primary care committee agenda - wandsworth ccg care... · september 2019 . 09:30 – 11:00 ....

W A N D S W O R T H C C G P A G E 1 O F 1

Board Intelligence Hub template

Primary Care Committee Agenda

Meeting of the Primary Care Committee Tuesday 3rd September 2019

09:30 – 11:00 Nightingale House

AGENDA – PART 1

P A R T A | M E E T I N G O P E N S T A R T D U R A T I O N

A01 Apologies, Declarations, Quorum pg2 CV 09:30

5 mins

A02 Chair’s Opening Remarks CV 09:30

A03 Minutes: Approval and Status of Actions pg8 CV 09:30

A04 Decisions ratified outside of the meeting since the last meeting on 28th May 2019 pg15 CV 09:30

P A R T B | D E C I S I O N S A N D D I S C U S S I O N S

B01 Terms of Reference pg17 CV 09:35 10 mins

B02 Integrated Primary Care Commissioning pg27 KS/EG 09:45 15 mins

B03 Practices half day closure review pg34 KG 10:00 20 mins

B04 Finance Report pg51 NM 10:20 10 mins

B05 Primary Care Networks Development and Primary Care at Scale Update pg61

HP 10:30 20 mins

B06 Any Other Business CV 10:50 5 mins

P A R T C | P A R T 1 M E E T I N G C L O S E

C01 Chair’s Closing Remarks CV 10:55 5 mins

C02 Close of Part 1 11:00

C03 Upcoming meetings – Tuesday 3rd December, 09:30, venue TBC Tuesday 3rd March 2020, 09:30, venue TBC

W A N D S W O R T H C C G P A G E 1 O F [ X ] W A N D S W O R T H C C G P A G E 1 O F [ X ]

Page 1 of 75

Register of Interests (updated August 2019)

All GPs have declared an interest in Primary Care Networks

Name

Current position (s) held in the CCG i.e.

Governing Body member; Committee

member; Member practice; CCG

employee or other

Do you

have any

interests to

declare?

(Y or N)

Declared Interest

(Name of the organisation and nature of business)

Fin

anci

al In

tere

st

No

n-F

inan

cial

pro

fess

ion

al

Inte

rest

No

n-F

inan

cial

Pe

rso

nal

Inte

rest

Ind

irec

t

Inte

rest

Nature of Interest

From To

Action taken to mitigate

risk

James Blythe Managing Director

Governing Body Member

Member of Executive Management

Team

Member of Primary Care

Commissioning Committee

Member of Finance Committee in

Common

Member of Integrated Governance

Quality Committee

Y

1. Spouse is an employee of St George's University Hospitals NHS

Foundation Trust and has a specialist training number with HEE South

London

2. Spouse will leave St George's Hospital and work for Kingston Hospital

from Oct 2019.

1

2

1. May 2017

2. Oct 2019

1. Oct 2019 I am not present at specific

discussions relating to the

relevant service.

Page 2 of 75

Name




employee or other

Do you

have any

interests to

declare?

(Y or N)

Declared Interest


Fin

anci

al In

tere

st

No

n-F

inan

cial

pro

fess

ion

al

Inte

rest

No

n-F

inan

cial

Pe

rso

nal

Inte

rest

Ind

irec

t

Inte

rest

Nature of Interest

From To


risk

Neil McDowell Director of Finance for Merton and

Wandsworth CCGs

Member of Governing Body, Merton

and Wandsworth CCGs

Member of Finance Committee, Merton

and Wandsworth CCGs

Member of Audit & Governance

Committee, Merton and Wandsworth

CCGs


Commissioning Committee, Merton and

Wandsworth CCGs


Committee

Member of Integrated Governance and

Quality Committee

Y

1. Spouse is Chief Finance Officer for Surrey Heartlands CCGs. 1 Adherence to COI policy

Julie Hesketh Director of Quality and Corporate

Governance, LDU

Member of Governing Body Merton and

Wandsworth


Committee


Quality Committee

Member of Audit and Governance

Committee Merton and Wandsowrth

Y

1. Personal involvement in Richmond Education Network (not for profit

organisation). This is done outside of CCG hours.

Adherence to COI policy

Katharine (Katie) Denton Director of Primary Care

Transformation

Member of MCCG Governing Body

Member of WCCG Board

Member of LDU Clinical Oversight

Group


Team

Member of Merton Primary Care

Committee

Member of Wandsworth Primary Care

Committee

N

No interests declared Adherence to COI policy

Page 3 of 75

Name




employee or other

Do you

have any

interests to

declare?

(Y or N)

Declared Interest


Fin

anci

al In

tere

st

No

n-F

inan

cial

pro

fess

ion

al

Inte

rest

No

n-F

inan

cial

Pe

rso

nal

Inte

rest

Ind

irec

t

Inte

rest

Nature of Interest

From To


risk

John Atherton Director of Performance Improvement

Member of Governing Body


Quality Committee


Committee

N


Josh Potter Director of Commissioning

Member of Governing Body


Committee


Commissioning Committee


and Quality Committee

N


Stephen Hickey Wandsworth CCG - Governing Body

(Vice Chair);

Lay Member, Governance Wandsworth -

Health and Wellbeing Board;

LDU and SWL Finance Committee in

Common;

Audit Committee (Chair);

Remuneration Committee (Chair);

Workforce Committee;

Primary Care Committee;

Integrated Quality & Governance

Committee

Y

1. Trustee for Merton Community Transport Charity 1 1. 01/12/2017 Transparency if relevant

issues arise

Dr Mike Lane Governing Body voting member

CCG Deputy Clinical Chair

Joint Wandle Locality Lead


Quality Committee member

Wandsworth Primary Care Committee

member

Y

1. Non-partner GP, Grafton Medical Partners (Grafton Primary Care

Network)

2. Practice is a member of Battersea Healthcare CIC but Dr Lane holds no

director post and has no specific responsibilities within that organisation

other than those of other member GP.

3. London Maternity Lead, Royal College of General Practitioners.

4. Volunteer Doctor - Crisis Homeless charity.

5. Volunteer Doctor - St Johns Ambulance Charity.

6. Member - National Maternity Transformation Board Stakeholder

1

3

6

4

5

1. 2019

2. 2014

3. 2006

4. 2006

5. 2016

6. 2016

1-6 Adherence to COI

policy

Page 4 of 75

Name




employee or other

Do you

have any

interests to

declare?

(Y or N)

Declared Interest


Fin

anci

al In

tere

st

No

n-F

inan

cial

pro

fess

ion

al

Inte

rest

No

n-F

inan

cial

Pe

rso

nal

Inte

rest

Ind

irec

t

Inte

rest

Nature of Interest

From To


risk

Dr Kieron Earney Joint West Wandsworth Locality Lead

Y

1. GP Partner, Putneymead Group Medical Practice.

2. Putneymead is a member of Battersea Healthcare CIC although I hold

no role within that organisation.

3. Putneymead Group Medical Practice is a member of the West

Wandsworth Primary Care Network.

1

2

1. July 2016 1. and 2 adherence to COI

policy

Chris Savory Lay Member, Finance

LDU Finance Committee

Wandsworth Audit Committee

Wandsworth Primary Care Committee

N


Page 5 of 75

Name




employee or other

Do you

have any

interests to

declare?

(Y or N)

Declared Interest


Fin

anci

al In

tere

st

No

n-F

inan

cial

pro

fess

ion

al

Inte

rest

No

n-F

inan

cial

Pe

rso

nal

Inte

rest

Ind

irec

t

Inte

rest

Nature of Interest

From To


risk

Dr Waqaar Shah Joint Wandle Locality Lead

Wandsworth CCG Governing Body

member.

Chairman, Promoting Good Health

Clinical Oversight Group. Wandsworth

Health and Wellbeing Board member.

Executive Management Team. Wandle

Locality Forum co-chair. Primary Care

Transformation Group.

