PRIMARY CARE COMMITTEE

Thursday 7th July 2016

at 1.30pm the Boardroom, Nutgrove Villa

AGENDA

ITEM

1:30pm Welcome and Introductions

Paul Melia

Lay Member – Patient & Public Involvement

(Chair)

Apologies for Absence

Chair

Declarations of Interest Note that GP members have a standing declaration of interest on this agenda as providers of primary care

services within Knowsley however, should GP’s have any specific interests in any particular item they must

be declared individually at each meeting. All other members of the Committee will also be asked

to declare an interest.

Chair

1.35pm

Minutes and Matters Arising of the Previous Meeting held on Thursday 5th May 2016.

Document PC(07)01

Chair

1.40pm

Action Log

• Smoking in Knowsley

Document PC(07)02

Document PC(07)03 Dr Gabriel Agboado

Public Health Programme Manager

Education & Training

1.50pm Primary Care Nursing Workforce Education & Training

Document PC(07)04

Helen Meredith Chief Nurse

The Primary Care Committee is asked to APPROVE the proposal.

2:00pm

Workplan Following Scrutiny Review of the Uptake of Cancer Screening Programmes in Knowsley The Primary Care Committee is asked to NOTE the content of the report

Document PC(07)05

Dr Paul Morris Clinical Lead - Cancer

Primary Care Developments

2:10pm Primary Care Estates & Technology Transformation Fund Bid The Primary Care Committee is asked to NOTE the content of the report.

Document PC(07)06

Alex Robertson Interim Programme

Director

Performance

2:20pm Primary Care Performance Report – Development Update The Primary Care Committee is asked to NOTE the content of the report.

Document PC(07)07

Ian Stewardson

Director of Strategy & Performance

Medicines Management

2:30pm Medicines Management Work Plan Update The Primary Care Committee is asked to NOTE the content of the report.

Document PC(07)08

Mark Pilling Interim Head of Medicines

Management

2:40pm

Administration of Subcutaneous Fluids within Community Settings The Primary Care Committee is asked to APPROVE the content of the report.

Document PC(07)09

Mark Pilling Interim Head of Medicines

Management

Contracts

2:50pm Practice Change Proposal – Aston Manor Farm & St Johns Surgery The Primary Care Committee is asked to APPROVE the practice change proposal.

Document PC(07)10

Clare Barrow Head of Finance &

Contracts

Sub Group Key Issues

3.10pm Estates Group The Primary Care Committee is asked to NOTE the content of the report

Document PC(07)11

Paul Brickwood Chief Finance Officer

3:15pm Medicines Management Sub-Committee The Primary Care Committee is asked to NOTE the content of the report

Document PC(07)12

Mark Pilling Interim Head of Medicines

Management

Items for Receipt

1.

Quality Committee – 29th March 2016

Document PC(07)13

2.

Finance & Performance Committee – 27th April 2016

Document PC(07)14

3.

Medicines Management Sub-Committee – 6th April 2016

Document PC(07)15

DATE AND TIME OF NEXT MEETING:

Thursday 1st September 2016

3pm in the Boardroom, Nutgrove Villa

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Document PC(07)01

NOTES OF THE PRIMARY CARE COMMITTEE held on Thursday 5th May 2016

in the Boardroom, Nutgrove Villa

Present Apology MEMBERS

Paul Melia Lay Member – Patient & Public Involvement Dianne Johnson Accountable Officer Paul Brickwood Chief Finance Officer Helen Meredith Chief Nurse Craig Porter Interim Director of Service Redesign and

Improvement

Ian Stewardson Director of Strategy and Performance Dr Robin Macmillan Secondary Care Doctor Peter Murphy Registered Nurse Lorraine Hannon Lay Member – Audit & Governance Dr Andrew Pryce Clinical Leader Dr David Stokoe Clinical Lead – Primary Care Quality Dr Nisha Shah Clinical Membership Group Representative Dr John O’Donnell Clinical Membership Group Chair

IN ATTENDANCE Dr Thomas Kinloch LMC Representative Sarah McNulty Health & Wellbeing Board Representative Rosemary Sowerby Healthwatch Knowsley Present: Kendra Waring Primary Care Programme Manager Mark Pilling Michelle Diable Clare Barrow

Interim Head of Medicines Management Personal Secretary Head of Finance and Contracts

1 Welcome and Introductions: Action

A round of introductions took place and Paul Melia welcomed everyone to the Committee meeting.

2 Apologies for Absence:

Apologies for absence have been received from Mark Lammas, Dr John O’Donnell and Dr Thomas Kinloch.

3 Declarations of Interest:

All GP’s present declared an interest as providers of primary care services in Knowsley.

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Mark Pilling declared that he is the Managing Director and a shareholder of MP Health Solutions Ltd. Rosemary Sowerby declared that her daughter was working within public health as part of her university dissertation. Ian Stewardson declared that he is a substantive Director employed by St Helens and Knowsley Teaching Hospitals NHS Trust. Dr Kinloch was not in attendance but wished to declare that he is married to his practice nurse.

4 Minutes and Matters Arising of the Previous Meeting held on Thursday 17th March 2016:

The minutes of the previous meeting were agreed as an accurate record with one amendment to be made; page 2, agenda item 5, 2nd paragraph, line 2 should read ‘care at the chemist’ instead of ‘care of the chemist’. With the above amendment, the minutes of the meeting held on the 17th March 2016 were agreed as an accurate record.

5 Action Log: Performance Dashboard Verbal Update:

Following a request from a previous meeting, Ian Stewardson provided the following verbal update on the performance dashboard by exception:-

• A&E waiting times was RAG rated as red, work is on-going by the CCG to address this;

• One MSA breach at Liverpool Heart and Chest Hospital NHS Foundation Trust was reported in June 2015 which was a one off occurrence;

• There is a focus on mental health providers especially Mental Health Care Programme Approach (CPA) and Improved Access to Psychological Therapies (IAPT). The CCG is working with 5 Boroughs Partnership NHS Foundation Trust to ensure national target deliverance:

• One MRSA incident was reported at Aintree University Hospitals NHS Foundation Trust in August 2015 which was a one off occurrence;

• Non elective demand is up by 1% above plan; • A&E activity in secondary care and other access to urgent

care is up by 1%; • Patients are accessing walk in centres more instead of

going directly to A&E; • Elective patient activity is slightly below plan; • Trusts are shifting electives over night to day cases and

vice versa which appears to be a general theme, indicating a good platform for next year;

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The CCG is looking at neighbouring health systems in relation to primary care reporting to be clear on what primary care indicators are. There is more work to be done and an update on the progress of the plan will be presented at the next meeting. Action: Ian to present progress towards a primary care performance dashboard and some available information at the next meeting. Action Log Update All actions from the previous meeting were completed. The Committee received the following action log updates: Action 1 – confirm whether it was two or three practices that have applied to close their lists. An update to be circulated. Michelle Diable confirmed that it was two practices who had applied to close their lists. Action 2 – Present a briefing on tobacco control at a future meeting. Sarah McNulty to present above briefing at the July 2016 Committee meeting. Action 6 – Performance Dashboard Update This item was on the agenda.

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6 Primary Care Non- Medical Training and Development:

Helen Meredith introduced this item and accompanying paper which seeks to provide an update on the allocation of educational funding for the primary care workforce (non-medical). Helen advised that the total Health Education funding for the year ahead is £30,658. The existing practice nurse forum is being re-launched where nurses will come together regularly to share information and learning. The forum will engage with GPs as employers in the development of local workforce. The Training Needs Analysis (TNA) will be based on the RCGP Primary Care Nurse competency framework. The TNA plan seeks to identify the main issues and will be presented at the next meeting. Action: Helen to present the Training Needs Analysis Plan at the next meeting. Helen explained that there are good examples locally of universities working in partnership with CCGs to design and improve bespoke training modules to support primary care

HM

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nursing which the CCG will explore. Helen noted that the wider primary care workforce will also require development. Dr Pryce suggested having a training fund for practice nurses set aside and if training needs are identified perhaps the CCG should pay for the courses. There are currently no resources in primary care for this funding. Clare Barrow noted that contractually as employers practices have to ensure staff are competent to carry out their roles and wondered if the concept of pooled resources among practices could be explored. However it was noted that although funding from NHSE had reduced the CCG had not spent the available funding in 2015/16 and the first step is to avoid this happening in 2016/17.. Sarah McNulty suggested that some work is being undertaken by the Cheshire and Merseyside Hypertension Scheme to identify training needs. Action: Clare Barrow and Helen Meredith to explore the concept of pooled money for nursing education and training once the training needs analysis is completed. The Primary Care Committee noted the content of the report.

CB

7 Risks relating to the Committee:

Dawn Boyer introduced this item and accompanying briefing paper which seeks to provide the committee with the strategic and operational risks which are the responsibility of the Primary Care Committee. Dawn referred the Committee to Appendix A – an extract from the risk register comprising those risks attributed to Primary Care. The Committee noted that there was one extreme risk identified which was failure to stay within agreed prescribing budget. This was partially mitigated by savings achieved through targeting waste and cost optimisation, the recruitment of additional staff in the Medicines Management team and recent implementation of the Optimise Rx system. Further mitigating actions are under way. A revised risk assessment will be completed. The remaining risks are assessed as moderate and current and proposed additional controls to mitigate these risks are shown in Appendix A. Dianne Johnson advised the Committee of the new process being introduced whereby risks which are the responsibility of a committee are presented at the beginning of each meeting to support committee members to consider the risks and any additional risks during the meeting. The Primary Care Committee reviewed the content of the report and determined that the risk was accurately reflected.

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8 Re- provision of services previously provided by the Options

(APMS) Contract:

Kendra Waring introduced this item and accompanying briefing paper which seeks to update the Committee on the re-provision of services previously provided by the Options (APMS) Contract. Formal notice was given by the CCG in September 2015 and the Options (APMS) contract expired on 31st March 2016. The service consisted of a number of components, each of which was managed via a planned approach to ensure that patients continued to be registered with a GP from 1st April 2016. Following the transition, just one practice experienced a few teething problems and the CCG received only four calls in the first week. The committee noted that the cost of the Options service was £2.157 million per annum and although replacement services will utilise some of this resource, it is estimated that approximately £1.3million will be released on a recurrent basis. The CCG intends to reinvest all such resources to support improvements in primary care quality in practices as a supplement to the funds released through the PMS review. Dr Pryce wished to thank the team involved in demobilisation of the Options Service and the re-provision of the services. The process was smooth and timely. The Primary Care Committee noted the content of the report.

9 General Practice Operational Update:

Kendra Waring introduced this item and accompanying briefing paper which seeks to provide an update on the latest GP patient survey results, practice changes, list closures and recently published CQC inspection reports. With regards to the GP survey, it was noted that the CCG generally fares well in comparison to the national results across the whole of the survey and levels of satisfaction appear to have improved in the majority of areas compared with the previous survey. Dr Kinloch was not in attendance but wished to make the following observation in relation the patient survey results relating to satisfaction with nurses. “The figures for our practice bear no resemblance to the feedback that we received from patients and I suspect strongly that patients who responded to the survey do not know the difference between the somewhat disjointed treatment room/district nursing service that we have to cope with and our Practice Nurse”.

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Dr Stokoe suggested paying more attention to the Friends and Family Test results too. The committee noted the CQC inspection ratings for the following practices;

• St John’s Surgery - CQC inspection undertaken on 28th October 2015, overall rating was good;

• Pilch Lane Surgery - CQC inspection undertaken on 10th November 2015, overall rating was good;

• Bluebell Lane Medical Practice - CQC inspection undertaken on 6th January 2016, overall rating was inadequate;

• Longview Medical Centre - CQC inspection undertaken on 19th January 2016, overall rating was good;

• Colby Medical Centre- CQC inspection undertaken on 29th January 2016, overall rating was requires improvement;

• St Laurence’s Medical Centre - CQC inspection undertaken on 9th February 2016, overall rating was good;

The Committee noted that Dr Stokoe is based at St Laurence’s Medical Centre. Some themes have emerged through the inspections e.g. safeguarding training; awareness of internal systems within the practices and HR and recruitment processes and records. Helen advised that all practices will be offered Adult Safeguarding training. Dianne added that mandatory training may not be 100% but if the majority of staff are compliant it should be looked at in context as some may not be recording information. Learning should be shared and themes identified. Craig Porter introduced the Operational plan for 2016/17. The plan focuses on primary care work streams; long term conditions, improving referral quality and nursing homes and locality multi-disciplinary teams. Craig Porter advised that there are 2 primary care elements within the plan; improving services and delivering QIPP. Craig referred the Committee to page 15 of the paper to point 6.5 - Development of four locality MDTs outlining the key schemes and initiatives to be developed. Regular updates will be presented to the Committee. The Primary Care Committee noted the content of the report.

10 2016/17 Primary Care Budgets:

Paul Brickwood introduced this item and accompanying briefing paper which seeks approval form the Committee to allocate the CCG’s 2016/17 Primary Care Allocation by expenditure type.

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Paul highlighted the national changes whereby an investment of £220 million has been introduced. Paul referred the Committee to page 4 of the paper, item 5 – the primary care budget proposals for their approval. The CCG has received an allocation of £30.14million for 2016/17. Going forward, regular reports will be produced for the Committee to review. These will include an analysis of expenditure against budget plus a forecast outturn for the full year. The Primary Care Committee approved the primary care budget for 2016/17.

11 Bluebell Lane Medical Practice CQC Briefing:

Clare Barrow introduced this item and accompanying briefing paper which seeks to inform the Committee of the outcome and key findings of the Care Quality Commission (CQC) inspection of Bluebell Medical Practice undertaken on 6th January 2016 and published on 14th April 2016. Clare advised that the CQC inspection report outlines some serious failings in the services provided to the patients registered with Bluebell Medical Practice. The majority of issues highlighted relate to the practice not having an effective governance system in place. This will take time to resolve. Many of the concerns had been identified during a previous inspection undertaken by the CCG and an action plan is in place. Dianne Johnson advised that following the CQC publication of the report and associated comments re safeguarding at the practice a Section 11 Audit was been carried out within 5 working days and results showed that the practice was complaint. It was noted that there is a risk that the improvements made may not be sustainable following the withdrawal of support from the Hollies Medical Centre on 31st May 2016. A further CQC inspection will be undertaken before 31st October 2016. The CCG will continue to monitor and support the practice. A new Business Manager is due to commence at the Practice in June 2016. The Primary Care Committee noted the content of the report.

12 Medicines Management Work Plan 2015/16 Progress Report:

Mark Pilling introduced this item and accompanying paper which seeks to provide the Committee with the progress and impact of the Medicines Management Work Plan for 2015-16. It was noted that the actions identified within the report continue

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to demonstrate that regular review of prescribing and repeat medication will help ensure that prescriptions remain appropriate to the condition of the patient, are safe, effective and cost efficient. Mark noted that whilst prescribing costs increased overall in February 2016, the annual cost growth has begun to reduce since January 2016. Prescribing safety audits have continued to be undertaken and reception staff have received extensive training in relation to good practice in managing repeat prescriptions. It has been identified that there is a higher level of medicines waste than originally estimated and a piece of work within the planned waste medicines review to better understand why many patients do not take their medicines as intended. Poor compliance with medication results in patients needing to see their GP more frequently, an increased risk of hospital admission and in potentially premature death. Mark also noted that a large percentage of patients are still not being contacted within the 10 days prior to their prescription due date at all by their community pharmacy although this has greatly improved in the last six months. The Primary Care Committee noted the content of the report.

