primary care commissioning committee · counselling and youth work with young people aged 11-25...
TRANSCRIPT
Primary Care Commissioning Committee
Tuesday 27 February 2018, 5.15 pm – 6 pm Boardroom, CCG offices, Riverside House, NE15 8NY
Agenda
No Timing Item Papers Presenter
1 5.15 Welcome and Apologies for Absence - Chair
2 Confirmation of Quoracy - Chair
3 Declarations of Interest Enc Chair
4 Minutes of the Primary Care Commissioning Committee meeting held on 28 November 2017 Enc Chair
5 Action Log Enc Chair
6 5.20 Blaydon GP Practice To follow NHSE
7 5.35 Proposals for General Practice Transformation in Gateshead 2018/19 Enc Gateshead
Transf Team
8 5.45 Enhanced Service for General Practice – DVT Pathway Enc Graeme Hunt
9 5.55 Any Other Business - All
Date of next meeting:
Tuesday 27 March 2018, Newcastle Civic Centre
Declaration of Interest Register 2017/18 (updated 6/12/2017)
EMPLOYEES: Declaration completed by employees
Fina
ncia
l Int
eres
t
Non
-Fin
anci
al
Prof
essi
onal
Inte
rest
Non
-Fin
anci
al
Per
sona
l Int
eres
t
From To
Gov
erni
ng B
ody
QSR
Audi
t Com
mitt
ee
Prim
ary
Care
Co
mm
issi
onin
g Co
mm
ittee
Rem
uner
atio
n
Exec
Com
mitt
ee
Staf
f
Coppin (Taylor) Mandy Lay Member Self
Streetwise Young People's Project which receives funding from Newcastle LA,
Public Health and NGCCG towards sexual health,
counselling and youth work with
young people aged 11-25 years.
Yes DirectCEO of Streetwise
Young People's Project
OngoingWill be declared at
meetings as necessaryY Y Y 02/06/17
Corrigan JoeChief Finance
OfficerSelf
Sibling is GP whose practice is a member of
Cumbria Commissioning
Group
NoWill declare in meetings
where relevantY Y Y Y Y 06/07/17
self Gateshead Council
Yes Direct Senior Officer ongoingWill declare if needed at
meetingsY
spouse NHS England Yes Indirect employee ongoingWill declare if needed at
meetingsY
Cunliffe BillSecondary Care
ClinicianSelf
Care Quality Commissioner
NilMember of CQC Inspection Team
01/04/2017 31/08/2018 Y Y Y Y Y 04/07/17
Self
Healthwatch Newcastle and Healthwatch
Gateshead (Tell Us North CIC) ,
engagement and involvement
statutory organisation
Yes Yes Yes IndirectChief Executive
(employee)01/04/2017 Ongoing
Will be declared at meetings as necessary
Y
DECISION MAKERS: Declarations completed by Governing Body; members of Governing Body committees; staff grade 8d and above; joint committee members; members of advisory groups which contribute to direct or delegated decision making on the commissioning or provision of tax payer services
Date
Com
plet
ed
Com
men
ts
Edusei Stephanie
Primary Care Commissioning
Committee attendee
08/06/17
Costello John
Gateshead HWB representative on
Primary Care Commissioning
Committee
08/06/17
Committees
Surname ForenameCurrent Position(s)
in CCGDOI/Status
Declared interest- (name of
organisation and nature of business)
Is the interest direct or indirect?
Nature of Interest Action Taken
Type of Interest Date of Interest
SelfA New View Ltd,
management consultancy
Yes Direct Director 01/04/2017 Ongoing
Will not seek to do business with the CCG.
Will delclare at meetings as necessary.
Y
Gertig Paul Lay Board Member Daughter yes Indirect
I have one daughter working in the Gateshead Foundation Trust
as a Doctor on her 2nd Foundation
year.
Aug-15 Aug-17To declare at meetings if it might be perceived as
a conflictY Y Y Y 17/06/17
Newcastle YMCA. The YMCA hold
public health funding for anti-
obesity programme.
yes Directchief Executive
Officeron-going
will declare at meetings if necessary
Y Y Y Y
Personal friend with Dr D Howarth and family, Senior Partner, Denton Turret Medical
Group. Friendship started 10 years
ago.
No no yes IndirectClose Personal
friendship dating back 10 years.
On-goingwill declare at meetings
if necessaryY Y Y Y
Kirk Stephen Clinical Director Self DirectPartner in Practice
in CBCon-going Y Y Y 06/06/17
McGrath Jillian Head of Finance spouseWorks for North East Ambulance
ServiceNo Yes Yes Indirect
employed in organsiation which the CCG contracts
with
Pre-dates CCG
present no conflict Y Y Y 31/08/17
McHugh KatharinePortfolio Manager
Primary CareSelf Nothing to declare Y Y 23/10/17
SelfTyne & Wear Sport
Board - TrusteeYes
Trustee Board member
2015 PresentWill declare at meetings
as requiredY Y
Self
Association of Directors of Public
Health - Board Member and
Honorary Treasurer
Yes Yes No Sessional payments 2006 PresentUnlikely to be a conflict - will declare as necessary
Y Y
Self Durham University No Yes No Academic honorary
status2009 Present
Unlikely to be a conflict - will declare as necessary
Y Y
Hurst JeffLay Member and
Deputy ChairSelf 07/09/17
Newcastle
SelfNewcastle University
No Yes No
Academic honorary status (and Vice-
Chair of FUSE strategy board)
1999 PresentUnlikely to be a conflict - will declare as necessary
Y Y
SelfNational Institute
for Health ResearchNo Yes No
Programme Advisory Board
Member2014 Present No conflct Y Y
SelfJournal of Public
HealthNo Yes No
Joint Editor - Unpaid - Faculty of
Public Health2013 Present No conflct Y Y
Wife
Queen Elizabeth Hospital Gateshead
/ City Hospitals Sunderland
IndirectConsultant
Histopathologist1997 Present
Will declare at meetings as required Y Y
Morris Neil Medical Director Self Gateshead CBC Yes Direct GP Deputy OngoingDeclared at relevant
CCG meetingsY Y Y Y Y 29/06/17
Mulholland Jane Director of
Operations and Delivery
Self Nothing to declare Y Y Y Y Y 26/06/17
Date register last updated and published - 06/12/2017
Milne Eugene
Newcastle Wellbeing for Life
Board representative on
Joint Commissioning
19/06/17
Declaration of Interest Register 2017/18 (updated 6/12/2017)
EMPLOYEES: Declaration completed by employees
Fina
ncia
l Int
eres
t
Non
-Fin
anci
al
Prof
essi
onal
Inte
rest
Non
-Fin
anci
al
Per
sona
l Int
eres
t
From To
Gov
erni
ng B
ody
QSR
Audi
t Com
mitt
ee
Prim
ary
Care
Co
mm
issi
onin
g Co
mm
ittee
Rem
uner
atio
n
Exec
Com
mitt
ee
Staf
f
Coppin (Taylor) Mandy Lay Member Self
Streetwise Young People's Project which receives funding from Newcastle LA,
Public Health and NGCCG towards sexual health,
counselling and youth work with
young people aged 11-25 years.
Yes DirectCEO of Streetwise
Young People's Project
OngoingWill be declared at
meetings as necessaryY Y Y 02/06/17
Corrigan JoeChief Finance
OfficerSelf
Sibling is GP whose practice is a member of
Cumbria Commissioning
Group
NoWill declare in meetings
where relevantY Y Y Y Y 06/07/17
self Gateshead Council
Yes Direct Senior Officer ongoingWill declare if needed at
meetingsY
spouse NHS England Yes Indirect employee ongoingWill declare if needed at
meetingsY
Cunliffe BillSecondary Care
ClinicianSelf
Care Quality Commissioner
NilMember of CQC Inspection Team
01/04/2017 31/08/2018 Y Y Y Y Y 04/07/17
Self
Healthwatch Newcastle and Healthwatch
Gateshead (Tell Us North CIC) ,
engagement and involvement
statutory organisation
Yes Yes Yes IndirectChief Executive
(employee)01/04/2017 Ongoing
Will be declared at meetings as necessary
Y
DECISION MAKERS: Declarations completed by Governing Body; members of Governing Body committees; staff grade 8d and above; joint committee members; members of advisory groups which contribute to direct or delegated decision making on the commissioning or provision of tax payer services
Date
Com
plet
ed
Com
men
ts
Edusei Stephanie
Primary Care Commissioning
Committee attendee
08/06/17
Costello John
Gateshead HWB representative on
Primary Care Commissioning
Committee
08/06/17
Committees
Surname ForenameCurrent Position(s)
in CCGDOI/Status
Declared interest- (name of
organisation and nature of business)
Is the interest direct or indirect?
Nature of Interest Action Taken
Type of Interest Date of Interest
SelfA New View Ltd,
management consultancy
Yes Direct Director 01/04/2017 Ongoing
Will not seek to do business with the CCG.
Will delclare at meetings as necessary.
Y
Gertig Paul Lay Board Member Daughter yes Indirect
I have one daughter working in the Gateshead Foundation Trust
as a Doctor on her 2nd Foundation
year.
Aug-15 Aug-17To declare at meetings if it might be perceived as
a conflictY Y Y Y 17/06/17
Newcastle YMCA. The YMCA hold
public health funding for anti-
obesity programme.
yes Directchief Executive
Officeron-going
will declare at meetings if necessary
Y Y Y Y
Personal friend with Dr D Howarth and family, Senior Partner, Denton Turret Medical
Group. Friendship started 10 years
ago.
No no yes IndirectClose Personal
friendship dating back 10 years.
On-goingwill declare at meetings
if necessaryY Y Y Y
Kirk Stephen Clinical Director Self DirectPartner in Practice
in CBCon-going Y Y Y 06/06/17
McGrath Jillian Head of Finance spouseWorks for North East Ambulance
ServiceNo Yes Yes Indirect
employed in organsiation which the CCG contracts
with
Pre-dates CCG
present no conflict Y Y Y 31/08/17
McHugh KatharinePortfolio Manager
Primary CareSelf Nothing to declare Y Y 23/10/17
SelfTyne & Wear Sport
Board - TrusteeYes
Trustee Board member
2015 PresentWill declare at meetings
as requiredY Y
Self
Association of Directors of Public
Health - Board Member and
Honorary Treasurer
Yes Yes No Sessional payments 2006 PresentUnlikely to be a conflict - will declare as necessary
Y Y
Self Durham University No Yes No Academic honorary
status2009 Present
Unlikely to be a conflict - will declare as necessary
Y Y
Hurst JeffLay Member and
Deputy ChairSelf 07/09/17
Newcastle
SelfNewcastle University
No Yes No
Academic honorary status (and Vice-
Chair of FUSE strategy board)
1999 PresentUnlikely to be a conflict - will declare as necessary
Y Y
SelfNational Institute
for Health ResearchNo Yes No
Programme Advisory Board
Member2014 Present No conflct Y Y
SelfJournal of Public
HealthNo Yes No
Joint Editor - Unpaid - Faculty of
Public Health2013 Present No conflct Y Y
Wife
Queen Elizabeth Hospital Gateshead
/ City Hospitals Sunderland
IndirectConsultant
Histopathologist1997 Present
Will declare at meetings as required Y Y
Morris Neil Medical Director Self Gateshead CBC Yes Direct GP Deputy OngoingDeclared at relevant
CCG meetingsY Y Y Y Y 29/06/17
Mulholland Jane Director of
Operations and Delivery
Self Nothing to declare Y Y Y Y Y 26/06/17
Date register last updated and published - 06/12/2017
Milne Eugene
Newcastle Wellbeing for Life
Board representative on
Joint Commissioning
19/06/17
Page 1 of 5
D R A F T
Minutes of a meeting of the
Primary Care Commissioning Committee held on Tuesday 30 January 2018 at Gateshead Civic Centre
Present:
Members: Mr Jeff Hurst Lay Member (Chair) JH Ms Mandy Coppin Lay Member MC Dr Steve Kirk GP Clinical Director SK Ms Jill McGrath Head of Finance JMc Dr Neil Morris Medical Director NM In attendance: Mr John Costello Gateshead Health and Wellbeing Board JC Ms Steph Edusei Healthwatch SE Mr Graeme Hunt Commissioning Delivery Manager, NECS (item 6) GH Ms Wendy Stephens NHS England WS Members of the public Ms Sue Tulloch PA Support ST
01/18 01 Welcome and Apologies for Absence
Apologies (members) received from Dr Bill Cunliffe (Secondary Care
Clinician) and Ms Jane Mulholland (Director of Operations and Delivery) Apologies (in attendance) received from Ms Katharine McHugh (Designated
Lead for Primary Care). 01/18 02 Confirmation of Quoracy
The Committee was confirmed as quorate.
