment each year by the end of the period.
1.2. A cornerstone of the new GP contract framework is the creation of
primary care networks (PCNs) through the new Network Contract DES. A PCN
consists of groups of general practices working together with a range of local providers –
including across primary care, community services, social care and the voluntary sector –
offering more personalised, coordinated care to their local populations. There has been
an enthusiastic response to PCNs across the country: over 99% of practices have signed
up to participating in around 1,250 networks, firmly establishing PCNs as a route to
greater collaboration across general practice and the wider NHS.
1.3. The GP contract framework set out seven national services specifications that
will be added to the Network Contract DES: five starting from April 2020, and a further
two from April 2021. The purpose of this document is to provide
PCNs, community services providers, wider system partners and the public with
further detail of – and seek views on – the draft outline requirements for the first
five services, as well as how we plan to phase and support implementation.
Feedback we receive will shape the final version of the service requirements for
2019/20, as well as guidance for implementation. The five services are:
• Structured Medication Reviews and Optimisation • Enhanced Health in Care Homes (jointly with community
services providers) • Anticipatory Care (jointly with community services providers) • Personalised Care; and • Supporting Early Cancer Diagnosis
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1.4. We recognise that PCNs are at the early stages of development and
capacity-building, and that there are concerns about limiting their chances of
success by overburdening them at an early stage with unrealistic expectations for
new service delivery. We therefore propose to phase-in service requirements in a
way that is commensurate with the capacity available to PCNs through the contract
and the support available through wider system. Though a combination of the
additional workforce capacity within primary care, and the redesign of community
services provision to link with and support PCNs, we expect the Network Contract
DES both to reduce workload pressures on GPs and support improved
primary care services to patients.
1.5. The new PCN service specifications are only one part of the wider GP
Contract package. No decisions will be made on individual aspects of the
Network DES and the core Practice Contract without considering all aspects in the
round.
Developing the outline service specifications
1.6 NHS England and NHS Improvement (NHSE/I) has undertaken a wide-ranging process of evidence-gathering and engagement in order to inform these outline service specifications. This has included convening expert working groups for each of the five specifications, with representation from patients, working GPs and other clinicians, voluntary sector organisations (such as Cancer Research UK, Macmillan, and Age UK), NHS Providers Community Network, Local Government Association, commissioners, Royal College of General Practitioners, Public Health England and the British Medical Association. The input from these groups has been invaluable in shaping these proposals.
1.7 As a result of our engagement to date, we are confident that these specifications
are supported by a strong clinical evidence base and will enable PCNs to draw upon
the partnerships with other providers that are at the
heart of the network philosophy. The service requirements set out in the
specifications focus on interventions and cohorts where there is
significant scope to improve outcomes and people’s health and wellbeing.
1.8 The outline service specifications also illustrate the proposed metrics which –
through a new Network Dashboard – will enable PCNs to understand their own
position and support peer learning and quality improvement.
1.9 NHSE/I will continue to develop and refine the proposals in discussion with
GPC England on behalf of general practice through the annual GP contract
negotiations, and in response to feedback from patients, clinicians and
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organisations with an interest in primary care and the subject areas of the
specifications. The final version of the specifications will be published in early
2020 as part of the wider GP contract package for 2020/21. The final versions
will include further detail for each requirement, followed by guidance, to
support PCNs and other providers to deliver the requirements as effectively as
possible.
1.10 NHSE/I will continue to consider the opportunities and risks arising from these
specifications (and primary care networks more broadly) in relation to health
inequalities.
Funding and Additional Roles
1.11 The Network Contract DES provides funding entitlements worth £552m in
2020/21, rising to £1.799bn by 2023/24. This comes on top of increases to the core
practice contract worth £296m in 2020/21, rising to £978m in 2023/24.
Funding is not allocated directly for delivery of the service specifications; rather,
the largest portion of network funding (£257m in 2020/21, rising to £891m in 2023/24)
provides reimbursement for additional workforce roles that PCNs can engage to support
the delivery of the specifications and alleviate wider workforce pressures. This funding
enables the deployment of over 6,000 additional staff by 2020/21, rising to over 20,000
by 2023/24. For a PCN covering a population of 50,000 people, that could equate to
around five additional staff in 2020/21 and around 16 additional staff by 2023/24. This
represents a major uplift in the workforce capacity within primary care.
1.12 Providing that PCNs move forward swiftly to engage new staff and use their
additional roles reimbursement entitlement, there will be significant additional
capacity within primary care in 2020/21 to deliver the specifications.
Recruitment decisions by PCNs will depend on their priorities but an average PCN
could – indicatively – engage around 3 WTE clinical pharmacists, 1.5 WTE social
prescribing link workers, 0.5 WTE physiotherapists and 0.5 WTE physician
associates from April 2020. This would provide more than sufficient capacity
to deliver the requirements across all five services with significant capacity
remaining for these additional roles to provide wider support to GP
workforce pressures by handling appointments or queries that would otherwise
have been the responsibly of the GP.
1.13 We will be asking CCGs and ICSs to support PCNs and their community
providers to institute shared workforce models that can help maximise the
collaboration between local partners to deliver the specifications and build the
wider PCN.
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1.14 In addition to the funding for additional workforce roles, a typical practice within
a PCN will receive funding of £14,000 for participating in a PCN through their PCN
participation payment. Each PCN is guaranteed a cash payment of £1.50 per
registered patient and 0.25 FTE funding to support its Clinical Director.
Taken together, this provides over £109,000 for a PCN covering 50,000
people.
1.15 Other funding is available to PCNs through the contract agreement, for
example through their share of the Investment and Impact Fund (IIF) where they
make strong progress in delivering the service specifications. The IIF is worth
£75m in 2020/21, rising to £300m in 2023/24. An average PCN could secure
funding of c.£60,000 in 2020/21, rising to an additional c.£240,000 by 2023/24.
1.16 Alongside PCNs, community services providers will also see significant
funding increases over the next five years and, under our proposals, will take
a significant role in co-delivery in two of the service specs for Enhanced
Health in Care Homes and Anticipatory Care (via the proposed NHS Standard
Contract) – enabling the development of an integrated multidisciplinary team to take
forward the requirements in the outline specifications as a shared endeavour across
different partners. Consultation on the NHS Standard Contract will take place
December 2019 – January 2020.
Phasing of service requirements
1.17 NHSE/I is proposing to phase in the requirements over time in order to
ensure that they are deliverable as PCN workforce capacity grows, and as the
wider system infrastructure develops to support them. This means:
• implementing the requirements of two of the five specifications
(Structured Medication Reviews and Optimisation, Enhanced Health in Care
Homes) in full from 2020/21, as agreed in the GP contract framework; and
• phasing in the requirements of the Anticipatory Care, Personalised
Care and Early Cancer Diagnosis specifications over the period from 2020/21 to
2023/24. For these specifications, we have set out a headline trajectory for the
requirements over the next four years, with the detail subject to further annual
contract negotiations between NHSE/I and GPC England.
1.18 There are also significant overlaps between the requirements of the
specifications, as well as with other elements of the wider GP contract
package:
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• A significant proportion of the individuals who we propose should benefit
from a structured medication review will be care home residents for many PCNs.
• Delivery of the requirements in the Early Cancer Diagnosis specification
will support practices’ completion of the relevant Quality Improvement (QI) module
of the 2020/21 Quality and Outcomes Framework (QOF). Similarly, efforts made by
practices and networks to fulfil the Prescribing Safety QI module in 2019/20 will
facilitate their ability to meet the elements of the structured medication review and
optimisation specification.
Support from the wider system
1.19 The establishment of PCNs will improve the links between providers of
primary and community services, so that general practice feels much more
connected and supported by the wider NHS system. CCGs will be required to
play a major role in helping to co-ordinate and support delivery of the specifications,
in particular those that involve close collaboration with other partners such as the
care homes specification. CCGs will also support PCNs to develop standard
operating processes for their partnership, and ensure a clear and agreed
contribution to service delivery is made by other system partners within Integrated
Care Systems (ICSs) – documented in a local agreement. We will recommend that
the Local Medical Committee should be involved in the development of the local
agreement.
1.20 Where the outline specifications contain requirements for community services
providers, we intend to incorporate these into the NHS Standard Contact from
2020/21 to ensure they are taken forward everywhere in a reliable way.
1.21 In addition, where PCNs are struggling to recruit, CCGs and systems
should take action to support them. This may include, for example:
• running shared recruitment processes across multiple PCNs, or
supporting PCNs to carry out collaborative recruitment; potentially providing
management support to PCNs to help them run recruitment processes;
• brokering integrated workforce arrangements with other providers,
for example through rotational posts; and
• working with local representative groups and other stakeholders
to match people to unfilled roles.
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Relationship with existing locally commissioned services
1.22 We recognise that, for some of the specifications, a locally commissioned
service may already exist which covers some or all of the proposed requirements
set out in this document. These proposals are in draft: Clinical
Commissioning Groups (CCGs) should not, therefore, take final decisions
about existing locally commissioned services until the final Network Contract
DES for 2020/21 is published.
1.23 Once these specifications have been finalised, CCGs should work with
PCNs, community services providers, Local Medical Committees (LMCs), and
other stakeholders to support the transition – and, where required,
enhancement – of existing local service arrangements to meet the new
requirements whilst avoiding the unwarranted destabilisation of existing provision.
We would expect CCGs to make an assessment of any investment that they
continue to make in these areas, recognising that particularly as the expectations of
the specifications rise up to 2023/24, it may in the meantime be appropriate for them
to maintain delivery of a service where it currently exceeds the national requirements
for 2020/21.
1.24 Funding previously invested by CCGs in local service provision which is
delivered through national specifications in 2020/21 should be reinvested
within primary medical care and community services in order to deliver the
£4.5bn additional funding guarantee for these services. NHSE/I will be
collecting data on current spend and discussing how to ensure that the transition to
the national specification is manageable and affordable. Further requirements in
this respect will be set out at the conclusion of the GP contract negotiations for
2020/21.
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2. Structured Medication Review and Medicines Optimisation
Introduction
2.1 Structured Medication Reviews (SMRs) are a NICE approved clinical
intervention that help people who have complex or problematic polypharmacy1. SMRs
are designed to be a comprehensive and clinical review of a patient’s medicines and
detailed aspects of their health and are delivered by facilitating shared decision making
conversations with patients aimed at ensuring that their medication is working well for
them.
2.2 Evidence shows that people with long term conditions using multiple medicines
have better clinical and personal outcomes following an SMR.2 Timely application of
SMRs to individuals most at risk from problematic polypharmacy will support a reduction
in hospital admissions caused by medicines related harm in primary care. It is estimated
that £400 million is wasted in unnecessary medicines related harm admissions to
hospital annually.3
2.3 Most prescribing takes place in primary care. Through the increased
collaboration brought about by the establishment of PCNs, there is a significant
opportunity to support the meeting of international commitments on anti-microbial
prescribing. Undertaking SMRs in primary care will result in a reduction in the number of
people who are over-prescribed medication, reducing the risk of an adverse drug
reaction, hospitalisation or addiction to prescription medicines. Better prescribing will also
ensure better value for money for the NHS, reduce waste and improve its environmental
sustainability, for example by reducing the use of short acting beta agonist inhalers
(SABA) and switching to low carbon alternative inhalers.
Existing provision and available support for PCNs
2.4 Since 2015, NHS England has funded two pilot schemes to support the
establishment of Clinical Pharmacists working in general practice. Significant progress
in medicines optimisation has already been made across the country in using the skills
of these individuals, and the service requirements to undertake SMRs will be more
achievable as a result.