13 Prescribing Budget Paper 2016/17:

Mark Pilling introduced this item and accompanying paper which seeks approval of the methodology and allocation of budgets to practices and commissioned services for 2016-17. Mark advised that the budget setting process now includes a weighting for care home residents. Mark referred the Committee to Appendix 1 – Practice and Commissioned Service Prescribing Budgets 2016-17. Clare Barrow noted that a GP from Trentham was also prescribing at a practice in Hackney, London. The costs have been identified and invoices sent and payments received. Mark also agreed to clarify the large budget increase to Trentham. Mark also advised that he would also investigate why Sexual Health Service budget has reduced significantly to £397.10 and add an explanation in to the comments column. Action: Mark to investigate why the Trentham and Sexual Health Service Budgets have changed significantly and report back at the next meeting. The Primary Care Committee delegated the Accountable Officer to approve the budgets once the clarifications had been satisfactorily resolved.

MP DJ/MP

14 Estates Group – 16th March 2016:

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Paul Brickwood updated the group following the Estates Group Meeting held on 16th March 2016. Paul advised that NHS England (NHSE) was not in attendance. He also advised that the old Twig Lane and Westvale Clinic buildings –no longer suitable for patient services need to be closed as soon as possible to avoid the increase in costs and provide land for new housing. Clare updated the Committee following the Primary Care Management Meeting regarding the Prescot list closure. The diabetic administrative team will relocate to the Resource Centre which would allow practice room expansion which will allow the practice to take on more patient registrations.

15 Medicines Management Sub-Committee – 6th April 2016:

Mark Pilling updated the group following the Medicines Management Sub-Committee held on 6th April 2016. Mark informed that an advice and referral mechanism has been introduced to enable the CCG to target accumulation of waste medicines in patient’s homes when attended by district nurses.

16 Quality Committee – 19th January 2016:

The Primary Care Committee received the minutes of the Quality Committee which was held on 19th January 2016.

17 Finance and Performance Committee – 24th February 2016:

The Primary Care Committee received the minutes of the Finance and Performance Committee which was held on 24th February 2016.

18 Medicines Management Sub-Committee – 3rd February 2016:

The Primary Care Committee received the minutes of the Medicines Management Sub-Committee which was held on 3rd February 2016.

Details of the next meeting:

Thursday 7th July 2016 1:30pm to 3:30pm

Boardroom, Nutgrove Villa.

1

Document PC(07)02

PRIMARY CARE COMMITTEE ACTION LOG

5th May 2016 Task Responsibility Deadline RAG

1 Sarah to present a briefing on tobacco control at the next meeting.

Sarah McNulty 7th July 2016 G

2 Ian to present the performance data improvement plan progress at the next meeting.

Ian Stewardson 7th July 2016 G

3 Helen to present Training Needs Analysis Plan at the next meeting.

Helen Meredith 7th July 2016 G

4 Clare to explore the concept of having a pooled budget for nursing education and training.

Clare Barrow 7th July 2016 A

5 Mark to investigate why the Trentham and Sexual Health Service Budgets havereduced significantly and report back at the next meeting.

Mark Pilling 7th July 2016 A

Key

Green – done

Amber – on schedule

Red – deadline passed and not done

Date of last update Updated by Version

5th May 2016 Michelle Diable 0.15

Document PC(07)03

PRIMARY CARE COMMITTEE SMOKING IN KNOWSLEY

Executive Summary Smoking is the single biggest preventable cause of health inequalities in the UK and is responsible for about half the difference in death rates in men by socioeconomic status.

In Knowsley smoking related death rate is estimated to be 435 per 100,000 population aged 35 or above, accounting for 822 years of lost productivity. This is significantly above regional and national averages. The total annual cost to the local economy is estimated to be £49.0m equivalent to £1,976 per smoker per year.

The total annual cost of managing these conditions to the NHS in Knowsley is estimated to be about £7.3m. There is an immense potential to reduce health care cost if smoking prevalence could be further reduced in Knowsley.

To further support activities to reduce smoking prevalence in Knowsley we recommend the following:

• Smoking in pregnancy: 1. Knowsley is jointly implementing the babyClear pathway with St Helens and Halton to

improve support for pregnant women smoking at the time of booking. Currently no all maternity units are implementing the pathway. It is recommended the CCG consider working with partner CCGs (e.g. Liverpool and Sefton) to ensure consistency of smoking cessation support for Knowsley pregnant women across all trust serving the borough by implementing the babyClear pathway. This may involve a CQUIN.

2. Parliamentary Under Secretary of State for Care Quality, visited Knowsley on 21st April 2016 to discuss local actions to reduce smoking prevalence at the time of delivery. To deliver on the actions proposed during the ministerial visit would require the involvement of CCG and primary care colleagues. We recommend a lead is identified to be involved in local task group(s) which would be set up.

• Support in primary care 1. The Knowsley Stop Smoking Service has been holding smoking cessation sessions in 4

GP Practices. It is recommended that more GP Practices sign up to have smoking cessation sessions delivered within their premises.

2. Brief interventions by clinicians followed by referrals are effective in improving clients’ engagement and quit rate. It is recommended that primary care professionals make every contact with patients count by delivering brief interventions, referring clients and reminding those who fail to take up referrals at subsequent visits of the benefits of quitting.

1 Purpose of the briefing

1.1 To brief Primary Care Committee on the impact of smoking on population health, health care cost, progress made in Knowsley in reducing smoking prevalence and specific actions being taken further reduce smoking prevalence to be in line with national aspirations.

1.2 To seek CCG and Primary Care support to further reduce smoking prevalence in Knowsley.

2 Background

2.1 Smoking is the single biggest preventable cause of health inequalities in the UK and is responsible for about half the difference in death rates in men by socioeconomic status (1).

2.2 In England almost 80,000 people die each year due to smoking related causes accounting for 17% of all deaths of adults aged 35 or over (2). In Knowsley smoking related death rate is estimated to be 435 per 100,000 population aged 35 and above. This is significantly above regional and national averages of 323 and 275 respectively.

2.3 In addition to the negative health effects associated with smoking there is a significant economic cost. In Knowsley the total annual cost to the local economy is estimated to be £49.0m equivalent to £1,976 per smoker per year (3).

2.4 Smoking prevalence in Knowsley has fallen from 31% in 2010 to 21.7% in 2014 (Figure 1). Similar patterns have been observed at both regional and national levels. Though Knowsley had a higher smoking prevalence over the period, the rate of fall in the borough was higher than national and regional averages.

Figure 1: Trend for smoking prevalence in Knowsley compared with regional and national trends – 2010 to 2014 (Source: Local Tobacco Profiles for England, 2016 base on Integrated Household Survey [IHS] data)

2.5 Smoking at time of delivery is a key national area for focus as smoking during pregnancy has a number of negative health implications for mother and baby. Though this shows a downward trend overall, the prevalence in Knowsley remained higher than those seen in comparator areas (Figure 2).

2010 2011 2012 2013 2014

Knowsley 31.0% 28.1% 23.6% 23.4% 21.7%

North West 23.0% 22.0% 21.6% 20.1% 19.9%

England 20.8% 20.2% 19.5% 18.4% 18.0%

0%

5%

10%

15%

20%

25%

30%

35%

Smok

ing

prev

alen

ce (%

)

Figure 2: Trend for smoking prevalence at the time of delivery (Source: Health and Social Care Information Centre)

3 Performance the local stop smoking services

3.1 The number of smokers accessing smoking cessation service in Knowsley has declined (Table 1 in Appendices). This is in line with national trends, and there is some thinking this could be in part due to the overall reduction in smoking prevalence. Public Health England has given additional reasons for the decline including structural changes resulting from transition of public health to local authorities, which have resulted in some local authorities not reporting data on smoking cessation activities, and increased availability and use of e-cigarettes by smokers who are trying to stop or cut down (4). The majority of the referrals into specialist service are self-referrals.

3.2 4-week quit rate 4-week quit rate in Knowsley has improved over the last 3 years with the quit rate exceeding

the North West average over the last 2 years of the period (Figure 3 in Appendices).

4 Actions being taken locally

4.1 Varenicline PGD for Pharmacists

4.1.1 Existing evidence indicates the use of Varenicline is associated with superior quit rates compared with nicotine replacement products and bupropion, and is more cost-effective (5).

4.1.2 Use of Varenicline among Knowsley smokers wishing to quit is the lowest in Cheshire and Merseyside (Figure 4 in Appendices). Additionally there seemed to be a direct correlation between the proportion of smokers using Varenicline and 4-week quit rate – the higher the proportion using Varenicline, the higher the quit rate (figures 4 and 5 in Appendices).

4.1.3 Based on the above pieces of evidence, Knowsley Council with the support of the CCG is carrying out a 6-month pilot to allow pharmacist to dispense Varenicline using a Patient Group Direction (PGD) developed by Champs for Cheshire and Merseyside local authorities to increase access to Varenicline. The pilot started in March and will end in September 2016. If it proves to be successful on evaluation, it would become a permanent feature of the intermediate service.

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

England 15.1% 14.4% 14.4% 14.0% 13.5% 13.2% 12.7% 12.0% 11.4%

North West 19.9% 19.2% 18.8% 18.6% 17.7% 17.1% 16.4% 15.3% 14.5%

Knowsley 24.2% 27.7% 25.5% 26.4% 26.0% 22.6% 23.8% 20.6% 19.4%

Liverpool City Region 21.1% 19.2% 19.0% 20.0% 18.6% 18.0% 17.4% 16.5% 15.8%

Statistical Neighbours 25.6% 23.3% 23.1% 22.8% 21.8% 21.5% 21.1% 20.0% 18.1%

0.0%

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10.0%

15.0%

20.0%

25.0%

30.0%

Prev

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f sm

okin

g at

the

time

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ery

(%)

4.2 Reducing prevalence of smoking in pregnancy and after delivery

a) Reward scheme

4.2.1 Knowsley Stop Smoking Service has been implementing a reward scheme since 2011 to incentivise pregnant women from most deprived areas to quit. An evaluation of the local scheme showed it was effective in improving quit rate and this is in keeping with evidence base (6). The scheme has now been rolled out to all pregnant women as part of the poverty reduction strategy since January 2015.

b) babyClear

4.2.2 babyClear is a Public Health England sponsored programme to help increase quit rates among pregnant mothers across Knowsley, Halton and St Helens. Under this scheme maternity units will ensure they screen all pregnant women for smoking and refer at least 90% of all pregnant women smoking at the time of booking to stop smoking services.

c) Ministerial visit

4.2.3 The Honourable Ben Gummer MP, Parliamentary Under Secretary of State for Care Quality, visited Knowsley on 21st April 2016 to discuss local actions to reduce smoking prevalence at the time of delivery. Issues identified included:

a) Maximising existing opportunities to signpost pregnant women. b) Sharing best practice across Liverpool City Region.

4.2.4 The Minister committed to establishing an Expert Working Group with representation from e.g. Health and Social Care Information Centre, Commissioners from NHS England, policy people.

4.3 Other actions to reduce smoking prevalence locally include:

a) A CQUIN for the implementation of NICE Guidance on smoking cessation (PH48) (7) is being delivered across all services provided by 5 Boroughs Partnership NHS Trust.

b) Establishing electronic referral system with hospitals c) Quit Buddy and Quit Online remote support services meaning clients could use an

online tool or mobile text to receive support from the Stop Smoking Service, without the need to visit the service.

5 Implications for the CCG

5.1 Cost of smoking to the CCG

5.1.1 Knowsley has higher prevalence of smoking-related health conditions compared with regional and national averages (Figure 6 in Appendices).

5.1.2 The total annual cost of managing these conditions to the NHS in Knowsley is estimated to be about £7.3m. £6.9m of this cost is directly incurred in treating smoking-related ill health and £360,325 incurred treating the effects of passive smoking in non-smokers (3).

5.1.3 There is an immense potential to reduce health care cost if smoking prevalence could be reduced further in Knowsley.

5.2 Financial impact of Varenicline PGD

5.2.1 It is estimated the cost of Varenicline dispensed in pharmacies to the CCG would be between £68,632.20 and £107,616.00 annually, based on a modelling of data from the stop smoking service. This estimate assumes 75% of all clients who wish to use Varenicline would use the pharmacy service.

5.2.2 A potential benefit to primary care associated with this initiative would be a reduction in GP consultation for Varenicline prescriptions.

5.3 CCG and Primary care support

5.3.1 To deliver on the actions proposed during the ministerial visit would require the involvement of CCG and primary care colleagues. The CCG Accountable Officer is currently liaising with the Department of Health on some of the actions. We recommend a CCG lead is identified to be involved in local task group(s) which would be set up.

5.3.2 The Knowsley Stop Smoking Service has been holding smoking cessation sessions in four Practices in 2015/16. These sessions have been very useful in engaging clients who go on to quit. We suggest more practices sign up to have sessions delivered within their premises.

5.3.3 Knowsley is jointly implementing the babyClear pathway with St Helens and Halton to improve support for pregnant women smoking at the time of booking. Currently not all maternity units serving Knowsley are implementing the pathway for Knowsley women (e.g. Liverpool Women’s and Ormskirk). We recommend the CCG work with partner CCGs (Liverpool and Sefton) to ensure consistency of smoking cessation support for Knowsley pregnant women across all trust serving the borough. This may involve a CQUIN to implement the pathway.

5.3.4 Brief interventions by clinicians followed by referrals are effective in improving clients’ engagement and quit rate. We suggest primary care professionals make every contact with clients count by delivering brief interventions, referring clients and reminding those who fail to take up referral at subsequent visits of the benefits of quitting.

6 Summary

6.1 This briefing highlights the impact of smoking on population health, health care cost, progress made in Knowsley in reducing smoking prevalence and specific actions being taken to increase the further reduce smoking prevalence, to be in line with national aspirations.

6.2 Smoking prevalence is declining in Knowsley at a faster rate than national and regional averages. However it is still higher than national and regional averages and would require a more concerted effort from all partners to sustain the pace of decline.

Dr Sarah McNulty – Consultant in Public Health Dr Gabriel Agboado – Public Health Programme Manager

Background Documents: NONE

7 Appendices Table 1: Referral sources for clients referred into the Knowsley Stop Smoking service*

Referral source 2011 2012 2013 2014 Total %

COPD Team 20 100 107 153 380 3.9%

Whiston 17 112 40 36 205 2.1%

Knowsley GPs 23 47 69 77 216 2.2%

Healthy Lifestyle Hub - 118 126 131 375 3.8%

Liverpool Women’s 6 37 27 48 118 1.2%

Self-referral 1,096 2,921 2,060 2,166 8,243 83.7%

Other - - 311 - 311 3.2%

Total 1,162 3,335 2,740 2,611 9,848 100.0%

Figure 3: 4-week quit rate trend – 2006/07 to 2014/15 (Source: Health and Social Care Information Centre)

* Figures exclude numbers using intermediate service provided by Community Pharmacies. Quality of data is not reliable in the earlier periods.