01/18 03 Declarations of Interest
Declarations of interest documentation had been circulated with the agenda. There were no further declarations made relating to items on the agenda.
01/18 04 Minutes of the Previous Meeting held on 28 November 2017
The minutes of the previous meeting were agreed as an accurate record.
Page 2 of 5
01/18 05 Action Log
There were no outstanding actions due for this month.
01/18 06 Primary Care Based Enhanced Services for 2018/19 Graeme Hunt, Commissioning Delivery Manager NECS, informed the
Committee that in late 2016/17 the CCG undertook a consultation exercise with practices in Newcastle and Gateshead with regard to reinvestment of PMS monies. He provided details of two proposed enhanced services within the Basket of Care for approval by the Committee – Diabetes and Anti-Psychotic Monitoring.
These services had been considered by a number of groups providing
feedback and scrutiny with costings worked up against affordability. Equity across Newcastle and Gateshead was an important factor.
Steve Kirk, who had been involved in developing the Diabetes specification,
highlighted the duplication that currently exists in primary and secondary care. This service will facilitate the transfer of stable diabetic patients into primary care with support from the Diabetes Centre. It will also help with patient assessment for the national diabetes prevention programme and provide a structured approach for diabetes care in primary care.
With regard to the Anti-Psychotic Monitoring providing better physical health
care for mental health patients, this service aims to ensure effective management of patients on a consistent basis across all practices in Newcastle and Gateshead.
The Committee unanimously approved the service specifications and
payment of Enhanced Services for Diabetes and Anti-Psychotic Monitoring on the basis of: • increasing access to diabetes prevention services • providing support to practices in a structured approach to diabetes care • removing duplication of services in primary and secondary care • improving the physical health of patients with mental health problems • the obligation to reinvest the funding into primary care • bringing equity across Newcastle and Gateshead and moving towards
best practice
01/18 07 Ponteland Road Health Centre – Procurement Options In October 2017, the Committee agreed to attempt to procure a provider for a
standalone practice under the APMS contract for the Ponteland Road Health Centre. The Committee had acknowledged at the time that the risk of the procurement being unsuccessful, would lead to dispersal of the practice list in a reduced timeframe.
Wendy Stephens reported that, unfortunately, it had not been possible to secure a provider.
Page 3 of 5
The Chair reminded the Committee that the arguments for attempting the procurement had been persuasive and the Committee had accepted the risk of the shorter timescale for dispersal should the procurement exercise be unsuccessful. The Committee had been hopeful of a positive result and were disappointed that a provider had not been identified and they were now facing dispersal. It was recognised that anyone taking on the contract would face challenges and therefore only a bid that was seen as sustainable and achievable could be considered. The current provider had stated they were finding it difficult due to recruitment issues.
Concern was expressed about the challenges being faced in recruitment of
GPs and the implications this has for the future with the new working models that are emerging. Stakeholders need to respond to the changes in order to ensure continuity of patient care.
It was reported that NHS England’s dispersal plan ensures clinically vulnerable patients are monitored to ensure they register with another practice. If they fail to do so, they will be allocated to the nearest practice to where they live and NHS England will work with the practices to support those patients. Steph Edusei highlighted the importance of effective contact with patients to ensure their understanding of the situation. Communication by letter should be kept simple and straightforward and other methods of conveying the message should also be used. Patients should first have the option to choose and be helped to make an informed choice. She agreed that Healthwatch would assist with the communication exercise. Mr A K Jassal, Ponteland Road Pharmacist, said that his bid had failed to meet the necessary requirements but still maintained an interest and requested discussions with the CCG to help resolve these. It was explained that this would mean the tender process would need to be opened up again to the market with the potential of being unsuccessful for a second time. This would create further delay and the emergency contract was due to finish at the end of March 2018. The procurement legislation must be followed with equal opportunity provided to all potential bidders. There had been strong reasons for the bid being unsuccessful and, therefore, not taken forward. Councillor Oskar Lavery (Blakelaw) asked for further information on the bids received and reasons for non-compliance. It was confirmed that only one bid had been received and the reasons for non-compliance were reported to the bidder but could not be shared with others. With regard to dispersal, Councillor Lavery asked that the accessibility of the nearby practices be considered from the perspective of the patient. Only one of the two nearby practices is close enough to attend on foot and, particularly in the dark, the route would be a concern for the vulnerable. Bus routes to
Page 4 of 5
the practices were not direct requiring a trip into town to access the appropriate bus. It was noted that support was needed for practices taking on dispersed patients in relating to their capacity to do so. The Committee noted the outcome of the procurement exercise and, following the discussion at the meeting involving committee members and the public, approved the recommendation in the report for the commencement of dispersal of the Ponteland Road Health Centre patient list on the basis that the procurement exercise had failed to secure a provider of the service.
01/18 08 Grainger Medical Group – Procurement Outcome At the October 2017 meeting, the Committee agreed that a procurement
exercise to identify a provider for a practice on the Elswick site be attempted. Wendy Stephens reported that the procurement exercise ended on 6 December 2017 and no bids had been received.
The Committee now needed to consider whether to close the practice at the
end of the emergency contract, 31 March 2018, and disperse the patient list or offer the emergency contract provider a six month extension to allow time to either disperse the practice list or conduct a second procurement exercise.
It was noted that public consultation on dispersal had not previously been
pursued, the patient list being too large and with limited capacity available nearby. Also this was not in keeping with the CCG’s strategy for the area.
The Chair was concerned that having not previously engaged with patients
on the option of dispersal, this was not something they would wish to pursue lightly. Considering the size of the patient list and the investment already made in this practice, he felt that an option to continue to look for a provider should be considered.
Neil Morris agreed that a second procurement exercise, although not
guaranteed to be successful, was his preferred option. Steph Edusei was concerned that there should be clear communication with
patients to ensure they understand the situation and the implications should a second procurement exercise be unsuccessful.
Councillor Oskar Lavery (Blakelaw) speaking on behalf of Elswick
colleagues, strongly agreed on the need to keep the practice open and that dispersal be a last resort. This is an extremely deprived area with challenging health issues.
Members voted unanimously to conduct a second procurement exercise
offering the existing emergency provider a six month contract extension to allow for this to take place. This decision was based on:
Page 5 of 5
• there had been no previous consultation with patients about dispersal • the significant size of the patient list that would need to be dispersed • the issues and capacity of other practices in the area • the CCG’s strategy for practices in this location
The hope was that there would be a successful outcome to the second procurement exercise but it was noted that patients would need to be informed as part of the communication exercise regarding the second procurement that should it fail to identify a contract provider, this could lead to dispersal of the practice list.
01/18 09 Primary Care Budget Monitoring Month 8 (2017/18) Jill McGrath presented the report which outlined performance against the
approved primary care budgets at Month 8. The forecast outturn position is reported as breakeven at this point however early Month 9 figures are starting to see some level of underspend emerging.
Budget risks remain including premises costs where there has been variable
information provided by Property Services. Some detailed information is now becoming available and quarterly updates have been requested which should help clarify the situation.
The Committee noted the position at Month 8.
01/18 10 £3 Per Head Transformational Support Process Neil Morris presented the paper outlining the proposed process for allocating
these funds. The paper highlighted the wide engagement with GPs and various groups to agree the process for how the money should be spent.
The Committee unanimously agreed to the process outlined in the report.
01/18 11 Any Other Business
There was no further business
Agenda item 5
Primary Care Commissioning Committee – February 2018
Action Log
Meeting date
Minute reference
Action Lead
Due Status
28/11/17 11/17 06 Impact of Integrated Multi-Morbidity Clinics in General Practice – Qualitative Outcomes British Heart Foundation evaluation to forwarded to the Committee
S Chapman Mar 2018 Ongoing
27/06/17 06/17 06 Central Resilience Funds Proposal Feedback to the PCCC following engagement workshops
K McHugh Apr 2018 Ongoing
Cover Sheet
Meeting Title Primary Care Commissioning Committee
Date 27 February 2018
Agenda Item 7
Report Title Proposals for General Practice Transformation in Gateshead 2018/19
Synopsis The General Practice Five Year Forward View (GPFV - NHSE, 2016), committed to a £171 million one-off investment by CCGs, starting in 2017/18, for transformational support to general practice. This is intended to be used to;
• “stimulate development of at scale providers for extended access delivery
• stimulate the implementation of the 10 high impact changes in order to free up GP time
• secure sustainability of general practice to improve in-hours access”
In the CCG GPFV Plan the CCG committed to invest this funding on “work including;
• Gateshead and Newcastle Transformation Teams; the CCG currently funds transformation teams in both Newcastle and Gateshead to support new models of care and to deliver the aspirations of the GPFV.
• Additional work in the Basket of Care project to support the transfer of care out of hospital into general practice
• Work in practices to reduce demand on secondary care • Workforce developments such as extended nurse roles and
additional GP roles” The Gateshead General Practice Transformation team (GGPTT) was set up in 2015. It is funded by Newcastle Gateshead CCG for 3 years and hosted by CBC Health. Funding the GGPTT is an element of the CCG’s support to general practice. The Team’s remit has included developing resilience through working together ‘at scale’ and through new care models.
Over the summer of 2017 a group of Gateshead GPs, practices managers and practice nurses (‘The Engine Room’) worked with the support of CBC Health and GGPTT to produce at set of proposals for General Practice at Scale, across the following workstreams:
• Transfers of Care • Urgent Care and Access • Care of complex younger patients • Care of complex older patients • Structure, governance and organisational development
The Engine Room proposals were presented to Gateshead practices at a large workshop on 30 November, attended by almost all Gateshead practices. These proposals have been collated into a programme of work for general practice transformation in 2018/19.
A strong general practice based organisation is needed to lead on this work, and the development of this role is a key priority to support sustainable general practice and to support the best care across the system. A clear recommendation from the Engine Room work was to develop the GP Federation role within CBC Health in Gateshead both to move forward the clinical workstreams and to meet the strategic needs in the system. For example, engagement in strategic discussions about health and care, and within the Gateshead Care Partnership, will be through the Federation. The attached paper (Appendix 1) describes the transformation plans for general practice in Gateshead, and sets out detailed proposals for 2018/19, for funding from the CCG transformation funds.
Implications and Risks
The current pressures on general practice present a very clear risk to the health and care system. Measures to support sustainability in general practice are a crucial priority for the CCG. It is well recognised nationally that one way of reducing the risks is through developing strong, resilient, general practice by working at scale and through new models of care.
The need for general practice to work together as a single voice within the ‘system’ is clear. Strategic developments in the wider system are moving forward quickly, and general practice needs to be able to clearly articulate its perspective in these discussions, to ensure developments and innovations can deliver the best outcomes for patients across the entirety of their care. There is great potential for development of a range of functions, including service provision at scale, care pathway re-design, service development and system development.