1 Problematic polypharmacy arises when multiple medicines are prescribed inappropriately, or when the intended benefit of the medicines are not realised or appropriately monitored, potentially due to clinical complexity or clinical capacity.
2 NICE Guideline 5 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, 2015
3 Medicines related harm in older adults, Pharmaceutical Journal: https://www.pharmaceutical-journal.com/news-and-analysis/news/medication-related-harm-in-older-adults-costs-the-nhs-400m-each-year-study-finds/20204894.article?firstPass=false
9 27
2.5 The additional roles reimbursement scheme introduced as part of the Network
Contract DES in 2019 has made funding available for Clinical Pharmacists to be
recruited in all PCNs from April 2019, building upon the existing base from the
earlier pilots. This workforce will be key in delivering SMRs, and given this degree
of existing capacity and expertise, we believe it is reasonable to expect the new
national SMR service requirements to be delivered in full from April 2020.
2.6 It is expected that a number of GP appointments may be prevented when
individuals have a proactive SMR: supporting the alleviation of workforce pressures
on GPs and reducing the risk of harm to patients – an evaluation will be
commissioned in year one.
Proposed Service Model
2.7 We propose that PCNs identify people who would benefit most from receiving
an SMR. The following groups have been identified as being most likely to benefit
from an SMR:
• all patients in care homes as per the Enhanced Health in Care Home
specification;
• patients with complex and problematic polypharmacy, specifically those on
10 or more medications;
• patients who are being prescribed medicines that are commonly and
consistently associated with medication errors;
• patients with multiple long-term conditions and/or multiple comorbidities –
in particular respiratory disease and cardiovascular disease;
• housebound, isolated patients and those with frailty – particularly patients
who have had recent admissions to hospital and/or falls;
• patients who have received a comprehensive geriatric assessment as
per the anticipatory care requirements; • patients with severe frailty; and • patients prescribed high numbers of addictive pain management
medication.
2.8 A variety of tools have been developed to help clinicians to identify patients with
complex and problematic polypharmacy with multi-morbidity, including PINCER,
EPACT2, Openprescribing and Eclipse Live. PCNs can select appropriate tools that
help them to proactively identify patients from the cohorts outlined above through
audit of GP IT systems. Guidance will be published to support PCNs in the
identification of patients, including a guide to the selection of these tools.
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2.9 We propose that PCNs also develop processes for identifying patients who
need to be referred for an SMR reactively. PCNs must consider guidance
concerning reactive referrals.
2.10 PCNs must ensure that only appropriately trained clinicians working within their
sphere of competence should undertake SMRs. These professionals will need to
have a prescribing qualification and advanced assessment and history taking skills –
or be enrolled in a current training pathway to develop these skills – and must be
able to take a holistic view of a patient’s medication. This could include:
• Clinical Pharmacists • General Practitioners • Advanced Nurse Practitioners
2.11 We expect that undertaking a SMR would take considerably longer than an
average GP appointment, although the exact length should vary. PCNs should allow
for flexibility in appointment length for SMRs depending on the level of complexity
presenting with individual cases. Clinicians should conduct SMRs in line with the
principles of shared decision making, and consider the holistic needs of the patient,
providing advice, signposting and making onward referrals where relevant, including
new responsibilities to signpost to healthy living pharmacies.4
2.12 SMRs should be an ongoing process in which an individual appointment or
discussion constitutes an episode of care. Regular review and management
should be undertaken and SMRs should not be treated as a one-off exercise.
2.13 As part of our commitment to a more sustainable NHS, SMRs should also
support patients to switch to low carbon inhalers, where clinically appropriate.
2.14 Further guidance will be issued on processes to undertake an SMR, built from
NICE guidance, the Scottish Polypharmacy model and evidenced best practice.
Proposed service requirements for 2020/21
2.15 From April 2020, practices working as part of PCNs will:
• identify a clinical lead who will be responsible across the PCN for the
delivery of the service requirements in this section.
4 Community pharmacy contractors will be required to become an HLP Level 1 by 1st April 2020 as agreed in the five-year deal between PSNC, NHS England and NHS Improvement and the Department of Health and Social Care; this reflects the priority attached to public health and prevention work. https://psnc.org.uk/services-commissioning/locally-commissioned-services/healthy-living-pharmacies/
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• run locally-defined processes at least twice yearly, on a six-monthly basis, to
identify the patients within the practice-registered population that require SMRs.
This must include consideration of patients within the cohorts described in
paragraph 2.7.
• develop local processes for reactive SMR referrals, adhering to
published guidance;
• provide written communication to patients invited for an SMR, detailing
the process and intention of the appointment;
• offer SMRs to 100% of identified patients, except in exceptional
circumstances where the commissioner agrees that proven capacity constraints
(where the PCN had demonstrated all reasonable attempts to ensure capacity
had been undertaken) would justify a lower proportion of identified patients to
be offered a SMR;
• undertake SMRs and follow-up consultations in line with detailed guidance.
CCGs will review variation in the numbers of SMRs undertaken, which will inform
the potential development of a standardised requirement in future years;
• use appropriate clinical decision-making tools to support the delivery
of SMRs, examples of which will be provided through guidance;
• clearly record all SMRs within GPIT systems, as well as using appropriate
clinical codes to signify the reasons for an SMR;
• develop local PCN action plans to reduce inappropriate prescribing of (a)
antimicrobial medicines, (b) medicines which can cause dependency, and (c)
nationally identified medicines of low priority. This plan will react to guidance
specifying how the PCN will deliver against the guidance;
• work with community pharmacies locally to ensure alignment with delivery of
both the New Medicines Service (to support adherence to newly-prescribed
medicines) and developing medicines reconciliation services (to support effective
transfers of care between hospital and community);
• ensure delivery of SMRs and medication optimisation aligns to the work of
medicines optimisation teams within CCGs local to the PCN.
Proposed Metrics
2.16 Proposed metrics to monitor the success of the service are set out below:
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Metric description
1. The number of individual SMR episodes undertaken, including:
• The number of SMR processes undertaken (number of
individual patients given one or more SMR appointment)
• The number of SMR follow-up appointments
2. Outcome measurement to monitor impact of SMR
3. Prescribing rate of nationally identified medicines of low value that
should not be routinely prescribed
4. Prescribing rate of low carbon inhalers
5. Prescribing rate of medicines that can cause dependency
6. Prescribing rate of anti-microbial medication
2.17 Reducing unwarranted prescribing spend in particular areas is likely to be one
early focus of the Investment and Impact Fund, with progress expected to be
measured against baseline levels of performance in 2019/20.
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3. Enhanced Health in Care Homes
Introduction
3.1 One in seven people aged 85 or over permanently live in a care home. People
living in care homes account for 185,000 emergency admissions each year and 1.46
million emergency bed days, with 35-40% of emergency admissions being potentially
avoidable5. Evidence suggests that many people living in care homes are not having
their needs assessed and addressed as well as they could be, often resulting in
unnecessary, unplanned and avoidable admissions to hospital and sub-optimal
medication regimes.
3.2 People living in care homes should expect the same level of support as if they
were living in their own home. This can only be achieved through collaborative working
between health, social care, the voluntary sector and care home partners.
3.3 In 2016, the New Care Models programme developed and tested the Enhanced
Health in Care Homes (EHCH) Framework6 to improve health and care provision for
people living in care homes. In implementing the EHCH service, local areas showed how
to improve services and outcomes for people living in care homes and those who require
support to live independently in the community7.
3.4 Given the efficacy of the model, the Long-Term Plan and GP Contract
Framework made a commitment to implementing the clinical elements of EHCH
nationally during 2020/21. Implementation of the EHCH service is a national priority for
primary and community care-based service integration, and we will be expecting all
ICSs/STPs and CCGs to prioritise supporting full and successful delivery.
Existing provision and available support for PCNs
3.5 There is evidence of substantial existing enhanced primary and community
provision to residential and nursing homes. Data collected from CCGs for 2018/19
suggests that there is already significant local spend on such services. In combination
with additional support described below, we believe that this existing capacity and
expertise will enable implementation of this specification at a faster pace than other
services.
5 https://www.longtermplan.nhs.uk/online-version/chapter-1-a-new-service-model-for-the-21st-century/1-we-will-boost-out-of-hospital-care-and-finally-dissolve-the-historic-divide-between-primary-and-community-health-services/#ref 6 https://www.england.nhs.uk/wp-content/uploads/2016/09/ehch-framework-v2.pdf 7 https://www.health.org.uk/publications/reports/emergency-admissions-to-hospital-from-care-homes
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3.6 We have drawn on evidence from these service models as well as evaluations
of the New Care Models to design the service requirements below, and to inform
forthcoming guidance for implementation, which will include advice on collaborative
service redesign with other providers such as community services.
3.7 Delivery of this specification must happen in partnership between general
practice and community services. The proposed Standard Contract requirements will
ensure a contractual basis for the requirements attributable to community service
providers, and CCGs will oversee local agreements between providers within a PCN
to ensure that primary and community care are supported in delivery by relevant
partners being held to account.
3.8 We anticipate CCGs will also support delivery of this service by holding a list of
care homes in the area and agreeing the responsibilities of PCNs in relation to each
home, including making sure that each care home is aligned to a single PCN. An
approach to the reinvestment in primary care of existing expenditure by CCGs in
this area of work and the potential for uneven distribution of care homes between
PCNs will be discussed as part of contract negotiations. CCGs can also support
improved joint working between PCNs and social care their established
relationships with social care commissioners in local authorities.
3.9 We acknowledge that the geographical distribution of care homes means that
PCNs will be affected differently by the service requirements in this specification.
We are considering this issue further, alongside the potential economies of scale
provided by the opportunity to provide enhanced support to care homes at a
network level rather than through individual practices.
Proposed Service Model
3.10 The EHCH service will focus on national roll out of the first four clinical
elements of the EHCH framework: enhanced primary care support;
multidisciplinary team support; reablement and rehabilitation; and high-quality end-
of-life care and dementia care. The service requirements are shared across both
PCNs and other providers (particularly community services) who will work together
to deliver the model.
3.11 In implementing this model nationally, we expect to:
• Improve the experience, quality and safety of care for people living in
care homes, their families and their carers;
• Reduce avoidable ambulance journeys, A&E attendances and
emergency admissions to hospital for people living care home residents;
15 33
• Improve sub-optimal medication regimes in care homes; and
• Support more people living in care homes to die in a place of their
choosing.
3.12 Given the significant progress already made across the country in implementing
these model elements, we expect this service to be delivered, in full, during 2020/21.
In future years we will consider whether and how to bring out of hours provision
under the authority of PCNs, to ensure more effective and coordinated out of hours
support for care homes.
In scope population
3.13 All people who live permanently in care homes (both residential and nursing)
are eligible for the service. This includes people living in residential and nursing
homes that deliver specialist support (such as specialist learning disability and
dementia units) but does not include people living in secure units for mental health.
3.14 Supported living environments and extra care facilities are not currently in
scope for this service but may be covered by other services to be delivered
through the network contract DES, including anticipatory care, medications
reviews and personalised care.
3.15 For the purposes of this document, the term ‘care home’ encompasses all types
noted above.
Proposed service requirements:
3.16 During 2020/21, practices working as part of PCNs and working with providers
of community services, will:
Practices, working as part of PCNs Other providers of community
services, including mental health
1 By 30 June 2020, identify a clinical
lead who will be responsible across
the PCN for the delivery of the
service requirements in this section.