2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 2014-2015

Knowsley 54.0% 45.5% 40.1% 41.0% 41.0% 39.3% 45.6% 48.6% 47.2%

North West 49.1% 46.7% 46.1% 46.0% 44.2% 45.4% 47.6% 43.3% 45.3%

England 53.3% 51.6% 50.2% 49.4% 48.7% 49.1% 51.6% 51.3% 51.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

4-w

eek

quit

rate

Table 2: 4-week quit rate (2014/15)†

Area Quit rate

National Rank North West Rank

Wirral 39.5% 137 18 Knowsley 47.2% 110 16 St Helens 48.7% 95 14 Sefton 48.9% 93 13 Liverpool 50.6% 83 11 Halton 56.6% 49 6 Merseyside average 48.0% Not applicable Not applicable North West 45.3% Not applicable Not applicable England 51.0% Not applicable Not applicable National best (Warrington) 82.6% 1 Not applicable National worst (Manchester) 23.4% 151 Not applicable

Figure 4: Proportion of quit attempts using Varenicline (2014/15) (Source: Health and Social Care Information Centre)

† Not all local authorities submit quit data to the Health and Social Care information Centre

14.9%

16.0%

19.7%

24.7%

28.5%

29.6%

34.7%

35.4%

48.6%

19.5%

25.2%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

Knowsley

Liverpool

Cheshire East

Wirral

Sefton

St Helens

Halton

Cheshire West and Chester

Warrington

North West

England

% smokers using Varenicline as quit aid

Figure 5: Contribution of Varenicline use to 4-week quit rate (2014/15) (Source: Health and Social Care Information Centre)

Figure 6: Knowsley tobacco profile: Smoking related ill health (Source: Local Tobacco Profiles for England, 2016)

39.5%

47.2%

47.9%

48.7%

48.9%

50.6%

54.3%

56.6%

82.6%

45.3%

51.1%

54.1%

54.5%

58.7%

50.9%

56.0%

56.8%

72.1%

68.7%

89.4%

59.2%

60.8%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Wirral

Knowsley

Cheshire West and Chester

St Helens

Sefton

Liverpool

Cheshire East

Halton

Warrington

North West

England

4-week quit rate

Champix

Overall Quit rate

8 References

1. Jha P, Peto R, Zatonski W, Boreham J, Jarvis MJ, Lopez AD. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. Lancet. 2006 Jul 29;368(9533):367-70. http://www.ncbi.nlm.nih.gov/pubmed/16876664

2. Statistics on Smoking 2015. Health and Social Care Information Centre (2015). Available online at: http://www.hscic.gov.uk/catalogue/PUB17526/stat-smok-eng-2015-rep.pdf (accessed on 21 Dec 2015)

3. Action on Smoking and Health (ASH), 2016. The local cost of tobacco. Version 5.2

4. Public Health England (2016). Evaluation of ‘Linking the most popular with the most effective: e-cigarettes and stop smoking services’ seminar series

5. NICE technology appraisal guidance 123: Varenicline for smoking cessation

6. D. Tappin, L. Bauld, D. Purves, K. Boyd, L. Sinclair, S. MacAskill, J. McKell, B. Friel, A. McConnachie, L. de Caestecker, C. Tannahill, A. Radley and T. Coleman, “Financial incentives for smoking cessation in pregnancy: randomised controlled trial,” British Medical Journal, vol. 350, no. h134, 2015.

7. NICE (2013). Smoking: acute, maternity and mental health services. NICE Guidance [PH48]. https://www.nice.org.uk/guidance/ph48

Document PC(07)04

Report to Knowsley Clinical Commissioning Group Primary Care Committee

Date of meeting: 7th July 2016

Report title: Primary Care Nursing Workforce Education and Training Need Analysis

Report presented by: Helen Meredith, Chief Nurse

Purpose of the report: This report sets out the proposal for a detailed Training Needs Analysis (TNA) to be undertaken.

Further reports will be brought to the committee throughout the year with the outcome of the TNA and additional training / education to be commissioned around the primary care nursing workforce.

Recommendations:

Action / Decision required

The Primary Care Committee is recommended to:

Approve the proposal

Delegated Powers:

For decision reports only

N/A

Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply

1. Patient centred

2. Safe X

3. High quality X

4. Cost effective X

5. Outcome focused

6. Closer to home

7. Affordable X

[one page only]

Page 1 of 14

PRIMARY CARE COMMITTEE

PRIMARY CARE NURSING WORKFORCE EDUCATION AND TRAINING

Executive Summary Health Education England North West (HEENW) allocated funding for primary care development to offer training and education to nursing and administrative staff in primary care. The investment needs to ensure sufficient supply of both existing and new roles, and this presents a range of key opportunities for practices within Knowsley CCG. The CCG plans to develop a structured approach to producing a training need analysis in general practice. This would ensure that there is prioritisation and alignment of educational opportunities with improved coordination and consistency and links to the CCG’s strategic aims. The paper provides a summary of funding allocated to the CCG for Primary Care non-medical training and development for 2016/17 from HEENW, and an update on the planning being undertaken by the CCG to utilise this funding to develop the Primary Care workforce.

Page 2 of 14

1. Purpose of the briefing 1.1 The purpose of the briefing is to provide an update on the allocation of educational funding

for the Primary Care nursing workforce, and an update on the planning being undertaken by the CCG to utilise this funding to develop the Primary Care nursing workforce.

2. Background 2.1 Health Education England North West (HENW) has been working with the CCG to provide

funding to develop a skilled Primary Care nursing workforce, and support continuous professional development (CPD). The scope of the training fund allocation also includes access to accredited CPD modules and bespoke training.

3. Key Issues 3.1 HEENW Funding 2016/17 3.1.1 As per the previous Primary Care Committee report, numerous different reports have

highlighted concerns about the challenges now and in the future for the Primary Care nursing workforce. HEENW have allocated funding to the CCG to develop its Primary Care nursing workforce. Non-recurrent funds have been made allocated to the CCG for the following:

3.1.2 Service Level Agreement (SLA) modules; This allocation can be used to access CPD

modules delivered by Higher Education aimed at the development of clinical staff groups including access to Non-Medical Prescribing modules. HEENW allocation for 2016/17 is £2,694 which is significantly reduced from 2015/16 allocation of £17,260. This decrease is broadly similar for all CCGs and reflects a decrease in HEENWs central funding allocation.

3.1.3 Flexible Cash Allocation; The CPD flexible cash allocation enables the CCG to purchase

CPD not available through the service level agreements with the eleven North West Universities; including bespoke education and training, leadership and management training. The CCG can utilise this allocation to host events and educational sessions at local venues for the non-medical workforce within primary care. This applies to practice managers, administrative and clinical staff including nurses, health care assistants and pharmacists. The CPD cash allocation for 2016/17 is £24,141 which remains on a par with the allocation for 2015/16, which was £24,077.

3.1.4 PHE Training allocation; Health Education England (HEE) has allocated non-recurrent

funding to the CCG of £3,823 for 2016/17 to fund practice nurses and health care assistants training in specific areas of; immunisations and vaccinations, cervical cytology, and motivational interviewing.

3.1.5 Non-Medical Prescribing allocation; Health Education England (HEE) has allocated non-

recurrent funding to the CCG of for any interested parties as part of the North West 2016/17 Workforce Transformation offer.

3.2 Issues currently facing the Primary Care Nursing Workforce

a) A third of General Practice face to face contacts are undertaken by Practice Nurses (GP Taskforce COGPED Census);

Page 3 of 14

b) Almost 4 in 5 UK GPs (78%) surveyed reported that their practice used nurses as case managers or navigators for patients with serious chronic conditions, a higher figure than in any of the other 10 OECD countries surveyed (Commonwealth Fund 2012);

c) Lack of clarity regarding the role of general practice nursing; d) No consistent approach to service delivery; e) Lack of a national profile for the role, with no clear career framework; f) Disparity and lack of consistency, accessibility, availability and funding for training and

CPD; g) Lack of access to clinical supervision; h) Limited access to protected time and commitment from employer for supervision; i) Disparity in pay and terms and conditions; j) At least 20% of practice nurses are likely to retire in the next five years.

3.3 The previous Primary Care Committee report referenced the following initiatives to further

develop and support the Primary Care nursing workforce:

a) Re-launch of the Practice Nurse Forum; b) Development of a leadership model within the CCG with primary care nurse champions /

facilitator roles to support nursing development; c) The development of a non-medical Education and Training Strategy.

3.4 Training Needs Analysis for 2016/17 3.4.1 The General Practice (GP) nursing workforce is at the core of primary health care in the

CCG, yet their development and training needs remain largely unaddressed. A Primary Care Nurse Training Needs Analysis is a key priority to commission appropriate training packages. In 2015/16, information gathered at various Primary Care Nurse Forums demonstrated the key areas where nurses identified training requirements; however 2015/16 HEENW allocated funds were unspent.

3.4.2 As a result of the unspent funds in 2015/16, the Primary Care Committee requested a

robust programme management process was followed to understand the training and education requirements of the Primary Care nursing workforce for 2016/17, ensuring appropriate engagement with both the nursing and medical workforce to ensure a common understanding is obtained regarding these requirements.

3.4.3 The Royal College for General Practitioners published a competency framework for

Practices Nurses which will form the basis of a survey to be completed by all Primary Care nursing staff to allow for comprehensive needs analysis information to be made available to the CCG. The survey needs to establish if respondents require training, general updates, shadowing or other education in relation to each of the below areas of practice, within Table 1.

Primary Care Nursing Workforce Competencies Anticoagulation Dementia Leadership Appraisal of others Depression Learning disabilities Asthma Diabetes Management

Audit, review and research Disease modifying anti rheumatic drugs, rheumatoid arthritis, therapeutic monitoring

Mental health

Cancer Ear care Minor illness

Cardiovascular disease End of life, palliative care and terminal illness Minor injury

Page 4 of 14

Cervical Screening Epilepsy Osteoporosis

Chronic kidney disease Equality and diversity Prescribing and medicines management

Clinical guidelines Equipment and stock management Reflective practice

Communication with teams Health and safety Safeguarding; adults and children

Consultation Health promotion Spirometry Contraception and sexual health Heart failure Tissue viability and wound care

Contracts, regulations , CQC, QOF, service redesign Hypertension Travel health and vaccination

COPD Immunisations; adult and child Treating people with dignity and respect

Data protection Infection control Venepuncture Table 1: Competencies to be included on Primary Care nursing workforce education and training survey.

3.4.4 In addition to the above competencies Table 2 documents the demographic information

proposed to be collected. Primary Care Nursing Workforce Demographic Information Accountability; do you hold a valid NMC registration Age Total number of years employed Number of hours employed per week AfC Band equivalent Do you have an appraisal? How often do you have an appraisal? Date of last appraisal Do you use the CCG template for your training approvals? if not, why not Who carries out your appraisal? Who would you like to carry out your appraisal? Would you like your appraisal to be linked to a primary care nurse competency framework? Table 2: Demographic information to be included on Primary Care nursing workforce education and training survey. 3.5 Training Plan 2016/17 3.5.1 Service Level Agreement (SLA) funds, can be used for supporting practice nurses with CPD

for enrolling to core modules in university, defined by HEENW, as those identified as supporting workforce transformation, which is restricted to:

a) Non-Medical Prescribing; b) Multi-professional Support for Learning and Assessment in Practice; c) Clinical Examination; d) Clinical Leadership; e) GP Nursing.

Page 5 of 14

3.5.2 There are excellent examples locally of universities working in partnership with CCGs to

design and provide bespoke training modules to support Primary Care. These modules and courses can be delivered locally either by staff accredited by the university or university tutors and accessing local teaching hospitals facilities as opposed to staff travelling to university sites.

3.5.3 Another CCG has developed an Advanced Practitioner programme with Primary Care

support by GP mentors in local practices. This has helped to support gaps in recruitment to General practitioner vacancies and may be worth exploring locally.

3.5.4 The CCG will work with universities and colleagues in neighbouring CCGs to explore all

available options. 3.5.5 PHE Training allocation funds will be utilised in supporting practice nurses and health care

assistants in attending courses on cervical screening and motivational interviews. Some of the funds will be utilised as backfill cost, as stipulated in the allocation agreement.

4. Implications for the CCG 4.1 Issues currently facing the Primary Care nursing workforce are documented in section 3.2

of this report. 4.2 To align Primary Care will the CCGs future strategies the nursing workforce are required to

have the competencies to provide effective care in the community. The HEENW allocation of funds allows the CCG to train and educate its nursing workforce in areas which both the individuals and Practices require.

4.3 HEENW allocated funds are non-concurrent, and should the CCG not utilise the HEENW

allocated funds by the end of 2016/17, they will be returned to HEENW.

5. Actions being taken by the CCG 5.1 The CCG will follow a robust programme management process to understand the training

and education requirements of the Primary Care nursing workforce for 2016/17. A Project Initiation Document has been written and 3 Highlight Reports have been written to provide a status update to the CCGs Work Plan Steering Group. The Project Plan has been written however following a mapping session with the Programme Management Team a number of further actions are required before the survey can be sent to the Primary Care nursing workforce. These include;

a) Understanding the preferred methods of communication with each Practice and their

nursing workforce to ensure the maximum amount of returns. b) Understand the current mandatory training requirements and compliance with

mandatory training for the Primary Care nursing workforce. The CCG currently does not know the mandatory training requirements for Primary Care nurses, and does not receive any information on the mandatory training compliance of Primary Care nurses.

c) Identifying both Nurse and GP ‘Champions’ in each locality to support this process and ensure a higher completion / return rate.

d) Inform the GP membership of this process to ensure all Practices support this process, understand the need to ensure the nursing workforce receives development and ensures that the nursing workforce will be allocated the time to develop themselves with skills to further enhance the effectiveness of the individual, and the practice.

Page 6 of 14

5.2 Although the above actions will delay the survey being distributed, for the effectiveness of

the project these actions are necessary to maximise the return and quality of information. It is anticipated that these aspects of the project will be completed by the end of August / early September 2016.

5.3 As an interim measure the CCG will send out a competency based survey to the Primary

Care nursing workforce to obtain a partial understanding of the education and training requirements whilst a detailed project plan is followed. Due to the need for the CCG to commence its education and training programme and for it to be able to utilise the HEENW allocated funds an interim survey is aimed to obtain an initial understanding of education and training requirements.

5.4 Throughout the coming weeks, the survey will be distributed via email on a weekly basis to

ensure it is reaching all of the nursing workforce and providing an opportunity for the nursing workforce to respond. This will also identify issues with obtaining responses and highlight any specific Practices or Localities which require separate methods of communication, such as face-to-face visits or telephone interviews. The CCG will ensure this survey is discussed at the Practice Nurse Forum with the benefits of the CCG being aware of the education and training requirements explained. This forum will also allow for any face-to-face interviews to collect information to take place. The interim nursing survey will close on 31st July 2016, where the information will be analysed. The nursing survey is available in Appendix 1 of this report.

5.5 The CCG will monitor the submissions received and will raise any significant issues

received to the Chief Nurse and Executive Management Team. In addition, an initial identification of themes for future training requirements will be available. Should this interim solution provide a high response rate this will form a significant aspect of the Training Needs Analysis.

5.6 The CCG will also contact the GP membership with a survey for each GP / Practice to

identify areas of development for its nursing workforce. The CCG will explore the possibility of providing the survey at the next Protected Time Event to obtain information from both GPs and the nursing workforce. The interim GP survey will close on 31st July 2016, where the information will be analysed. The CCG will also look to present an update to the Clinical Membership Group following the interim survey to explain the initial findings and the next steps for the project. The GP survey is available in Appendix 2 of this report.

5.7 Further actions linked to this project include the following:

a) Explore the potential of whether the GP Practices could use the online e-learning system, which all CCG staff use, for their Mandatory Training.

b) Explore the potential to link the Safeguarding Training Needs Analysis, which has been approved to be used by the CCG, within Primary Care, to ensure that the correct training is provided to all Primary Care staff.

c) Expand the project further to incorporate all of the non-medical workforce within Primary Care.

d) Work with HEENW regarding the e-workforce tool and ensure that the CCG submits all relevant information on the online tool.