Staff working in Gateshead practices have been fully engaged in
developing the proposals to move forward in the clinical pathways proposed. We risk losing this energy and motivation if we do not support a clear arrangement to implement their plans, with strong leadership.
Recommendation It is recommended that the proposals in the paper be supported and funding allocated for 2018/19 to enable the work to move forward.
Report history The report has been discussed by: Operational Group (CB/GGPTT/Engine Room) – February 1st 2018 CCG Delivery Group – February 6th 2018 To be discussed by CCG Primary Care Committee – February 27th 2018
Lead Director & Report Author
Director: Neil Morris Title : Medical Director
Author: Gateshead General Practice Transformation Team
Classification Official
Purpose (click one box only) Decision ☒ Information ☐
Benefits to patients & the public
Fundamentally, implementing these proposals will support general practice in developing resilience, and in sustainability in meeting day to day workload and demand. It will also support enhanced quality of care, as practices work together on implementing these proposals to support the care redesign for some of our most vulnerable patients.
Links to Strategic objectives
These proposals link to all the CCG strategic objectives.
Identified risks & risk management actions
Each workstream to be supported will have a risk log and a risk management plan in place.
Resource implications
The resource implication of the work is set out in the papers, and totals £399,521.
Legal implications & equality and diversity assessment
Legal advice will be taken where required in terms of working at scale.
Sustainability implications
The funding is short term and therefore a key element of all workplans is to ensure that transformation projects are complete and included in mainstream activity, and plans for ongoing delivery are in place.
NHS Constitution Principles; 1 The NHS provides a comprehensive service available to all 3 The NHS aspires to the highest standards of excellence and professionalism 6 The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources
Next steps Once funding is confirmed, arrangements will be put in place to move
the work forward as described in the detailed paper at Appendix 1.
Appendices Appendix 1: Proposals for General Practice Transformation in Gateshead 2018/19 Appendix 2: Outline of Proposals from Clinical Workstreams of Engine Room November 2017
Appendix 1
Proposals for General Practice Transformation in Gateshead 2018/19
1. Introduction
This paper presents proposals to take forward general practice transformation work in Gateshead in 2018/19. These proposals build on the transformation and engagement work achieved through the work of the Gateshead General Practice Transformation Team (GGPTT).
This transformation work is at the core of developing general practice at scale in Gateshead, to secure resilience and sustainability for general practices. It is also about realising a long-term vision which places general practice at the heart of the health and care system.
2. Background and strategic context
The GGPTT has worked with practices in Gateshead since the summer of 2015, to support general practice to meet the challenges faced from pressures such as in recruiting staff; rising clinical workload; financial pressures; and increased administrative pressures, e.g. CQC registration. The Team is funded by the CCG and hosted within CBC Health. Building resilience and sustainability in general practice by working at scale has been a core aim of the Team.
When the GGPTT was formed it initially worked extensively to engage general practices, listening carefully to what practices perceived to be their challenges, and generating ideas as to the sorts of initiatives that would help practices to preserve the best of what they do now, while changing, adapting and improving to meet the challenges they face.
The Team heard some very clear messages from Practices: Practices are local, independent, community based units, with a history in their locality, extensive knowledge of the families and patients in their care, and their own way of doing things. The overwhelming majority of GPs and practice staff do not want to change this – it is the very essence of what makes general practice unique, valued and effective.
Yet Practices recognised that it is increasingly difficult to manage all aspects of their work at practice level, and that by working collectively with other neighbouring, or like-minded practices, they can achieve their common aims more efficiently and effectively and with less duplication. They can also work together as a group to employ staff, or manage a service – things which are not feasible when operating as individual practices. Practices also recognise that they need to be more resilient. Even those practices who feel they are well staffed and managing well, acknowledge that they are potentially vulnerable: the impact of one or two changes in staffing can be significant, and potentially disastrous, in general practice teams.
The GGPTT initially designed a work programme with Practices to look at 5 areas, where we could test and implement ideas which would make a difference to practices, patients and their staff, build resilience and sustainability. These workstreams included very practical elements as well as more strategic work, through social prescribing, nursing, multi-disciplinary team working; and improving access to increase capacity. Another workstream looked more generally at working at scale, including examining new models of care and looking carefully at what has been achieved across England in implementing ‘new models of care’
Alongside this work, discussions in the health and care system in Newcastle and Gateshead have moved on. Strategic Transformation Plans were published, and a Communities and Neighbourhoods plan for the CCG put in place. The Gateshead Care Partnership (GCP), a Gateshead based partnership, took on the provision of community nursing services in October 2016. Building on this, strategic discussions continued between the
Local Authority, acute Trust, CBC and other key providers in the Gateshead health and care system, who have committed to move forward as an ‘integrated care system’. It is widely recognised that these strategic discussions need more input from general practice, and that practices need a single voice, to strengthen this input. General Practice needs to work collaboratively, through a strong ‘at scale’ organisation, to ensure it is able to secure its future by, for example, taking on services for the whole population, working collectively on quality improvement and care pathways, and supporting practices in times of vulnerability.
In this context, early in 2017, the GGPTT worked closely with the CCG and CBC Health to move to the next level of engagement of general practice. A programme of work was agreed: an intensive piece of work over 4 months, where colleagues from practices would work on developing visions and proposals across 4 areas:
• Transfers of Care • Urgent Care and Access • Care of complex patients (split into older complex and younger complex patients) • Structure, governance and organisational development (to support the proposals from the above)
Subsequently, over the summer of 2017 a group of Gateshead GPs, practices managers and practice nurses, entitled ‘The Engine Room’ worked with the support of CBC Health and GGPTT to produce a set of proposals for General Practice at Scale, based on these workstreams. Each workstream produced a set of recommendations (see summary in Appendix 2), and these Engine Room proposals were presented to Gateshead practices at a large workshop on 30th November, attended by all but 2 of the Gateshead practices.
Following the meeting, practices have completed a survey monkey questionnaire to indicate the proposals they would be interested in taking forward. The Engine Room team, with the GGPTT is currently processing these responses to plan the next steps in implementing this work.
3. Proposed Arrangements for January to March 2017
The GGPTT was funded for 3 years from 2015 and this funding is coming to an end at 31st March 2018. Whilst Newcastle Gateshead CCG has indicated that there is transformation funding available to support moving this work to the next stage in 2018, this will not be confirmed until February 2018, and in addition, 3 of the 5 members of the team are due to retire at the end of March.
In this context, a set of interim management arrangements are proposed with clinical leads and practice managers from the engine room project progressing the work on behalf of each of the workstreams. This approach will ensure momentum is continued with the work while funding sources are found and will also ensure continued engagement from those interested colleagues. Funding is still available within the current GGPTT budget until 31st March 2018, to support an interim working group supported by the GGPTT and CBC Health to maintain the development and implementation of the engine room proposals. As the current GP lead of the GGPTT will be retiring at the end of March it is proposed that an interim chair be agreed to ensure continuity.
The short-term aims will be the development of the pilots for transfers of care, planning the pilot for the urgent care workstream and work on agreeing a model for the involvement at scale of Gateshead General Practices in shared care prescribing for substance misusers.
Proposals for the interim working group are:
• GP chair/ lead GP • GP and practice manager leading on transfers of care • GP and practice manager leading on substance misuse and complex younger people
• GP leading on urgent and same day care • GP and practice manager leading on structure and governance • GP leading on complex older people • Practice Manager leading on CQC polices and determining clear cost savings on indemnity, joint
purchasing and accounting. • CBC Chief Executive • GPTT lead nurse • GGPTT business manager
4. Proposed Arrangements for 2018/19- Gateshead General Practice Transformation
The need for general practice to work together as a single voice within the ‘system’ is clear. Strategic developments in the wider system are moving forward quickly, and general practice needs to be able to clearly articulate its perspective in these discussions, to ensure developments and innovations can deliver the best outcomes for patients across the entirety of their care. There is great potential for development of a range of functions, including service provision at scale, care pathway re-design, service development, system development. Developing a strong organisation to lead on these is a key priority not only for sustainable general practice but to support the best care across system.
One of the clear outputs from the Engine Room work is to develop the role of a GP Federation to move forward the clinical workstreams and to meet the strategic needs in the system. It was agreed this Federation should be developed within CBC Health, and that engagement in strategic discussions about health and care, and within the Gateshead Care Partnership, will be through the Federation. The aspiration is that all Gateshead practices agree to be part of the Federation, so that there is a strong and clear voice for Gateshead general practice in the important strategic decision-making process. The Federation will develop a longer-term vision to take on a provision and planning function, meeting the needs above.
As the next step towards Federation development, we are working to establish the Federation as an entity within CBC Health by 2018/19. The Federation will have a clear workplan for 2018/19, and will be supported by a Management Team to support its development in the initial stages. In the longer term, it is envisaged that the Federation will develop more fully in the system.
The following chart shows the workstreams proposed for 2018/19:
5. Proposed Work Plan and Resourcing for Gateshead General Practice Transformation 2018/19
The work plan for each of the workstreams identified above is summarised in the table below.
The workplan is developed from the recommendations from the engine room work in 2017, and from feedback from the Practices at and following the workshop on 30th November 2017. Each workplan is supported with costed plans, a broad overview is shown in the table.
Workstream Recommendation Lead Timescales Transfers of care
i) Pilot and test ways of working, comparing Docman and EMIS solutions across 5 practices (3 months) ii) Complete evaluation and develop a cost share model for practices to consider iii) Develop a roll out plan with interested parties and begin implementation
Clinical Lead Supported by a Practice Manager and CBC Manager Administrative support
Pilot 2017/18 short term Evaluate and develop a model for roll out in 2018/19
Urgent Care and Access
i. Develop project plan ii. Undertake patient engagement on a
new model (working with Involve NE) iii. Work with interested practices to
develop detailed operational arrangements and protocols
Clinical Lead Supported by GP Practice Manager
Develop project plan 2017/18 Start working towards pilot in 2018/19 (spring or autumn)
Programme Board/Federation
Board (in CBC)
Management Team
Clinical workstreams
Complex older patients
(GCP lead) Transfers of care Urgent care and
access Younger complex
patient
substance misuse
Developing MDT working and link
workers
Chronic pain
Sustainability planning
Non clinical workstreams
Research and audit
Efficiencies/back office
Longer term models of working
at scale
iv. Test new way of working at scale on same day access (groups of 5 practices)
medium term
Care of Younger Complex patients (1) Substance misuse
This service is being re-designed and re-commissioned by the Local Authority We need to work at scale with Gateshead practices and with appropriate partner organisations, to bid for the contracts
Clinical lead/s CBC Health team GP and Practice Management input
January 2018 onwards, in line with procurement timescale short term
Care of the Younger complex patient (2)
To take forward the 3 tier working recommendations from the workstream:
a) Medically unexplained symptoms pilot
b) Chronic pain pilot c) MDT working d) Role of link workers
Clinical Lead Practice Manager
2018/19 2019/20 medium to longer term
Care of the complex older patient
To take forward the recommendations from the workstream in developing a 3-tier service for complex older patients and moving towards a virtual frailty service
There is a clear link in this workstream with the work of GCP Recommendations to be taken forward by GCP under its workstreams
2018/19 medium term
Developing a supporting management structure and infrastructure
Recommendation to develop the Federation of GP practices in Gateshead, within CBC Health. This will: i. Develop its role as the
‘voice’ of General Practice, influencing decision making in the wider health and care system
ii. Support the implementation of the clinical workstreams, and other at scale work for Gateshead GP
iii. Support those practices who wish to look at alternative models for working together in the longer term
Developing the Federation agreement and establishing the entity will be a key short-term goal
Develop a management team to support this work. Interim arrangements for a management team for 2018/19: Core Team Clinical Lead/Lead GP Business Manager Lead Nurse Administrator Sessional GP input from GPs, Practice Manager Workforce Leads
Interim arrangements in place 2017/18, and for 2018/19 One of the objectives of this work programme will be to develop a sustainability plan for 2019 and beyond, and a management team Short term
Delivering efficiencies from working at scale
To progress further the work on delivering efficiencies through working at scale, through non-clinical/back office function, and e.g. bulk procurement
Sessional input from a Practice Manager
2017/18 2018/19 Medium term
6. Vision for the Future
We will have developed an effective GP at scale organisation that will take forward the transformation work and in addition support practices in the following areas;
7. Outcomes
By March 2019 we will aim to have:
• An effective General Practice Federation, as an entity within the structure of CBC Health with clear leadership structure, vision and strategy and resourced plan for sustainability going forward.