2 From no later than 30 June 2020, Work alongside PCNs and care
ensure every person living homes to ensure delivery of the
permanently in a care home has a multidisciplinary elements of the
named clinical team, including staff service model described below
from the PCN and relevant providers
16 34
of community services, who are
accountable for the care delivered
through the EHCH model.
3 From no later than 30 June 2020,
ensure every care home is aligned to
a single PCN, and its multidisciplinary
team (MDT), which is responsible for
supporting that care home and
delivering the EHCH service for
people living in that home that are
already registered with a practice in
the PCN or choose to register with a
practice in the PCN.
By 30 June 2020 each PCN will
agree the care homes for which it has
responsibility with its CCG. People
entering the care home should be
supported to re-register with the
aligned PCN and have the benefits of
doing so clearly explained.
Where people choose not to register
with a practice in the aligned PCN,
requirements 4-9 below should be
delivered by their registered practice,
either directly or through local sub-
contracting arrangements.
4 From no later than 30 June 2020, By no later than 30 June 2020, co-
establish and manage a design with the PCN, and thereafter
multidisciplinary team (MDT) of participate in, a multidisciplinary team
professionals, working across (MDT) of professionals, to work in
organisational boundaries to develop close collaboration with care homes
and monitor personalised care and to develop and monitor personalised
support plans, and the support offers care and support plans.
defined in them, for people living in
care homes. Attend MDT meetings and manage
delivery of the MDT if agreed locally.
5 From no later than 30 June 2020, From no later than 30 June 2020,
establish protocols between the care support the establishment of
home and wider system partners for protocols between the care home
information sharing and shared care and wider system partners for
planning, use of shared care records information sharing and shared care
planning, use of shared care records
17 35
and clear clinical governance and and clear clinical governance and
accountability accountability.
6 From no later than 30 September From no later than 30 September
2020, deliver a weekly, in person, 2020, deliver, participate in or
‘home round’ for their registered prepare for home rounds as agreed
patients in the care home(s). The with the PCN and provide initial triage
home round must: of people living in care homes who
have been flagged for review.
• be led by a suitable clinician. On
at least a fortnightly basis this
must be a GP. With local
agreement the GP can be
substituted by a community
geriatrician.
• involve a consistent group of staff
from the MDT.
• focus on people identified for
review by the care home, those
with the most acute and
escalating needs or those who
may require palliative or end-of-
life care.
7 From no later than 30 September From no later than 30 September
2020, own, and coordinate delivery 2020, deliver, as determined by the
of, a personalised care and support MDT, elements of holistic
plan with people living in care homes assessment for people in care homes
based on relevant assessments of across five domains; physical,
needs and drawing on assessments psychological, functional, social and
that have already taken place where environmental, drawing on existing
possible and: assessments that have taken place
where possible.
• ensure that this plan is developed
and agreed with each new Provide input to the person’s care
resident within seven days of and support plan within seven
admission to the home, and within working days of admission to the
seven days of readmission home, and within seven working days
following a hospital episode. of readmission following a hospital
Review the plan when clinically episode.
appropriate and refresh it at least
annually;
18 36
• ensure the plan is developed with Deliver palliative and end of life care,
the person or/or their carer, and as required, to care home residents
reflects their personal goals; 24 hours a day.
• ensure the plan is tailored to the
person’s particular needs (for
example if they are living with
dementia) and circumstances
(such as those people
approaching the end of their life).
8 From no later than 30 September From no later than 30 September
2020, coordinate, alongside 2020, provide one-off or regular
community providers, one-off or support to people within care homes
regular support to people within care based on the needs defined in the
homes, based on the needs defined personalised care and support plan
in the personalised care and support and those identified by care home
plan and those identified by care staff.
home staff.
This support must include, but is not
Directly deliver or support delivery of limited to:
elements of this support where
appropriate, including: • community nursing
• tissue viability
• structured medication reviews • falls prevention, advice and
(SMRs), delivered according to strength and balance training
the requirements of the SMR • oral health
specification. • speech and language therapy
• activities to support the
including dysphagia assessment
and support
achievement of goals identified as • dietetics
important to the person in their • hydration and nutrition supportpersonalised care and support • continence assessment and careplan, including reasonable efforts (urinary and faecal) to build links with local
• psychological therapies e.g. viaorganisations outside of the
IAPT services or local older home.
people’s mental health services
• cognitive stimulation or
rehabilitation therapy and
reminiscence therapy for people
with dementia
9 From no later than 30 September From no later than 30 September
2020, provide, through the MDT, 2020, support the identification and
identification and assessment of
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eligibility for urgent community assessment of eligibility for urgent
response services community response services and:
• deliver urgent community
response services (which include
provision of crisis response within
two hours and reablement within
two days of referral);
• deliver specialist mental health
support in cases of mental health
crises and challenging
behavioural and psychological
symptoms of dementia
Where the above would help a
person to remain safely and recover
in their care home as an alternative
to hospital admission or to support
timely hospital discharge.
10 Provide support and assistance to Make opportunities for training and
the care home by: shared learning available to care
home staff, drawing on existing
• supporting the professional continued professional development
development of care home staff programmes for staff working in
by identifying opportunities for community services.
training and shared learning;
• working with the care home and
wider system partners to address
challenges the home is facing in
coordination with the wider health
and care system;
• delivering relevant vaccinations
for care home staff, in line with
the provisions set out in the
seasonal influenza DES.
11 From no later than 30 September From no later than 30 September
2020, working with the CCG to 2020, support the development and
establish processes that improve delivery of transfer of care schemes.
efficient transfer of clinical care
between residential homes, nursing
homes and hospices and between
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care homes and hospitals, as
described by NICE guidance89.
Facilitate and support local and
national initiatives to support
discharge from hospital and
psychiatric inpatient units, such as
trusted assessor schemes.
12 From no later than 30 September From no later than 30 September
2020, establish clear referral routes 2020, support the development of
and information sharing clear referral routes and information
arrangements between care homes, sharing arrangements between the
PCNs and out of hours providers and care home and other providers.
providers of a full range of
community-based services including
specialist mental health, dietetic,
speech & language therapy, palliative
care and dementia care.
Proposed Metrics
3.17 Potential metrics to monitor the success of the service include, but are not
limited to:
Metric description
1. The rate of emergency admissions for people living in care homes.
2. The rate of urgent care attendances for people living in care homes.
3. The proportion of people living in a care home who have a
personalised care and support plan in place.
4. The number of people living in a care home who receive an
appointment as part of the weekly care home round
5. The number and proportion of people living in a care home who
receive a structured medication review.
6. The number and proportion of people living in a care home who
receive a delirium risk assessment.
8 https://stpsupport.nice.org.uk/transfer-of-care/index.html 9 https://www.nice.org.uk/guidance/ng27/chapter/Recommendations#supporting-infrastructure
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4. Anticipatory Care
Introduction
4.1 Anticipatory care helps people to live well and independently for longer through
proactive care for those at high risk of unwarranted health outcomes. Typically, this
involves structured proactive care and support from a multidisciplinary team (MDT).
It focuses on groups of patients with similar characteristics (for example people living
with multimorbidity and/or frailty) identified using validated tools (such as the
electronic frailty index) supplemented by professional judgement, refined on the
basis of their needs and risks (such as falls or social isolation) to create a dynamic
list of patients who will be offered proactive care interventions to improve or sustain
their health.
4.2 It supports the focus on prevention in the Long-Term Plan, and the ambition
that people can enjoy at least five extra healthy, independent years of life by
2035.
4.3 The service has three key aims:
• Benefitting patients with complex needs, and their carers, who are at
risk of unwarranted health outcomes by enabling them to stay healthier for longer,
with maintained or improved functional ability and enjoy positive experiences of
proactive, personalised and self-supported care.
• Reducing need for reactive health care for specific groups of patients and
supporting actions to address wider determinants of health.
• Delivering better interconnectedness between all parts of the
health system and the voluntary and social care sectors
4.4 These aims will be achieved through a combination of:
• population segmentation, followed by risk stratification and clinical
judgement, to identify people who would benefit most; and
• multi-disciplinary primary and community teams, including social care
and the voluntary sector working together.
4.5 Anticipatory care is intrinsically linked to population health management models
developing and already in place in systems across the country. The service focuses
on the “rising risk population”, comprising those with multiple long-term conditions
and/or frailty, who may have underlying risk factors like unhealthy
22 40
lifestyles, behavioural risks, social isolation or poor housing. Addressing many of
these risk factors will require non-clinical interventions and strong working
relationships with local voluntary, community and civic groups, as well as system
public health teams.
4.6 In future years we will establish a standardised approach to the identification of
individuals to receive the service. There is a range of approaches currently in place
across the country, and the evidence base is still developing. 2020/21 therefore
represents an opportunity to build and embed ways of working and service models
which will expand and develop in future years. We will continue to monitor outcomes
from different local approaches, and would welcome submissions of evidence where
these have been successful.
Existing provision and available support for PCNs
4.7 Population health management (PHM) tools that can support risk stratification
are already in place in a number of areas across the country. They are usually
hosted by ICSs but drawing on data from MDTs based across PCNs and
community service providers. PHM tools will predict and identify patients who are
at risk of adverse health outcomes, and the particular interventions that would
support them to remain healthy.
4.8 The first year of the service is predominately a preparatory year, with target
populations to be agreed by the PCN through discussion with their CCG and their
ICS/STP. CCGs and ICSs will support PCNs by sharing information and access to
risk stratification tools successfully in use that could be used by PCNs
4.9 General practices already have a unique understanding of the health needs of
the communities they serve. By joining together health and social care information
with other information from wider public sources like housing and education, and
applying predictive modelling techniques, PCNs have the opportunity to draw on
deeper intelligence to better understanding which people in their areas might
benefit from more targeted and proactive care.
Proposed phasing of objectives from 2020/21 to 2023/24
4.10 By 2023/24, we expect all PCNs and community service providers – working
together – to offer an Anticipatory Care model based on the following
components:
o Identification of specified key segments of the PCN’s registered practice
populations who have complex needs and are at high risk of unwarranted
health outcomes.
23 41
Population health management tools – hosted by ICSs but drawing on data from
MDTs based across PCNs and community service providers – will predict and
identify patients who are at risk of adverse health outcomes, and the particular
interventions that would support them to remain healthy.
Over time, as population health management tools are validated for increasing
cohorts, this will mean a reduction in the need for additional manual segmentation
and stratification of the identified patients. By 2023/24, PCNs and community service
providers will access, interrogate and filter a list of which individuals are most likely
to benefit from different health and care interventions.
o Maintenance of a comprehensive and dynamic list of identified
individuals who would benefit from anticipatory care, based on the
outcome of the population segmentation approach above.
This list will be dynamic: it will be maintained and updated in real time based on
population health intelligence.
o The delivery of a comprehensive set of support for those individuals
identified as eligible through the anticipatory care list, through an MDT
based across PCNs and community service providers.
The available support provided to each individual will be based upon each their
personalised care and support plan, but support offers will include a broad range
of primary and community services support via the MDT. Establishing this
support infrastructure is a key component of the 2020/21 requirements.
4.11 Complex population cohorts require the skills of different healthcare
professionals working together as a multidisciplinary team. For MDTs to achieve
their goal, PCNs and other health and care partners must share relevant patient
information and develop whole system data sharing and data processing
agreements, drawing on national guidance. In time, this data will be sourced from
Local Health and Care Records.