5.8 Further updates on this project will be provided to Primary Care Committee.

Page 7 of 14

6. Summary

6.1 The CCG has been allocated a limited resource by HEENW in 2016/17 for the educational development of the primary care non-medical workforce. Any funds not utilised at the end of 2016/17 are required to be returned by the CCG to HEENW.

6.2 The CCG Primary Care Committee is asked to:

a) Approve the plan for developing a Training Needs Analysis. b) Note the content of the surveys to obtain training and education requirements from

the Primary Care nursing workforce and from the perspective of each GP and / or Practice.

c) Note the interim measures being implemented, whilst the full project plan is implemented.

Clinical Lead – Helen Meredith, Chief Nurse Managerial Lead – Dianne Johnson, Accountable Officer

Signatory details: Mark Lammas, Acting Quality & Safety Operational Manager Mark.Lammas@knowlseyccg.nhs.uk / 0151 244 4170

Background Documents:

RCGP General Practice Foundation, General Practice Nurse Competencies, December 2012

http://www.rcgp.org.uk/membership/practice-teams-nurses-and-managers/~/media/Files/Membership/GPF/RCGP-GPF-Nurse-Competencies.ashx

Appendices:

Appendix 1: Primary Care Nursing Workforce Education & Training Survey (Nursing)

Appendix 2: Primary Care Nursing Workforce Education & Training Survey (GP)

Page 8 of 14

Appendix 1

Primary Care Nursing Workforce Education & Training Survey (Nursing) The CCG plans to develop a structured approach to producing a training needs analysis for the Primary Care nursing workforce. This would ensure that there is prioritisation and alignment of educational opportunities with improved coordination and consistency and links to the CCG’s strategic aims. The Primary Care Nursing Workforce Education & Training Survey is an opportunity for the nursing workforce to identify areas where further training and development is required. The CCG has been allocated a non-recurrent fund from Health Education England North West to be utilised on education and training for the Primary Care nursing workforce. The CCG requests your participation in the below survey. Your response and information provided is much appreciated by the CCG and will allow the CCG to identify areas to further develop the Primary Care nursing workforce.

GP Practice

Locality (Please mark an ‘x’ in the appropriate section) Kirkby Halewood West Knowsley East Knowsley

Please mark an ‘x’ in the appropriate section in the table below for all of the Primary Care nursing workforce competencies, whilst added some further information if selecting the ‘Other Education Requirement’.

Primary Care Nursing Workforce Competency

Education & Training Requirement No

Training Need

Training Required

Update Required

Shadowing Required

Other Education Requirement (Please

Specify) 1 Anticoagulation 2 Appraisal of others 3 Asthma

4 Audit, Review & Research

5 Cancer

6 Cardiovascular Disease

7 Cervical Screening

8 Chronic Kidney Disease

9 Clinical Guidelines

10 Communication with teams

11 Consultation

12 Contraception & Sexual Health

Page 9 of 14

Primary Care Nursing Workforce Competency

Education & Training Requirement No

Training Need

Training Required

Update Required

Shadowing Required

Other Education Requirement (Please

Specify)

13 Contracts, Regulations, CQC, QOF, Service Re-design

14 COPD 15 Data Protection 16 Dementia 17 Depression 18 Diabetes

19 Disease modifying anti rheumatic drugs, rheumatoid arthritis, therapeutic monitoring

20 Ear Care

21 End of Life, Palliative Care & Terminal Illness

22 Epilepsy 23 Equality & Diversity

24 Equipment & stock management

25 Health & Safety 26 Health Promotion 27 Heart Failure 28 Hypertension

29 Immunisations; Adult & Child

30 Infection Control 31 Leadership 32 Learning Disabilities 33 Management 34 Mental Health 35 Minor Illness 36 Minor Injury 37 Osteoporosis

38 Prescribing & Medicines Management

39 Reflective Practice

40 Safeguarding; Adults & Children

41 Spirometry

42 Tissue Viability & Wound Care

43 Travel Health & Vaccination

44 Treating people with dignity & respect

45 Venepuncture

Page 10 of 14

In addition to understanding the education and training requirements of the nursing workforce the CCG would like to obtain some further information regarding the demographic of its current Primary Care Nursing Workforce.

Primary Care Nursing Workforce Demographic Information Response 1 Accountability; do you hold a valid NMC registration Yes No 2 Age Years 3 Total number of years employed Years 4 Number of hours employed per week Hours Per Week 5 Agenda for Change Band equivalent Band 6 Do you have an appraisal? Yes No 7 How often do you have an appraisal? 8 Date of last appraisal 9 Do you use the CCG template for your training approvals? Yes No 10 if not, why not 11 Who carries out your appraisal? 12 Who would you like to carry out your appraisal?

13 Would you like your appraisal to be linked to a primary care nurse competency framework? Yes No

Thank you for completing the Primary Care Nursing Workforce Education & Training survey. Your information will be used to populate a Training Needs Analysis for the nursing workforce. Please submit your response to either of the below methods:

a) Email: Mark.Lammas@knowsleyccg.nhs.uk

b) Post: Mark Lammas Acting Quality & Safety Operational Manager

Knowsley Clinical Commissioning Group (CCG) Nutgrove Villa Westmorland Road Huyton L36 6GA

Page 11 of 14

Appendix 2 Primary Care Nursing Workforce Education & Training Survey (GP) The CCG plans to develop a structured approach to producing a training needs analysis for the Primary Care nursing workforce. This would ensure that there is prioritisation and alignment of educational opportunities with improved coordination and consistency and links to the CCG’s strategic aims. The Primary Care Nursing Workforce Education & Training Survey is an opportunity for the nursing workforce to identify areas where further training and development is required. The CCG has been allocated a non-recurrent fund from Health Education England North West to be utilised on education and training for the Primary Care nursing workforce. The CCG requests your participation in the below survey. Your response and information provided is much appreciated by the CCG and will allow the CCG to identify areas to further develop the Primary Care nursing workforce from the perspective of the Practice and where if feels further development of its nursing workforce is required.

GP Practice

Locality (Please mark an ‘x’ in the appropriate section) Kirkby Halewood West Knowsley East Knowsley

Please mark an ‘x’ in the appropriate section in the table below for all of the Primary Care nursing workforce competencies, whilst added some further information if selecting the ‘Other Education Requirement’.

Primary Care Nursing Workforce Competency

Education & Training Requirement No

Training Need

Training Required

Update Required

Shadowing Required

Other Education Requirement (Please

Specify) 1 Anticoagulation 2 Appraisal of others 3 Asthma

4 Audit, Review & Research

5 Cancer

6 Cardiovascular Disease

7 Cervical Screening

8 Chronic Kidney Disease

9 Clinical Guidelines

10 Communication with teams

11 Consultation

12 Contraception & Sexual Health

Page 12 of 14

Primary Care Nursing Workforce Competency

Education & Training Requirement No

Training Need

Training Required

Update Required

Shadowing Required

Other Education Requirement (Please

Specify)

13 Contracts, Regulations, CQC, QOF, Service Re-design

14 COPD 15 Data Protection 16 Dementia 17 Depression 18 Diabetes

19 Disease modifying anti rheumatic drugs, rheumatoid arthritis, therapeutic monitoring

20 Ear Care

21 End of Life, Palliative Care & Terminal Illness

22 Epilepsy 23 Equality & Diversity

24 Equipment & stock management

25 Health & Safety 26 Health Promotion 27 Heart Failure 28 Hypertension

29 Immunisations; Adult & Child

30 Infection Control 31 Leadership 32 Learning Disabilities 33 Management 34 Mental Health 35 Minor Illness 36 Minor Injury 37 Osteoporosis

38 Prescribing & Medicines Management

39 Reflective Practice

40 Safeguarding; Adults & Children

41 Spirometry

42 Tissue Viability & Wound Care

43 Travel Health & Vaccination

44 Treating people with dignity & respect

45 Venepuncture Page 13 of 14

Thank you for completing the Primary Care Nursing Workforce Education & Training survey. Your information will be used to populate a Training Needs Analysis for the nursing workforce. Please submit your response to either of the below methods:

a) Email: Mark.Lammas@knowsleyccg.nhs.uk

b) Post: Mark Lammas Acting Quality & Safety Operational Manager

Knowsley Clinical Commissioning Group (CCG) Nutgrove Villa Westmorland Road Huyton L36 6GA

Page 14 of 14

Document PC(07)05

Report to Knowsley Clinical Commissioning Group Primary Care Committee

Date of meeting: Thursday 7th July 2016

Report title: Workplan following Scrutiny Review of the Uptake of Cancer Screening Programmes in Knowsley

Report presented by: Dr Paul Morris, Clinical Lead - Cancer

Purpose of the report: The purpose of this report is to inform the Primary Care Committee of the cancer screening workplan and progress against the fourteen recommendations made in the Overview and Scrutiny Board review of the Uptake of Cancer Screening Programmes in Knowsley report published February 2016.

Recommendations:

Action / Decision required

The Primary Care Committee is asked to note the progress against the recommendations following the Scrutiny Board Review

Delegated Powers:

For decision reports only

N/A

Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply

1. Patient centred x

2. Safe

3. High quality

4. Cost effective x

5. Outcome focused x

6. Closer to home

7. Affordable

[one page only]

Page 1 of 8

PRIMARY CARE COMMITTEE

WORKPLAN FOLLOWING SCRUTINY REVIEW OF THE UPDATE OF CANCER SCREENING PROGRAMMES IN KNOWSLEY

Executive Summary The Council’s Overview and Scrutiny Board’s work programme for 2015/16 included a review of the uptake of cancer screening programmes in Knowsley. The aim of the review was to examine the current performance, challenges and opportunities in relation to improving uptake of breast, cervical and bowel screening programmes amongst Knowsley residents. The review, which included evidence, presented by providers of services the CCG commissions and Merseyside & Cheshire Area Team managers, set out 14 recommendations intended to improve the uptake of cancer screening, particularly amongst vulnerable or hard to reach groups.

The report identifies progress on the recommendations put forward including support to primary care in the promotion of cancer screening, reviewing coverage and uptake data at practice level to highlight those below national targets, working with patient participation groups to develop the role of cancer champions and supporting local community groups in raising awareness. A comprehensive work plan with a progress report against recommendations and actions has been produced detailing the progress against each of the recommendations – attached appendix A

Priority activity for the next 6 months is identified as:-

• producing a health equity audit • developing the role of cancer champions and promoting cancer screening awareness

amongst the local population • to identify and share ‘best practice on ways to improve on current screening uptake by

general practices • further develop local initiatives..

The Primary Care Committee is asked to note the progress update.

Page 2 of 8

1. Purpose of the briefing

1.1 The purpose of the briefing is to provide the Primary Care Committee with an overview of the uptake of cancer screening programmes in Knowsley and to provide an update on progress against the fourteen recommendations made by the Overview and Scrutiny Board following the scrutiny review of uptake of cancer screening (February 2016), highlighting current priorities and propose next steps.

2. Background

2.1 Cancer is one of the leading causes of mortality in Knowsley, the Overview and Scrutiny board review of the Uptake of Cancer Screening Programmes in Knowsley, (attached) made fourteen recommendations to effect improvements in cancer incidence and mortality rates across Knowsley and were submitted to the CCG Governing Body in May 2016.

2.2 The recommendations were developed to highlight the need to reduce the higher than

average cancer incidence rates and help to reduce mortality from cancer in Knowsley. 2.3 The recommendations put forward for Cabinet approval were developed following evidence

submitted from NHS England, as commissioners of the programmes as well Knowsley CCG, GPs and screening providers.

3. Key Issues 3.1 The cancer screening coordinator role has used the recommendations relevant to the CCG

to formulate a work plan to address the key areas of work required to improve cancer screening coverage and raise cancer awareness amongst the population of Knowsley

4. Implications for the CCG 4.1 A Strategic Action Plan for Cancer in Knowsley identified the need to improve cancer

screening programme uptake across Knowsley as one of the key priority action areas.

4.2 Cancer screening uptake for Knowsley is amongst the lowest in Merseyside with current breast cancer screening rates amongst the worst for Merseyside and the North West.

4.3 Cancer screening is essential in reducing incidence and mortality from cancer. Clinical research and evidence shows that cancers detected at an earlier stage have a better outcome than late stage presentation.

5. Actions being taken by the CCG 5.1 Following on from the Scrutiny Review of the Uptake of Cancer Screening Programmes in

Knowsley the CCG has appointed a cancer screening coordinator whose role will look to improve coverage and uptake for the three cancer screening programmes in Knowsley. Key work streams identified for this post are;

a) To support general practices to increase participation rates of cancer screening programmes across the borough

Page 3 of 8

b) Identifying and developing a range of effective interventions to improve uptake c) Identify and share good practice across the borough in the general practice setting d) Strengthen relationships with community groups and wider stakeholders, ensuring

effective liaison with other health and social care providers

6. Summary

. 6.1 The report provides an update on the current progress of the Scrutiny Review of the Uptake of Cancer Screening Programmes in Knowsley approved by the Governing Body in June 2016

Clinical Lead – Dr Paul Morris, Clinical Lead - Cancer

Managerial Lead – Kendra Waring, Programme Manager – Primary Care

Signatory details: Yvonne Brown, Cancer Screening Co-Ordinator Yvonne.Browne@knowsleyccg.nhs.uk

Background Documents:

Overview and Scrutiny Board - Scrutiny Review of the Uptake of Cancer Screening Programmes in Knowsley February 2016

A Strategic Action Plan for Cancer in Knowsley

Appendices:

1 – Recommendations and progress / workplan

Page 4 of 8

Theme

Recommen

dation

number

CCG LeadDate to be

completed

Overal

l RAG

Curren

t RAG

Update on20/06/2016

Health Equity audit in progress – CCG working in liaison with

Public health analyst from Knowsley MBC and Health Professional Facilitator for CRUK

Monthly update meetings held – next meeting 20th June 2016

Draft document will be submitted for approval CCG Chief Officer and Public Health lead

2.

YB

YB attending programme board meetings to highlight issues around

poor uptake , performance and quality and feeding back to CCG and

Public Health leads for action as appropriate

3.Screening coordinator undertaking programme of practice visits to

discuss cancer screening rates. To date 19 practices have been visited

or are scheduled to be visited . These visits include discussion on

current coverage / uptake rates by practice /locality and providing an

opportunity to offer support as needed by each practice to improve

screening uptake and share best practice . Have developed 'top tips'

based on best practice identified through visits and sharing this

information out to all practices. . A full progress report on findings and

actions agreed with each practice will be produced and shared with

primary care colleagues within the CCGAt each practice visit - practices are reminded about the use of flagging

patient records to provide consistent reminders to all staff / clinicians

to prompt patients when they attend surgery

Liaising with local area team (NHSE) and CRUK to ensure Knowsley

practices participate in initiatives

YB

Checking that each practice has identified a cancer champion and

advising that this is seen as best practice to support the improvement

of screening rates

Cancer Screening - Scrutiny Review work plan

Created 01.03.2016 current version20/06/2016

Detail

That a health equity audit be

carried out to understand health

inequalities in cancer screening and

to inform future working across

partners to address inequalities.

The health equity audit should

focus on:

• Identifying particular ‘groups’ of

people who may not be accessing

screening e.g. geographical areas,

vulnerable people such as drug

users, alcoholics, people with

learning disabilities, people with

physical disabilities (e.g. access to

mobile breast screening).