• Developed the Federation to engage General Practice and to speak on behalf of practices in the wider health and care system.
• Developed the Federation with the support of CBC to support practices that are struggling. • Consulted with the CCG and practices to develop new ways of working to ensure the enhanced
service offer is available universally across Gateshead Practices. • Agreed with practices how the Federation can support practices with preparation for CQC
inspections to reduce variation and improve quality • Developed cost share models for back office functions, joint purchasing agreements and support for
governance within practices to realise savings for practices.
GP Federation
General Practice Resilience
New and additional Services/population
based provision
Working at scale
General practice Transformation
Quality / Reducing Variation/
CQC
Representation and system
development
Provision of GP Services
• Increased resilience in General Practice and reduced the risk of practices failing by facilitating joint working across the range of projects listed below.
• Piloted working at scale in managing transfers of care, developed a cost share model for ongoing provision and roll out across Gateshead for interested practices
• Piloted a model for working at scale on same day access, evaluated this pilot and if successful, develop a plan to roll out to interested practices.
• Supported and coordinated a Gateshead wide Primary Care led bid for shared care for substance misuse.
• Worked with partners to deliver other recommendations from the younger complex patient group • Implemented the primary care elements of the new frailty model which will improve care and
reduce pressure on all parts of the health and social care system. • Supported local implementation of the GPFV • Have taken forward and supported discussions with those practices who wish to look at other
governance models, e.g. super partnership • Have clear mechanisms to link into cross cutting programmes, such as IM&T, workforce, planning
and strategy
We will work with the CCG and CBC Health to develop measures and evaluation for these outcomes.
8. Engagement
The proposals put forward for general practice transformation in Gateshead have been developed through an engagement programme which has been integral to the work programme of the GGPTT. The Engine Room programme was launched at a TITO event, and throughout the process a series of engagement events with practice staff were held. The core of these proposals have been developed by GPs, Practice Nurses and Managers who work in Practices in Gateshead, through the Engine Room exercise. The detail of the proposals were presented to Practices on 30th November, at which over 100 colleagues working across Gateshead practices were present, and through which feedback was received.
Following the November meeting, a Leadership Group and an Operational group was formed, meeting regularly to manage the next steps. Colleagues from practices, the GGPTT, CBC Health and the CCG as well as the LMC are represented on these Groups. In terms of wider engagement, the GGPTT are co-located with the leadership team of the Gateshead Care Partnership (GCP), and GCP staff have been involved in the relevant Engine Room workstreams. The GCP Board (which includes representatives from the QE, Local Authority, CBC and NTW NHS Trust) received a presentation on the outcome of the Engine Room proposals in November 2017. We have also worked with Involve on developing a patient engagement programme which will be implemented as we implement the proposals.
This paper is due to be discussed by the CCG Delivery Group on 6th February 2018.
9. Leadership
The delivery of this programme of work will need support from a leadership team. It is proposed to appoint a small core team to support the clinicians and practice managers who are leading the workstreams on a sessional basis. The core team will co-ordinate all the workstream and other activity, and work closely with CBC Health, Newcastle Gateshead CCG and the GCP on moving the full general practice transformation programme forward.
10. Proposal Costs
Core Leadership Team Weekly Sessions/wte
Lead GP 4 Lead Nurse 4 Business Manager 0.4 wte Adminstrator 0.5 wte Total costs core team
117,537
Sessional staff and Clinical Leadership GP Clinical leads 4 Practice Manager input 4 Practice Nurse input 1 Workforce lead 2 Total costs sessional staff
94,300
Non Pay costs Travel, venues and non pay - 15,000 Fees - 30,000 Overheads costs/office etc
- 25,684 282,521
Transfers of Care Project Roll out costs – admin staffing 1.00 27,000 Urgent Care (same day access) Contribution to costs of establishing a pilot for practice collaboration on same day urgent care
90,000
Total Costs 399,521 Notes: costs for the core team are based on salaried staff and include on costs/holiday etc.
The Federation will be developed within CBC Health, and the core team be appointed within CBC Health, to begin to shape and drive forward this agenda. Staff who undertake work on a sessional basis will invoice for their time and be paid from the budget held by the Federation within CBC. One of the objectives of the management team over the 2018/19 year will be to develop a model for sustainability for the Federation going forwards including a clear vision and strategy.
Transfers of care costs include funding to support a member of the administration team to support practices with the roll out of the programme through 2018/19. Leadership costs are included in the costs of sessional input to the work programme.
Costs for the urgent care/same day access pilot are to set up and test a pilot. The detailed costings for this have been worked up by the Engine Room team with support from CCG Finance team, and full costs are estimated at £156k for a full 6 month pilot. Funding of £90k is requested from the transformation fund to support this work, and to test ways in which practices can work together on this very significant element of daily workload.
11. Funding
National funding was identified by NHS England in the GPFYFV for GP transformation work. In Newcastle Gateshead CCG the following criteria were agreed to allocate this funding:
• Gateshead and Newcastle Transformation Teams; the CCG currently funds transformation teams in both Newcastle and Gateshead to support new models of care and to deliver the aspirations of the GPFV.
• Additional work in the Basket of Care project to support the transfer of care out of hospital into general practice
• Work in practices to reduce demand on secondary care • Workforce developments such as extended nurse roles and additional GP roles
The proposals in this document have been developed by staff from within general practice in Gateshead, to support working at scale. Implementing these proposals more fully will support general practice in developing a sustainable model of working, which is resilient and which will form a sound basis on which to strive for continuous service improvement for Gateshead patients. Funding is sought from Newcastle Gateshead CCG, against the £3/head monies, to support the above proposals.
Gateshead GP Transformation Team
February 2018
Appendix 2
Outline of Proposals from Clinical Workstreams of Engine Room November 2017
Care of Older, Complex Patients
Our proposal is to create a model of care that includes a three-tier ‘enhanced offer’ for the care and support of older people with complex needs in Gateshead. This offer will form part of the wider People, Community and Care system model; with delivery embedded in the local transformation of community services, general practice and care home services. Gateshead is well placed to support people and families living with complex needs. In essence, we need to provide a common approach to the prevention and early recognition (through case-finding) of older people with complex needs (including frailty), followed by an appropriate assessment and tailored proactive and responsive coordinated care and support – managing frailty as a LTC and offering Care and Support Planning across a lifetime.
Care of the Younger Complex Patient
The group looked at the factors that contribute to this complexity and cost. We believe these include:
• Poor mental health • Substance misuse • Health and Social Care Funding Cuts • Welfare Reforms • Homelessness • Chronic Pain • Persistent Physical Symptoms (sometimes known as Medically Unexplained Symptoms)
Proposed clinical models
We would like to suggest a tiered approach to supporting these complex younger patients within practices. Within the services offered we feel that the principles of care mirror those suggested for complex older people:
• Identification of younger complex patients • Good case management, including a case manager who the patient knows and trusts • The provision of good multi-disciplinary (MDT) working at practice, locality and borough wide level
The proposed service model is illustrated in the diagram:
Transfers of Care
This project has:
• Looked at handling of clinical correspondence • Piloting a centralised workflow management system • Quality and safety essential components • Aim to save time for GPs and admin staff
We have developed a proposed centralised process for workflow management (see diagram). Under our proposal, participating practices will receive incoming clinical information in either electronic or paper form and will process it into a central workflow inbox. This inbox will then be processed centrally and managed by a skilled team of administrative staff and pharmacists who will read code, make adjustments to medications and then file the document if no further action is required. If further tasks such as a nurse or phlebotomy appointment are required then a task can be sent to the practice. If a letter contains vital clinical information (as agreed by the practices) the letter would be workflowed back to the appropriate GP.
This project has generated considerable interest from Gateshead practices as it will help practices to save time spent on administration and therefore spend more time on clinical and patient facing issues. We anticipate the new model to be widely rolled out to interested practices once we have tested and refined the detail.
Pilot
Tier 3
Monthly MDT Meeting with representation from each partner agency detailed in Appendix 1
.
Tier 2 Specialist provision for those with needs that
cannot be met at Tier 1. GPSI undertaking shared care prescribing on a
locality basis Chronic pain pilot.
Medically unexplained symptoms pilot Link workers providing 1-1 support including
assessment and intervention for those patients that are unable to access/navigate services
without support.
Tier 1 Primary Care Navigators working in practices. Offering signposting and support for patients who are able to access services with signposting and advice only.
The scope of the pilot is;
• Comparing Docman system to EMIS system • CBC run practices will test EMIS • Glenpark and Wrekenton practices to test Docman • Information collated on which is the best system, the time saved and other benefits e.g. quality • Recommendations on further implementation will be made
Urgent Care and Access
The following illustration describes the rationale for looking at urgent same day access for patients to their GP.
E-mail letters/contacts
Electronic letters Paper letters
scanned
Triage team
NO action required -
FILETake Action
Coding teamPharmacy
team
File
Admin/GP
IN P
RACT
ICE
OU
TSID
E O
F PR
ACTI
CEIN
PRA
CTIC
E
Proposal for Workflow Management (at scale)
Develop an urgent care
system that fits into existing primary care frameworks
Increase practice’s
resilience and ability to cope with increasing
demand
Continue to provide better access safely and with high
quality.
Certain patients prefer seeing their own GP and that their
own GP provides the best level of
care for them.
Following research and analysis, the Group proposed a hub based model of an urgent care team run by GPs and advanced nurse practitioners (ANP). The idea would be to build on the success of the ExtraCare model, and to expand the provision in the hubs to provide a further same-day service. This would include access to a multidisciplinary team as needed, such as a mental health worker. The model is illustrated below:
Cover Sheet
Meeting Title Primary Care Commissioning Committee – PUBLIC
Date 27 February 2017
Agenda Item 6
Report Title Blaydon GP Practice
Synopsis Blaydon GP Led Practice is a GP practice which is based at the Blaydon Primary Care Centre, Shibdon Road, Blaydon, NE21 5NW which delivers essential, additional and enhanced services to a registered list of 2,067 patients (2,014.01 weighted) as of 01 January 2018 under an APMS contract.
The contract is held by Community Based Care Ltd (CBC) and is due to expire on 30 June 2018. There is now a requirement to determine the future of the practice beyond 30 June 2018.
In order to determine commissioning intentions, the CCG has undertaken the following:
• Market engagement to establish the willingness of the market to deliver a service in the area, preference of contracting model and what barriers there could be to bidding for the service;
• Patient/stakeholder engagement to help to support the development of options to be taken forward for consultation.
• Patient/Stakeholder consultation to determine level of support for two options identified;
• An overall review of the current service and the local area (previously considered at committee).
The two options identified are: • Option 1 – Procurement (Keep a practice); • Option 2 – Closure of the practice and dispersal of the patient list.
The consultation outcome showed that, not unexpectedly, the majority of patients supported the option to keep Blaydon GP Practice open. The full consultation outcome report can be seen in Appendix 3.