Proposed service requirements for 2020/21
4.12 During 2020/21, practices working as part of PCNs and working with providers
of community services, will:
Practices, working as part of PCNs Other providers of community
services, including mental health
24
42
1 From no later than 30 June 2020, From no later than 30 June 2020,
present a coherent local Anticipatory assist with the development and
Care model by: improvement of system-level
• identifying a responsible clinical population health management
lead for delivery of the model; approaches to identify patients with
• assisting with the development complex needs that would benefit
and improvement of system-level from Anticipatory Care.
population health management
approaches to identify patients Support the coordination of the care
with complex needs that would and support of people being treated
benefit from anticipatory care; by the Anticipatory Care model,
• working with others to develop building links and working across the
and establish, clinical system to facilitate development of a
accountability and governance wider model of integrated care for
arrangements to manage the individuals living with complex needs
model, through shared design with
providers of community services Work with others to develop and
and mental health care, engaging agree delivery, clinical accountability
with social care and voluntary and governance arrangements with
services, drawing on existing practices working as part of a PCN,
system-level programmes where engaging with other providers of
possible; community services, mental health
• taking a leading role in care, social care and voluntary
coordinating the care and support services.
of people as patients begin to be
Work with the CCG, PCN, providers treated by Anticipatory Care -
building links and working across of social care and voluntary sectors
the system to facilitate and patient representative groups to
development of a wider model of co-design and clearly set out how and
integrated care for individuals where the range of support service
living with complex needs. offers described below (which will be recurrently available through MDTs
for those receiving anticipatory care)
and other support services will be
delivered.
2 From no later than 30 June 2020, From no later than 30 June 2020
with CCG support, work with others to work with others to develop and sign
develop and sign data sharing data sharing agreements with
agreements between practices and practices and with other providers
with providers delivering community delivering community and mental
and mental health services, local health services, local acute Trusts,
acute hospitals voluntary sector voluntary sector organisations and
organisations and social care to providers of social care to support the
support the operation of MDTs and operation of MDTs and the
25 43
the development of population health development of population health
analytics data sets. data sets.
Support the development of system- Support the development of system-
level linked data sets to build level linked data sets to build
population health analytics population health analytics
capabilities, including the extraction capabilities, including the extraction
of anonymised, patient level data. of anonymised, patient level data.
3 From no later than 30 June 2020, From no later than 30 June 2020,
identify a priority list of patients who support the prioritisation of a target
are at rising risk of unwarranted cohort of patients based on
health outcomes, based on the CCG professional judgement and/or
standard approach where applicable. validated tools.
Prioritisation should focus upon:
• individuals with complex
needs: including multiple long-
term conditions and/or with
frailty.
• those that are amenable to
improvement through multi-
disciplinary intervention and
• those that are at high risk of
their condition progressing or
circumstances or needs
substantially changing within
the next six months.
4 From no later than 30 June 2020, From no later than 30 June 2020,
establish and manage an MDT, to align relevant community nursing and
meet regularly to coordinate and therapy staff to the local PCN and
manage the care of the cohort of identify other professions that may
people on the Anticipatory Care list. need to be involved in the MDT
discussion.
Attend and participate in the MDT
discussion – using available
information to plan and co-ordinate
the care of patients discussed.
5 From no later than 30 June 2020, co- From no later than 30 June 2020, co-
ordinate and deliver comprehensive ordinate and deliver constituent parts
needs assessments, targeted needs
26 44
assessments or care co-ordination of comprehensive and targeted needs
reviews for the people in this cohort, assessments with the PCN.
recording this activity and the
person’s individual goals in a
personalised care and support plan. Develop or add to care and support
plans for the individuals which the
MDT identifies should be supported
by community health professionals
6 From no later than 30 June 2020, From no later than 30 June 2020, co-
coordinate the delivery of support ordinate support offers if locally
offers as identified by the needs agreed.
assessment and the patient’s
personal goals. Via the responsible Deliver relevant support offers as
lead, retain overall clinical identified in the patient’s needs
responsibility for the delivery of this assessment and care and support
plan. plan, to include (not exhaustive):
The available support offers must • fall risk assessment and
include (not exhaustive): intervention including bone health
• medicines optimisation to address management and strength and
problematic polypharmacy, in line balance training
with the process established in the • rehabilitation services
SMR specification • continence services
• social prescription using a broad • tissue viability service
range of community assets to • care co-ordination
support well-being and address • mobility assessment
•
loneliness and isolation • continence assessment (urinary
carer identification and and faecal)
signposting to local support • carer identification and
• annual comprehensive or targeted signposting to local support
needs assessment for other • annual comprehensive or targetedvalidated cohorts with complex needs assessment for other needs. validated cohorts with complex
• annual care coordination review needs.
for other validated cohorts with • annual care coordination reviewcomplex needs. for other validated cohorts with
• adoption of patient activation complex needs.
•
measures • relevant outreach services for
non-medical interventions from hard to reach groups and those
the personalised care and support with protected characteristics. plan
• mental health assessment and
interventions to identify and
27 45
manage depression and anxiety,
including IAPT
• cognitive assessment (to identify
dementia and delirium risk) and
post diagnosis dementia support
(including cognitive stimulation
therapy and cognitive
rehabilitation therapy).
Deliver annual review of those
patients actively supported by
community health providers
(especially those patients who are
housebound)
Proposed metrics
4.13 Potential metrics to monitor the success of the service include, but are not
limited to:
Metric description
1. Number of individuals in receipt of the Anticipatory Care model
2. Number of needs assessment carried out for individuals in receipt of
the Anticipatory Care model.
3. Number of individuals in the active cohort of the anticipatory care
model with a personalised care and support plan.
4. Number of individuals in the active cohort of the anticipatory care
model receiving a falls risk assessment.
5. Number of individuals in the active cohort of the anticipatory care
model receiving a delirium risk assessment
6. Number of SMRs for the active cohort on the anticipatory care model
7. Number of SMR follow-ups in the active cohort on the anticipatory care
model
8. Number of individuals in the active cohort on the anticipatory care
model given a referral to social prescribing service or where social
prescribing is declined
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5. Personalised Care
Introduction
5.1 Chapter one of the NHS Long Term Plan (LTP) makes personalised care
business as usual across the health and care system as one of the five major,
practical changes to the NHS service model. Personalised care means people
have choice and control over the way their care is planned and delivered, based on
‘what matters’ to them and their individual diverse strengths, needs and
preferences. This happens within a system that supports people to stay well for
longer and makes the most of the expertise, capacity and potential of people,
families and communities in delivering better health and wellbeing outcomes and
experiences.
5.2 Universal Personalised Care: Implementing the Comprehensive Model”10 is the
delivery plan for personalised care, published by NHS England in January 2019
following the LTP. The Comprehensive Model builds on the success the NHS has
had in implementing personalised care in a variety of settings and locations across
the country. The experience and evidence thus far (and as set out in Universal
Personalised Care) has shown that benefits include:
• improvement to people’s experiences of care and their health
and wellbeing, including for people who face the greatest health inequalities;
and
• more effective use of NHS services, including reduced crises that
lead to unplanned hospital or institutional care.
Existing provision and available support for PCNs
5.3 There is substantial existing provision and support available to PCNs through
the personalised care national programme, and its regional networks. This
includes:
• Dedicated clinical support tools are available via GPIT systems to
support professionals in having shared decision making conversations with
cohorts where this is a service requirement in 20/21; and
• Well-developed social prescribing in many areas – often occurring at a
scale that already exceeds the 2020/21 requirement. Building on this success,
there will be free training provided by HEE available to all
10 https://www.england.nhs.uk/wp-content/uploads/2019/01/universal-personalised-care.pdf
29 47
social prescribing link workers, as well as access to regional support networks.
5.4 Evidence from existing social prescribing schemes and clinical expertise
suggests that GP appointments can be prevented when individuals receive a social
prescribing intervention, and onward referral to appropriate services. Delivery of this
service (which will be mostly be carried out by staff funded in full via the Network
DES) has a clear potential to reduce GP burden at a local and national level.
Proposed Service Model
5.5 The Comprehensive Model for Personalised Care brings together six evidence-
based and inter-linked components, each of which is defined by a standard,
replicable delivery model. The six key components are11:
1. Shared decision making 2. Personalised care and support planning 3. Enabling choice, including legal rights to choose 4. Social prescribing and community-based support 5. Supported self-management 6. Personal health budgets (PHBs) and integrated personal budgets.
Proposed phasing of service objectives from 2020/21 to 2023/24
5.6 To achieve the benefits of personalised care the Comprehensive Model needs
to be delivered in full. For example, social prescribing is more effective when it is
delivered with a complementary approach to shared decision making. Over the four
years of Network Contract DES, we will phase in increasing levels of activity across
the six component areas as summarised below:
2020/21 Personalised Care and Support Planning
Requirement of personalised care and support plans to be in place for at least 5-
10:1000 weighted population. This must include:
• All people in last 12 months of life • All individuals eligible in the Anticipatory Care and Enhanced
Health in Care Homes cohorts
Promotion of Personal Health Budgets
Requirement to promote of Personal Health Budgets for:
• People with a legal right to a Personal Health Budget
11 Further detail of each of the six components can be found in the Universal Personalised Care: Implementing the Comprehensive Model.
30
48
• Any other cohorts identified as eligible for a Personal Health Budget
within the CCG local offer
Shared Decision Making
Priority shared decision-making clinical situations, to include at least:
• MSK: Back pain, hip pain, knee pain and shoulder pain (led by
physiotherapists)
Training and shared learning
Prioritise the following roles for training:
• Team members undertaking personal care and support planning
conversations • Clinical pharmacists hosting Structured Medicine Reviews • MSK practitioners • Social prescribing link workers
Social prescribing
Required number of social prescribing referrals at least:
• 4-8:1000 weighted population.
Supported self-management
PCNs to use the Patient Activation Measure (PAM)12 for the following cohorts:
• People living with newly diagnosed Type 2 diabetes • People referred to social prescribing link
workers 2021/22 Personalised Care and Support Planning Requirement of personalised care and support plans to be in place for 10-
15:1000 weighted population.
Promotion of Personal Health Budgets
Continue to promote as per 2020/21, and develop offer to directly provide
Personal Health Budgets for specific cohorts
Shared Decision Making
Priority shared decision-making clinical situations, to include at least:
• MSK: Back pain, hip pain, knee pain and shoulder pain • Reducing stroke risk in people with AF
Training and shared learning
• Further staff cohorts to be confirmed
12 The PAM is a tool designed to measure the level to which people feel engaged and confident in taking care of their condition. Further information is available here:https://www.england.nhs.uk/personalisedcare/supported-self-management/patient-activation/pa-faqs/
31 49
Social prescribing
Required number of social prescribing referrals:
• 8-12:1000 weighted population.
Supported self-management
• PCNs to use the Patient Activation Measure for additional cohorts to
be confirmed.
2022/23 Personalised Care and Support Planning
Requirement of personalised care and support plans to be in place for 15-
20:1000 weighted population.
Promotion of Personal Health Budgets
Continue to promote as per 2020/21, and begin to offer Personal Health Budgets
directly for specific cohorts Shared Decision Making
Priority shared decision-making clinical situations, to include at least:
• MSK: Back pain, hip pain, knee pain and shoulder pain • Reducing stroke risk in people with AF • Additional clinical situations to be confirmed.
Training and shared learning
• Further staff cohorts to be confirmed
Social prescribing
Required number of social prescribing referrals:
• 12-16:1000 weighted population.
Supported self-management
• PCNs to use the Patient Activation Measure for additional cohorts
to be confirmed.