Understanding more about why

people in the most deprived

communities are not accessing

screening

1.       Health Equity Audit

YB Sep-16

electronic flagging systems for non

responders to screening

Nominating a practice screening

champion and ensuring that

information on screening, such as

leaflets / visual displays, are

accessible to vulnerable / hard to

reach groups

Participating in local initiatives to

improve uptake, such as non

responder project with NHS

England

That NHS England, Knowsley CCG,

Public Health and Provider

organisations agree clear roles and

responsibilities around screeening,

including the role of programme

boards and responsibility to act on

poor uptake and quality issues in

the programme

That GP’s be actively encouraged by

NHS England and CCGs as the leads

for Primary Care Quality, to make

the promotion of cancer screening

a priority and consider mechanisms

such as:

YB

Page 5 of 8

YB

Checking all sample takers are trained and up to date as per national

guidelines for training . Looking to provide non clinical staff training

on cancer screening and awareness raising to support improvements

by promoting cancer screening at every opportunity within general

practices

Attended PPG forum (8th June 2016) to highlight role and

opportunities to attend local PPG groups to raise profile of cancer

screening and provide support to develop 'cancer champions' within

practices.. Engaging with individual practice PPGs

4.       Liaison with Mersey Area Team, Public Health and service providers to

gain access to relevant data

Providing coverage data through access to Open Exeter for breast and

cervical data and Open Exeter BCSS for bowel screening data

Liaising with service providers and Screening and Immunisation Area

Team for regular data updates

5.     

That commissioners (NHS

England and CCG) learn

from best practice from

Knowsley and

neighbouring authorities,

where screening uptake

has increased and

incentivise participation

in such interventions

Liaised with screening coordinator at Halton CCG to review their

current initiatives

Liaised closely with Cancer Research UK and Screening and

Immunisation Area Team to link in with current Mersey wide 2 year

plan to increase uptake in cancer screening programmes ensuring

Knowsley is linked in with any initiatives

6.

YB

Have met with Aintree and Royal Liverpool bowel screening units to

gain overview of roll out of bowel scope screening and attended

Liverpool & Wirral bowel screening operational meetings. Ensuring

that practices involved in 1st wave of Whiston unit going live for bowel

scope screening in June 2016 have been informed and ensuring that

bowel scope screening information sheet for primary care has been

disseminated to all practices - discussed as part of practice visits.

7

YB

Member of bowel, breast and cervical programme boards and

operational meetings that enables me to gain updates on key issues

and initiatives being discussed, rolled out across local CCGS.

Liaised with Bowel unit at Aintree to support screening for people with

a learning disability – event at Knowsley Disability Cancer scheduled

for 28th June 2016

Currently running a programme of practice visits , taking screening

data for each practice to formulate discussion on performance and

ways in which this can be improved through support and training and

awareness raising amongst their practice populations. This includes

offering enagagemnet opportunities with Bowel and breast screening

units as appropriate

8

This work is being led by Sarah McNulty from Public Health and I am

keeping n contact with her on this issue.

Noted that this issue is raised by every practice during my visits and

this is fed back to Sarah

9

Not a direct action for CCG - Unsure where this work is up to

10

YB

YB

That all providers explore further

opportunities to influence uptake,

such as working with practices to

promote their endorsement of the

programmes

That the bowel screening centre

should explore the ability of

practices and others to disctribute

bowel cancer screeningh kits

opportunistically

Working with patient participation

groups (PPGs) to promote their role

as screening champions and

challenging practices who

underperform whilst promoting

and supporting initiatives in uptake.

Ensuring practice staff are fully

trained and educated on a regaular

basis in conducting screening (for

cervical) or discussing screening

(breast and bowel) with patients.

That the Council, CCG and NHS

England support and work with the

bowel scope screening providers to

ensure population-wide roll out of

the programme in Knowsley as

soon as possible and support and

endorse the introduction of FIT

testing in the faecal occult blood

testing screening programme.

That NHS England works with the

CCG and Public Health to provide

quarterley practice level data to

practices, linked to 'top tips' for

improving uptake.

That the bowel Cancer Screening

centre considers and tests the use

of patient leaflets at different parts

of the pathway to support uptake

Page 6 of 8

Area Screening & Immunisation Team are currently reviewing Breast

Screening unit

Have met with Councillor O’Mara to discuss options to engage

with her and colleagues to promote cancer screening awareness. Further work is required in this area

Have linked in with Mersey Area Team MP engagement event and will look to progress any actions from that event that could be adapted / promoted within Knowsley

YB

Have met with a number of local community groups such as Age UK Knowsley, Knowsley Pensioners Advocacy service and Cancer in Older People project, Knowsley Disability Concern, Health watch and Ivan to promote cancer screening. Linking in with coiuncil community engagement staff to support any local initiatives to raise awareness of cancer screening

12

Public Health are supporting Fire Safe and Well training and training

events are being held across the Mersey region for implementation of

this project in June / July 2016. Training programme for fire personnel

has been developed and rolled out across the region facilitated by

CRUK.

13

KW

This is being looked at by the CCG and Public Health Lead.

Looking to identify and link in with current and planned campaigns

Promoted national bowel cancer awareness campaign by supporting staff event at CCG

Promoting cervical screening awareness week (13-19 June 2016) across CCG, MBC and all practices to raise awareness

YB

Member of local cancer champions board for KPAIS to promote and endorse development of local cancer champions to raise awareness amongst wider communities

• That there is thorough evaluation

and analysis of campaigns to

identify good practice and whether

improvements have been made

• That they have a focus on

championing cancer screening

amongst particular groups of

people who are not currently

accessing screening e.g. those in

areas of high deprivation

That the breast screening service re-

considers the use of out of hours /

weekend appointments for women

to encourage uptake

That the Council contunies to

actively play its health promotion

role in relation to screening by

11.      

YB

Raising awareness to staff within

the organisation about the benefits

of screening

Exploring the possibility of elecetd

memebrs acting as cancer screening

'champions' and role models within

the local community, using local

knowledge and community

perspectives to send positive

messages about screening e.g.

breast screening is not painful

• That local ‘knowledge’ and local

people who have experience of the

screening programmes are used to

identify avenues for spreading

positive messages about screening

e.g. through third sector

organisations like Healthwatch

Knowsley

Working in partnership with local

community groups and third sector

organisations, including

Healthwatch Knowsley , to promote

screening programmes. Continuing

to offer the IVAN service as the

'onestop shop' of cancer and cancer

screening

That work continues in identifying

how public sector partners, such as

the Fire and Rescue service, can be

trained to promote screening and

assist in making appointments or

requesting screening kits

That an evaluation of the 12 month

cancer screening co-ordinator post

is undertaken with consideration

given by commissioners to

extending the post further

That local and national cancer

screening campaigns are supported

and welcomed, with the following

considerations:

14.     

YB

Page 7 of 8

YB

Liaising with Healthwatch Knowsley re the promotion of breast keening for over 70’s and also highlighting bowel screening

programme can continue beyond the age of 74.

YB

Looking to develop initiatives with large employers within Knowsley – meeting with QVC 29

th June 2016 - working closely ith council heakltyh and well being workforce officer to impekenbt this work

YB

Looking to engage with community pharmacies to offer awareness training to counter staff to promote cancer screening - meeting with Health Living pharmacies 16th June 2016

• That social media is used more

proactively to spread positive

messages about screening

• That messages address the

particular worries and concerns of

local people e.g. that breast cancer

screening is painful

• That messages to promote self-

referral for breast cancer screening

in the over 70s

Page 8 of 8

Document PC(07)06

Report to Knowsley Clinical Commissioning Group

Primary Care Committee Date of meeting: 7th July 2016

Report title: Primary Care Estates and Technology Transformation Bid

Report presented by: Alex Robertson, Interim Programme Director

Purpose of the report: The purpose of this briefing is to inform the Primary Care Committee of the progress to date, next steps and submission arrangements for the bid to the Primary Care Estates and Technology Transformation Fund.

Recommendations:

Action / Decision required

The Clinical Membership Group is recommended to note the content of the report.

Delegated Powers:

For decision reports only

N/A

Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply

1. Patient centred x

2. Safe x

3. High quality x

4. Cost effective x

5. Outcome focused x

6. Closer to home x

7. Affordable x

[one page only]

Page 1 of 9

PRIMARY CARE COMMITTEE

PRIMARY CARE ESTATES AND TECHNOLOGY TRANSFORMATION FUND SUBMISSION

Executive Summary The Primary Care Estates and Technology Transformation (formerly Infrastructure) Fund, a £1 billion investment programme to support general practice to make improvements across a range of areas, including in premises and in technology, was introduced by the government in December 2014 to enable the direction of travel set out in the NHS Five Year Forward View. Knowsley CCG is submitting a bid for investment in both estates and primary care technology which supports and is aligned with the core criteria as set out by NHS England, focusing on:

1) Improved access to effective care;

2) Increased capacity for primary care services out of hospital;

3) Commitment to a wider range of services as set out in the CCG’s commissioning intentions to reduce unplanned admissions to hospital;

4) Increased training capacity.

The total remaining from the original £1 billon is unclear at this stage.

Page 2 of 9

1. Purpose of the briefing

The purpose of the briefing is to inform the Primary Care Committee of the progress to date, next steps and submission arrangements for the bid to the Primary Care Estates and Technology Transformation Fund.

2. Background 2.1 The Primary Care Estates and Technology Transformation (formerly Infrastructure) Fund

was introduced by the Government in December 2014 to enable the direction of travel set out in the NHS Five Year Forward View. It was a multi-year £1billion investment programme to help general practice make improvements, including in premises and technology. It is now known as the Primary Care Estates and Technology Transformation Fund.

2.2 Initial bids for investment in 2015/16 were made by GP practices and the majority of these

focused on helping practices make improvements in access to clinical services by extending existing GP premises. In October 2015, CCGs were advised that they would become responsible for submitting applications under the Fund for premises or technology-based investment in primary care infrastructure in future years.

2.3 The details received so far about the fund indicate that the following areas are in scope for

consideration:

a) Significant improvements or extensions to existing facilities used for primary medical care services;

b) Refurbishment of unused or under-utilised premises that will increase clinical capacity;

c) Construction of new premises;

d) Implementation of IT systems which support the development of primary care at scale and integrated working practices; for example to support integrated care models and record sharing;

e) Technology systems which enable the delivery of a service which is paper free at the point of care; for example, through the use of integrated digital care records;

f) Technology which enables the public to have better access to services; for example to enable electronic prescribing, new forms of clinical consultations, via email, webcam, telephone or clinical decision support, or to access clinical services better within a local community setting instead of at hospital.

3. The CCG’s area of focus

3.1 The CCG’s bid focuses on how it can use technology effectively to support the implementation of its strategic objectives. Additionally, the bid will build on previous

Page 3 of 9

successes, such as the Local Improvement Finance Trust (LIFT) initiative, to protect and enhance investment already made in primary care estate.

3.2 NHS England has stated that all CCG recommendations, whether premises or technology related, will be considered against a number of core criteria, which deliver against the key priorities below:

a) Improved access to effective care;

b) Increased capacity for primary care services out of hospital;

c) Commitment to a wider range of services as set out in the CCG’s commissioning intentions to reduce unplanned admissions to hospital;

d) Increased training capacity.

4. Developing the submission

4.1 A core team has been pulled together; the bid is being managed by Alex Robertson, the CCG’s Interim Programme Director. Paul Brickwood is the Lead Executive and Sponsor for the submission.

4.2 The submission focuses on the CCG’s requirements - what problems it wishes to solve, and understanding what estates and technology-based solutions will help solve these problems, which meet NHS England’s stated core criteria, summarised above.

4.3 A workshop took place on Thursday 24th March, which was attended by a broad range of stakeholders, including a number of GP’s, CCG colleagues, and Healthwatch. This provided valuable initial input into defining requirements and developing the submission. In addition to the workshop, GP’s have been invited to provide input to the submission.

5. Core areas of focus

The submission focuses on a number of key areas; these include:

5.1 Estates Phase 1 – needs assessment

The CCG will engage specialist resource to carry a requirements definition, and produce a report outlining:

a) The current status of the space in the LIFT buildings;

b) The opportunity to make further changes to under-utilised spaces, soft furnished rooms etc;

c) The investment required, and timescales for the work;

Page 4 of 9

d) A benefits case.

The CCG is seeking funding to complete the needs assessment and benefits case outlined above, which constitutes Phase 1 of the Estates work.

Phase 2 – making the changes

Once Phase 1 has been completed, there will be a clear understanding of the investment required to update the estates to deliver optimum value, and facilitate increased access to primary care services. At this point, further investment will be sought from the Fund to enable the work to be carried out, and for the benefits to be realised.

5.2 Information Technology The submission focuses on building on core IT platforms already in place across the Borough, with EMIS at the core. The submission will be seeking funding to: a) Enable EMIS to be implemented across patient-facing staff in 5 Boroughs Partnership

NHS Foundation Trust (5BP);

b) Implement virtual access for professionals across 5BP and general practice, remotely through both laptop and tablet infrastructure;

c) Rolling out VoicePower digital dictation across 5BP, building on the rollout which is

underway in general practice; d) Improving patient access and take up of existing remote access services; e) Improving use of patient self-help tools; f) Defining requirements for, and subsequently implementing, assistive technology.

6. Key Issues

6.1 No material issues have been identified at this stage.

7 Process of application

7.1 Further guidance has been received, and considered during the development of the bid. The submission portal opened on 2nd June and will close on 30th June; it is the CCG’s intention to submit the bid before 30th June, to enable NHS England’s Area Team to review the bid and provide any feedback ahead of the closing date.

7.2 The CCG anticipates that feedback will be received in late August 2016, once the initial submission has been reviewed. Depending on the feedback, further work (including the development of more detailed business cases) may be required.

8 Funding levels

8.1 The total funding available under the Fund is unclear at this stage; the CCG awaits clarification of any potential submission limit.

Page 5 of 9

9 Implications for the CCG

9.1 There are no adverse implications envisaged for the CCG.

10. Governance and probity

10.1 The submission is close to being finalised in readiness for submission ahead of the deadline of 30th June. The high level details of the submission, and the core criteria for the submission, were presented to the Clinical Membership Group in June 2016.

Managerial Lead – Paul Brickwood, Chief Financial Officer

Project Manager – Alex Robertson, Interim Programme Director

Signatory details: Alex Robertson; alex.robertson@knowsleyccg.nhs.uk

Background Documents:

None

Appendices:

1. Letter to GP Membership, 29th March 2016

Page 6 of 9

Dear colleague Primary Care Transformation Fund bid Background

The Primary Care Transformation (formerly Infrastructure) Fund was introduced by the Government in December 2014 to enable the direction of travel set out in the NHS Five Year Forward View. It is a multi-year £1billion investment programme to help general practice make improvements, including in premises and technology.

In January 2015, GP practices were invited to submit bids for investment in 2015/16. The majority of these focused on helping GP practices make much needed improvements in access to clinical services by extending existing GP premises.

In October 2015 CCGs were advised that they would in future become responsible for submitting applications under the Fund for premises or technology-based investment in primary care infrastructure in future years. As part of that, CCGs were asked to develop commissioning plans designed to provide health care services for the future, including producing Local Estates Strategies and Local Digital Road Maps. The aim of this was to have clarity from which to establish a three-year pipeline of investment in estates and technology.

Knowsley’s Primary Care Transformation Fund (PCTF) bid

Knowsley CCG has now been asked to prepare and submit a bid to NHS England and the details received so far indicate that the following areas are in scope for consideration:

1. Significant improvements or extensions to existing facilities used for primary medical care services.

Page 7 of 9

2. Refurbishment of unused or under-utilised premises that will increase clinical capacity

3. Construction of new premises;

4. Implementation of IT systems which support the development of primary care at scale and integrated working practices; for example to support integrated care models and record sharing

5. Technology systems which enable the delivery of a service which is paper free at the point of care; for example, through the use of integrated digital care records

6. Technology which enables the public to have better access to services; for example to enable electronic prescribing, new forms of clinical consultations, via email, webcam, telephone or clinical decision support, or to access clinical services better within a local community setting instead of at hospital.