Information in respect of each option, alongside an assessment of each option has been undertaken and each option has been scored against specific criteria. The scores for each option are as follows; Option 1 – Procurement - 310
2
Option 2- Closure and dispersal - 420
Implications and Risks
• The practice contract is due to end and so a decision is required to determine next steps. A number of risks are identified within the report
• The list is small and there is a risk that there will be no bidders for the contract. There are a number of practices in the local area but any resulting dispersal will place pressure on local practices as a result of patients transferring to other practices in the area.
Recommendation The Primary Care Commissioning Committee is asked to: • Note the outcome of market engagement, patient/stakeholder
engagement and consultation; • Discuss the two options outlined within the report and determine
which of the two options is to be approved. If the decision is to procure:
o Authorise that the Procurement and Evaluation Strategy can be approved by CCG officers following determination of the final decision;
o Consider next steps should a procurement exercise not be successful.
Report history None
Lead Director & Report Author
Director: Dr Neil Morris Title : Medical Director
Author: Kelly Wilson and Wendy Stephens Title: NHS England
Classification Official
Purpose Decision ☒ Information ☐
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Benefits to patients & the public
Access to primary care services
Links to Strategic objectives
Links to all strategic objectives.
Identified risks & risk management actions
Identified risks are noted within the report
Resource implications
Human resources to undertake project.
Legal implications & equality and diversity assessment
There are no legal implications at present for this project.
Sustainability implications
The project is designed to determine options for the delivery of sustainable primary care.
NHS Constitution Principles; 1 The NHS provides a comprehensive service available to all 3 The NHS aspires to the highest standards of excellence and professionalism 6 The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources.
Next steps Consider the options available and determine the preferred option. Appendices Report from NHS England and associated appendices
4
Blaydon GP Practice Practice options review
1. Introduction 1.1 The purpose of this report is to present the options for the future of Blaydon GP Practice to
the Committee, alongside information regarding the outcome of consultation, to enable to Committee to make a decision regarding the future of the practice.
2. Background
2.1 Blaydon GP Practice delivers essential, additional and enhanced services to 2,067 patients (2,014.01 weighted) as at 01 January 2018 under an APMS contract from a purpose built health centre at Shibdon Road, Blaydon.
2.2 The contract, originally provided by South Tyneside Hospitals Foundation Trust, was due to expire on 31 May 2014; negotiations with the provider did not reach an agreement to extend the contract and the provider advised they no longer wished to provide the contract past the expiry date. Therefore NHS England at the time awarded the contract to Gateshead Community Based Care (CBC) under an emergency arrangement until 31 January 2015.
2.3 In-line with NHS England entitled “Managing the end of time-limited contracts for primary medical services”; the service and contract was reviewed. The original review identified that the practice list should be dispersed but patient and stakeholder engagement would be required. Following the engagement exercise with patients and stakeholders, it was agreed by NHS England to pause the process and a commitment was given to Gateshead Overview and Scrutiny Committee (OSC), to explore other options to enable retention of the service. One potential viable option explored to enable the service to continue was for it to be contracted as a branch surgery of an existing GMS or PMS practice within Gateshead. This would have meant that services could continue, but simply via an alternative contracting route.
2.4 A procurement exercise was undertaken in December 2014, and NHS England Cumbria and the North East received two bids however only one progressed to the evaluation stage and the bid did not meet the minimum requirement and therefore no contract could be awarded.
2.5 NHS England had discussed with OSC the risk of not being successful at procurement, including the cost of premises and a low list size which may not be financially viable and that there may be no bids or no successful bids. In both instances NHS England discussed with OSC that it planned to go back out but undertake an open procurement exercise, should this be the case.
2.6 In March 2015, NHS England progressed to full open market procurement. At the close of the procurement exercise on 27 April 2015, no bids were received from potential service providers.
5
2.7 In May 2015, NHS England and NHS Newcastle Gateshead CCG agreed to extend the current contract for six months to 31 January 2016 to allow for engagement and consideration of further options for service delivery. It was subsequently agreed to extend the contract to 31 March 2016, to consider these options further.
2.8 NHS England and NHS Newcastle Gateshead CCG agreed to offer the contract as previously offered in March 2015 but with reduced hours. Patient and stakeholder engagement concluded on 1 February 2016 and results showed that patients and local stakeholders were keen to see the service continue, even at reduced hours.
2.9 In February 2016, NHS England offered the contract as a branch surgery to existing GMS/PMS and APMS practices in Gateshead with reduced hours of 30 hours per week. At the close of the procurement exercise on 03 March 2016, no bids were received from potential service providers.
2.10 The existing contract with Gateshead CBC was therefore extended to 30 June 2016 to allow discussions to take place with potential bidders, to understand why they didn’t bid, and to consider options further.
2.11 To allow more time to consider alternative models and to provide stability to the patient
population, a Single Tender Action request was approved by the Commercial Executive Group at NHS England in June 2016, which allowed a further 2 year extension to the emergency contract with Gateshead CBC taking the contract end date to 30 June 2018. In the meantime, the CCG and NHS England have undertaken further market engagement and consultation with patients and stakeholders to determine the options available.
3. Service information 3.1 The practice is located in the Blaydon ward, in Gateshead West, as shown in Appendix 1. 3.2 The practice is open 8am to 6 pm Monday to Friday and is located within a purpose built
NHS building; NHS Property Services is the landlord. Annual total charges for rent, service charges and facilities management for 2017/18 are high which present an issue for providers. Whilst some costs are reimbursable (rent, rates, water rates and clinical waste), not all are. NHS England and the CCG are discussing the charges with NHS Property Services at present.
3.3 The practice list size as at 01 January 2018 is 2,067 (2,014.01 weighted). The practice list
has steadily increased since October 2014 from 1,309 patients to 2,067 (an increase of 758 patients). In the last 12 months the list size has increased by 342 patients. A breakdown of wards in which patients reside is shown in Appendix 2.
3.4 In terms of staffing numbers the practice has a locum nurse, a locum GP, salaried GP (not
full-time) and administrative staff. In term of patient numbers per WTE GP this equates to 1,590 which is lower than the average in the area which is 2,206 patients per WTE GP.
4. Market Engagement
4.1 A service review paper was presented at Newcastle Gateshead CCG’s Primary Care
Commissioning Committee meeting in October 2017 which detailed the outcome of patient engagement exercise and market engagement exercise. In terms of market engagement,
6
although there were 7 organisations who viewed the documentation, only 1 response was received and that was from the incumbent provider.
In summary, the respondent stipulated the following: • The list is too small for it to be delivered as a standalone contract over 5 days per
week and should be commissioned as a branch surgery of a larger practice for 5 sessions per week;
• If APMS is the contract model, then the contract length would need to be at least 7 years to make the practice viable;
• The service charges for the building are the key barrier to a successful procurement as they are extremely high.
5. Consultation 5.1 The outcome of market engagement and patient and stakeholder engagement were utilised
to determine the options to be considered for consultation. Two options were agreed by Committee to be taken forward for consultation with patients and stakeholders, as follows;
• Option 1 – Keep a GP practice in Blaydon Primary Care Centre • Option 2 – Close the practice
5.2 The consultation ran from 06 November 2017 to 14 January 2018. Patients and
stakeholders were invited to take part in the consultation through a number of different engagement methods.
5.3 Meetings and phone calls were conducted with key stakeholders, followed by a formal
briefing. The list of stakeholders included;
• Local MPs • Overview and Scrutiny Committee • Healthwatch Gateshead • Local Medical Committee • Health and Wellbeing Board • Ward Councillors
5.4 Patients registered at the practice were written to with details on what was being consulted
on; patients were also provided with information on the options available, a set of commonly asked questions and a survey to complete. Patients also had the option to complete the survey electronically and hard copies were also available at the GP practice.
5.5 In addition, two events were organised by Healthwatch Gateshead which took place at Blaydon library on 07 and 08 December 2017 (one day time and one evening event), the events objectives were to explain about the reasons for the consultation and to provide patients with the opportunity to ask questions and make comments. The events were publicised via social media, in Healthwatch’s newsletter, on Healthwatch’s web site and on posters distributed in the local area, at the GP practice and at the library. Local Councillors were also informed of the event. A total of 26 people attended the events.
5.6 Healthwatch also attended two community events in the area; in total Healthwatch engaged with 33 patients at the two events.
5.7 Of the 1,996 practice patients invited to complete the survey a total of 334 individuals responded, a 16.7% response rate. The key findings of the consultation were as follows;
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• For option 1: Keep Blaydon GP Practice open; o 96.1% stated they would be very or fairly happy with this option (91.6% very happy &
4.5% fairly happy); o 2.1% said they would be very or fairly unhappy with this option (1.8% very unhappy
& 0.3% fairly unhappy).
• For option 2: Close the practice; o 3.6% stated they would be very or fairly happy with this option (2.1% very happy &
1.5% fairly happy); o 91.5% said they would be very or fairly unhappy with this option (81.5% very
unhappy & 10% fairly happy).
• When asked to give their preference on the two options, option 1 was the preferred option (96.9%) compared to option 2 (3.15%).
• Patients were asked to give their views and comments on option 1, which have been grouped in to categories. The most common comment groups were as follows;
o The high standard of care received at the practice; o The location and ease of accessing the practice; o Concerns over demand on other practices if the practice was to close; o Ease of making an appointment.
• Patients were asked to give their views on option 2, which have been grouped in to
categories. The most common comment groups were as follows;
o Poor experience and/or reputation of other GP practices in the area; o Other practices in the area are too full/not accepting patients, difficulty in making
appointments and limited choice; o Blaydon GP Practice provides a high standard of care in clean and modern
premises; o Patient reluctance to change practices/concern over continuity of care.
The full consultation outcome report produced by North of England Commissioning Support (NECS) can be seen in Appendix 3 and report from Healthwatch is shown in Appendix 4.
6. Future housing developments 6.1 The 2013-2018 Gateshead Housing Strategy states a need for an extra 10,700 homes by
2030 in Gateshead to meet the needs of an ageing population, equating to a gross new build figure of 13,200 (of which around 15% would be needed for affordable rent and low cost homeownership), with approximately 700-800 new homes being built per annum over a 5 year period.
6.2 Consequently, there are significant private housing developments on going in Blaydon and the Blaydon river front area (e.g. Persimmon, Barrat), and on their completion, a future increase in local population may put a strain on primary medical care services.