2023/24 Personalised Care and Support Planning
Requirement of personalised care and support plans to be in place for 20-
25:1000 weighted population.
Promotion of Personal Health Budgets
Continue to promote as per 2020/21, and have in place a clear offer of Personal
Health Budgets directly for specific cohorts
Shared Decision Making
Priority shared decision-making clinical situations, to include at least:
• MSK: Back pain, hip pain, knee pain and shoulder pain • Reducing stroke risk in people with AF
32 50
• Additional clinical situations to be confirmed.
Training and shared learning
• Further staff cohorts to be confirmed
Social prescribing
Required number of social prescribing referrals:
• 16-22:1000 weighted population.
Supported self-management
• PCNs to use the Patient Activation Measure for additional cohorts
to be confirmed.
Proposed service requirements for 2020/21
5.7 From April 2020, practices working as part of PCNs will:
• Identify a clinical lead who will be responsible across the PCN for
the delivery of the service requirements in this section.
• increase the number of personalised care and support conversations and
plans for identified cohorts across a PCN, in line with the standard replicable model,
so that at least 5:1000 weighted population receive a PCSP. In 2020/21 the required
cohorts are:
o People in last 12 months of life
o Individuals eligible in the Anticipatory Care and Enhanced Health in
Care Homes cohorts
Further cohort options to consider include:
o People with multiple long-term conditions and/or at high risk of hospital
admission o People with a diagnosis of Cancer
• promote personal health budgets across a PCN to enable delivery of legal
rights to a PHB and any other cohorts identified as eligible within the CCG’s local
offer.
• deliver shared decision making for different clinical situations using available
decision support tools. The priority cohorts for 2020/21 are patients with
musculoskeletal conditions such as back pain, hip pain, knee pain and shoulder
pain. These conversations will be led by trained physiotherapists
33 51
• facilitate relevant training, shared learning and quality improvement for staff in
PCNs. For 2020/21 PCNs should prioritise the following roles for training:
o Team members undertaking personalised care and support planning
conversations
o Clinical pharmacists hosting Structured Medicine Reviews o PCN MSK practitioners o Social prescribing link workers
• support the delivery of effective social prescribing so that at least 4:1000
weighted population receive a referral.
• use Patient Activation Measure to enable more personalised support for
people with different levels of knowledge, skills and confidence. For 2020/21 the
required cohorts are:
o People living with newly diagnosed Type 2 diabetes
o People referred to social prescribing link workers
Proposed metrics
5.8 Potential metrics to monitor the success of the service include, but are not
limited to:
Metric description
1. The number of personalised care and support plans delivered
(including measure of delivery rate for required cohorts)
2. The quality of personalised care and support plans
3. The number of shared decision making conversations completed
(including measure of delivery rate for required cohorts)
4. The quality of shared decision making conversations
5. The number of social prescribing referrals made
6. The number of patient activation measurement assessments
undertaken (including measure of delivery rate for required cohorts)
7. The number of Personal Health Budgets
34 52
6. Supporting Early Cancer Diagnosis
Introduction
6.1 The NHS Long Term Plan (LTP) sets an ambition that, by 2028, the proportion
of cancers diagnosed at stages 1 and 2 will rise from around half now to three-
quarters (75%) of cancer patients. Achieving this will mean that, from 2028, 55,000
more people each year will survive their cancer for at least five years after
diagnosis.
6.2 Primary care has a vital role to play in delivering this ambition, working closely
with wider system partners including Cancer Alliances, secondary care, local
Public Health Commissioning Teams and the voluntary sector. Through the
requirements in the Network Contract DES, primary care networks will:
• Improve referral processes across GP practices, including by introduction
of locally agreed standardised systems and processes for identifying people with
suspected cancer, referral management and safety netting13.
• lead and coordinate the contributions of practices and the PCN to efforts to
increase the uptake of existing National Cancer Screening programmes among
their local populations.
• Improve outcomes through reflective learning and collaboration with local
partnerships
6.3 An average PCN will have around 250 new cancer diagnoses each year.
Moving from around one half to three quarters of these getting a diagnosis at
stage one or two would mean around 60 more people being diagnosed early,
increasing their likelihood of survival.
Existing provision and available support for PCNs
6.4 The service requirements support and further embed the clinical best practice
detailed in NICE Guideline 12: Suspected cancer: recognition and referral. All
practices are already implementing the NICE guidelines and the development
process for this specification has shown that much of general practice is already
engaged in the actions set out in this specification to improve referrals, screening
uptake and reflective practice
13 Safety netting is defined for these purposes as ensuring attendance at appointments following urgent referrals for suspected cancer the results of investigations are received and acted upon appropriately and reviewing people with any symptom that is associated with an increased risk of cancer but who do not meet the criteria for referral or other investigative action.
35 53
6.5 PCNs will be supported by local system partners in the delivery of the
specification and the ultimate improvement of local early diagnosis rates:
• Improving early diagnosis is a strategic and delivery priority for the 20
Cancer Alliances across England and they will support and work with PCNs to
deliver the outcomes in this specification.
• The Public health national service specifications set out programmes for
supporting early diagnosis for breast, cervical and bowel cancers and regional public
health commissioning teams and Cancer Alliances will work with PCNs on local
screening improvement plans.
• Voluntary organisations also have a defined local support offer which includes
training, communities of practice with expert cancer GPs and practice nurses, and
advice on population-level data to help drive service improvement.
6.6 The implementation of wider Long Term Plan commitments will also support
PCN implementation of this service. National Screening Programmes are being
modernised and the development of a new referral pathway for people with serious
but non-specific symptoms through Rapid Diagnostic Centres (RDCs) starting in
2019/20 will provide support faster diagnosis through more efficient diagnostic
pathways and a clearer route for those with unclear symptoms.
Proposed Service Model
6.7 Over the four-year period, PCNs should provide a leadership, enablement and
support function across their component practices to deliver the service
requirements and ensure the highest standards across its practices. By 2023/24, all
PCNs will be expected to be undertaking a range of activity to contribute to
realisation of their local Cancer Alliance target for number of people diagnosed at
stages 1 and 2, set through the LTP planning process.
6.8 Through the PCN Dashboard, PCNs will have access to a variety of data
allowing them to understand and explore trends in cancer presentation and
diagnosis locally. National data sets will also enable comparison with other areas
and encourage PCNs to learn from one another. Working with partners, such as
Cancer Alliances, local public health commissioning teams and voluntary
organisations, offers an opportunity for PCNs to leverage available support,
guidance and training.
6.9 It is anticipated that the scope of activity undertaken by PCNs will increase year
on year, as PCNs become more established and are able to build on what is learnt
through audit and exploration of data and significant event analysis in the
36 54
early years. The proposed trajectory for this is set out in more detail in the table
below, with specific requirements to be determined in future years.
6.10 The requirements for 2020/21 complement the content of the Quality
Improvement QOF domain – Early diagnosis of cancer, which includes activity on
improving referral practice and increasing screening uptake. Where practices take
up this Quality Improvement QOF Domain, PCNs will ensure that associated
learning and best practice is shared. Delivery of some parts of this specification will
also contribute to Continued Professional Development requirements for practice
and staff working in the PCN.
Proposed phasing of service objectives from 2020/21 to 2023/24
6.11 The requirements in this specification will be phased over time, as capacity
both within PCNs and the wider pathway for cancer diagnosis and treatment
increases. The table below summarises the expected phasing of objectives from
2020/21 to 2023/24:
2020/21 Improving referral practice
• Enable and support practices to improve the quality of their referrals
for suspected cancer (including recurrent cancers), in line with NICE guidance and
making use of new RDC pathway for people with serious but non-specific
symptoms where available.
• Introduce safety netting approach for monitoring patients referred for
suspected cancer and those who have been referred for investigations to inform
decision to refer. • Ensure patients receive high-quality information on their referral.
Increasing uptake of National Cancer Screening Programmes
• Building on existing practice-level actions, lead and coordinate
practices’ contribution to improving screening uptake.
• Develop a PCN screening improvement action plan for 2021/22 that
contributes to delivery of the local system plan (shared with Public Health
Commissioning team and Cancer Alliance)
Improving outcomes through reflective learning and local system
partnerships
• Develop a community of practice across the PCN and encourage
practices’ engagement with local system partners, in particular the Cancer
Alliance, to enable delivery of the service requirements.
2021/22 Improving referral practice
• Increase the proportion of people diagnosed at stages 1 and 2
by identifying and referring suspected cancer early, contributing to delivery of
local CA target for improvement
37 55
• Continue to review and improve referral practices, building on
2020/21 learning and activities, including through Significant Event Analysis and
peer to peer learning and further analysis of local population data
• Expand safety netting to include monitoring of patients with non-
specific symptoms where the GP has a significant clinical concern but are not
immediately referred for suspected cancer.14 • Continue to ensure patients receive high-quality information on their
referral (for all future years)
Increasing uptake of National Cancer Screening Programmes
• Deliver agreed actions from their 2021/22 PCN screening
improvement action plan, in line with Public Health Commissioning and Cancer
Alliance plan. Update plan for 2022/23
Improving outcomes through reflective learning and local system
partnerships
• Working with local system partners (including patient groups), PCNs
to proactively engage the local community to promote healthier lifestyles,
awareness of signs and symptoms and availability of support.
2022/23 Improving referral practice
• Increase the proportion of people diagnosed at stages 1 and 2
by identifying and referring suspected cancer early, contributing to delivery of
local CA target for improvement
• PCNs continue to review and improve referral practices, building
on 20/21 learning and activities, including through Significant Event Analysis and
peer to peer learning
Increasing uptake of National Cancer Screening Programmes
• Update & implement local screening improvement action plan.
Improving outcomes through reflective learning and local system
partnerships
• Working with local system partners, PCNs proactively engage the
local community to promote healthier lifestyles, awareness of signs and
symptoms and available support. This includes identifying people at higher risk of
developing cancer.
2023/24 Improving referral practice
14 NG12 recommends considering a review for people with any symptom that is associated with an increased risk of cancer where the GP has a concern, but who do not meet the criteria for referral or other investigative action. The review may be planned within a time frame agreed with the person or patient-initiated if new symptoms develop, the person continues to be concerned or their symptoms recur, persist or worsen. GP IT systems are structured to enable this practice.
38
56
• Increase the proportion of people diagnosed at stages 1 and 2
by identifying and referring suspected cancer early, contributing to delivery of
local CA target for improvement
• All patients are receiving high-quality information about their referral.
Those that are deemed to require additional support for their referral are
signposted to the PCN social prescribing link workers.
• Continued implementation of a consistent approach to safety netting
across the PCN, and all people with serious but non-specific symptoms into Rapid
Diagnostic Centres.
Increasing uptake of National Cancer Screening Programmes
• Subject to success of pilots, Targeted Lung Health Checks are
scheduled for national roll out. PCNs should help practices to encourage
participation in the programme for those who could benefit.
Improving outcomes through reflective learning and local system
partnerships
• Working with local system partners, proactively engage the local
community to promote healthier lifestyles, awareness of signs and symptoms
and availability of support. This includes identifying people at higher risk of
developing cancer.
Proposed service requirements for 2020/21
6.12 From April 2020, practices working as part of PCNs will:
• identify a clinical lead who will be responsible across the PCN for the
delivery of the service requirements in this section.
• improve referral practice for suspected cancers, including recurrent cancers.