Clinical Leads.

Task and Finish Group.

Primary Care Operations Group.

Integrated Governance and Quality

Committee.

Wandsworth and Merton Primary Care

Clinical Quality Reference Group.

MCP Quality Oversight Group.

MCP Transformation Group. Finance

Committee in Common.

Y

1. GP partner at Chatfield Health Care (practice is a member of Battersea

Healthcare CIC).

2. Chairman of the Prostate Cancer Guideline Committee, National

Institute for Health and Care Excellence.

3. Royal College of General Practitioners National Clinical Expert in Eye

Health.

4. Peer reviewer, British Journal of General Practice.

5. Eye Health Forum member, Department of Health.

6. Board member, Clinical Council for Eye Health Commissioning.

7. Honorary Treasurer, Section of Primary Care and General Practice,

Royal Society of Medicine.

8. Expert Adviser, Centre for Guidelines, National Institute for Health and

Care Excellence.

9. Appointed Chair of the Neonatal Infection Update Guideline

Committee at NICE.

1

2

3

4

5

6

7

8

9

1. 2017

2. 2017

3. 2017

4. 2017

5. 2017

6. 2017

7. 2017

8. April 2018

9. July 2018

1-8 To declare this interest

at the start of any meeting

where a conflict may be

relevant; to discuss with

the chair at the outset

whether participation is

possible or appropriate; to

step out of meetings or

decision making if the

conflict cannot be

managed

Carol Varlaam Wandsworth CCG Board Lay Member,

Patient and Public Involvement

Integrated Governance & Quality

Committee

Audit Committee

Remuneration Committee

PPI reference Group (Chair)

Primary Care Committee (Chair)

N


Dr Natasha Curran Secondary Care Governing Body

Member

Member of Integrated Quality &

Governance CommitteeY

1. Medical Director Health Innovation Network 30 hours/week

2. Consultant in Anaesthesia & Pain Medicine, University College

London Hospitals

1

2

1. 25/06/18 Adherence to COI policy

Page 6 of 75

Name




employee or other

Do you

have any

interests to

declare?

(Y or N)

Declared Interest


Fin

anci

al In

tere

st

No

n-F

inan

cial

pro

fess

ion

al

Inte

rest

No

n-F

inan

cial

Pe

rso

nal

Inte

rest

Ind

irec

t

Inte

rest

Nature of Interest

From To


risk

Page 7 of 75

1

Minutes of the meeting of the Primary Care Commissioning Committee (Part 1) held on Tuesday 28th May 2019

Chair: Carol Varlaam Present: Voting Members Carol Varlaam (CV) Lay Member, Patient and Public Involvement Katie Denton (KD) Director of Primary Care Transformation Nick Cuff (NiC) Associate Lay Member Stephen Hickey (SH) Lay member Julie Hesketh (JH) Director of Quality and Governance Dr Natasha Curran (NaC) Secondary Care Doctor Non-Voting Members James Gillespie (JG) Wandsworth Healthwatch Dr Mike Lane (ML) Locality lead for Wandle Dr Waqaar Shah (WS) Locality lead for Wandle Tim Hodgson (TH) LMC representative In attendance:

Emma Gillgrass (EG) Associate Director of Primary Care Transformation

Robert Hudson (RH) Deputy Director of Finance Kate Symons (KS) Associate Director of Primary Care

Transformation Kasia Gaj (KG) Deputy Head of Primary Care, NHS England -

South West London Primary Care Team Muna Ahmed (MA) Interim Governance Officer Apologies Neil McDowell (NM) Director of Finance James Blythe (JB) Managing Director Dr Zoe Rose (ZR) West Wandsworth LCG Lead Dr Nicola Jones (NJ) CCG Chair John Atherton (JA) Director of Performance Chris Savory (CS) Lay member Josh Potter (JP) Director of Commissioning Dr Nicola Williams (NW) Clinical Director Battersea Councillor Paul Ellis (PE) London Borough of Wandsworth

A01

Apologies, Declarations, Quorum

Apologies were received as above. The meeting was not quorate, as both the Managing Director and Local Finance Director were on leave. Therefore, any decisions will be ratified outside the meeting. No additional conflicts of interest were declared.

A02

Clinical Chair’s Opening Remarks

Page 8 of 75

2

CV informed all that there is a new Health and Wellbeing Member – Councillor Melanie Hamilton.

A03

Minutes of Previous Meeting on 4th September and 4th December 2018 and action log

Minutes 4th September 2018 – approved. 4th December 2018 – approved. Action log All actions were closed. 18/030 - RH confirmed allocations will be set annually. Close.

A04 Decisions ratified outside of the meeting

KD presented the decisions which were ratified outside the meeting.

1. The Committee was asked to approve the recommendation from the PCOG to recommission the London wide DES for 2019-20 and note that the portal is to be decommissioned and practices continue to be offered the London Minor Surgery DES in 2019/20. The Committee supported and approved the recommendation by the PCOG. Neil McDowell and James Blythe ratified the decision.

2. The Committee was asked to note and approve the updated guidance on Managing Serious Incidents in General Practice. The Committee noted and approved the updated guidance. Neil McDowell and James Blythe ratified the decision. The guidance also went to the Merton Primary Care Commissioning Committee in December, where they made one amendment to the guide.

The Committee APPROVED the guidance with the amendment.

B01

Primary Care Commissioning Update

Primary Care Operations Group – SAS The Junction The Committee had previously agreed that there is a need to continue offering primary medical care services on this site, with an agreement that the Alternative Provider Medical Services (APMS) service needed to be re-procured. As part of the wider review of the other contracts, and public engagement on the service model to be delivered on the site, a decision was taken by the Governing Body to procure an integrated service model via the APMS contract in order to secure the ongoing provision of primary care services, alongside extended access via a hub service. Any new APMS contracts are required to be approved by NHS England; through submission of a Business Case.

Page 9 of 75

3

On the 14th May our business case was approved by the Clinical Executive Group (CEG). We can now move forward with the procurement of the new service model at the Junction. The decision to award the contract will be made by this committee. Members of the public will be on the procurement panel and will add Healthwatch. NiC felt the timescales were tight for a new provider to mobilise the service. KD has been assured that when the Market testing was conducted, providers reported that 6 months is enough time to mobilise the service. The governance process for procurement is that it will go to the EMT and Operations Group and the final decision to WPCCC. It was noted that some members of EMT will be conflicted. Joint Primary Care Quality Review Group (PCQRG) Update EG provided a summary of the practices that have been inspected by the CQC recently:

• Open Door Surgery – inspected in November and rated “Good” overall. Areas of improvement were to review procedures for appraisals and protected learning time.

• Tooting Bec Surgery – inspected in January 2019 and rated overall as “Good”. No specific areas of improvement identified.

• Balham Park Surgery – inspected in February 2019 and rated overall as “Good”. One area of improvement is follow up on care actions. Their complaints process was rated “Outstanding”.

• Wandsworth Medical Centre – inspected in March 2019 and rated overall as “Good”. Areas of improvement were in identifying carers, their Legionella risk assessment and maintaining uptake of diabetes monitoring, cervical cancer screening and childhood immunisations.

• Lavender Hill – inspected in February 2019. Rated overall as “Requires improvement”. For the “safe” domain – areas of improvements were Legionella risk assessment, processes to ensure medicines and equipment were in date and to keep a record of blank prescription stationery. For the “Well Led” domain, improvements required are around staff training and governance. The CCG was not expecting the issues identified. The Practice Support Team will assist the practice with the improvements.

Complaints - In 2017-18, Wandsworth practices reported 458 new complaints, with 94% being resolved and 348% being upheld. A further 17 complaints were made directly to NHSE. Learning from incidents - recent learning has followed two incidents relating to monitoring of patients on anti-psychotic medication ordering and collecting prescriptions. Work is ongoing to share appropriate guidance with practices. JH commented that learning from safeguarding incidents will be shared with primary care. The Primary Care Committee NOTED the Primary Care Commissioning Update Report.