6.3 Table 1 below shows three noteworthy developments in the immediate vicinity of the
Blaydon area, which will see a total of 1391 dwellings built over a 10 year period from 2013, which will impact upon the demand for primary medical services:
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Table 1 – Planned Housing Developments Neighbourhood
Year Total 12-
13 13-14
14-15
15-16
16-17
17-18
18-19
19-20
20-21
21-22
22-23
Dunston 0 26 75 65 15 14 0 60 114 67 26 462 Dunston Hill 0 0 0 0 0 0 30 3 0 80 80 193 Metrogreen 0 0 0 0 0 0 0 0 330 288 118 736
Further subsequent information provided by Gateshead Council shows more housing development applications planned or pending approval as follows: MetroGreen It is the Council’s intention to have an Area Action Plan and Delivery Strategy in place for development commencing in 2020. Current planned provision in for 850 houses by 2030. Baseline work is currently being undertaken looking at a range of topics including social infrastructure in the MetroGreen area. This includes healthcare provision. Potential housing development will be clearer when ‘option development and testing’ has been completed – the estimated timescales for the MetroGreen AAP are: Baseline: Oct 2017 – March 2018 Option development and testing: March 2018 – Oct 2018 Draft Plan: March 2019 – June 2019 Submission Draft Plan: June 2019 – Sept 2019 Examination: March 2020 Adoption: July 2020 Crawcrook North This is being developed by Taylor Wimpey for 187 houses – planning permission was granted last December. They have recently started on site and estimate that it will take 4-5 years to build out (based on an assumption of 30-40 houses being constructed each year) – so completed in 2021/22. This site lies to the east of Crawcrook Lane and to the north of the football ground. Crawcrook South This is being developed by Story Homes for 169 houses – planning permission was granted last December. Like the above, they have recently started on site and estimate 4-5 year build out based on the same rate as above and completion in 2021/22. This site lies in between Kepier Chare/Westfield Avenue and the bypass (A695). Ryton The site is allocated for a maximum of 550 houses. A planning application has been submitted for part of the site for 350 houses but is yet undetermined as there are outstanding issues to resolve with the landowners and the prospective housebuilders – Bellway and Taylor Wimpey. If the application is granted, development could potentially commence later in 2018. If a 7-8 year build out is assumed (larger sites are generally built out at slightly quicker rate), completion would be in 2025/26. This site lies in between Cushy Cow Lane, Woodside Lane and the bypass (A695). Other Sites Other sites are as follows:
9
High Spen East (planning application refs DC/15/01041/OUT and DC/17/00142/REM). Outline planning consent has been granted for up to 142 homes (land east of Collingdon Road, High Spen) but detailed permission is still to be granted. If it is granted, development may commence late 2017/early 2018 and take approx. 4 years to build out. High Spen West (near Glossop Street and golf course) – site allocated for approximately 42 homes. Planning application not yet submitted and not expected imminently. Highfield (near Highfield Road) – site allocated for approximately 70 homes. Planning application not yet submitted and not expected imminently. South Chopwell (rear of Valley Dene) – site allocated for approximately 216 homes. Planning application not yet submitted and not expected imminently. Middle Chopwell (rear of Derwent Street) – site allocated for approximately 89 homes. Planning application not yet submitted and not expected imminently. These are obviously the larger strategic sites in the Council’s Core Strategy - http://www.gateshead.gov.uk/Building%20and%20Development/PlanningpolicyandLDF/LocalPlan/Core-Strategy-and-Urban-Core-Plan/GatesheadandNewcastleJointDocuments.aspx. A further development plan document “Making Spaces for Growing Places” is currently being prepared which will allocate further housing sites, although these will tend to be smaller and the process still has some time to go. This can be viewed at http://www.gateshead.gov.uk/Building%20and%20Development/PlanningpolicyandLDF/LocalPlan/Making-Spaces-for-Growing-Places-DPD.aspx It is understood that NHS Newcastle Gateshead CCG and NHS Property Services have been consulted on this document. There are also smaller housing sites that are not specifically allocated (known as windfall sites) that the Council will have granted permission for. There is a significant number of these as they can be as small as one dwelling. There is a further relatively large site under construction which is the former Winlaton Care Village site on Garesfield Lane which has permission for 33 dwellings (refs. DC/13/01333/OUT and DC/15/01134/REM).
This building work, if it all goes ahead as planned, could result in an additional 2460 houses in the area within the next 10 years.
7. Options In terms of the options the Committee is asked to determine which option is to be approved to be implemented; 7.1 Option 1: Procurement (Keep the GP practice)
This option would entail the undertaking of an open market procurement exercise in an attempt to secure a provider to deliver GP services to the registered patient list under an APMS contract. This option would be for a contract which would deliver essential and
10
additional services and the provider would also have the opportunity to sign-up to deliver Directed Enhanced Services and QOF. The core opening hours would be 08.00am – 18.30pm Monday to Friday and the service would be delivered from Blaydon Primary Care Centre. The contract would require the provider to ensure that the practice is delivering services for 52.5 hours per week. There is no change proposed to the current practice boundary. The contract to be procured would be an APMS contract for 10 years with the option to extend the contract, subject to satisfactory performance, for a further 5 years. Contracts for over 5 years need to be authorised by NHS England’s Commercial Executive Group (CEG). NHS England, Cumbria and the North East has submitted a business case to CEG for a contract of 10 years (plus 5), the date of the next CEG meeting is 06 March 2018. If approval is not received, the procurement will need to be halted and a 5 year contract would be procured.
A key consideration in respect of this contract is that the list size is small and the contract has been procured several times (as a standalone contract and as a branch surgery) but without success. In the event there are no bidders for the contract, the Committee is asked to note that the list may need to be dispersed. The benefits and risks of this option are as follows;
Benefits of this option:
• No perceived change for patients; • This option was supported by the consultation outcome; • This option would ensure there is adequate provision in the area where there is to be
some housing developments in the future; • The practice list is steadily growing (an increase of 342 patients in the last 12 months)
making the practice more attractive to potential bidders, although at present the list is still low;
• No impact on other local providers.
Risks of this option:
The risks and mitigation for this option are shown below;
Risks Mitigation No bidders at all – market engagement and procurements in other areas suggest a list of this size is not sustainable.
If the contract could not be awarded the patient list may need to be dispersed. It may be necessary, due to the timescales, to extend the current contract for a short period to allow sufficient time to disperse the list.
Quality of bids means that there can be no successful contract award. New contractor is unable to mobilise contract on time
Risk of challenge to outcome of procurement exercise.
NECS to mitigate via internal processed.
Risk of patient and political challenge regarding possible change of provider
Communication with patients and stakeholders regarding decision made and reasons for decision.
11
Risk that procurement timeline is not abided by
Contingencies built in to programmes by NECS, may reduce mobilisation period.
Risk that a lease cannot be agreed for premises
Practice would occupy under current premises under a ‘tenancy at will’ until leases can be agreed.
Risk that a longer contract is not approved by the Commercial Executive Group (CEG)
Approval has been sought from CEG for a longer term contract. Should approval not be granted a procurement exercise would need to commence for a contract which reflects the stipulations within the SFIs which is currently 5 years – this would affect the timeline and therefore an extension to the existing contractor on existing financial terms may need to be sought in the interim whilst a new procurement exercise is undertaken.
Risk that approval from CEG is not received in time
Should approval not be received at the CEG meeting in March 2018 a procurement exercise could commence at risk, pending approval (see above if approval is not granted).
Risk to the CCG as any potential sustainability fund may exceed the budget for the service
No mitigation identified. CCG will need to determine if their overall budget will allow the additional monies to be available for this procurement.
There is a risk that the practice is not financially viable at the current patient numbers
Practice will need to actively grow its list which may result in a further risk to other local practices (if patients de-register from them to register at Blaydon GP Practice).
Risk that premises costs do not reduce placing further financial pressure on the practice
NHS England and the CCG are working with NHS Property Services to assess charges
7.2 Option 2: Close the practice and disperse the patient list
As the contract is due to end on 30 June 2018, there is an option to disperse the practice list with effect from 01 July 2018; the current list size as at 01 January 2018 is 2,067.
During consultation, 91.5% of patients said they would be unhappy with the option of the practice closing. Concerns raised include the poor experience and/or reputation of other practices, other practices being too full and the loss of a practice with a high standard of care. As there is sufficient time before the end of the contract to address the dispersal of the patient list, local practices would have time to put arrangements in place to take additional
12
patients. Patients would be provided with a detailed list of other local practices that are currently accepting new patients and would be asked to approach a practice to register at. One of the main considerations for dispersal is the effect of the additional patients seeking to register with practices in the local area. Appendix 5 identifies the practices within a 5.2 miles radius of Blaydon GP Led Practice. There are three practices within 1.2 miles and a further eleven practices in total within 5.2 miles. All the practices have open lists and the average number of patients per whole time equivalent (WTE) GP is 2,206. In the event of dispersal, patients are more likely to choose to register with a practice close to their home. In terms of wards in which patients reside (Appendix 2) the following is known;
• There are 911 patients who reside in Blaydon, with two other practices within the Blaydon area, Chainbridge Medical Partnership (who is actively growing its list) and Hollyhurst Medical Centre;
• Rowlands Gill has 461 patients with three surgeries within the area; • Whickham has 260 patients, with one practice based within the area; • Ryton has 152 patients with three surgeries within the area; • Chopwell has 21 patients and has one practice within its area; • Dunston has 14 patients with six surgeries in the area.
As part of a dispersal plan, new guidance from NHS England advises that additional support should be given to all patients who have not registered elsewhere by the end of the contract (30 June 2018), meaning that NHS England would allocate all patients who have not registered themselves to ensure they have continuity of care, whereas previously NHS England has only allocated those patients categorised as ‘clinically vulnerable’. As the current contractor is operating under an emergency APMS contract, the CCG is liable for costs associated with dispersal (redundancy costs will be reimbursed); the CCG should note that staff may still be eligible for transfer under TUPE arrangements and may challenge this with their employer.
Managing the dispersal of a patient list would require CCG and NHS England managerial resource and this should be taken in to consideration if this option is pursued.
The benefits and risks associated by patients are as follows;
Benefits of this option:
• Supports primary care working at scale; • Ensures service sustainability in the local area; • There would be a financial saving to the CCG;
Risks of this option:
The risks and mitigation for this option are shown below;
Risks Mitigation Lack of support from patients / other stakeholders
If the practice is closed, patients would be supported to find an alternative practice
Impact on surrounding practices Practices within the area would have
13
Risks Mitigation time to address capacity issues although recruitment of clinicians remains a concern. Practices would receive an additional new patient registration fee for every patient they register in the first year.
Void space costs - The premises costs associated with Blaydon Health Centre are high, if the space remains unoccupied the CCG are liable for void space costs.
There will be savings to the CCG if NHS Property Services can occupy the rooms vacated by the practice. However the CCG is paying the total premises costs at present anyway.
8. Scoring of options
8.1 An assessment of each option against specific criteria has been undertaken in accordance with the following criteria;
1. Premises 2. Affordability to the CCG 3. Whether it supports the strategy of the CCG 4. Whether consultation outcomes support the scheme 5. Whether market engagement indicates the option is attractive and affordable to
providers.
8.2 A weighted scoring system, as indicated in the table below was used to acknowledge the different level of priority for each of the elements.
Scoring Weighting
Response to element
Score Priority Weighted score
Yes 3 Low 10 Possibly 2 Medium 20 Unlikely 1 High 30
No 0 Very high 40 8.3 The weighting applied to each element is as follows;
Are the premises available to support the scheme with capacity for the patient list?
Very high
Is the scheme affordable to the CCG? High Does the scheme support the CCGs strategy? High Does the outcome of consultation indicate support for this scheme?
High
Does market engagement indicate the option is attractive and affordable to providers?
Very high
8.4 The maximum score possible for the options is 510, and it is proposed that a threshold of
60% (score of 306) should be the minimum score to consider for final decision of future provision. The scores for each option are show in Appendix 6 and are summarised below;
14
Option Total scores 1 - Procurement 310 2 – Dispersal 420
9. Next steps 9.1 The Primary Care Commissioning Committee is asked to:
o Note the outcome of market engagement, patient/stakeholder engagement and consultation;
o Discuss the two options outlined within the report and determine which of the two options is to be approved.
9.2 If the decision is to procure:
o Authorise that the Procurement and Evaluation Strategy can be approved by CCG officers following determination of the final decision.
o Consider next steps should a procurement exercise not be successful.