This will be done by:
o using local data including practice level data to explore local patterns in
presentation and diagnosis of cancer.
o enabling and supporting practices to improve the quality of their referrals for
suspected cancer, in line with NICE guidance and making use of Clinical Decision
Support Tools and the new RDC pathway for people with serious but non-specific
symptoms where available.
o introducing a consistent approach to monitoring patients who have beenreferred urgently with suspected cancer or for further investigations
39 57
undertaken to exclude the possibility of cancer (‘safety netting’) in line with NICE
Guideline 12. This should build on relevant approaches already in place in
constituent practices and drawing on evidence.
o ensuring that patients receive high-quality information on their referral
including why they are being referred, the importance of attending
appointments and where they can access further support.
• increase uptake of National Cancer Screening Programmes. This will be done
by:
o leading and coordinating constituent practices’ contribution to a local
screening uptake improvement plan, working with the local Public Health
Commissioning team and Cancer Alliance. PCNs should identify actions relevant
for their particular populations that they will take forward.
o building on actions already underway across practices to agree and deliver
with practices any 2020/21 improvement activity identified.
o standardising processes across the PCN to encourage the uptake of
National Cancer Screening Programmes.
o working with local system partners to agree a 2021/22 Network-level
action plan for improving uptake of cancer screening programmes across the PCN.
• improve outcomes through reflective learning and local system partnerships.
This will be done by:
o developing a community of practice among practice level clinical staff
that will inform Network-level improvement action plans
o investigating historic referral diagnosis data to identify trends and
opportunities for proactive work across the PCN to improve referrals and early
diagnosis, and to identify cases which should be used for peer to peer learning
and significant event analysis (including patients who presented many times
before diagnosis and those diagnosed late).
o facilitating and supporting constituent practices to conduct Network-wide
Significant Event Analyses and peer to peer learning sessions, taking advantage
of the broad range of cases across a PCN.
40
58
o facilitating and encouraging practices’ engagement with local system
partners, including Patient Participation Groups, secondary care, the relevant Cancer
Alliance and Public Health Commissioning teams, to inform ongoing improvement
activity.
Proposed metrics
6.13 Potential metrics to monitor the success of the service may include, but are not limited
to:
Metric description
1. The proportion of cancers diagnosed at early stage (stage 1 and 2) –
progress towards local Cancer Alliance target
2. PCN-level participation in breast, bowel and cervical screening
programmes
3. Proportion of urgent cancer referrals that were safety netted
4. The number of new cancer cases treated that have resulted from a two
week wait referral (the ‘detection’ rate)
5. The number of two week referrals resulting in a diagnosis of cancer
(the ‘conversion’ rate)
6. Number of cancers diagnosed via emergency presentation
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1
Newham CCG Month 09 Finance Report – 2019/20
1. Summary
This report provides an update on the Primary Care delegated commissioning financial position for the Clinical Commissioning Group (CCG).
2. Key Risks and Issues
Since April 2016, the CCG has had fully delegated responsibility for Primary Care from NHS England. This means that the CCG is responsible for the budgeting and authorisation of primary care payments, and meeting any shortfalls in expenditure.
This summary provides an update on the Primary Care delegated financial position for the
CCG.
At Month 09 (December 2019) the CCG is reporting a £0.2m overspend and is forecasting a year end overspend of £0.3m against the budget of £55.3m. Although this overspend is comprised of a number of issues; the key issues are as follows:
Rent – a number of practices have not claimed rent reimbursements for a number ofyears, work has been ongoing throughout 2019/20 to ensure that claims are made bypractices and that where needed revaluations are completed. This has led to a numberof rent reclaims being higher than previous years and has attributed to the reserves lineyear to date (YTD) overspend of £0.5m.
Additional Roles Reimbursement Scheme – It is understood that whilst the AdditionalRoles Reimbursement scheme has started and Networks have employed additionalmembers of staff, not all PCNs have yet submitted claims to the NEL Primary CareTeam for staff engaged.
60
2
3. Primary Care Revenue financial position for December 2019
The summarised CCG’s revenue financial position;
YTD Predicted FOT
Budget Actual Variance Variance Budget Forecast Variance Variance
£'000 £'000 £'000 % £'000 £'000 £'00 %
General Practice - APMS 4,118 4,248 130 3% 5,306 5,846 541 10%
General Practice - GMS 6,558 6,483 (76) (1)% 8,939 7,687 (1,252) (14)%
General Practice - PMS 18,160 18,149 (11) - 24,302 24,072 (230) (1)%
QOF + Other Medical Services 2,704 2,712 7 - 3,606 3,606 - -
Premises 5,145 5,615 471 9% 6,859 6,827 (32) -
Enhanced Services 3,984 3,605 (379) (10)% 5,198 5,679 481 9%
PCN Network 703 660 (43) (6)% 963 996 33 3%
QIPP - - - - - - - -
Primary Care Commissioning Staff - - - - - - - -
Primary Care Winter Resilience - - - - - - - -
Co-Commissioning Levies - - - - - - - -
Additional Spend 18 115 97 527% 25 25 - -
Co-Commissioning Reserve - - - 120 830 710 593%
Co-Commissioning Headroom Reserve
- - - - - - - -
41,390 41,586 196 55,317 55,567 250
General Practice Contract payments
The APMS contract budget line represents 5 GP practices and is 10% of the total
budget.
The GMS contract budget line represents 17 GP practices and is 16% of the total
budget.
The PMS contract budget line represents 26 GP practices and is 44% of the total
budget.
The overall combined spend for APMS, GMS and PMS contracts has resulted in an
adverse over-spend of £0.1m year to date and a break even forecast outturn. The
expected list size growth in Q4 will be mitigated by the release of the residual delegated
commissioning reserve.
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3
Quality Outcomes Framework
The YTD QOF position for 19/20 is based on a total level achieved in 2018/19.
Practices received aspiration payments calculated as 70% of 18/19 QOF achievement
which is paid in monthly instalments during the year.
Premises Costs Reimbursement
Premises expected outturn for the year are reported with an overall under-spend of
£(0.1m), broken down below:
FOT
Budget Forecast Variance Variance RAG
£'000 £'000 £'000 %
Rent Reimbursements 5,285 5,247 (37) (1)%
Business Rates 975 988 13 1%
Water Rates 31 31 - - 3
Clinical Waste 22 22 - - 3
Other Premises Cost 170 162 (9) (5)% 3
Voids and Subsidies 377 377 - -
Premises 6,859 6,827 (32) 3
Rent: FOT risks relating to rent are currently allocated against the delegated
commissioning reserve.
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4
Direct Enhanced Services (DES)
Enhanced Services are projected to be over-spend by £0.5m, based on current claims
of which £0.4m is related to Q1 pressure for Extended Hours DES (prior to the
implementation of the new scheme under the PCN framework) and an increase in
provisions relating to unclaimed EHA. The balance is primarily driven by (1) An
increase in prescribing fees (2) An extension of the year 1 PMS transitional payments.
The CCG has seen significate levels of under achievement against outcome measures
within the current year; which will result in a number of clawbacks. However the
requirement to reinvest these clawbacks within primary care means the CCG will not
realise any benefit from these clawbacks.
FOT
Budget Forecast Variance Variance RAG
£'000 £'000 £'000 %
Extended Hours Access 971 1,366 396 41%
Minor Surgery 139 141 2 1% 3
Prof Fees Prescribing 154 214 59 38%
Learning Disability 146 146 - - 3
Unplanned Admissions - - - - 3
Equalisation List (KPIs) 3,788 3,812 24 1% 3
Enhanced Services 5,198 5,679 481 9%
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5
4. Breakdown of Primary Care Allocation for financial year 2019/20
Table 3: PC Allocation by category - 2019/20
Budget Budget
£000's %
General Practice - APMS 5,306 10%
General Practice - GMS 8,939 16%
General Practice - PMS 24,302 44%
QOF + Other Medical Services 3,606 7%
Premises 6,859 12%
Enhanced Services 5,198 9%
PCN Network 963 2%
QIPP - -
Primary Care Commissioning Staff - -
Primary Care Winter Resilience - -
Co-Commissioning Levies - -
Additional Spend 25 -
Co-Commissioning Reserve 120 -
Co-Commissioning Headroom Reserve - -
Co-Commissioning Contingency - -
55,317
10%
16%
44%
7%
12%
9% 2%
General Practice - APMS
General Practice - GMS
General Practice - PMS
QOF + Other Medical Services
Premises
Enhanced Services
PCN Network
QIPP
Primary Care Commissioning Staff
Primary Care Winter Resilience
Co-Commissioning Levies
Additional Spend
Co-Commissioning Reserve
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6
5. Comparison of the Primary Care Allocation for financial years 2018/19 and
2019/20
Comparison of PC Allocations by category by Financial Year
PC Allocation
19/20
PC Allocation 18/20
Variance
£0 £0 £0
General Practice - APMS 5,306 4,908 398
General Practice - GMS 8,939 7,813 1,125
General Practice - PMS 24,302 27,322 (3,019)
QOF + Other Medical Services 3,606 4,176 (571)
Premises 6,859 6,624 235
Enhanced Services 5,198 1,068 4,130
PCN Network 963 - 963
QIPP - - -
Primary Care Commissioning Staff - - -
Primary Care Winter Resilience - - -
Co-Commissioning Levies - - -
Additional Spend 25 - 24
Co-Commissioning Reserve 120 971 (852)
Co-Commissioning Headroom Reserve - - -
Co-Commissioning Contingency - - -
55,317 52,884 2,433
This table highlights where the allocation changes have occurred;-
in Premises where the budget had been optimistically reduced in the belief that rental
reviews will not negatively impact on spend in this financial year even though they will in
future years,
on the DES line which includes several new initiatives (as specified in the publication: A
five year framework for GP contract reform to implement The NHS Long Term
Plan)
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7
6. Breakdown of allocation for the component parts of the Primary Care Network
DES
PC Networks Allocation - 2019/20
PCN Budget
2019/20
Budget as % of
Allocation
£000 %
PCN Clin Pharmacist
PCN Soc Prescribing
PCN Participation 758 79%
PCN Clinical Director 205 21%
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Primary Care Network DES
This Primary care Network DES is a new addition for this financial year. This is part of the
strategy, more fully described in A five year framework for GP contract reform to
implement The NHS Long Term Plan, published in January 2019, where the Department of
Health describes how the NHS will meet the challenges facing primary care.
PCN Participation and PCN Clinical Director are projected to plan, in-line with monthly
payments already setup for the schemes.
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Primary Care Commissioning Committee Part I meeting: 15.00-16.00 Wednesday 5 February 2020 FO21 Plaistow Room, 4th Floor Unex Tower, 5-7 Station Street, London E15 1DA
Title Updated Terms of Reference (ToR)
Agenda item 2.1
Author Lauren Sibbons, Head of Primary Care - Newham, WEL CCGs
Presented by Lauren Sibbons, Head of Primary Care - Newham, WEL CCGs
Contact for further information
Lauren Sibbons, Head of Primary Care - Newham, WEL CCGs,
020 3816 3858
This paper is for ☒ Decision ☐ Monitor ☐ Discussion ☐ For Information
Action required The Committee is asked to approve minor administrative amendments to the Committee’s Terms of Reference reflecting the establishment of the Newham, Tower Hamlets and Waltham Forest (WEL) CCGs arrangements.