B02

B02 Finance report

Page 10 of 75

4

Robert Hudson provided the finance report:

- Primary Care which includes co-commissioning, prescribing and business as usual, underspent by £500k in 2018/19. However, Primary Care co-commissioning overspent by £640k . This was due to budgets being set higher than the allocation.

- The underspend was largely in prescribing. There was a discussion about whether there will be a similar disparity between the budget and allocation this year. RH explained that there will be a gap of £1.4m this year. It was confirmed that this can be offset by savings elsewhere and that reserves and contingency can also be utilised. TH raised concern about the underspend in primary care. KD explained that it was offset by the overspend in co-commissioning within primary care.

The Primary Care Committee NOTED the Primary Care Finance Report.

B03 Terms of Reference

The following points were discussed and amendments to be made to the terms of reference:

- NJ had sent comments prior to the meeting. NJ suggested the Independent GP role is moving from a voting member to non voting, given the difficulty in recruiting one. The Committee agreed. ML stated that he would be happy to swap with a South East London GP.

- CV stated that there are three lay members and one associate lay member who are voting members and this should be reflected in the ToR.

- Para 33 re Frequency – is was agreed that para 33 will be amended to say the committee will meet quarterly with at least two meetings in public.

- The LMC raised concern that there was not a local GP as a voting member. It was clarified that GPs can participate fully in discussions. However, they can not be voting members, as they would be conflicted. This is standard across all CCGs in London.

- Para 15 to mention Primary Care Networks. - Para 19 is lifted from the NHS England guidance and should be edited

to make it relevant to the Committee. - LMC queried why the NHSE team is no longer part of the membership.

It was explained that the NHSE team has now been devolved into the CCG and that KG will attend the Committees. It was agreed that the SWL Primary Care Team will be added to the membership.

There was a discussion about the governance of the Clinical Directors of the PCNs. The contracting team will have oversight of the Directly Enhanced Scheme and managed via the Operations Group and the PCQRG.

There was a brief discussion about the possibility of swapping a SWL GP (Mike Lane), with a South East London GP, for the Committee. This would require further exploration. The Primary Care Committee DISCUSSED the Terms of Reference.

B04

Special Allocation Scheme Contracting in SWL

Page 11 of 75

5

KS informed all that CCGs with delegated authority for commissioning primary medical services are responsible for ensuring that a Special Allocation Scheme (SAS) is set up for the patients living in their area. The service would be offered to patients living in Kingston, Merton, Richmond, Sutton and Wandsworth CCGs. Croydon has its own arrangements in place, as an Alternative Provider Medical Services (APMS). There are two options for commissioning SAS which are an APMS contract or a Directly Enhanced Service (DES) arrangement. There have been detailed discussions with all SWLCCGs outlining the risks and opportunities of both options. The preferred commissioning route has been a DES arrangement. It has been agreed that the service would continue to be called the “Primary Care Extra Service”. The Wandsworth Operations Group and the Wandsworth PCOG have previously discussed this briefing paper and agreed with the recommendation that the most appropriate commissioning model for the service is via a south west London Enhanced Service Model. The Committee was asked to note that the cost per CCG will be £22,000 per annum. This is an increase to the current service cost by £8,976 per CCG. This is to cover the new additional national criteria. JH questioned what would happen if one of the CCGs does not want to pay the additional cost and queried whether it is value for money. KS explained that it is value for money because it would cost the CCGs more money to provide the service themselves. The service will be provided at one site for SWL, from 8am to 6:30pm. Outside of these hours, the patients will need to call 111. The quality of the service will be monitored by the KPIs and service specification, as well as feedback from patients. The current service is reported as good. The SWL Primary Care Team oversees the service. The Primary Care Committee NOTED the increase in the cost and APPROVED the Special Allocation Scheme service for SWL.

B05 NHSE Transformation Funding

EG informed all that this is the second year of transformation funding from NHS England. The CCG will receive £2.2m which will fund the 8-8 extended access and Primary Care at Scale (PCAS). The Access Funding will continue to deliver 8-8 access to primary care in Wandsworth. Whereas the PCAS Funding will support the development of Primary Care Networks and continue schemes from 2018-19. Battersea Healthcare (BHCIC) is the provider extended access and PCAS. The 2019/20 guidance for 8-8 access has not been published yet. However, the draft guidance sets out a number of amendments to the 2018-19 specification, such as, an increase from 30 minutes per 1000 population to 32 minutes per 1000 population and the use of digital approaches to support new models of care. The current priorities for BHCIC in delivering PCAS are:

Page 12 of 75

6

• Support PCN development - information has been collated from practices about future needs/ priorities which will be used to guide the ‘offer’ and support a coordinated approach.

• Primary Care Network projects/pilots - introduction of new clinical and non-clinical models (which are beyond the scope of currently commissioned services).

• Progression and evolution of current workstreams - some current projects will carry forward, some will evolve further, and new projects will be delivered. The workstreams will be closely aligned to PCN development.

BHCIC will be working with practices to further develop these priorities and produce a plan for the use of the Transformation Funding for PCAS by the end of June 2019. SH queried what will happen in 2020/21, when there is no extra funding. It was clarified that the money will go to the PCNs and that 8-8 access will continue to be delivered. The Committee NOTED the Transformation Funding to be received and APPROVED in principle the plans for the Primary Care at Scale and Access funding.

18/044 B06 Applications for Primary Care Networks in Wandsworth

On 31st January 2019 NHS England and the BMA General Practitioners Committee in England published a five-year framework for GP Contract Reform to implement The NHS Long Term Plan. The agreement sets out the changes in the 2019/20 GMS Contract, confirms the direction for primary care for the next ten years and most importantly, introduces a new Primary Care Network Contract which outlines a significant shift in the future of general practice and primary care. The Network Contract Directed Enhanced Service (DES) documentation was published on the 31st March 2019; which provided further clarity of the details of the contract, as well as the Network DES Specification. The Specification sets out the requirements for the first year of the contract; including the establishment of Primary Care Networks (PCNs) which will play a crucial role in delivering integration, driving transformation and supporting the Integrated Care System. A Primary Care Network will see practices coming together, typically to service a population of between 30,000 and 50,000 people. They will deliver new projects and develop new roles within primary care. The applications to form a PCN were received by 15 May 2019. The applications were reviewed by non-conflicted members of the Primary Care Operational Group, ensuring that they met the requirements as detailed in the Network Contract. There were 9 proposed PCNs. The outcomes of the review process concluded that the PCNs:

• Covered 100% of the practices in Wandsworth • Provided 100% coverage of the registered population • Were geographically contiguous • That no PCN contained practices outside of CCG boundary • No networks under 30,000 patients

Page 13 of 75

7

• 3 Networks were over 50,000 patients. Local knowledge and rationale was used to determine that this would be acceptable.

CV thanked the primary care team, practices and the LMC for all of their work on this to ensure the timescales were met. The Committee felt the rationale for the larger Networks was justified. There was a discussion about the names of the Networks, as it was felt that some of the names may cause confusion. KD will feed this back to the Networks. Patients and the public will be engaged. The Primary Care Committee NOTED and APPROVED the recommendation to approve the applications for the Primary Care Networks in Wandsworth.

B06

Any Other Business

None.