The CCG’s area of focus

We anticipate that the CCG’s bid will focus on how we can use technology effectively to support the implementation of our strategic objectives.

NHS England has stated that all CCG recommendations, whether premises or technology related, will be considered against a number of core criteria, which deliver against the key priorities below:

1. Improved seven day access to effective care

2. Increased capacity for primary care services out of hospital

3. Commitment to a wider range of services as set out in the CCG’s commissioning intentions to reduce unplanned admissions to hospital

4. Increased training capacity

Developing the bid

A core team has been pulled together; the bid is being managed by Alex Robertson, the CCG’s Interim Programnme Director. I will act as Sponsor for the bid.

The project is at requirements definition stage – understanding what problems we wish to solve, and understanding what technology-based solutions will

Page 8 of 9

help us solve these problems, which meet NHS England’s stated core criteria, summarised above.

A workshop took place on Thursday 24th March, which was attended by a broad range of stakeholders, including a number of GP’s, CCG colleagues, and Healthwatch. This provided valuable initial input into defining our requirements and developing our submission. We will continue to engage with stakeholders as the submission develops.

We would also welcome any thoughts or suggestions, which may feed in to the process and enrich our submission. Please contact Alex Robertson: (alex.robertson@knowsleyccg.nhs.uk)

The CCG’s submission is due by the end of April 2016, and we will ensure you are kept informed of progress both as the submission develops, and with any updates from NHS England after the submission has been reviewed.

Yours sincerely

Paul Brickwood

Chief Finance Officer

Page 9 of 9

Document PC(07)07

Report to Knowsley Clinical Commissioning Group

Primary Care Committee Date of meeting: 7th July 2016

Report title: Medicines Management Work Plan Update

Report presented by: Mark Pilling – Interim Head of Medicines Management

Purpose of the report: To provide a progress report against the Medicines Management Work Plan.

Recommendations:

Action / Decision required

The Primary Care Committee is asked note the current progress and proposed actions to continually improve prescribing quality, cost efficiency and reduce waste.

Delegated Powers:

For decision reports only

N/A

Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply

1. Patient centred x

2. Safe x

3. High quality x

4. Cost effective x

5. Outcome focused x

6. Closer to home x

7. Affordable x

[one page only]

Page 1 of 12

PRIMARY CARE COMMITTEE

MEDICINES MANAGEMENT WORK PLAN UPDATE REPORT

Executive Summary The Medicines Management Team (MMT) implemented a Work Plan for improving prescribing quality, optimising prescribing and reducing medicines waste in 2015-16. The report describes the continued progress and impact of the waste reduction element of the Work Plan for 2016-17. The Committee is asked to note the impact of the Work Plan 2016-17 and progress with the continued waste reduction and prescribing efficiency element of a proposed Work Plan for 2016-17 to deliver a QIPP target of £1.2M in 2016-17.

Page 2 of 12

1. Purpose of the briefing 1.1 The purpose of the report is to provide the Committee with the a review of impact of the

Medicines Management Work Plan for 2015-16 and the continued work 2016-17 to reduce medicines waste and increase cost efficiency. The Committee is asked to note the impact of the Work Plan 2016-17 and initial progress with the provisional 2016-17 Work Plan to deliver a medicines management QIPP target of £1.2M in 2016-17.

2. Background 2.1 The Medicines Management Work Plan 2015-16 aimed to optimise the use of medicines for

maximum patient benefit and provide best value to the NHS. The Work Plan was implemented with measurable improvements (Appendix 1). Areas of medicines use where waste can be targeted and reduced were addressed. Initiatives commissioned by the CCG included a dietician to reduce the inappropriate prescribing of oral nutritional supplements, and two Repeat prescription Co-ordinators to monitor and make interventions in respect of repeat prescription ordering by pharmacies.

2.2 Whilst prescribing costs have increased overall, March 2016 annual cost growth has

been reduced to 3.5 per cent from a peak in 2016 of 4.86%. The CCG Repeat Prescription Co-ordinator pilot and the continued work of the MMT continue to impact on expenditure in the early part of 2016-17.

3. Key Issues 3.1 Specific cost pressures on prescribing continue to arise from an ageing population, new

treatments and recommendations from specialists for GPs to commence treatment and participate in shared care of specialist and often expensive medication

3.2 There are specific challenges with rising costs as the range of types of medication available

for patients with long-term conditions increases. For example, a patient with both Diabetes and COPD could be regularly taking 8 to 10 medications in total for these 2 conditions alone. Ten years ago the medicines available for the same patient would have been nearer 6 or 7.

3.3 Practice specific waste medicine reductions are continuing in 2016-17 with estimated

avoidable waste believed to be in excess of £1M. 4. Actions taken by the CCG 4.1 In 2015-16 there was a continuous programme of work to review and address prescribing

safety issues improve prescribing quality and reduce avoidable medicines waste. The MMT looked at ensuring practices had safe and effective systems for dealing with repeat prescriptions and to assess the impact community pharmacy has had ordering repeat prescriptions on behalf of patients.

4.2 Repeat prescribing Training was provided to 87% of reception staff in Knowsley practices

aimed at reducing risk of harm to patients and reducing avoidable waste. Community pharmacy ordering systems have improved. A Working Group to continue this improvement has been established. For each practice there are tabulated records of safety and cost efficiency achievements. Appendix 1 - the Medicines Management Dashboard summaries performance against the Medicines Management Work Plan against agreed KPIs.

Page 3 of 12

4.2 The commissioned dietician released efficiency savings totalling £144,524 at the end of

February 2016 with a current negative annual cost growth of – 20.8% (compared to - 19.8% in January 2016).

4.3 So far in 2016-17, GP Practices and the MMT have achieved combined waste reduction

and QIPP cost efficiency savings of £404,356. In addition, the OptimiseRx software, integrated within the EMIS GP Clinical system, has also increased cost effectiveness with a projected annual return on investment of £168,000 (net), greater than anticipated, and greater than the previously commissioned software ScriptSwitch.

4.4 A recent audit estimates that there is currently £1,150,000 per annum of avoidable waste being prescribed in Knowsley attributable to the actions of practice staff or community pharmacy. The proposed Work Plan for 2016-17 will continue with a focus to reduce this avoidable waste problem from pharmacy ordering systems in addition to avoidable waste being caused by patients, carers, care homes, secondary care and other care providers. 4.5 A pilot of deployment of ‘Repeat Prescription Co-ordinators’, responsible for scrutinising and approving each repeat prescription request, and therefore ensuring every patient has been contacted and that all medication is needed has been implemented at Wingate MC and at Aston HC (Manor Farm Surgery). The early evaluation of this pilot is summarised in Appendix 2 suggesting that in addition to reducing medicines waste and unnecessary expenditure there are a range of quality interventions that are regularly achieved including advice and appointment facilitation with a practice nurse or GP for example. 4.6 The Total Purchase Pilot of Dressings supply went live in Kirkby in February 2016 Current

expenditure including VAT is less than anticipated (approximately £20,000 per month) although there may still be some prescribing of ‘regular repeat’ dressings and this will be analysed. Evaluation has commenced and will consider:

• Analysis of Prescribing data and cost • Formulary Compliance and Dressings waste • Time to Treatment and other quality benefits • Case Studies • Views of GPs and practices Antibiotic prescribing

5. Evidence and Engagement 5.1 The CCG Medicines Management Team working with local health economy prescribers,

practices and local Trusts will continue to optimise medicines use. Continuing to review and revise the Medicines Management Work will increase and sustain improvements to improve the quality of medicines use, maximise patient safety and reduce medicines waste.

5.2 The work areas highlighted for the Medicines Management Work Plan for 2016-2017 will

be aligned with CCG current priorities and reflected in the Primary Care Quality Premium (PCQP) 2016-17. The proposed prescribing element for 2016-17 recognises the influential role of CCG Prescribing Leads and Practices, in making improvements to prescribing quality, reducing risk of harm to patient’s from medication and reducing unnecessary prescribing expenditure. The PCQP aims to provide resource and support for sustainable improvements to systems and process for medicines management within GP Practices. Practices who achieve the targets of the programme will be rewarded with payments linked to their list size.

Page 4 of 12

5.3 The Work Plan for 2016-17 will include a programme of work in collaboration with Practice Clinical Prescribing Leads:

5.3.1 To reduce the number of medicines not taken as intended and ensure patients have sufficient information to support taking medicines;

5.3.2 To reduce hospital admissions by optimising medicines use, ensure appropriate

monitoring and review and prevent adverse reactions to medicines; 5.3.3 Further training of Practice staff on repeat prescribing systems that will further

reduce the possibility of medication errors and reduce medication wastage estimated at £1.15m in Knowsley of which two thirds has been recently estimated to be preventable;

5.3.4 There will be a programme of public engagement to reduce medicines waste; 5.3.5 There is a real threat to healthcare from antibiotic resistance. There will be a

programme of Antibiotic Stewardship at practice level including audit and education to reduce in appropriate antibiotic prescribing;

5.3.6 Adherence to good practice prescribing in line with Pan Mersey Area Prescribing

Committee will drive up the safety, quality and cost-effectiveness of prescribing; 5.3.7 Implementation of revised shared care processes will also increase equity of access

to medicines, reduce risk of patient harm; 5.3.8 Review, feedback and education for the prescribing decision software, Optimise Rx

will increase medicines safety and cost effectiveness; 5.3.9 Following on from 2015-16, there will be a continuous review of all patients

prescribed Oral Nutritional Supplements; 5.3.10 The ‘Dressings off Prescription’ initiative currently piloted in Kirkby locality pending

final evaluation will be rolled-out across all localities; 5.3.11 The CCG Medicines Management Team has identified some key areas of work for

2016-17 that it is anticipated will have a large impact on reducing the prescribing costs of practices (appendix 3) and these will be prioritised based on realistic impact.

5.4 As part of managing at risk patients in the community, the Medicines Management Team in 2016/17 will continue to advise GPs and also focus on specific preventative measures:

5.4.1 Optimising the identification and management of patients with Atrial Fibrillation with a focus on the increase in uptake of anticoagulation therapy where appropriate;

5.4.2 Supporting improvement in prescribing for asthma, COPD and diabetes;

5.4.3 Effective management of poly-pharmacy in the elderly.

5.3 A programme of work has commenced with the Commissioning Team at KMBC to work

with Care Home and Domiciliary Care provider organisations. The MMT will provide advice to KMBC on the safety and quality of medicines use in care homes and by domiciliary care providers. MMT will also audit the quality of medicines management of care homes and domiciliary care providers to increase patient safety and reduce medicines waste.

Page 5 of 12

6. Summary 6.1 This report describes recent actions and achievement for 2015-16 and the implementation of the Medicines Management Work Plan 2016-17 together with the deployment of Repeat Prescription Co-ordinators, to achieve safe, high quality and cost- effective prescribing with the minimum of medicines waste. The identified actions within this report continue to demonstrate that regular review will help ensure that prescriptions remain appropriate to the condition of the patient, are safe and effective.

Clinical Lead – Dr Aftab Hossain Managerial Lead – Mark Pilling

Signatory details: Mark Pilling, mark.pilling@knowsleyccg.nhs.uk

Telephone: 0151 676 5604 Background Documents: None. Appendices: Appendix 1 – Medicines Management Work Plan Dashboard 2016-17 Appendix 2 – Evaluation of Repeat Prescription Monitors Appendix 3 – Medicines Management QIPP Plan, June 2016

Page 6 of 12

Appendix 1 Medicines Management Dashboard at 31st May 2016

Improvement Area Headline Metric Target March 16 Exceptions

Community Pharmacy patient ordering systems

% patients contacted by pharmacies prior to repeat prescriptions 79.1% 70.4%-

Significant improvement in the last 6 months since initial audit demonstrated that only 46.5% of patients were contacted

% prescription request errors 5.0% 8% The error rate has decreased from 18.2% (of which a third was attributable to GP Practice errors).

GP repeat prescribing systems and Medicines

managers in GP practices

Monthly Prescribing expenditure (£) £2,642,598 £2,780,304

Rolling 12mth Prescribing expenditure (£) £31,915,431 £32,446,028

Annual growth of prescribing expenditure 2.25% 3.5% Annual Cost Growth peaked at 4.9% in 2015.

Monthly prescription volume (total items) 344,920 367,374

Rolling 12mth prescription volume (total items) 4,165,697 4,527,482 LTCs and hospital led prescribing influencing volume growth

Monthly average cost per item £7.66 £7.57

Rolling 12mth average cost per item £7.66 £7.76

Percentage of GP practices undertaking a repeat prescribing risk assessment with an agreed action plan 87.0% 93.8%

Percentage of Knowsley CCG registered GP practice reception staff completing repeat prescriber training 80.0% 86.7%

Public Information Campaign

Percentage of Knowsley CCG registered practices actively and visibly promoting patient awareness to

medicines waste 80.0% 83.0%

Practices to display Public Information Campaign poster by 31st March 2016

Review of patient prescribed sip feeds

Monthly expenditure on sip feeds (£) £64,590.71 £46,562.13

There has been significant month on month reduction in sip feed costs

Rolling 12mth expenditure on sip feeds (£) £722,667.00 £709,453 £13K less than Target

Rolling 12mth average cost per item for sip feeds £38.25 £41.21

As a result of quality improvement fewer patients supplementing on a ’ad hoc’ basis explains the higher cost per item as a result of more appropriate prescribing

Page 7 of 12

Appendix 3 Medicines Management Prioritised QIPP Plan, June 2016

Schedule Owner P = Pharmacist T= Technician

Area of Work Intended Outcome Current Annual costs Anticipated Impact

July P or T Vitamin B compound Review, request bloods if needed, stop if not working/needed. £48,000 £30,000 July T Buprenorphine Patches Switch to BuTec (15mcg imminent) TBC £75,000 July T Quetiapine MR If reason for MR from consultant switch to Ebesque XL if no reason refer

back into service for reason – if no reason for MR convert to IR. £67,000 £35,000

July T Fentanyl Patches To Fencio or Matrifen (CD branding guidelines) £58,000 £23,000 July T Oxycodone MR To Longtec (CD branding guidelines) TBC £23,000 July T Azithromycin Caps To tabs and three times per week as COPD team. TBC £11,000 July P or T Doxazosin MR To IR £14,000 £10,000 July T Oxycodone IR To Shorttec (CD branding guidelines) TBC £10,000 July T Prednisolone EC Switch to normal as EC are black on PanMersey TBC July P Iron Review, request bloods if needed, stop if not working/needed. £148,000 £48,000 July P Orlistat Review, stop if not working or target not reached. £85,000 £10,000 August P or T Salmeterol/Fluticasone Switch to a PanMersey guidelines option. £552,000 £250,000 August P or T Seretide, Sirdupla, Flutiform Switch to a PanMersey guidelines option. £871,000 £300,000 August T Tadalafil Switch to Sildenafil if not tried, reduce quantities. £136,000 £100,000 August T Pregabalin in Epilepsy or

GAD Switch to Alzain. £108,000

August P Solifenacin To Tolterodine IR. £414,000 £100,000 August P or T Symbicort Switch to a PanMersey guidelines option. £333,000 £73,000 August T Vardenafil Switch to Sildenafil if not tried, reduce quantities. £10,000 £8,000 August P Sodium Flouride Toothpaste If from community dentist send back. £7,000 £7,000 August P Magnesium Supplements Review, request bloods if needed, stop if not working/needed. £56,000 August P Dutasteride Switch to Finasteride. £13,000 £9,200 August P Tamsulosin & Dutasteride Switch to Finasteride and Tamsulosin separately. £13,000 £5,000 Sept P High Cost GLP-1 agonists Review and stop if not working or switch to Lixisenatide. £231,000 £163,000 Sept P or T Emollients Review and switch. £434,000 £100,000 Sept P or T Barrier Preps Review and switch. £13,000 £3,000 Sept P Gliptin Reviews Review and switch. TBC TBC Sept P & T Care home waste Review processes and ordering systems. TBC £30,000 Sept P or T Baby Milks Review and stop if inappropriate. TBC TBC Sept P or T NHSE Commissioned Meds Review and refer back if appropriate to do so. TBC TBC

Page 8 of 12

Page 9 of 12

Appendix 2 EVALUATION OF THE ROLE OF REPEAT PRESCRIBING MONITORS

1. Introduction and Background 1.1 The Repeat Prescribing Co-ordinators have been in Post since the end of November 2015

in Wingate Medical Centre and the beginning of January 2016 in Manor Farm. At present one Co-ordinator is working Tuesday to Thursday, and the other is now working Monday to Thursday from April 2016.