Executive summary
The Committee’s Terms of Reference were previously approved by the CCG’s Governing Body on 19 December 2018. The following revisions have been made to the ToR by way of update:
Schedule 1 – List of Members
Voting Attendees
Vice – Chair: Newham CCG Board Nurse amended to Newham CCG Lay Member
CCG Managing Director: Newham CCG Managing Director amended to WEL CCGs Managing Director
CCG Chief Finance Officer: Newham CCG Interim Chief Finance Offer amended to WEL CCGs Executive Director of Finance
CCG Primary Care Lead: Newham CCG Associate Director of Primary Care amended to WEL CCGs Interim Director of Primary Care
The note “For the remainder of 2018/19, in the absence of a second Lay Member, the Board nurse will assume the role of Vice-Chair” has been deleted.
Non-Voting Attendees
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Reference to ‘North East London Commissioning Alliance’ amended to ‘North East London Primary Care Team’
Supporting papers Appendix A: Terms of Reference (updated January 2020)
Next Steps/ Onward Reporting
No planned further presentation or reporting, as due to the minor nature of the administrative amendments these revised ToR do not require ratification by the CCG’s Board.
Where has the paper been already presented?
This paper has not been presented elsewhere.
How does this fit with NHS Newham CCG strategic Priorities?
Strategic Priorities • To commission a Newham-based integrated health and care system which
delivers high quality services for the residents of Newham, in accordance withstatutory requirements
• To commission and develop GP services that are modern, accessible and fitfor the future in caring for our residents
Enabling Priorities • Ensuring we maintain our performance across the key business areas
Outcomes • We will improve access to, and, the quality of, Primary Care• We will clearly be able to demonstrate how we have improved outcomes for
our residents
Commissioning Priorities • To implement the five-year framework for GP contract reform to implement
The NHS Long Term Plan.
Risk BAF.05– Failure to effectively monitor the quality, performance and activity ofcommissioned services, with a focus on ensuring the delivery of better clinicaloutcomes.
BAF.07 Failure to effectively deliver a primary care strategy that isadequately resourced to service Newham residents
Equality impact This report conserves the duty of Newham CCG in respect of equality and this has been considered when developing the risks for consideration and any mitigating actions described. An Equality Impact Assessment has previously been conducted for Primary Care and the delivery of primary care services and concluded that services are available and accessible for all Newham residents.
Stakeholder engagement
There has been no formal engagement on the amendments made to the report as they are minor administrative points with no material change.
Financial Implications
There are no financial implications associated with this report other than those identified within the specific risks and actions. Any resulting financial impact will need to be managed within existing resource and if needed, further discussion at Board level if budgets are exceeded.
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Appendix A –
Newham CCG Primary Care Commissioning Committee Terms of Reference
(Revised January 2020)
1. Introduction and Background
1.1 Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that NHS England was inviting Clinical Commissioning Groups to expand their role in primary care commissioning. Each Clinical Commissioning Group (‘CCG’) was invited to submit an expression of interest setting out its preference for how it would like to exercise expanded primary medical care commissioning functions.
1.2 One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to individual CCGs. Accordingly, in October 2014 the CCG submitted an application to NHS England to exercise these commissioning functions for its own geographical area.
1.3 In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended) (‘NHS Act 2006’), NHS England subsequently delegated the exercise of the functions specified in section 4 below to Newham CCG.
1.4 Newham CCG has established its Primary Care Commissioning Committee as a committee of its Governing Body. The purpose of the Primary Care Commissioning Committee is to be a corporate decision making body for the management of the delegated functions and the exercise of the delegated powers.
1.5 These Terms of Reference set out the membership, remit, responsibilities and reporting arrangements of the Committee.
2. Statutory Framework
2.1 NHS England has delegated to Newham CCG the authority to exercise the primary care commissioning functions set out in section 4 below for its own geographical area in accordance with section 13Z of the NHS Act 2006.
2.2 Arrangements made under section 13Z of the NHS Act 2006 may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and the CCG.
2.3 Arrangements made under section 13Z of the NHS Act 2006 do not affect the liability of NHS England for the exercise of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it) it must comply with the statutory duties set out in Chapter A2 of the NHS Act 2006 and including:
No. Statutory Duty Section of NHS Act 2006
1. Management of Conflicts of Interest 14O
2. Duty to promote the NHS Constitution 14P
3. Duty to exercise its functions effectively, efficiently and economically
14Q
4. Duty as to improvement in quality of services 14R
5. Duty in relation to quality of primary medical services
14S
6. Duties as to reducing inequalities 14T
7. Duty to promote the involvement of each patients 14U
8. Duty as to patient choice 14V
9. Duty as to promoting integration 14Z1
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10. Public involvement and consultation 14Z2
2.4 In respect of the delegated functions from NHS England the CCG will need to exercise those functions in accordance with the relevant provisions of section 13 of the NHS Act 2006 including:
No. Statutory Duty Section of NHS Act 2006
1. Duty to have regard to impact on services in certain areas
13O
2. Duty as respects variation in provision of health services
13P
2.5 The Primary Care Commissioning Committee is established by the Governing Body in accordance with Schedule 1A of the NHS Act 2006.
2.6 The members of the Committee acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.
3. Role of the Committee
3.1 The role of the Committee is to carry out the function relating to the commissioning of primary medical services under section 83 of the NHS Act 2006. This includes the following:
Decisions in relation to the commissioning, procurement and management of Primary Medical
Services Contracts, including but not limited to the following activities:
o Decisions in relation to Enhanced Services;
o Decisions in relation to Local Incentive Schemes (including the design of such schemes)
o Decisions in relation to the establishment of new GP practices (including branch surgeries)
and closure of GP practices;
o Decisions about ‘discretionary’ payments;
o Decisions about commissioning urgent care (including home visits as required) for out of
area registered patients;
o The approval of practice mergers;
o Planning primary medical care services in the area, including carrying out needs
assessments;
o Undertaking reviews of primary medical care services;
o Decisions in relation to the management of poorly performing GP practices and including,
without limitation, decisions and liaison with the CQC where the CQC has reported non-
compliance with standards (but excluding any decisions in relation to the performers list);
o Management of delegated funds;
o Premises costs directions functions;
o Co-ordinating a common approach to the commissioning of primary care services with
other commissioners in North East London where appropriate; and
o Such other ancillary activities that are necessary in order to exercise the Delegated
Functions.
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3.2 In performing its role, the Committee will exercise its management of the functions in accordance with
the Delegation and the Delegation Agreement that the CCG entered into with NHS England. The Delegation and the Delegation Agreement sit alongside these Terms of Reference. The Delegation Agreement is contained in Schedule 2.
3.3 In addition to carrying out the function relating to the commissioning of primary medical services under section 83 of the NHS Act 2006, the role of the Committee will also be to provide assurance to the Board that the CCG is obtaining value for money for grant funding invested in the development of the GP Federation.
3.4 The functions of the Committee are undertaken in the context of a desire to promote increased co-
commissioning to increase quality, efficiency, productivity, value for money and remove administrative barriers.
3.5 The Committee will have due regard to any relevant quality and safety issues which may arise as
agreed by Committee members. 3.6 In performing its role, the Primary Care Commissioning Committee will act within the powers
delegated to it by NHS England. 3.7 Decisions made by the Primary Care Commissioning Committee will be binding on NHS England as
long as decisions are made within the scope of the powers delegated to it. 3.8 In performing its role, Committee members will act in good faith towards each other, work
collaboratively, review evidence, share information, provide objective expert input and endeavour to reach a consensus and collective view.
5. Membership
5.1 The membership of each of the Primary Care Commissioning Committee will meet the requirement of its Constitution.
5.2 The Committee shall have a lay and executive majority. 5.3 The Committee shall have the following non-voting attendees:
NHS England representative(s);
Health and Wellbeing Board representative(s);
Healthwatch Representative(s);
LMC Representative(s);
Non-conflicted external clinicians.
5.4 The list of members and non-voting attendees is set out in Schedule 1. 5.5 Committee members may nominate deputies to represent them in their absence and make decisions
on their behalf. Non-voting attendees may nominate deputies to represent them in their absence. 5.6 The Committee may call additional experts to attend meetings on a case by case basis to inform
discussion. 5.7 The Committee may invite or allow additional people to attend meetings as attendees. Attendees may
present at Committee meetings and contribute to the relevant Committee discussions, but are not permitted to participate in any formal vote.
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5.8 The Committee may invite or allow people to attend meetings as observers. Observers may not present at Committee meetings, contribute to any Committee discussion or participate in any formal vote.
6. Chair and Vice Chair of the Committee
6.1 The Chair of the Committee shall be a Lay Member from Newham CCG. The Committee Chair shall not be the Chair of the CCG’s Audit Committee nor a Conflict of Interest Guardian.
6.2 The Vice Chair of the Committee shall be a Lay Member from Newham CCG. The Committee Vice Chair shall not be the Chair of the CCG’s Audit Committee nor a Conflict of Interest Guardian.
7. Voting
7.1 Each voting member of the Primary Care Commissioning Committee shall have one vote with resolutions passing by simple majority.
7.2 The Chair or Vice-Chair Lay Member will have the casting vote.
8. Decisions
8.1 The Committee will make decisions within the bounds of their remit.
8.2 Decisions of the Committee will be binding on NHS England in respect of the management of functions delegated to it by NHS England (section 13Z of the NHS Act 2006).
8.3 Due to the nature of primary care commissioning, the Committee recognises that some urgent and immediate decisions may need to be made outside of Committee meetings. The Primary Care Commissioning Committee may therefore delegate urgent and immediate decisions that need to be made outside of Committee timescales in accordance with clauses 8.4 – 8.5 and 8.7 below.
8.4 Urgent decisions requiring a response within 24 hours will be made collectively by the following people or their nominated deputies:
The Single Accountable Officer/Managing Director;
The Chair or Vice-Chair Lay Member.
8.5 Immediate decisions requiring a response within two weeks will be made at a Committee meeting where practicable. Where this is not practicable the following people or their nominated deputies will collectively make the decision:
The Single Accountable Officer/Managing Director
The Chair or Vice-Chair Lay Member
8.6 Due to the nature of primary care commissioning the Committee recognises that the following non-contentious, low risk, decisions may be made outside of Committee meetings by those listed in clause 8.7 below: :
Requests to add or remove a partner;
Retirement of a partner and addition of a new partner;
Partnership changes - 24 hour retirement;
Opening of a patient list;
Increases in practice boundaries.
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8.7 The following people or their nominated deputies may collectively make the non-contentious, low risk decisions set out in clause 8.6 above:
The Chair or Vice-Chair Lay Member;
The Single Accountable Officer/Managing Director
8.8 Decisions made outside of Committee meetings will be reported to the Committee at the next Committee meeting. This may be in a public or private part of the meeting depending on the nature of the business and the decision(s) made.
9. Quorum
9.1 The Primary Care Commissioning Committee must have a Lay and Executive majority to be quorate with three of the five voting members in attendance. One Lay Member must also be present.
9.2 If any representative is conflicted on a particular item of business they will not count towards the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted to satisfy the quorum requirements.
10. Frequency of Meetings
10.1 The Committee shall meet monthly or as otherwise agreed by the Committee.
11. Notice of Meetings
1.1 Notice of a Committee meeting shall be sent to all Committee members no less than 7 days in advance of the meeting.
11.2 The meeting shall contain the date, time and location of the meeting.
11.3 Where Committee meetings are to be held in public the date, times and location of the meetings will be published on Newham CCG’s website.
12. Agendas and Circulation of Papers
12.1 Before each Committee meeting, an agenda setting out the business of the meeting will be sent to every Committee member no less than 7 days in advance of the meeting.
12.2 Before each Committee meeting the papers of the meeting will be sent to every Committee member no less than 7 days in advance of the meeting.