Close of Part 1

Page 14 of 75

Cover Sheet Template for Committee Meetings Final Version 1.2 July 2018 Page 1 of 2

Wandsworth Clinical Commissioning Group Wandsworth Primary Care Commissioning Committee in Public Date 3rd September 2019

Document Title Decisions ratified outside of the Committee Lead Director (Name and Role)

Katie Denton, Director of Primary Care Transformation

Clinical Sponsor (Name and Role)

Author(s) (Name and Role)

Muna Ahmed, Governance Officer

Agenda Item No. A04 Attachment No. A04i Purpose (Tick as Required) Approve Discuss Note

Executive Summary As the meeting on the 28th of May 2019 was not quorate, the Committee agreed that any decisions made would be approved and ratified by Directors outside the meeting. The following items were ratified:

1. Minutes from Sept and December 2018 – the Committee approved both sets of minutes for parts 1 and 2.

2. Updated guidance on Managing Serious Incidents in General Practice – the Committee approved the amendment made by Merton Primary Care Commissioning Committee in December.

3. Special Allocation Scheme service for SWL (excluding Croydon) – the Committee noted the increase in the cost and approved the Special Allocation Scheme service for SWL.

4. NHS Transformation Funding - the Committee noted the Transformation Funding to be received and approved in principle the plans for the Primary Care at Scale and Access funding.

5. Applications for Primary Care Networks in Wandsworth - The Committee noted and approved the recommendation to approve the applications for the Primary Care Networks in Wandsworth.

Reason for Committee Review: To note the outcomes of the decisions from the May 2019 Committee. Key Issues: None Conflicts of Interest:

X

Page 15 of 75


N/A Mitigations: N/A

Recommendation: To note the outcomes of the decisions from the May 2019 Committee.

Corporate Objectives This document will impact on the following CCG Objectives:

N/A

Risks This document links to the following CCG risks:

N/A

Mitigations Actions taken to reduce any risks identified:

N/A

Financial/Resource/ QIPP Implications

None

Has an Equality Impact Assessment (EIA) been completed?

This is not required

Are there any known implications for equalities? If so, what are the mitigations?

No

Patient and Public Engagement and Communication

This is not required

Previous Committees/ Groups Enter any Committees/ Groups at which this document has been previously considered:

Committee/Group Name: Date Discussed:

Outcome:

Supporting Documents None

Page 16 of 75

Wandsworth Clinical Commissioning Group Wandsworth Primary Care Commissioning Committee in Public Date 3rd September 2019

Document Title Terms of Reference annual review Lead Director (Name and Role)

Katie Denton, Director of Primary Care Transformation



Muna Ahmed, Governance Officer

Agenda Item No B01 Attachment No. B01i

Purpose Approval Discussion Noting

Executive Summary: The Terms of reference for the WPCCC are being presented because they are due for an annual review.

Key Issues: The Committee needs to ensure that the membership remains appropriate and that the remit and responsibility of the committee continues to accurately reflect the requirements and operation of the committee.

Conflicts of Interest: None noted.

Recommendation: The Committee is asked to: Approve the terms of reference as a comprehensive framework for the Committee.

√

√

Page 17 of 75

Corporate Objectives This paper will impact on the following:

This Committee impacts on all corporate objectives of the CCG and the terms of reference ensure that the objectives are effectively considered.

Risk This paper links to the following CCG risks:

Financial Implications

Has an Equality Impact Assessment been completed

Not applicable for the terms of reference.

Are there any known implications for equalities

None known

Patient and Public Engagement and communication

The PPI Lay Members Chairs the committee.

Committees previously considered at

Discussed at the previous 2 WPCCCs

Supporting Documents Terms of reference document.

Page 18 of 75

Wandsworth CCG Primary Care Commissioning Committee

Terms of reference

Introduction 1. In accordance with its statutory powers under section 13Z of the National Health

Service Act 2006, NHS England has delegated the exercise of the functions specified in Schedule 2 of the Delegation Agreements to these Terms of Reference to Wandsworth CCG.

2. The CCG has established the Wandsworth CCG Primary Care Commissioning

Committee (“Committee”). The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers.

3. The relationship the Primary Care Commissioning Committee has with NHS

England will be revised on an ongoing basis, though this will be outlined in Schedule 4 of the Delegation Agreement.

4. It is a committee comprising representatives of the following organisations:

• Wandsworth CCG • NHS England • Wandsworth Borough Council • Local Medical Committee (LMC) • Healthwatch

Statutory Framework 5. NHS England has delegated to the CCG authority to exercise the primary care

commissioning functions set out in Schedule 2 of the Delegation Agreements in accordance with section 13Z of the NHS Act.

6. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between the NHS England Board and the CCG.

Page 19 of 75

7. Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including:

a) Management of conflicts of interest (section 14O);

b) Duty to promote the NHS Constitution (section 14P);

c) Duty to exercise its functions effectively, efficiently and economically (section 14Q);

d) Duty as to improvement in quality of services (section 14R);

e) Duty in relation to quality of primary medical services (section 14S);

f) Duties as to reducing inequalities (section 14T);

g) Duty to promote the involvement of each patient (section 14U);

h) Duty as to patient choice (section 14V);

i) Duty as to promoting integration (section 14Z1);

j) Public involvement and consultation (section 14Z2).

8. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those set out below:

• Duty to have regard to impact on services in certain areas (section 13O); • Duty as respects variation in provision of health services (section 13P).

9. The Committee is established as a Committee of the Wandsworth CCG Governing

Body in accordance with Schedule 1A of the “NHS Act”. 10. The members acknowledge that the Committee is subject to any directions made

by NHS England or by the Secretary of State.

Role of the Committee 11. The Committee has been established in accordance with the above statutory

provisions to enable the members to make collective decisions on the review, planning and procurement of primary care services in Wandsworth, under delegated authority from NHS England.

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12. In performing its role the Committee will exercise its management of the functions

in accordance with the agreement entered into between NHS England and Wandsworth CCG, which will sit alongside the Delegation Agreement and terms of reference.

13. The functions of the Committee are undertaken in the context of a desire to

promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

14. The role of the Committee shall be to carry out the functions relating to the

commissioning of primary care services under section 83 of the NHS Act.

15. This includes the following:

• GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract);

• Primary Care Networks (PCNs)

• Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);

• Design of local incentive schemes as an alternative to the Quality Outcomes

Framework (QOF);

• Decision making on whether to establish new GP practices in an area;

• Approving practice mergers; and

• Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes). 16. The Committee will also carry out the following activities:

a) To plan, including needs assessment, primary care services in Wandsworth; b) To undertake reviews of primary care services in Wandsworth; c) To co-ordinate a common approach to the commissioning of primary care

services generally; d) To manage the budget for commissioning of primary care services in

Wandsworth.

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17. The Committee is accountable for exercising the agreed delegated functions from

NHS England; these functions operate at practice level and not at individual Primary Care Contractor level.

Geographical Coverage 18. The Committee will be responsible for making decisions relating to Primary Care

in Wandsworth.

Membership 19. 19. CCGs (and NHS England with regards to joint arrangements) can agree

the full membership of their primary care commissioning committees, within the following parameters:

20. The primary care commissioning committee must be constituted to have a lay and executive majority, where lay refers to non-clinical. This ensures that the meeting will be quorate if all GPs had to withdraw from the decision-making process due to conflicts of interest;

21. The primary care commissioning committee should have a lay chair and lay vice

chair. 22. GPs can, and should, be members of the primary care commissioning committee

to ensure sufficient clinical input, but must not be in the majority. CCGs may wish to consider appointing retired GPs or out-of-area GPs to the committee to ensure clinical input whilst minimising the risk of conflicts of interest (and where the primary care commissioning committee is commissioning a new care model, the CCG should consider whether that committee has sufficient clinical expertise taking into account the range of services being commissioned).

23. A standing invitation must be made to the CCG’s local HealthWatch representative

and a local authority representative from the local Health and Wellbeing Board to join the primary care commissioning committee as non-voting attendees, including, where appropriate, for items where the public is excluded for reasons of confidentiality;

24. Other individuals could be invited to attend the primary care commissioning

committee on an ad-hoc basis to provide expertise to support with the decision-making process. Formatted: Font: Bold

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24.25. If a voting member is unable to attend in person, the member will nominate a

suitable deputy to attend in his/her place. The deputy will retain the same voting right as the member they are deputising for.