1.2 The Co-ordinators review the majority of all paper prescription requests that the surgery

receive on that day which can come via the Community Pharmacy, Nursing Home, other 3rd party e.g. Appliance Contractor or the patient. The Co-ordinators complete the Repeat Prescription Monitoring Summary Sheet from the paper prescription requests that the surgery receive daily.

1.3 The Co-ordinator reviews each prescription, and attempts to contact the patient to confirm

the items they have ordered are correct and if it has come via a Pharmacy they will check to see if the Pharmacy spoke to the patient to confirm the items they required. To increase efficiency and throughput, the Co-ordinator screens each prescription, if it is likely that all items would be required e.g. BP and other essential medication, the patient may not be contacted.

1.4 The Co-ordinator completes a Repeat Prescription MOT Telephone Call Script and Record

when speaking to the patient. In this a record is kept of who ordered the repeat prescription, whether they received all the items they requested and whether they received any items they did not need.

1.5 The patient is also asked if they have any excess medicines at the home and whether there

is anything else the Co-ordinator can help them with. 2. Progress to date 2.1 In the time that the Repeat Prescription Co-ordinators have been in post they have made a

monthly cost saving of £7,769.41 (November to April) with a projected yearly saving of £58,686.05.

2.2 During the review of scripts and telephone conversations with patients, quality and costs

interventions were made including:-

a) Items changed to acute prescriptions if patients had excess or did not require the items on a monthly basis;

b) Removing meds that patients are no longer require off the repeat screen; c) Advising patient to attend a review and arranging these. d) Reducing number of tablets to the number required e) Cancelling prescriptions that have been submitted too early f) Arranging for removal of excess medicines at patients’ homes

Page 10 of 12

g) Updating patient contact details h) Advising patients who are not taking meds correctly to see the GP or Practice Nurse i) Items that have been missed are added to the script

2.3 Any interventions that require a GP input are tasked to the relevant GP to approve and

notes added to the Pharmacy screen. 3. Evaluation to Date 3.1 The total number of items on scripts reviewed during the review period for both practices

was 16,006 and the total number of items ticked was 12,126. This equates to approximately 13% for Wingate and 44.5% for Manor Farm of items on repeat scripts not being ticked.

3.2 A summary of the data collection for Wingate Medical Centre is detailed below:-

Month No of patients contacted attempted

No of patients available

Quality Interventions made

Cost interventions made

Monthly costs savings

Projected Yearly cost saving

November 44 27 19 26 477.83 3,077.28 December 159 79 6 52 835.47 4,826.20 January 258 145 4 99 1,365.10 8,654.81 February 301 192 6 42 592.99 4,016.77 March 350 238 2 50 1,459.00 7,754.43 April 383 255 0 62 878.91 8,169.87

3.3 A summary of the data collection for Manor Farm is detailed below:-

Month No of patients contacted attempted

No of patients available

Quality Interventions made

Cost interventions made

Monthly costs savings

Projected Yearly cost saving

January 151 55 42 80 143.62 5,287.31 February 215 52 34 66 39.22 4,209.93 March 114 58 66 87 897.25 3,376.01 April 51 19 70 57 564.04 2,842.94

3.4 Approximately 37% of patients attempted to be contacted at Wingate Medical Centre were

available and approx. 63% in Manor Farm. 3.5 At the end of the review the patient is asked whether there is anything the Co-ordinator can

help them with. Comments have included items being missing, not being given the option to cross of items by the Pharmacy, getting items they do not need and not being contacted by the Pharmacy to confirm what items they need.

3.6 It has been acknowledged by both practices that in addition to actively preventing waste

reduction, the Co-ordinators have:

3.6.1 Integrated their role into the repeat prescription management process within the two practices. Working in tandem with other staff, from the practice and the CCG Medicines Management Team.

3.6.2 Provided a range of quality and added value interventions as a result of direct

contact with patients. Interventions have included making appointments with practice nurses or GPs in a patient is experiencing health problems or problems with their medication.

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3.7 The projected yearly cost savings of £40k and a salary cost to March 2016 of £18,000 (total

for both Co-ordinators suggests the Co-ordinator save twice what they cost in salary. 4. Summary and Conclusion 4.1 The Co-ordinators have demonstrated evidence of a significant role in engagement with

patients to improve quality in medicines use and reduce waste. Whilst it is not always possible to easily speak with each patient every month, were patients are contacted this often results in changes to prescription accuracy and may also result in referral to another healthcare professional.

4.2 It is proposed that a second wave of Co-ordinators be deployed so that all localities have

the experience of the impact if a Co-ordinator. This extension and increase in the number of Co-ordinators may also be considered within a hub, a small centre or room were several Co-ordinators could be engaged with and act for all practices. A more systematic approach to ensure all patients are contacted at least once every year.

Clinical Lead – Dr Aftab Hossain Managerial Lead – Mark Pilling

Signatory details: Mark Pilling, Mark.Pilling@knowsleyccg.nhs.uk 0151 676 5604

Page 12 of 12

Document PC(07)07

Report to Knowsley Clinical Commissioning Group Primary Care Committee

Date of meeting: 07 July 2016

Report title: Primary Care Performance Report – Development Update

Report presented by: Ian Stewardson, Director of Strategy & Performance

Purpose of the report: A progress update on the development of primary care performance reporting.

Recommendations:

Action / Decision required

The committee is recommended to:

Note the content of the report.

Delegated Powers:

For decision reports only

N/A

Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply

1. Patient centred x

2. Safe x

3. High quality x

4. Cost effective

5. Outcome focused x

6. Closer to home

7. Affordable

[one page only]

Page 1 of 8

PRIMARY CARE COMMITTEE

PRIMARY CARE PERFORMANCE REPORT DEVELOPMENT

Executive Summary The CCG has put in place a work plan to ensure that it meets its delegated commissioning responsibilities. In order to discharge this responsibility effectively, the CCG requires suitable performance reporting.

Helen Meredith, Chief Nurse, is leading work to identify the requirements for primary care reporting. Based on initial discussions, the high level requirements will focus on quality and safety.

Ian Stewardson, Director for Strategy & Performance, supported by Andrew Thomas, Head of Planning and Performance, will work with the CCG’s BI suppliers and a range of interested parties to develop reporting that is fit for purpose.

The intention is to work over the next three months with these suppliers to source the data and design a presentational format that meets the requirements. This will include engagement with GP clinical leads to refine the design, and it is intended that a mock-up will be circulated for comment and agreement before the next Primary Care Committee.

Once this work is concluded, the desired outcome is that, at any given point in time, the CCG will have a clear understanding of:

• How well it is fulfilling its delegated responsibilities for commissioning primary care; • The quality of primary care; • Progress against transformation milestones; and • The impact of transformation.

Page 2 of 8

1. Purpose of the briefing 1.1 The purpose of this briefing is to describe progress in developing primary care reporting. 2. Background 2.1 With effect from 01 April 2015, the CCG became responsible for the commissioning,

procurement and management of Primary Care Medical Services contracts under a formal delegation agreement with NHS England (NHSE).

2.2 The CCG has put in place a work plan to ensure that it meets its delegated commissioning

responsibilities. In order to discharge this responsibility effectively, the CCG requires suitable performance reporting. This may take the form of a dashboard, but the reporting requirements are likely to be broader in scope.

3. Key Issues and update on development 3.1 The CCG already collects and reports a range of information in relation to primary care, in

particular in the context of reporting to the Quality Committee. Examples are included at Appendix 1. This includes such information as:

• Care Quality Commission inspection ratings • GP survey results • Friends and Family Test scores

3.2 Helen Meredith, Chief Nurse, is leading work to identify the future requirements for primary

care reporting. Based on initial discussions, the high level requirements will focus on contractual requirements and quality, in particular:

a) Patient Safety

• Incident reporting • Safeguarding incidents • Healthcare associated infections • Immunisation and vaccination uptake • QOF (selected indicators)

b) Patient Experience

• Access • Complaints • Friends and Family Test • Patient Surveys

c) Effectiveness

• Emergency admissions • A&E attendances • Referral Rates • Pathway compliance

d) Workforce

• Staffing levels (Clinical & Non-clinical) • Locum GPs (policies for employment) • Professional body registration & indemnity insurance

Page 3 of 8

• DBS checks • Annual appraisal/PDP • Staff training

3.3 The work to establish and refine the requirements is on-going, but at a high level it is

expected that this will result in the development of reporting solutions for primary care which will:

• Support the CCG in discharging its delegated commissioning responsibilities; • Provide assurance as to the quality of primary care; • Enable the CCG to monitor the progress of, and impact of, its transformation

programme in primary care. 3.4 Ian Stewardson, Director for Strategy & Performance, supported by Andrew Thomas, Head

of Planning and Performance, will work with a range of interested parties to develop reporting that is fit for purpose.

3.5 The CCG purchases a range of Business Intelligence (BI) services from Midlands and

Lancashire Commissioning Support Unity (MLCSU), as well as a separate reporting tool, Supplied by Health Intelligence. The intention is to work over the next three months with these suppliers to source the data and design a presentational format that meets the requirements. This will include engagement with GP clinical leads to refine the design, and it is intended that a mock-up will be circulated for comment and agreement before the next Primary Care Committee.

4. Implications for the CCG 4.1 Once this work is concluded, the desired outcome is that, at any given point in time, the

CCG will have a clear understanding of: • How well it is fulfilling its delegated responsibilities for commissioning primary care; • The quality of primary care; • Progress against transformation milestones; and • The impact of transformation.

4.2 It is also anticipated that there will be benefits to practices in assembling data from a range

of sources that helps to build a holistic picture of primary care.

4.3 Failure to develop and establish the required reporting may impact negatively on the achievement of key outcomes, and the transformation priorities identified by the CCG in its operational plans for 2016/17.

4.4 This work will require a significant resource input from the planning and performance functions, along with engagement with and input from a range of individuals across the CCG. Success will also be dependent on building a constructive dialogue with BI suppliers.

5. Actions being taken by the CCG 5.1 Engagement with MLCSU and Health Intelligence has already been initiated. Ian

Stewardson has held discussions with both suppliers to secure a commitment to working with the CCG to develop primary care reporting. Follow up meetings have been set up with MLCSU and Health Intelligence in early July to discuss the CCG’s requirements.

Page 4 of 8

5.2 In addition, the CCG is taking advantage of an opportunity to attend an MLCSU hosted session describing developments on primary care reporting that are in train for other MLCSU clients. There may be an opportunity to address some or all of the CCG’s reporting requirements by accessing this product. As the CCG is engaging with MLCSU in the development phase, there may also be opportunities to influence the development to the benefit of all parties. The Head of Planning and Performance is attending this session on 29 June 2016.

6. Summary

6.1 The CCG has put in place a work plan to ensure that it meets its delegated commissioning

responsibilities. In order to discharge this responsibility effectively, the CCG requires suitable performance reporting.

6.2 Helen Meredith, Chief Nurse, is leading work to identify the requirements for primary care reporting. Based on initial discussions, the high level requirements will focus on quality and safety.

6.3 Ian Stewardson, Director for Strategy & Performance, supported by Andrew Thomas, Head of Planning and Performance, will work with the CCG’s BI suppliers and a range of interested parties to develop reporting that is fit for purpose.

6.4 The intention is to work over the next three months with these suppliers to source the data and design a presentational format that meets the requirements. This will include engagement with GP clinical leads to refine the design, and it is intended that a mock-up will be circulated for comment and agreement before the next Primary Care Committee.

6.5 Once this work is concluded, the desired outcome is that, at any given point in time, the CCG will have a clear understanding of:

• How well it is fulfilling its delegated responsibilities for commissioning primary care; • The quality of primary care; • Progress against transformation milestones; and • The impact of transformation.

Managerial Lead – Ian Stewardson

Signatory details: Andrew Thomas, andrew.thomas@knowsleyccg.nhs.uk 0151 244 3109

Background Documents:

None

Appendices:

Sample reporting from Quality Committee

Page 5 of 8

Appendix One

Sample primary care data as reported to Quality Committee:

CQC Inspection Ratings:

GP Practice Date of

Inspection

CQC Inspection Rating

Are services

safe?

Are services

effective? Are services

caring?

Are services responsive to people’s

needs?

Are services well-led?

Overall rating for

this service?

Dr Kinloch & Partner

February 2015 Good Good Good Good Good Good

Hillside House Surgery

February 2015 Good Good Good Good Good Good

Nutgrove Villa Surgery

February 2015 Good Good Good Good Good Good

Prescot Medical Centre

February 2015

Requires Improveme

nt Good Good Good Good Good

Roseheath Surgery Ltd

February 2015 Good

Requires Improveme

nt Good Good Good Good

Tarbock Medical Centre

February 2015

Requires Improveme

nt Good Good Good Good Good

Dinas Lane Medical Centre

February 2015

Requires Improveme

nt Good Good Good Good Good

Dr Maassarani & Partners

February 2015

Requires Improveme

nt Good Good Good

Requires Improvemen

t

Requires Improvemen

t The MacMillan Surgery

February 2015 Good Good Good Good Good Good

Cedar Cross Medical Centre

February 2015

Requires Improveme

nt Good Good Good Good Good

Princess Drive Medical Centre

February 2015

This Practice has since merged with the Cornerways Medical Centre, with all patients having transferred to this Practice

Family Health Centre

February 2015

This Practice has since merged with the Dr Maassarani & Partners Practice, with all patients having transferred to this Practice

St John’s Surgery

November 2015

Requires Improveme

nt Good Good Good Good Good

Dr Suares & Partner

November 2015

Requires Improveme

nt Good Good Good Good Good

Bluebell Medical Centre

January 2016 Inadequate Inadequate Inadequate Inadequate Inadequate Inadequate

Longview Medical Centre

January 2016

Requires Improveme

nt Good Good Good Good Good

Colby Medical Centre

January 2016

Requires Improveme

nt

Requires Improveme

nt Good Good

Requires Improvemen

t

Requires Improvemen

t St Laurence’s Medical Centre

February 2016 Good Good Good Good Good Good

Page 6 of 8

Friends and Family Test (FFT) within Primary Care: Friends & Family Test: Primary Care The FFT is now completed in Primary Care, however the way in which it is undertaken is different in each Practice. By the 17th of each month, each Practice has to submit to NHS England the number of patients that have completed the FFT, including the number of respondents and the scores for each reply to the single question, to provide an overall rating score for each Practice. RAG ratings have compared ‘Recommended’ FFT performance against national averages. The total number of FFT responses submitted in each month is displayed in brackets.