15
Appendix 1: Practice boundary
16
Appendix 2: Breakdown of patients by ward
WARD NUMBER OF
REGISTERED PATIENTS
% OF LIST SIZE Practices per Ward
Blaydon 911 49.43% Chainbridge Medical Partnership
Oldwell Surgery Hollyhurst Medical Centre
Rowlands Gill 461 25.01% The Grove Cedars Medical Group
Dr Hurst, Murrell & Mather
Whickham 260 14.11% The Whickham Practice
Ryton 152 8.25% Grange Road Medical Practice
Dr S M Hilton Crawcrook Medical Centre
Chopwell 21 1.14% Dr M S Hassan
Dunston 14 0.76% Dr Tasker & Partners Teams Medical Practice
Bensham Family Practice Second Street Surgery Dr Krishnan & Partners
Oxford Terrace & Rawlings Road Medical Group
Bridges 6 0.33% Bridges Medical Practice
Eswick 5 0.27% Outside Blaydon Area
Kenton 3 0.16% Outside Blaydon Area
Eighton Banks 2 0.11% Outside Blaydon Area
Chester-le-Street
2 0.11% Outside Blaydon Area
Wardley 1 0.05% Outside Blaydon Area
Prudhoe 1 0.05% Outside Blaydon Area
Benwell 1 0.05% Outside Blaydon Area
Westgate 1 0.05% Outside Blaydon Area
Whitley Bay 1 0.05% Outside Blaydon Area
Cramlington 1 0.05% Outside Blaydon Area Data as at October 2017.
17
Appendix 3: Consultation outcome report
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
Appendix 4: Report from Healthwatch
70
71
72
73
74
75
76
77
78
79
80
81
Appendix 5 – Local Practice information
Practice Contract Type
Number of WTE GPs & NPs*
List Size (as at
01.01.18)
List Size per WTE GP & NP*
List Status Miles from
Blaydon Ward
Blaydon GP Led Practice APMS 1.3 2,067 1,590 Open 0 Blaydon
Chainbridge Medical Partnership GMS 6.15 11,180 1,818 Open 0.8 Blaydon
Oldwell Surgery GMS 3.12 5,242 1,680 Open 1.2 Winlaton & High Spen
Hollyhurst Medical Centre PMS 1.56 4,728 3,031 Open 1.2 Winlaton & High Spen
The Whickham Practice GMS 11.05 16,091 1,456 Open 1.5 Whickham
Denton Turret Medical Centre PMS 4.23 8,643 2,043 Open 2.7 Newcastle District
Betts Avenue Medical Group GMS 4.12 10,749 2,609 Open 2.8 Newcastle District
Grange Road Medical Practice GMS 1.25 3,744 2,995 Open 3.0 Ryton, Crookhill and Stella
Hollyhurst Medical Centre (branch site) GMS See
Hollyhurst Open 3.1 Ryton, Crookhill and Stella
Crawcrook Medical Centre GMS 2.88 6,991 2,427 Open 3.1 Ryton, Crookhill and Stella
Sunniside Surgery GMS 2.0 3,305 1,653 Open 3.1 Rowlands Gill
Westerhope Medical Group GMS 5.76 12,726 2,209 Open 3.6 Newcastle District
The Grove Surgery GMS 1.67 6,459 3,868 Open 3.7 Rowlands Gill
Newburn Surgery GMS 3.17 5,536 1,746 Open 4.1 Newcastle District
Cedars Medical Group GMS 3.23 5,693 1,763 Open 5.2 Rowlands Gill
Total 51.96 103,154 30,466
Average 3.68 7,368 2,206 *1.00 WTE NP is the equivalent of 0.6 WTE GP
83
Appendix 6 – Scoring assessment
Are there premises available to support the option with capacity for the patient list?
Is the option affordable to the CCG?
Does the option support the CCGs strategy?
Does engagement activity indicate support for this option?
Does market engagement indicate the option is attractive and affordable to providers within standard contract and financial terms?
Total
Rank
CRITERIA Is the CCG mandating premises to bidders? If so, are existing premises available and have capacity? If not, is it possible that bidders have premises available?
APMS rate Enhanced services Potential sustainability fund Premises costs
Workable list size General practice working at scale Ensuring quality and reduced variation in primary care Ensuring practice sustainability
Consultation outcome
Sustainability within normal contract terms Availability of workforce
510
Priority Very High High High High Very High Options R
esponse
Score
Weighting
Total
Response
Score
Weighting
Total
Response
Score
Weighting
Total
Response
Score
Weighting
Total
Response
Score
Weighting
Total
Option 1: Procurement
Y
3
40
120
N
0
30
0
P
2
30
60
Y
3
30
90
U
1
40
40
310
2
Option 2: Dispersal
Y
3
40
120
Y
3
30
90
Y
3
30
90
N
0
30
0
Y
3
40
120
420
1
Cover Sheet
Meeting Title Primary Care Commissioning Committee
Date 27 February 2017
Agenda Item 8
Report Title Enhanced Service for General Practice - DVT pathway 2018/19
Synopsis This paper details a proposed enhanced services for approval by the Committee; DVT Pathway. DVT – Aims of the Enhanced Service
• Timely assessment and management of suspected DVT in GP practices.
• Care closer to home for patients. • Use of Point of Care (POC) D-Dimer testing kits • Direct Oral Anticoagulant (DOACs) • Reduction in Ambulatory care attendances for suspected DVT
where patients can be managed in the community.
Implications and Risks
• Expectations relating to the creation of an Enhanced Service are high
• The services support the sustainability of general practice and transfer of care out of hospital.
• If not approved there is a risk practices not following the improved pathway.
Recommendation The Committee are asked to approve the service specifications and payment for the Enhanced Services for the DVT Pathway.
Report history
Lead Director & Report Author
Director: Neil Morris Title : Medical Director
Author: Graeme Hunt (NECS) Title: Commissioning Manager
Classification Official
Purpose (click one box only) Decision ☒ Information ☐
2
Benefits to patients & the public
• Care closer to home to a specification which ensures high quality accessible care.
• Increased sustainability of general practice. • Service efficiencies through management of demand in secondary
care. Links to Strategic objectives
Links to all of the strategic objectives.
Identified risks & risk management actions
• If enhanced services are not supported sustainability of general practice will not be supported and potential savings not realised.
• Practices have been alerted to the new pathway at events in Newcastle and Gateshead and involved in discussions to operationalise and pilot of the scheme.
• No guarantee that practices will sign up to deliver the Enhanced Services.
Resource implications
The change in pathway is planned to make DVT testing available at practice level for a clearly defined cohort of patients who are currently accessing this service via ambulatory care attendances in secondary care. The level of activity impacted has been estimated at approximate 2500 based on a small sample of DVTs carried out in Ambulatory Care at Gateshead. Discussions with the FTs have indicated activity may be significantly lower than these estimates and work to agree these figures continues. However, given that each patient treated under the new pathway will generate a net saving under tariff rules, it is proposed to progress on this basis. Details of estimated costs and savings are shown in Appendix 2 (Estimated activity and cost/saving schedule). In summary, an average current ambulatory care cost of £427 is expected to be replaced by a payment to practices of £40 per test (including the costs of obtaining the test). Other costs eg prescribing may also be incurred depending on the outcome for the patient and these have been reflected in the detail as far as possible based on the results of the sample work carried out in Gateshead. The service is therefore expected to be funded from projected savings through the reduction in ambulatory care attendances.
Legal implications & equality and diversity assessment
None as via GP Practices.
Sustainability implications
Sustainability of the project outcomes have been assessed as part of the project development.
NHS Constitution Principles; 1 The NHS provides a comprehensive service available to all 3 The NHS aspires to the highest standards of excellence and professionalism 6 The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources.
3
Next steps Subject to approval; issue these Enhanced Service contracts to GP
Practices for commencement April 2018. Appendices Appendix 1 DVT Pathway Service Specification
Appendix 2 Estimated activity and cost/saving schedule
Appendix 1:
App 1 Community Deep Vein Thrombosis
Appendix 2 Estimated activity and cost/saving schedule
Gateshead & Newcastle
427.00£ 427.00£ 9.74£ 40.00£ HIGHER
ACTIVITYLOWER
ACTIVITY
1.000000 Net impact Net impact
Pathway Estimated
Total activity per year per sample
Amb Care Attendance
Amb Care Attendance
Prescribing
Practice payments
*inclusive of kit cost
Total Cost Net Position (per sample
activity)
Net Position (based on
50% activity)
Test only required 800 341,812£ 32,020£ 32,020£ -£309,792 -£154,896Test and scan required 978 417,770£ 9,529£ 39,135£ 48,665£ -£369,106 -£184,553Scan and ambulatory care required 89 37,979£ 37,979£ 866£ 3,558£ 42,403£ £4,424 £2,212Scan and ambulatory care required 356 151,917£ 151,917£ 3,465£ 155,382£ £3,465 £1,733Ambulatory care only required 267 113,937£ 113,937£ 113,937£ £0 £0
2,490 1,063,416£ 303,833£ 13,861£ 74,713£ 392,407£ -£671,009 -£335,504
Current Pathway
cost Proposed Pathway cost
Community DVT Service Specification Page 1 of 10 2017/2018 (F)
SCHEDULE 2 – THE SERVICES A. Service Specifications Mandatory headings 1 – 4. Mandatory but detail for local determination and agreement Optional headings 5-7. Optional to use, detail for local determination and agreement. Service Specification No. Service Community Deep Vein Thrombosis (DVT) Pathway Commissioner Lead Provider Lead Period 1st April 2018 - 31st March 2019 Date of Review November 2018.
1. Population Needs
1.1 National/local context and evidence base
Deep vein thrombosis (DVT) is the term used to describe the formation of a thrombus (blood clot) in a deep vein, which partially or completely obstructs blood flow [National Clinical Guideline Centre, 2012a].
Deep vein thrombosis has an annual incidence of about 1 in 1000 people.[Tovey and Wyatt, 2003; Keeling et al, 2004; SIGN, 2010].
The development of a Community Deep Vein Thrombosis (DVT) pathway was identified for the investigation and management of patients with suspected lower limb DVT. This involves the use of Point of Care (POC) D-Dimer testing kits, Direct Oral Anticoagulant (DOACs) and direct access to venous ultrasound, in primary care and Out of Hours services, in order to avoid unnecessary visits to Ambulatory Care at local Hospitals 2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators
Domain 1 Preventing people from dying prematurely Domain 2 Enhancing quality of life for people with long-term
conditions
Domain 3 Helping people to recover from episodes of ill-health or following injury
Domain 4 Ensuring people have a positive experience of care x Domain 5 Treating and caring for people in safe environment and
protecting them from avoidable harm
2.2 Local defined outcomes
• Providing care closer to home • Avoiding unnecessary visits to Ambulatory Care at local Hospitals
3. Scope 3.1 Aims and objectives of service
a. Timely assessment and management of suspected DVT in GP practices. b. Care closer to home for patients. c. Use of Point of Care (POC) D-Dimer testing kits d. Direct Oral Anticoagulant (DOACs) e. Reduction in Ambulatory care attendances for suspected DVT where patients can be
managed in the community.
Community DVT Service Specification Page 2 of 10 2017/2018 (F)
3.2 Service description/care pathway
Below is a high level summary of the in hours GP pathway, this is 8am-6pm Monday to Thursday and 8am-1pm Friday (Newcastle Practices) and Monday to Friday 8am-6pm (Gateshead Practices)
Clinician Suspects DVT
Wells Score (2 or more): DVT likely
Does the patient meet any exclusion criteria for community pathway? (see specification 3.4)
YesNoBook USS scan on ICE
Phone USS department for appointmentIf >4 hour to scan, commence DOAC
Scan Negative for DVT
Sonographer to direct the patient from ultrasound to
ambulatory care
Wells Score (<2): DVT unlikely,
Undertake Point of Care testing
Calculate wells Score
D Dimer Negative
D Dimer Positive
Pathology other than
DVT seen on scan
DVT confirmed
Wells score <2 DVT excluded
Sonographer to give patient
leaflet
Wells score 2 or more
GP follow up / reconsideration of diagnosis
Refer to ambulatory care for assessment &
treatment
D Di
mer
Neg
ativ
e
Send Lab D Dimer
D Dimer Positive – Go
to Red Box
Community DVT Service Specification Page 3 of 10 2017/2018 (F)
3.2.3 Assessment and Investigation of Suspected Lower Limb Deep Vein Thrombosis (DVT) Initially if the clinician suspects a DVT they should undertake a Well’s score.