25.26. The Committee Membership includes:

• Chair – Lay Member • Lay member (Vice Chair) x2 • Associate Lay Members • Managing Director • Director of Transforming Primary Care • LDU Local Finance Director • WCCG Secondary Care consultant • General Practitioner (not within South West London)

• Director of Commissioning • Director of Quality & Performance

Non Voting Members • CCG Chair • GP Locality Clinical Leads x3 Representatives • HealthWatch Representative • LMC Representative • Health & Wellbeing Board Representative • General Practitioner (not within South West London)

• Member of the South West London Primary Care Team

Conflicts of Interest

26.27. In the interest of minimising the risks of conflicts of interest, it is recommended that GPs do not have voting rights on the primary care commissioning committee. The arrangements do not preclude GP participation in strategic discussions on primary care issues, subject to appropriate management of conflicts of interest. They apply to decision-making on procurement issues and the deliberations leading up to the decision.

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27.28. Conflicts of Interests will be managed in accordance with the CCG‘s current policy; ‘Standards of Business Conduct and Managing Conflicts of Interest Policy’.

28.29. Any conflicted Members may be required to leave the meeting for the relevant

discussions, as appropriate under direction by the Chair.

Meetings and Voting 29.30. The Committee will operate in accordance with the CCG’s Standing Orders.

The Governance Team for Wandsworth CCG will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than 5 working days before the date of the meeting. When the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as s/he shall specify.

30.31. Each member of the Committee shall have one vote. The Committee shall reach decisions by a simple majority of members present, but with the Chair having a second and deciding vote, if necessary. However, the aim of the Committee will be to achieve consensus by decision-making wherever possible.

31.32. The Chair shall determine if any conflicted member should leave the discussion

or be excluded from the decision making process.

Quorum

32.33. The Committee will be quorate with 5 out of the 10 voting Members in attendance, including two Lay Members (includes Associate Lay Member), and one of the Managing Director or Local Finance Director in attendance.

Frequency of meetings 33.34. The Committee shall meet at least quarterly, with at least 2 meetings in public,

withand the inclusion of ad hoc seminars held in private for developmental purposes.

34.35. Meetings of the Committee shall: a) be held in public, subject to the application of 31(b);

b) the Committee may resolve to exclude the public from a meeting that is open

to the public (whether during the whole or part of the proceedings) whenever

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publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

35.36. Members of the Committee have a collective responsibility for the operation of

the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

36.37. The Committee may delegate tasks to such individuals, sub-committees or

individual members as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest.

37.38. The Committee may call additional experts to attend meetings on an ad hoc

basis to inform discussions. 38.39. Members of the Committee shall respect confidentiality requirements as set out

in the CCG’s Constitution. 39.40. The Committee will present its minutes to the London Area Team of NHS

England and the governing body of Wandsworth CCG for information, including the minutes of any sub-committees to which responsibilities are delegated under paragraph 34 above.

40.41. The CCG will also comply with any reporting requirements set out in its

Constitution.

Decisions 41.42. The Committee will make decisions within the bounds of its remit.

42.43. The decisions of the Committee shall be binding on NHS England and

Wandsworth CCG.

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43.44. The Committee will produce an executive summary report which will be presented to the London Area Team of NHS England and the governing body of Wandsworth of the CCG.

Reporting

44.45. The Committee will report to the CCG Governing Body on the decisions made within the bounds of its remit.

Immediate and urgent decisions 45.46. There may be instances when the Committee is required to make a decision in

advance of the regular full committee meetings in light of unforeseen circumstances. Depending on the urgency of the matter such decisions may need to be immediate (i.e. to be made in 24 hours) or urgent (i.e. to be made in timeframes longer than 24 hours but in advance of the next scheduled meeting).

46.47. The Director of Transforming Primary Care will decide when an immediate or urgent decision is required and will initiate the decision making process.

47.48. In the instances where an immediate decision is needed the Director of

Transforming Primary Care will arrange a meeting with the Chair or Vice Chair (if Chair is not available) and the CCG Accountable Officer to take the decision. Such decisions will only be taken in exceptional circumstances, such as the need to close a practice due to clinical reasons or contractor death. Any immediate decisions taken under this procedure will be presented at the next Committee meeting.

48.49. In the instances when the Director of Transforming Primary Care deems it

necessary to request an urgent decision the Chair will be contacted. The Chair or Vice Chair (if Chair not available) may deem it necessary to call a meeting at short notice outside the regular full committee meetings as set out in paragraph 29 above.

Review 49.50. There will be an annual review of the Committee’s Membership and Terms of

Reference, to support efficient functioning.

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Wandsworth Clinical Commissioning Group Primary Care Commissioning Committee Date Tuesday, 03 September 2019

Document Title Integrated Primary Care Commissioning Update Paper Lead Director (Name and Role)

Katherine Denton



Kate Symons & Emma Gillgrass

Agenda Item No. B02 Attachment No. B02i Purpose (Tick as Required) Approve Discuss Note

Executive Summary Background: This report provides the Wandsworth Primary Care Committee with an update on how delegated Primary Care commissioning is being managed in Wandsworth; providing an update on some of the key programmes of work. Purpose: This paper provides the Committee with an update on the following:

• The work of the Primary Care Ops Group (PCOG) • The Junction Health Centre Update • An update from the Joint Primary Care Quality Review Group • A summary of the primary care contracting decisions

Reason for Committee Review: 1. The Committee are asked to note the work of the Primary Care Ops Group; specific

discussions have taken place focussing on the locality initiatives. The localities are currently reviewing both the citizen’s advice and welfare services and the interpreting services as both of these contracts come to an end in March 2020.

2. The Committee are also asked to note that the procurement for the new Integrated APMS Service at The Junction has started. Approval of the contract award be made by the Committee.

3. The Committee are asked to note the update from the Primary Care Quality Review Group with Specific focus to practice specific updates for Lavender Hill Group Practice, the results of the National GP Survey.

4. The Committee are asked to note the decisions taken over the last quarter.

YES

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Key Issues: 1. See above points

Conflicts of Interest: As per the usual GP COI Mitigations: As per the usual GP COI

Recommendation: The Committee are asked to note the ongoing work that has been jointly implemented across Primary Care under delegated commissioning arrangements.



None


N/A


None


N/A


N/A.


N/A.

Previous Committees/


Outcome:

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Groups Enter any Committees/ Groups at which this document has been previously considered:

Click here to enter a date.



Supporting Documents Integrated Report

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General Purpose – Integrated Primary Care Commissioning Paper Author: Kate Symons & Emma Gillgrass Sponsor: Katherine Denton Date: September 2019

The Report 1. Update from the Primary Care Operations Group (PCOG) Developing Primary Care Networks Much of the focus of the Primary Care Ops Group over the last quarter has been focussed on the publication of the new Network Contract DES and supporting the development of the Primary Care Networks. Further information around the progress of PCN development on Wandsworth is provided as a specific Primary Care Committee agenda item. Locality Initiatives The Locality Managers for Battersea, Wandle and West Wandsworth Locality’s are focussed on a number of locality specific indicatives to be delivered across Wandsworth. There was a specific focus on the current Citizens Advice & Welfare Service and the Interpreting Services contracts that are currently in place across Wandsworth. Both contracts are due to expire at the end of Match 2020, and as such each locality will be asked to review the current services in light of the potential requirements to re-procure these services. Discussions will be taking place at each Members Forums in order to review the current services, and this will feed into the procurement process for both these services. 2. The Junction Health Centre Procurement The Committee are asked to note that the procurement process for the new Integrated APMS Service at the Junction is now underway. Based on the contract value we are following the full OJEU (Official Journal of the European Union) Process supported by our local SBS team. A visit of the site and bidder briefing event took place in the 16th August, and the deadline for submission form any potential Bidders is the 16th September. The Committee should be aware that the approval to award a new contract following the full procurement process will be made by Committee.