12.3 If a Committee member wishes to include an item on the agenda they must notify the Chair via the Committee’s Secretariat no later than 7 days prior to the meeting. The decision as to whether to include the agenda item is at the absolute discretion of the Chair.
13. Minutes and Reporting
13.1 The minutes of the proceedings of a meeting shall be prepared by the Committee’s Secretariat and submitted for agreement at the following Committee meeting.
13.2 The approved minutes will be presented to the NHS England area team.
14. Conflicts of Interest
14.1 Conflicts of Interest shall be dealt with in accordance with Newham CCG’s Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest.
14.2 The CCG shall ensure appropriate local safeguards are in place to maintain the integrity of the role of Conflicts of Interest Guardian.
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14.3 The Committee shall have a Conflicts of Interest Register that will be presented as a standing item on the Committee’s agenda.
15. Gifts and Hospitality
15.1 Gifts and Hospitality shall be dealt with in accordance with the CCG’s Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest.
15.2 The Committee shall have a Gifts and Hospitality Register that will be presented as a standing item on the Committee’s agenda.
16. Meetings Held in Public
16.1 Meetings of the Committee shall be held in public unless the Committee resolves to exclude the public from a meeting. In which case the meeting, in whole or in part, may be held in private. The Committee may also exclude non-voting attendees and observers. Meetings or parts of meetings held in public will be referred to as ‘Meeting Part 1’. Meetings or parts of meetings held in private will be referred to as ‘Meeting Part 2.’
16.2 Non-voting attendees, observers and the public may be excluded from all or part of a meeting at the Committee’s absolute discretion whenever publicity would be prejudicial to the public interest by reason of:
The confidential nature of the business to be transacted; or
The matter is commercially sensitive or confidential; or
The matter being discussed is part of an on-going investigation; or
The matter to be discussed contains information about individual patients or other individuals
which includes sensitive personal data; or
Information in respect of which a claim to legal professional privilege could be maintained
in legal proceedings is to be discussed;
Other special reason stated in the resolution and arising from the nature of that business or of
the proceedings; or
Any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as
amended or succeeded from time to time; or
To allow the meeting to proceed without interruption, disruption and/or general disturbance.
17. Confidentiality
17.1 Members of the Committee shall respect the confidentiality requirements set out in these Terms of Reference unless separate confidentiality requirements are set out for the Committee in which event these shall be observed.
17.2 Committee meetings may in whole or in part be held in private as per section 16 above. Any papers relating to these agenda items will be excluded from the public domain. For any meeting or any part of a meeting held in private, all members and/or attendees must treat the contents of the meeting and any relevant papers as strictly private and confidential.
17.3 Decisions of the Committee will not be published by Committee members except where matters under consideration or when decisions have been made in private and so excluded from the public domain in accordance with section 16 above.
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18. Standards of Business Conduct
18.1 Committee members, attendees and/or observers must maintain the highest standards of personal conduct and in this regard must comply with:
The law of England and Wales;
The NHS Constitution;
The Nolan Principles;
The standards of behaviour set out in each NCL CCG Constitution;
Any additional regulations or codes of practice relevant to the Committee.
19. Training and Information
19.1 It is the responsibility of the CCG to ensure that their representatives at the Committee are provided with appropriate training and information to allow them to exercise their responsibilities effectively.
20. Sub-Committees
20.1 The Committee may not delegate any of its powers to a Committee or Sub-Committee but it may appoint sub-committees and/or working groups to advise and assist it in carrying out its functions.
20.2 Any sub-committees or working groups must abide by Newham CCG’s Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest.
21. Review of Terms of Reference
21.1 These Terms of Reference will be reviewed from time to time, reflecting experience of the Committee in fulfilling its functions and the wider experience of the CCG in primary medical services co-commissioning.
21.2 These Terms of Reference will be formally reviewed in April each year following the establishment of the Committee. These Terms of Reference may be changed or amended by mutual agreement of the Committee and on approval by the Governing Body in accordance with its Constitution.
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Schedule 1 - List of Members
This schedule sets out the membership, attendees, Chair and Vice Chair of the Primary Care Commissioning Committee
Voting Members
Position Title
Chair Newham CCG – Lay Member
Vice-Chair Newham CCG – Lay Member
CCG Board Nurse Newham CCG – Board Nurse
CCG Managing Director or nominated deputy
WEL CCGs – Managing Director
CCG Chief Finance Officer or nominated deputy
WEL CCGs – Executive Director of Finance
CCG Primary Care Lead or nominated deputy
WEL CCGs - Interim Director of Primary Care
Non-Voting Attendees
Health and Wellbeing Board representative
Health and Wellbeing Board, London Borough of Newham
Healthwatch representative Healthwatch Newham
Local Medical Committee representative or nominated deputy
Director of Primary Care Strategy, Londonwide LMCs
CCG GP representative Newham CCG – Elected GP representative
North East London Primary Care Team representative
Head of Primary Care Commissioning or Assistant Head of Primary Care Commissioning
Public Health representative Director of Public Health, London Borough of Newham
Local Authority representative
Head of Public Health Commissioning, Adults
The roles referred to in the list of voting members and non-voting attendees above describe the members’ and non-voting attendees’ substantive roles and/or any successor equivalent roles only and not the individual title or titles of any member. Names and job titles are provided for information purposes only and may be updated as required without the need to formally amend the Terms of Reference.
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Primary Care Commissioning Committee Part I – 15:00 – 16:00 Wednesday 5 February 2020
FO21 Plaistow Room, Unex Tower, Station Street, London E15 1DA
Title Boleyn Medical Centre – Temporary List Closure
Agenda item 2.2
Author Abdul Rawkib, NEL Primary Care Team, Senior Commissioning Manager
Presented by Lorna Hutchinson, NEL Primary Care Team, Assistant Head of Primary Care
Contact for further information
Abdul Rawkib, NEL Primary Care Team, Senior Commissioning Manager, e: [email protected], t: 020 3688 2121
This paper is for x Decision ☐ Monitor ☐ Discussion ☐ For Information
Action required To approve the request for Boleyn Medical Centre to temporarily close its patient list for a period of 4 – 6 months.
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Executive summary
Boleyn Medical Centre was rated ‘Inadequate’ by the Care Quality Commission (CQC) in the published September 2019 report and was placed in special measures. As a result of the findings from the CQC the practice are trying to embed changes in order to ensure CQC compliance. Significant workforce issues are having an impact on the daily operations of the practice and also implementing the changes advised by the CQC.
The practice has submitted a proposal to temporarily close its patient list for a period of 4 – 6 months, in order to undertake the relevant changes which would help the practice be taken out of special measures by the CQC.
Supporting papers Appendix A: Application to close practice list.
Next Steps/ Onward Reporting
Inform practice of Committee decision – February 2020
Review practice progress in achieving CQC compliance – May 2020
Practice list to re-open – August 2020
Where has the paper been already
presented?
This report has not been presented to any other Committee
How does this fit with NHS Newham
CCG strategic Priorities?
Strategic Priorities
• To commission and develop GP services that are modern, accessible and fitfor the future in caring for our residents
Outcomes
• We will improve access to, and, the quality of, Primary Care
Risk BAF.07.01 Failure to effectively deliver a primary care strategy that isadequately resourced to service Newham residents
Equality impact Although the practice has applied to temporarily close its patient list, the practice has agreed to register the newly born children of current patients and in extenuating circumstances vulnerable patient groups.
Stakeholder engagement
The practice have engaged with the practice which is co-located and alsowith members of its Primary Care Network (PCN).
Financial Implications
Newham CCG faces a significant financial challenge in 2019/20 and is undertaking a range of measures to ensure sustainability. This paper presents issues that may
have financial consequences. These are yet to be fully determined but if not already embedded in budgets or reserve provision, a further Board decision would
be required to release any additional expenditure commitment.
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1. Introduction and Background
1.1 Boleyn Medical Centre is a single handed Personal Medical Services (PMS) practice located within East Ham and is a member of the Central 1 Primary Care Network (PCN). Boleyn Medical Centre has a patient list size of circa 10,700 patients (raw list size – January 2020). Below is a breakdown of the patient list size from 2017 to present:
Raw list size Percentage increase/decrease
January 2017 9909
January 2018 9560 -4%
January 2019 9646 +1%
January 2020 10753 +11%
The patient list has been relatively steady, however there was a significant increase between January 2019 and January 2020 which saw the patient list grow by over 1000 patients in a year.
The practice was inspected by the Care Quality Commission (CQC) in July 2019 and was rated ‘Inadequate’ overall in the published September 2019 inspection report. Previously the practice was rated ‘Good’ across all domains in the published December 2016 report.
As a result of the inspection outcome in September 2019, the practice submitted a proposal in December 2019 to temporarily close its patient list. A summary of the proposal has been provided in section two of this report. The original application submitted by the practice for the temporary list closure is attached as Appendix A.
2. Proposal Summary
2.1
2.1.1
2.1.2
Rationale
Boleyn Medical Centre has applied to temporarily close its patient list in order to embed the changes identified by the CQC following the last inspection. Issues with recruitment have significantly impacted on the practice workload, which has made it difficult to implement the relevant changes successfully. The practice has encountered problems recruiting a salaried GP, practice nurse and full-time administrative staff. The practice most recently went out to advert in December 2019 for a salaried GP and practice nurse. No applications were received for either vacancy and the practice is exploring alternative recruitment options. At present the practice is using long-term locums to fill these posts.
Due to a lack of staffing, the practice are experiencing difficulty in implementing the changes advised by the CQC and the increase in patient registrations is further adding to the issue. The practice has advised that they are registering on average approximately 50 new patients a week.
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2.1.3
2.1.4
2.2
2.2.1
2.3
2.3.1
2.4
2.4.1
The practice has tried to implement a number of different measures in order to relieve the difficulties experienced as part of having an open list. This has included the following:
Upskilling of administrative staff to undertake HCA duties
Recruitment of additional administrative staff and a management consultant to support withCQC compliance
The Lead GP has changed working pattern in order to undertake administrative duties ondays off
Changes to appointment system – the practice piloted telephone triage, but reverted backto face-to-face due to feedback from clinicians following the pilot. The practice are nowonly using telephone consultations for test results were deemed appropriate.
Two additional telephone lines have been added and introduction of a phone queuingsystem.
Although the above measures have been introduced, this has not fully resolved the issues in achieving compliance with the CQC recommendations.
Engagement
As part of the proposal to temporarily close the practice list, the practice has engaged with its PCN members and the practice which is co-located within the same building (The Azad Practice). The practice have submitted evidence confirming that the PCN are in support of the proposal, which includes a supporting statement from the co-located practice. In addition, there are two practices within the PCN who are keen to grow their lists and would be happy for patients to be signposted to them to register. These two practices fall within a one mile radius of the practice.
Duration of Closure
The practice has proposed a temporary list closure of six months. However the practice is happy to accept a shorter period of four months if approved by the Committee.
Future Sustainability
The practice is currently operating at maximum capacity, which is adding to the difficulty of implementing the changes identified by the CQC. The practice is of the view that the temporary list closure would allow the practice to undertake the necessary compliance work as identified by the CQC and it would also allow the practice to recruit to the vacant substantive posts. This in effect would help the practice to manage its workload.
3.0 Recommendation
3.1 The Committee is asked to approve the temporary list closure for a period of six months in order to ensure that:
The practice is able to implement the changes as advised by the CQC in order to achievecompliance and be taken out of special measures.
The practice is given sufficient time to recruit and fill the vacant substantive posts.
The short-term stability of the practice is maintained.
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