3.2.4 WELLS Score
Wells scoring is a well-established clinical tool for assessing pre-test probability of a DVT as reproduced below.NICE2 recommend two-level DVT Wells score (WS): a score <2 indicates DVT ‘unlikely’; score ≥2 indicates DVT ‘likely’.
Clinical Feature Score
Active cancer (treatment ongoing, diagnosis within previous 6 months or metastatic/palliative)
1 point
Paralysis, paresis or recent plaster immobilisation of lower limb 1 point
Recent bed ridden for >3 days or major surgery in last 12 weeks requiring general or regional anaesthesia
1 point
Localised tenderness along course of the vein 1 point
Entire leg swollen 1 point
Calf swelling >3cm compared with asymptomatic leg 1 point
Pitting oedema confined to symptomatic leg 1 point
Collateral superficial veins 1 point
Previous DVT/PE 1 point
Alternate diagnosis at least as likely as DVT -2 points
TOTAL
WELLS score of 2 or over
If the outcome of the Well’s score is 2 or more (DVT likely), the patient must be assessed for exclusion criteria for the community pathway. If they do not meet any exclusion criteria they must be booked in directly for a venous ultrasound scan on ICE. If the patient does meet exclusion criteria they should be referred directly to Ambulatory Care.
The scan should be booked on ICE;
Newcastle Practices
Between 8:30am-5pm, Monday to Thursday and 8:30am to 1pm on a Friday, the ultrasound department then need to be phoned on 0191 2824492 to arrange the appointment. Ideally the patient should know their appointment time before leaving the surgery. However if they are being seen after 5pm the GP will need to make arrangements for ultrasound to be phoned the following morning at 8:30am or will need to send the patient to ambulatory care/assessment suite at the RVI.
Gateshead Practices
Between 8am-6pm the ultrasound department then need to be phoned on 0191 445 3077 (8-5pm) or 0191 4456268 (after 5pm) to arrange the appointment. The patient should know their appointment time before leaving the surgery.
Community DVT Service Specification Page 4 of 10 2017/2018 (F)
All Practices
If a scan can be booked and performed within 4 hours, the patient should attend for their scan, arriving 15 minutes before the appointment time.
If a scan cannot be booked and performed within 4 hours, the patient should be given a prescription of treatment dose Apixaban (10mg BD) OR Rivaroxaban (15mg BD). This should be given twice daily until the scan. We anticipate all scans will be within 24 hours so giving more than 3 doses should not be necessary.
PLEASE NOTE – In patients with a Wells score of 2 or more there is no need to perform D-Dimer test as it will not change the management of the patient. They should be referred directly to ultrasound scan.
A WELLS score of less than 2
If the outcome of the WELLS score is 1 or less (DVT unlikely), qualitative D-Dimer testing should be undertaken. A Biosynex D-dimer testing kit should be used.
If the D-Dimer test is positive then the patient should follow the pathway as if the WELLS score is 2 or more (as above). If the D- Dimer is negative, a venous D-dimer should also be sent to the lab for quality control. A lab D-dimer done in the morning should be checked by the GP later that day. A lab D-dimer done later in the day, would mean a positive result will be phoned through to the out of hours provider (For Newcastle Practices it is Vocare, for Gateshead Practices it is Gatdoc). If the lab D-dimer is also negative DVT is unlikely and alternative diagnoses should be considered.
3.2.5 Qualitative D-Dimer Testing in Primary care
Part of the pathway involves undertaking a qualitative D-Dimer test on patients who have a WELLS score of 1 or under (WELLS score of 2 and above will mean referral for a scan).
The result is visually interpreted giving a positive or negative result. The qualitative D- Dimer test can use a fingerstick whole blood specimen or venous whole blood specimen (taken in a EDTA, purple bottle).
Instructions to collect a finger stick whole blood specimen
If using a BIOSYNEX D Dimer (for more information refer to manufacturers leaflet)
• Store the kits at room temperature • Check the expiry date • Only open the kit when ready to use • Label the cassette with the patient’s name • Wash the patients hand with soap and warm water or clean with an alcohol swab – Allow to dry.
Community DVT Service Specification Page 5 of 10 2017/2018 (F)
• Ask the patient to warm up their hands and to increase circulation by clenching or hanging down by their sides
• Wash your hands • Put on gloves • Massage the hand without touching the site where you will puncture by rubbing down the hand
towards the finger tip of the middle or ring finger. • Puncture the skin, using the lancet provided within the kit on the side of the finger. • Gently rub the hand from wrist to palm to form a rounded drop of blood over the puncture site. • Use the pipette provided in the kit to draw up the blood. Ensure there are no bubbles. • Add 2 drops of blood onto the test strip • Immediately add 1 drop of the buffer, then start the timing for 10 minutes.
Results
Interpret the blood results after 10 minutes - IN GOOD LIGHT. Do not interpret any results after more than 15 minutes – results interpreted after this time with be invalid. Invalid –The control line (C) fails to appear. This may be caused by insufficient volume, expired test components or incorrect procedural techniques. Review the procedure and repeat the test. If the problem persists, discontinue to use the test kit immediately, and send a venous lab D-dimer for testing. Positive – Two lines appear, one line in the control line (C) area and in the test line (T) area. A faint line is still a positive. If unsure, err on side of caution and treat as positive. Negative – One line appears in the control line area (C). No line appears in the test line area (T). A negative result indicates that no D-dimer is present in the specimen or that the concentration is below the detection level of the test device.
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Home Visits
Please note blood can be used from a purple EDTA bottle, by drawing it up from the bottle using a pipette. We would suggest performing the test back at the surgery using this method, especially given the requirement to read the result in good light.
3.2.6 DOAC prescribing
The initial treatment is:-
Apixaban 10mg twice daily or
Rivaroxaban 15mg twice daily. Use is not recommended in patients with CKD 5 (eGFR <15), although for this pathway CKD4/5 is an exclusion criterion. At presentation patients should be issued with a FP10 for enough Apixiban/ Rivaroxaban to last until their scan – most likely a maximum of 3 doses. Rivaroxaban must be taken with a full meal otherwise it will not be absorbed. If the patient has a confirmed DVT they will be seen in Ambulatory Care and issued with a further prescription and a discharge summary detailing the anticoagulation regime, will be issued to the GP.
3.2.6 Venous Ultrasound scan
Ultrasound scans will be done at;
• RVI for Newcastle Practices • Queen Elizabeth Hospital for Gateshead Practices.
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NICE advise that scans should be performed within 4 hours of initial assessment. If this is not possible the patient should be commenced on a DOAC until the scan. Ultrasound scans need to be booked on ICE and between 8am and 6pm the requesting clinician will need to phone the ultrasound department 0191 445 3077 (8-5pm) or 0191 4456268 (after 5pm) to organise the scan time. Patients should be given a time, date and location of their ultrasound scan before they leave the GP surgery. It is anticipated that USS scan will take place within 24 hours of the request. If the patient has waited more than 48 hours please refer to ambulatory care. For housebound patients the patient transport service (PTS) can be booked.
Following the Ultrasound Scan
All patients with a positive scan, pathology other than DVT found on USS or with a high pre-test Well’s score will be directed to Ambulatory Care immediately after their scan for further review and management.
For those low risk patients with a negative scan, the sonographer will provide them with a short information sheet advising that their scan was negative for DVT and should they have ongoing symptoms they should contact their usual GP or 111.
Should a clinician have ongoing clinical suspicion of a DVT despite negative investigations, the pathway can be repeated one week later or they could discuss with the on-call acute care physician at the QE.
3.2.7 Review in Ambulatory Care for Confirmed DVT
Review will encompass:
• Explanation of the diagnosis and management of DVT
• Ensuring sure symptoms are improving: most patients stop thrombosing on anticoagulation though some patients will continue to progress and should be assessed for possible thrombolysis.
• History and examination to identify underlying cause of unprovoked DVT
• Patient education on DOAC medication.
• Advice to the patient regarding how long to continue their anticoagulation. This is usually until they are seen in VTE clinic.
• Whether any concomitant antiplatelet treatment should be continued.
• Current advice is that compression stockings are no longer recommended in the treatment of DVT.
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3.2.8 Further Follow Up
All patients with a confirmed DVT are followed up in VTE clinic after about 3 months. GPs should continue anticoagulation until the patient is seen in clinic.
3.3 Population covered
All patients >18 years of age, resident in England and registered with a NHS Newcastle Gateshead CCG general practice.
3.4 Any acceptance and exclusion criteria and thresholds
During OOH all patients with a suspected DVT will need to be referred to ambulatory care.
• Scan will be in more than 4 hours and there is a contraindication to a DOAC • Patient is already on therapeutic anticoagulation • Pregnancy or given birth within last 6 weeks or breastfeeding • Active cancer – Diagnosis within last 6 months, on active treatment or metastatic disease • Lower limb surgery in last two weeks e.g. knee or hip replacement • <18 years old • Suspected PE • Active peptic ulcer disease or other bleeding disorder • Uncontrolled hypertension: BP >180/120 • Known Thrombocytopenia: platelets <80 x 109/L • Known Severe renal impairment (CKD4 and 5) • Liver failure • Dual antiplatelet therapy • Concurrent medication: HIV medication, azole antifungals (e.g. itraconazole, ketoconazole),
rifampicin, phenytoin, carbamazepine, valproate, phenobarbital. • Patient weighs >120kg • Scan not available within 48 hours
3.5 Interdependence with other services/providers
Newcastle Upon Tyne Hospitals NHS Foundation Trust, QE Gateshead NHS Foundation Trust
4. Applicable Service Standards 4.1 Applicable national standards (eg NICE)
NICE CKS Deep Vein Thrombosis https://cks.nice.org.uk/deep-vein-thrombosis NICE Clinical guideline [CG144] Published date: June 2012 Last updated: November 2015, Venous thromboembolic diseases: diagnosis, management and thrombophilia testing https://www.nice.org.uk/guidance/cg144 NICE technology appraisal guidance TA341. Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism. June 2015. NICE technology appraisal guidance TA261. Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism. July 2012. NICE: partial update of NICE CG48. Post myocardial infarction: secondary prevention in primary and secondary care for patients following a myocardial infarction. June 2013.
4.2 Applicable standards set out in Guidance and/or issued by a competent body (eg Royal
Colleges) Not applicable
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4.3 Applicable local standards
Not applicable 5. Applicable quality requirements and CQUIN goals 5.1 Applicable quality requirements (See Schedule 4 Parts A-D)
5.2 Applicable CQUIN goals (See Schedule 4 Part E) 6. Location of Provider Premises The Provider’s Premises are located at: Within each General Practice in NHS Newcastle Gateshead CCG commissioned to deliver the service. 7. Individual Service User Placement
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SCHEDULE 3 - PAYMENT
A. Permitted Variations to Tariff, Non-Tariff Prices and Other Payment Arrangements Table 1: Non-Tariff Prices Service Description
Currency
Price
Assessment & management
£40.00
Table 2: Timing and amounts of payments in first and/or final Contract Year Quarterly payments based on £40 per item of service claimed via CLAIMIT system Claims must be submitted by day 10 of the following month READ Coding for Quality and Audit Purposes The recommended READ codes for recording the DVT pathway activity are as follows:
DVT Codes (CTV3) Used by SystmOne
Term Code Suspected Deep Vein Thrombosis XaNfd DVT Codes (Read 2) used by EMIS LV and EMIS WEB
Term Code Suspected Deep Vein Thrombosis 1JH