3. Joint Primary Care Quality Review Group (PCQRG) Update Lavender Hill Group Practice CQC Report Lavender Hill Group Practice was inspected by the CQC on 26th February 2019, with the inspection report published 3rd May 2019. The practice was rated overall “Requires Improvement” with “Good” for Effective, Caring and Responsive, and “Requires Improvement” for Well Led and for Safe. The CCG has meet with the practice to discuss the outcomes of the report and the contractual breaches and to ensure action plans are in place to address the issues raised. The practice are already making progress on implementing the improvements required.

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The practice have also be offered support through the Practice Support Team (PST) in addressing the areas identified as requiring improvement. National GP Patient Survey 2019 The GP Patient Survey (GPPS) is an England-wide survey, providing practice-level data about patients’ experiences of their GP practices. Ipsos MORI administer the survey on behalf of NHS England. The most recent data, was collected in the survey period January 2019 – March 2019. In Wandsworth 16,880 surveys were sent out, with a response rate of 24%. This is a lower response rate than England (33%) and South West London (29%). The survey asks a range of questions across areas such as making an appointment, perception of care and opening hours. For the overarching question “Overall, how would you describe your experience of your GP practice” 87% of Wandsworth patients rated their surgery as Fairly or Very Good, ranging for individual practices from 71% to 96% This compares to a national (England) rating of 83% and a South West London (Croydon, Kingston, Merton, Richmond, Sutton, Wandsworth CCGs) average of 85%. Wandsworth is generally rated in line with or above the South West London (SWL), London and England averages. Some of the key questions are highlighted in the table below.

Wandsworth SWL London England Overall how would you describe your experience of your GP surgery? (% Good) 87% 85% 80% 83% Generally how easy is it to get through to someone at your GP surgery on the phone? (% Easy) 78% 74% 69% 68% How satisfied are you with the general practice appointment times that are available to you? (% satisfied) 72% 69% 64% 65% Overall how would you describe your experience of making an appointment? (% Good) 74% 72% 66% 67% How easy is it to use your GP practice’s website to look for information or access services? (% easy) 77% 77% 73% 77% During last general practice appointment did you have confidence and trust in the healthcare professional (% yes) 96% 95% 94% 95%

Areas identified for improvement at a borough level, either because they have the lowest average scores or the biggest variation between practices include:

• Overall experience of making an appointment • How easy is it to get through to someone on the phone • How easy is it to use your GP practice’s website to look for information or access services

The table below shows for these areas the trends over the last four years how these areas compare to England and the variation within Wandsworth practices.

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Questions Jul-16 Jul-17 Aug-18 Jul-19 Jul-19 Variation Overall how would you describe your experience of making an appointment? (% Good)

WCCG 77% 74% 75% 74% 48% - 96% England 73% 73% 69% 67% -

Generally how easy is it to get through to someone at your GP surgery on the phone? (% Easy)

WCCG 75% 70% 80% 78% 43% - 99% England 70% 68% 70% 68% -

How easy is it to use your practice’s website to look for information or access services? (% easy)

WCCG 82% 77% 43% - 100% England

78% 77% -

These areas are all related to access and there is significant work taking place around improving access, extended hours, and digital access which should support improvements in these areas. The results from the GP Patient Survey have been discussed at the Primary Care Quality Group and shared with practices. Practices are encouraged to review their individual results, share with their patient groups and identify areas where they can make improvements. Primary Care Quality Review Group (PCQRG) meetings updates Additional areas reviewed and discussed at the PCQRG in May, June and July include Infection Control, Learning disability Health checks, Mental Capacity act and wider learning from incidents. Infection Control: Each year a list of GP practices are prioritised for infection control audit visits. Depending on the outcome of the audit some practices may require a follow up visit within the same year. In 2019-20 it is planned to inspect 15% of London GP practices, for Wandsworth this is approximately 4 practices. The audit cycle is typically 3 years. The PCQRG reviewed the current inspection ratings for practices and identified those whose last inspection was more than three years ago, and one practice that had a more recent inspection but was rated amber and so due for follow up. This list was passed to the Infection Prevention and Control team who carry out the inspections. Mental Capacity Act: Information was shared relating to a new template and guidance for completing Mental Capacity Act assessments. This has also been shared with practices.

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Learning from Incidents: Recent learning has followed two incidents relating to monitoring of patients on anti-psychotic medication ordering and collecting prescriptions. Work is ongoing to share the learning and guidance with practices, and support them to implement appropriate systems. 4. What general Primary Care Contracting decisions have been made in the last quarter? The following details the primary care contracting decision made from for Q1 of 2019/2020; under business as usual arrangements. Where the contractual changes are detailed these decision would have been made through the usual governance arrangements; and therefore taken at Committee level.

C O N C L U S I O N

The Committee are asked to note the ongoing work that has been jointly implemented across Primary Care under delegated commissioning arrangements.

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Wandsworth Clinical Commissioning Group Primary Care Commissioning Committee Date Tuesday, 03 September 2019

Document Title Audit of Subcontracting Arrangements of GP Practices declaring a Half Day Closure Lead Director (Name and Role)

William Cunningham-Davis



Kasia Gaj & SWL Primary Care Team

Agenda Item No. B03 Attachment No. B03i Purpose (Tick as Required) Approve Discuss Note

Executive Summary Background: On 11 April 2018 guidance was sent to Commissioners by NHS England outlining the expectations for the review of GP practice access arrangements, for assurance they meet the reasonable needs of their patients during core hours. The previous year’s focus had been on the practices who had declared regular periods of half day closing on the annual electronic GP Practice self-declaration (eDec). Following this a significant number of practices nationally had chosen to stop closing for half day. However, since the 2017/18 eDec was collected a number of practices had also declared that they were also closed regularly more than 7.5 hours per week during core hours. The guidance provided in April 2018 requests that a review of the access arrangements for this cohort of practices is also undertaken. This paper provides a report on those practices in South West London (SWL) who through their 2018/19 e-Dec submission declared half day closing, and those practices who are closed 7.5 hours or more per week during core hours. The report will detail:

• The follow up that has been made to confirm the stated position of the practices, including any discrepancies identified in relation to the opening hours published on NHS services and practice websites.

• The actions taken to fulfil the national requirement to substantiate what subcontracting arrangements are in place during the closure period to ensure the reasonable needs of the patients are being met.

Reason for Committee Review: 1. CCGs with a practice declaring a half day closure are asked to consider the response

from the practice to decide on any actions that are required or if the CCG are assured

YES

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that present arrangements for ensuring the reasonable needs of the patient are being met. Following this review and assessment to decide if any contractual breach action needs to take place.

Key Issues:

1. Section 3.6 – The Wandsworth CCG Position 2. Section 4 – What powers to commissioners have 3. Section 5 – Recommendations & Next Steps

Conflicts of Interest: As per the usual GP COI Mitigations: As per the usual GP COI

Recommendation: The Committee are asked to note recommendations in the paper.


Meeting our performance and financial objectives: Make the best use of our resources to benefit our patients and communities


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N/A


None


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N/A.

Previous Committees/ Groups Enter any Committees/ Groups at which this document has been previously considered:


Outcome:




Supporting Documents GP Half Day Closures SWL Review Paper

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SWL Primary Care Team September 2019

1

Audit of Subcontracting Arrangements of GP Practices declaring a Half Day Closure during 2018/19

Contents 1. Introduction ............................................................................................................................. 2 2. Context and background...................................................................................................... 2

2.1 Assurance guidance and Key Lines of Enquiries (KLOEs) ..................................... 3 2.2 Identifying GP Practices .................................................................................................... 3

3. South West London overview ............................................................................................. 4 3.1 Croydon CCG position ....................................................................................................... 4 3.2 Kingston CCG position ...................................................................................................... 5 3.3 Merton CCG position .......................................................................................................... 5 3.4 Richmond CCG position .................................................................................................... 5 3.5 Sutton CCG position ........................................................................................................... 6 3.6 Wandsworth CCG position ............................................................................................... 6

4. What powers do Commissioners have? .......................................................................... 7 5. Recommendations and Next Steps ................................................................................... 7 Appendix 1: Key Lines of Enquiries (KLOEs) ........................................................................ 9 Appendix 2: SWL 2018/19 Triangulation Report .................................................................. 12 Appendix 3: GMS & PMS Subcontracting contract clauses ............................................. 13

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2

1. Introduction On 11 April 2018 guidance was sent to Commissioners by NHS England outlining the expectations for the review of GP practice access arrangements, for assurance they meet the reasonable needs of their patients during core hours.

The previous year’s focus had been on the practices who had declared regular periods of half day closing on the annual electronic GP Practice self-declaration (eDec). Following this a significant number of practices nationally had chosen to stop closing for half day. However, since the 2017/18 eDec was collected a number of practices had also declared that they were also closed regularly more than 7.5 hours per week during core hours. The guidance provided in April 2018 requests that a review of the access arrangements for this cohort of practices is also undertaken.

This paper provides a report on those practices in South West London (SWL) who through their 2018/19 e-Dec submission declared half day closing, and those practices who are closed 7.5 hours or more per week during core hours. The report will detail:

• The follow up that has been made to confirm the stated position of the practices, including any discrepancies identified in relation to the opening hours published on NHS services and practice websites.

• The actions taken to fulfil the national requirement to substantiate what subcontracting arrangements are in place during the closure period to ensure the reasonable needs of the patients are being met.

2. Context and background The General Medical Services (GMS) and Personal Medical Services (PMS) Regulations require general practice contractors to provide essential and additional services at such times within core hours, ‘as are appropriate to meet the reasonable needs of patients’, and require the contractor to have in place arrangements for its patients to access those services throughout core hours in case of emergency. Core hours for GMS practices are defined as 8am-6.30pm, Monday – Friday, excluding weekends and bank holidays. Core hours for PMS and APMS practices are set out in their contract but largely mirror GMS core hours or longer.

The Public Accounts Committee (PAC) report into GP access held in March 2017 set out a number of recommendations. One was to ensure that no GP practice that was closed weekly for half a day should be in receipt of additional funds to provide ‘extended hours’ i.e. outside ‘core hours’ and secondly that patients should know what they can ‘reasonably’ expect of their GP practice during core hours.

In December 2017 the national team issued guidance to commissioners to assist in reaching an agreement whether practices access arrangements meet the reasonable needs of patients.

In April 2018 the NHS England National Team wrote to commissioners requiring them to give assurance that the reasonable needs of patients is being met when a practice is regularly closed for half a day, over four hours on any one day, or open for only 45 hours or less a week. In addition to this, commissioners were directed to assess subcontracted services.

The first audit was undertaken in September 2018 using the practices 2017/18 e-Dec submissions in relation to regular and intermittent periods of closure during their core hours. Each practice that had declared a half day closure was sent a letter detailing the change in requirements to enable participation in the extended hours DES as of 1st October 2017.

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3

A second audit was undertaken in 2019 (Appendix 2). Any practice that had declared a half day closing on their 2018/19 eDec was contacted by telephone to confirm the accuracy of their submission and what arrangements were in place for the half day closing. The information has been compared against the responses to the first audit, and any agreements/ recommendations made by commissioners at the time.

2.1 Assurance guidance and Key Lines of Enquiries (KLOEs) In order to seek assurance from practices that their access arrangements meet the reasonable needs of the patients, the practices were asked to respond to a list of questions (KLOEs – Appendix 1) to assist commissioners in determining if the practice meets the requirements and to clarify their sub-contracting arrangements (Appendix 4 - GMS & PMS subcontracting clauses). Each of the access queries varied, so when contacting the practices, the questions were tailored for each practice, as it was not always necessary/ applicable to ask for all of the KLOE questions to be responded to.

When reviewing half-day closures, practice responses were reviewed. The practices were asked to state if there were any changes to the information provided. In addition to this, all practices who declared they were open for 45 hours or less a week were contacted asking that they confirm their access and sub-contracting arrangements.

Commissioners are also required to review practice responses alongside other data streams such as those held by CCGs relating to A&E, admissions, hub data and patient survey and complaints. This will enable an informed decision on determining if the reasonable needs of the patients are being met or not. The Triangulation Report (Appendix 3) lists these practices with most recent data relating to:

• Sub-contract information • Raw list size @1/4/19 • Friends and Family Test data (if available) • GP Patient Survey results (2018/19) • NHS Choices ratings • A&E attendance rates • Total number of Hub appointments

This data has been provided alongside the summary of the practice responses (Appendix 2) to help inform the Commissioning teams in recommending next steps. The opening hours declared by the practices have been compared against practice website data and the NHS Services data to identify any discrepancies. Practices were also asked to amend these if they did not reflect the opening hours of the services.

2.2 Identifying GP Practices The Annual GP Practice self-declaration includes a specific question around ‘half day’ closing and required practices to report their hours of availability. This required each GP practice to complete and submit a template to confirm what arrangements were in place. A series of questions were raised in order to assess if these arrangements aligned to patient expectations in terms of meeting their reasonable needs. Key areas covered included:

• Ability to attend a pre-bookable appointment (face to face) • Ability to book / cancel appointments • Ability to collect / order a prescription • Access urgent appointments / advice as clinically necessary

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4

• Home visit (where clinically necessary) • Ring for telephone advice • Ability to be referred to other services where clinically urgent • Ability to access urgent diagnostics and take action in relation to urgent results

The services listed above have been refined following NHS England’s engagement with patient groups and patient representatives at a national level.

3. South West London overview The SWL Primary Care Team has contacted all practices who have declared half day closures and / or are open for 45 hours or less a week. Declarations of half day closures were also compared against the previous year’s responses. Some practices have since confirmed they are open for the full core hours.

A total of 20 practices have declared half day and/ or opening hours of 45 hours or less a week. The Triangulation Report (Appendix 3) has been provided alongside the summary of the practice responses (Appendix 2) to help inform Commissioners. The sections below provide a breakdown for each SWL CCG area. 3.1 Croydon CCG position There are six practices in Croydon that have declared regular periods of closure during core hours in the 2018/19 eDec. Two of these have half-day closures:

• One practice has a branch surgery. Although the main surgery is closed on Monday afternoons from 2pm-6.30pm, their branch site remains open during the full core hours. The branch site is approximately 30 minutes’ walk or 10 minutes’ drive from the main site. It’s also about a 30 minutes’ bus journey. However, as one of the sites remains open during the full core hours, no further action is required as there is no contractual breach.

• The other practice forms part of a group of three practices, and has arrangements in place for their patients to be managed from one of the other sites during the period of the half-day closure. The other site is approximately 10 minutes by car, 20 minutes bus journey, or 17 minutes walking.

Four have declared regular periods of closing 7.5 hours or more per week:

• The first practice has advised that the premises remain open during core hours, but their main phone lines are closed between 1pm-3pm. However, urgent calls are diverted to another number within the practice. A separate number is also available for patients to call regarding their prescriptions. The practice has advised that this process has been in place for 20 years. It has been discussed with the PPG and no concerns were noted.

• The second practice has confirmed that they are open during their full core hours. However, their phone lines are switched off daily 12.30pm–2pm, with an emergency number for patients to call and speak with the on-call GP.

• The third practice is closed daily 1pm-4pm, with access only for patients with pre-booked appointments during this time. The phone lines remain open. A prescription and post box is provided at the entrance door. The practice have noted that this is a historical arrangement which their patients are familiar with. They have recently discussed with their PPG and no concerns were raised.

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• The fourth practice is closed daily 1pm-3pm. They advised that they have an answerphone message that directs patients to another practice who they have made arrangements with to triage calls, and where appropriate contact the GPs to arrange a home visit and/ or prescribe medication. Patients are made aware of this during the registration process. It should also be noted that the practice advised that they do not currently have their own website or PPG established. It is a contractual breach for a practice not to have a PPG in place. (See recommendation in section 5).

3.2 Kingston CCG position There are two practices in Kingston that have declared regular periods of closure of more than 7.5 hours per week during core hours. There are no half-day closures.

• One practice confirmed that although they close their doors between 1pm-2.30pm each day, there is an emergency number for patients to call during this time. Details are also provided on their website. Patients are able to leave a message, and prescription box is provided at the front porch. Further information is available on their website.

• The second practice’s phone lines are closed between 12pm-1.30pm, and patients can leave a message during this time. An emergency number is available for patients and this is also shown on their website, with a GP on-call to deal with any urgent issues. They have also advised that no concerns have been raised by their PPG concerning the arrangements. At the time the practice was contacted they informed that they were circulating a questionnaire to their patients and will review the feedback concerning the opening hours.

3.3 Merton CCG position There are no practices in Merton that have declared regular periods or half-day closures during core hours for the 2018/19 e-Dec. However there are two practices with intermittent periods of closure every month.

• One of the practices is closed to patients between the hours of 1.30pm-2.30pm every two months for a practice meeting during this time, advising that they have a mobile number which is on the door and on a recorded message for emergencies. The SWL Primary Care Team have followed up with this practice, who confirmed that they close on Tuesdays every 2 months for one hour between 1.30pm-2.30pm for a practice meeting.

• The second practice declared that they close on a Wednesday afternoon quarterly for a Merton CCG arranged PLT. All Merton practices are invited to attend the PLT event in which the CCG has arranged SELDOC to provide cover. However, the expectation going forward is that all practices remain open during the full core hours, including periods of CCG and practice arranged training events. Practices must ensure they have a minimum level of staff available to maintain patient access to primary care services, or have approved subcontracting arrangements in place. (See recommendations in section 5).

3.4 Richmond CCG position There are seven practices in Richmond that have declared regular periods of closure during core hours in the 2018/19 eDec. Two of these have half-day closures:

• One practice closed at the end of July 2019; • The other practice confirmed they are open full core hours, effective immediately.

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Five have declared regular periods of closing 7.5 hours or more per week: • The first practice has confirmed they are now open their full core hours; • The second practice has advised that patients are able to contact the on call GP for

urgent appointments when the reception phones are closed between 8am-8.15am and 1pm-3pm. A box for prescriptions is available at the entrance and another at the reception desk. However, their website and NHS Choices have not been updated to reflect the correct opening hours. SWL primary care team to follow up with the practice regarding this;

• The third practice has stated that their phone lines are closed between 8am-8.30am and 6pm-6.30pm, with calls redirected to East Berkshire OOH service. Urgent calls are passed to the on-call GP during these times. Prescription/ repeat prescription requests are not dealt with during this time;

• The fourth practice is closed daily 8am-8.30am and 1pm-3pm. They have a contract with East Berkshire OOH services, who direct any urgent calls to the on-call GP. Prescriptions can be sent online or by email, with collections arranged with the pharmacy. They advised that the PPG are aware and supportive of these arrangements;

• The fifth practice’s phone line is closed daily between 8am-8.30am and 1.30pm-2.30pm, and 5.30pm-6.30pm on Fridays. Patients are able to leave a message and an on-call GP is available to deal with any urgent issues. The GP OOH team will contact the lead GP with prescription queries. The practice has discussed opening hours with their PPG and no concerns have been noted.

3.5 Sutton CCG position There was one practice in Sutton that declared regular periods of closure during core hours of more than 7.5 hours per week. When this was queried, the practice advised that this is no longer correct and that they are open for the full core hours. 3.6 Wandsworth CCG position There are practices in Wandsworth who have declared regular periods of closure during core hours in 2018/19. Three of these practices have declared regular closing of 7.5 hours or more per week, and the SWL Primary Care Team have followed up with the practices concerned.

• The first practice corrected the opening hours however they still remain closed between 1.30pm-3.30pm four days of the week. They advised that the practice and clinical staff are available during this time;

• The second practice closes between 1pm-2pm five days per week. On following up with the practice they have confirmed that:

o There are reception staff on duty o Patients can still gain physical access to the practice and by phone, and o A GP is available for urgent appointments o Their PPG and the CCG have been informed of these arrangements

• The third practice has declared they close Monday, Tuesday, Thursday and Friday 1.30pm-2.30pm. During this time cover is provided by Care UK and they have the contact details for the GP on call who provides triage and deals with any urgent appointments. There are no reception staff and there is poster in the entrance. An automated telephone message provides patients with the contact number for Care UK. The practice advised that this arrangement has been in place for many years and that the arrangements have been discussed/agreed with CCG;

• A fourth practice closes between 1pm-2pm Monday to Friday. On following up with the practice they confirmed that they have emergency mobile access number only,

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which is used by patients to access the on-call clinician. They have advised that they have consulted their PPG and that the CCG are aware of this arrangement;

• A fifth practice confirmed they close intermittently each month on a Monday for a practice meeting, on a Tuesday for staff training, on a Wednesday for a reception staff meeting, and on a Thursday for a practice staff and clinical meeting;

• A sixth practice declared half day closing in 2017/18 which was queried by the commissioning team, and has since confirmed the practice no longer closes half day. However their website still needs updating, so requires further follow up by the SWL Primary Care Team. The practice has also declared that they close between 1pm-4pm Monday to Friday, and cover is provided by Care UK who provide a telephone answering service, and a receptionist is available for face to face contact. This is currently being reviewed by the CCG.

4. What powers do Commissioners have?

Commissioners need to consider if the reasonable needs of the patient are being met by the practice, by looking at all sources of data and feedback available. This may include the GP patient survey results, patient complaints, impact on A&E and admissions along with evidence supplied by the practice including PPG engagement and feedback. Depending on the evidence received CCG Commissioners will need to be assured that practices are complying with the contract by either opening, remaining open during full core hours or ensuring adequate sub-contracting arrangements are in place. Once arrangements are confirmed if there is a dispute between the commissioner and the practice either on the services available or the subcontracted arrangements in place / it is proposed then commissioners may need to consider contractual action. For practices found to be in breach of contract, remedial notices will be required to agree a reasonable and proportionate pace of change and to set out the ongoing dialogue between the commissioner and the practice on progress made.

5. Recommendations and Next Steps CCGs with a practice declaring a half day closure are asked to consider the response from the practice to decide on any actions that are required or if the CCG are assured that present arrangements for ensuring the reasonable needs of the patient are being met. Following this review and assessment to decide if any contractual breach action needs to take place. The national team are due to publish another directive regarding assurance relating to practices who close periodically during core hours. Details are to follow when this is made available. If a practice proposes to sub-contract, the Contract Regulations require the practice to notify their commissioner. Where this is a case, the commissioner will need to be assured that a proposed arrangement will deliver essential medical services during core hours. This notification should be made at least 28 days prior to the proposed commencement of the sub-contract. In regard to practice or CCG (PLT) arranged training events, to date there has been some flexibility for practices to close and direct their patients to out of hours service providers during the periods of training. However, going forward any practice wishing to apply for

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planned closure during core hours will need to provide a written confirmation of what arrangements will be in place to deliver its contractual obligations. This includes practice and CCG arranged training events. At a minimum a system needs to be put in place so that the patients can access the services listed below to meet the reasonable needs of the patients;

• Ability to attend a pre-bookable appointment (face to face) – taking into the lone-worker policy, practices may wish to have more than one receptionist or member staff on d