GP Practice A

pr 1

5

May

15

Jun

15

Jul 1

5

Aug

15

Sep

15

Oct

15

Nov

15

Dec

15

Jan

16

Feb

16

Mar

16

Wingate Medical Centre (0) (0) (0) (0) (0) (0) 65% (17)

50% (12)

48% (31)

48% (21)

54% (13)

Dr Kinloch & Partner (1) 100% (7) (2) (2) 100%

(6) (3) 100% (9)

100% (13)

86% (7) (3) (2)

Dinas Lane Medical Centre

88% (138) (0) (0) (0) (0) 93%

(122) 88% (73)

92% (83)

94% (159)

91% (262)

91% (286)

Bluebell Lane Surgery (0) 100% (25)

85% (41)

75% (20) (0) (0) 67%

(43) 84% (25) (0) 92%

(25) (0)

Stockbridge Village Health Centre (0) (0) (0) (0) (0) (1) (2) (1) (0) (0) (0)

Park House Medical Centre

100% (29)

100% (25)

97% (30) (0) (0) 100%

(51) (0) 100% (44) (2) (0) 100%

(16)

Cornerways Medical Centre

100% (16)

100% (12)

100% (12)

100% (10)

100% (10)

100% (8)

100% (8) (0) 50%

(10) 87% (163)

83% (88)

Aston Healthcare Limited 75% (40)

87% (78) (0) 93%

(90) 78% (58)

72% (82)

79% (86)

78% (94)

83% (54)

91% (64)

67% (64)

Dr M Suares' Practice (0) (0) 95% (21) (0) (4) (1) 83%

(6) 100%

(7) (2) (0) (0)

Roseheath Surgery 100% (19)

83% (12)

97% (74)

100% (8)

100% (12)

94% (17)

94% (16)

100% (9)

93% (41)

86% (63)

83% (76)

Millbrook Medical Centre 90% (31)

80% (35) (0) (0) 86%

(14) 73% (11)

83% (18)

91% (11)

75% (16)

67% (21)

97% (29)

Dr RI King's Practice 91% (109)

89% (109)

92% (136)

98% (90)

88% (51%)

97% (32)

100% (23) (3) (0) (0) (0)

Longview Medical Centre (0) (0) (0) (0) (0) (0) 86% (76)

52% (92) (0) 75%

(32) (0)

Tarbock Medical Centre (0) 100% (10)

100% (5)

100% (11)

100% (8) (4) 100%

(10) 100%

(6) (3) (4) (4)

Trentham Medical Centre (0) (0) (0) (0) (0) (0) (0) (0) (0) 76% (25) (0)

Princess Drive Medical Centre

100% (20)

100% (6)

100% (6)

100% (8)

100% (8)

100% (6)

100% (7)

Practice merged with Cornerways Medical Centre

The Macmillan Surgery (0) (0) (0) (0) (0) (0) 100% (23) (0) (0) (0) (0)

Prescot Medical Centre 95% (21)

90% (10)

92% (12)

100% (5) (0) 88%

(8) 67% (6) (2) (4) 91%

(44) 100%

(6)

Hollies Medical Centre (0) 100% (19)

94% (93)

89% (62)

100% (5)

94% (31)

98% (40)

93% (14) (0) 92%

(50) 95% (21)

Dr Maassarani & Partners 87% (46)

91% (35)

96% (46)

100% (42)

64% (25)

89% (18)

89% (18)

76% (33)

90% (91)

93% (81)

88% (50)

Cedar Cross Medical Centre

100% (25)

91% (34)

100% (23)

100% (25)

97% (34)

94% (16)

100% (5)

100% (13)

100% (28)

97% (30)

100% (8)

Colby Medical Centre 88% (16)

100% (25) (0) (0) (0) (0) (0) (0) (0) (0) 94%

(16)

MK & NN Rahman (0) 92% (51) (0) (0) (0) 85%

(13) (4) 100% (6) (0) (0) (0)

St John's Surgery 86% (22)

93% (28)

100% (50)

100% (30)

100% (24)

100% (20)

100% (21) (0) 50%

(82) 100% (136)

100% (51)

Roby Medical Centre 86% (56) (0) (0) 88%

(58) (0) 84% (73) (0) 89%

(64) 98% (51)

94% (52)

98% (50)

Hillside House Surgery (0) (4) (0) 100% (5)

100% (7) (0) (0) (4) 83%

(6) (0) (0)

Primrose Medical Practice (0) (0) (4) (0) 75%

(12) (2) (2) 100% (6) (1) (1) (2)

Nutgrove Villa Surgery 90% (21)

100% (26)

100% (8)

92% (13)

100% (8)

91% (11) (3) 100%

(9) 100%

(7) 100%

(8) 100%

(5)

Options: EATPMC (Halewood) (0) (1) 91%

(22) Data issue (0) (0) (0) (1) (1) (0) (0)

Page 7 of 8

Options: EATPMC (Huyton) (0) (1) (0) Data

issue (3) 100% (11)

71% (7) (0) (2) (0) (0)

Options: EATPMC (Whiston) (0) (0) (0) Data

issue (3) 96% (24) (0) (0) (0) (0) (0)

Options: EATPMC (St Chads Health Centre)

100% (7)

100% (5) (0) Data

Issue 100%

(6) 100%

(6) (2) 100% (6) (4) (0) (0)

National Average 88% 88% 88% 89% 88% 89% 89% 89% 88% 89% 88%

Page 8 of 8

Document PC(07)09

Report to Knowsley Clinical Commissioning Group

Primary Care Committee Date of meeting: 7th July 2016

Report title: Administration of Subcutaneous Fluids within Community Settings

Report presented by: Mark Pilling – Interim Head of Medicines Management

Purpose of the report: Present the committee with the amendment to the draft procedure for administration of subcutaneous fluids within community settings for adult patients at end of life.

Recommendations:

Action / Decision required

The Primary Care Committee is recommended to agree the change to the procedure such that the decision to prescribe subcutaneous fluids within the community setting is the decision of the patient’s GP.

Delegated Powers:

For decision reports only

N/A

Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply

1. Patient centred x

2. Safe x

3. High quality x

4. Cost effective x

5. Outcome focused x

6. Closer to home x

7. Affordable x

[one page only]

Page 1 of 22

PRIMARY CARE COMMITTE

ADMINISTRATION OF SUBCUTANEOUS FLUIDS IN COMMUNITY SETTINGS FOR PATIENTS AT END OF LIFE

Executive Summary This report proposes a recommendation to accept a change to the current policy and procedure for the administration of subcutaneous fluids within the community setting. The policy change recognises the clinical responsibility of GPs when asked to prescribe subcutaneous fluids. The revised process and policy, agreed with 5BP will ensure that GPs cannot be directed to prescribe Subcutaneous fluids and that the decision to prescribe on a per patient basis resides with the patient’s GP.

Page 2 of 22

1. Purpose of the report 1.1 The purpose of the briefing is to provide an update on the current position in relation to the

administration of fluids for patients at end of life in community settings and to seek approval for and support to community nursing to undertake this procedure.

2. Recommendation This report proposes a recommendation to accept a change to the current policy and procedure for the administration of subcutaneous fluids within the community setting. The policy change recognises the clinical responsibility of GPs when asked to prescribe subcutaneous fluids. The revised process and policy, agreed with 5BP will ensure that GPs cannot be directed to prescribe Subcutaneous fluids and that the decision to prescribe on a per patient basis resides with the patient’s GP. 3. Background 3.1 Patients at end of life should have access to high quality evidence based care within a

setting of their choice and in accordance with their needs, wishes and preferences 1 in line with evidence based practice and clinical guidelines (NICE 2015). 2

4. Evidence and Consultation 4.1 NICE (CG 31) section 1.4 recommends everyone at end of life will need to have their

hydration status reviewed depending on their individual needs and wishes. Some patients will be able to maintain hydration without difficulty, others will have decided in advance, (Advanced Decision to Refuse treatment), they do not want to be assisted with hydration at the end of their life3 and some people at end of life and those closest to them may want to be supported through clinically assisted hydration.

4.2 Currently there is no agreed procedure to support prescribing and administration of

subcutaneous fluids within 5 Boroughs Partnership Foundation Trust Community Health Services.

4.3 Regional guidelines and audit 4 recommend that administration of fluids at the end of life is

individualised and should be a Multi-Disciplinary Team decision. 4.4 Fluids for administration at the end of life can be given subcutaneously although this route

is unlicensed. Non medical prescribers (NMP) do not prescribe off licence medicines within 5 Boroughs NHS Partnership Foundation Trust. An FP10 will be required to obtain fluids for administration by community nurses to patients at end of life in community settings.

4.5 The proposed procedure has been developed by 5 Boroughs Foundation Trust Intravenous

Therapy Lead, Governance Pharmacist / Non Medical Prescribing Lead and Operational Manager Specialist Nursing Services. 5. Proposals

5.1 The CCG will wish to consider the benefits and risks to patients and any implications for

prescribers and practices. 1 The Gold Standard Framework – Advanced Care Planning (2016) National Gold Standards Framework 2 The National Institute for Health and Care Excellence (NICE) – care of dying adults in the last days of life 3 Mental Capacity Act 2005 Advanced decisions to refuse treatment (Gov.uk) 4 Cheshire and Merseyside Palliative & End of Life Care Network Audit Group Audit and Clinical Guidelines – hydration at the end of life ( 2015)

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5.2 At a meeting on 6th June 2016, between Knowsley CCG, 5BP, LMC and End of Life Team, and including Dr Paul Barry as End of Life Lead GP, it was agreed:

5.2.1 That GP’s on a per patient basis, following a request for subcutaneous fluids, will make the decision on appropriateness to prescribe such fluids;

5.2.2 5BP to amend the current Subcutaneous Fluids Policy to clearly reflect that GPs cannot be directed to prescribe Subcutaneous fluids and that the decision to prescribe resides with the patient’s GP.

5.2.3 In addition it was confirmed that patients discharged from hospital and hospices will

be provided with any necessary Subcutaneous fluids at the time of discharge to the patient’s home.

6. Impact on Services to the Population 6.1 Prescribing and administration of fluids at end of life will be part of shared decision making

between the patient, their family / carers, the prescriber and community nursing staff. 6.2 Community nursing services in Knowsley will be unable to provide clinically assisted

hydration to patients at end of life in accordance with National, Regional and local guidelines without a clinical procedure and MDT shared care approach

6.3 People at end of life may request artificial hydration in community settings and to support

care in a place of their choosing. The MDT will need to have a procedure in place that defines responsibilities and supports this treatment whenever it is agreed in the best interest of the patient and those important to them. This supports the delivery of high quality end of life care and symptom control and management

6.4 Consideration will need to be given to prescribing of subcutaneous products for an

unlicensed indication. There will be a resource implication for GP prescribing budgets but this may be offset against hospital admission avoidance costs

7. Resource Implications 7.1 Financial

7.1.1 None apart from additional GP time in assessing patients and prescribing subcutaneous fluids. The costs of saline fluids for the anticipated volume and duration of end of life care is relatively small.

7.2 Human Resources

7.2.1 Additional GP time in assessing patients and prescribing subcutaneous fluids

7.3 Technology

7.3.1 None

7.4 Physical Assets

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7.4.1 None

8. Risk Assessment 8.1 The risks to the CCG associated with not taking the recommended course of action would

be to be seen as not following NICE recommendations. In addition, patients nutrition and hydration needs may not occur in a timely manner or in a place of their choosing at end of life. This will enhance the patient experience, comfort and quality of care at end of life.

8.2 In the absence of prescribing being undertaken by 5BP, not adopting the recommended

policy change may put patients at risk of a delay in receiving administration of subcutaneous fluids.

9. Summary

9.1 High quality standards for adults at end of life have been defined in recent published NICE

guidelines (2015). Delivered collectively the MDT can ensure care is coordinated, high quality, safe and effective. This enhances the experience of those at life and their families and carers.5 Currently there is no Procedure for delivery of artificial hydration within Knowsley Community Nursing Services. This workforce is capable of delivering subcutaneous fluids if and when prescribed. The procedure has been developed to clarify roles and responsibilities and to support shared care decision making with regard to this procedure.

9.2 The revised process and policy agreed with 5BP will ensure that GPs cannot be directed

to prescribe Subcutaneous fluids and that the decision to prescribe on a per patient basis resides with the patient’s GP.

Clinical Lead – Dr Aftab Hossain, Clinical Lead

Managerial Lead – Mark Pilling, Interim Head of Medicines Management

Signatory details: Mark Pilling, Interim Head of Medicines Management, 0151 676 5604

Background Documents:

The Gold Standard Framework – Advanced Care Planning (2016) National Gold Standards Framework The National Institute for Health and Care Excellence (NICE) – care of dying adults in the last days of life Mental Capacity Act 2005 Advanced decisions to refuse treatment (Gov.uk) Cheshire and Merseyside Palliative & End of Life Care Network Audit Group Audit and Clinical Guidelines – hydration at the end of life (2015) Actions for End of Life Care 2014-2016 NHS England

Appendices:

Appendix 1 - Administration of Subcutaneous Fluid (Hypodermoclysis) In Adult End of Life Care Procedure

5 Actions for End of Life Care 2014-2016 NHS England

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Appendix 1

Administration of Subcutaneous Fluid (Hypodermoclysis) in Adult End of Life Care Procedure This procedure applies Trust Wide

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Document control page

Procedure number Name of Procedure Administration of Subcutaneous Fluid

(Hypodermoclysis) in Adult End of Life Care

Name of linked Policy

End of Life Policy Medicines Management Policy

Accountable Director

Medical Director

Author with contact details

Beverley Tunstall Intravenous Therapy Clinical Lead Beverley.tunstall@5bp.nhs.uk and Governance Pharmacist Medicines Management

Status (draft/ ratified)

DRAFT

Ratifying Committee/ date

Review date Brief description of changes following review

Equality Impact Assessment

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. This Procedure has been Equality Impact Assessed and does not discriminate.

Version control

Version number

Development Timeline Date

DRAFT 0.1 First draft March 2016 DRAFT 0.2 Comment from Operational Manager 18th March

2016 DRAFT 0.3 Joint review of Procedure author and

Governance Pharmacist, Medicines Management 22nd March 2016

DRAFT 0.4 Minor amendments by author. 22nd March 2016

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Contents Page

Page 1 Introduction 4 2 Procedure details 4 3 Monitoring compliance with this procedure 10 4 References 11 5 Associated documents 12 Appendices Appendix 1 Administration 13 Appendix 2 Monitoring and Managing Complications 14 Appendix 3 Visual Infusion Phlebitis Score 15 Appendix 4 Infusion Administration Record 16 Appendix 5 Patient Information leaflet 17

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1. Introduction

Hydration requirements slowly decline during the advance of terminal illness. When patients are unable to tolerate sufficient oral intake, decision-making about instigating clinically assisted hydration may become relevant (NICE NG31 – December 2015). Decisions regarding hydration should be individualised to each patient. Adults who are potentially entering the last days of their lives should discuss with the wider Multi-Disciplinary Team (MDT) their wishes and what is important to them as part of shared decision making, this may include a discussion around anticipatory decisions around the use of clinically assisted (artificial) hydration. Hypodermoclysis is a technique used for the subcutaneous administration of large volumes of fluids and electrolytes in order to provide clinically assisted hydration when adequate oral fluid intake cannot be maintained or achieved. A review of the literature continues to give conflicting views as to the role and effectiveness of hypodermoclysis. The decision to offer, commence or continue this treatment must be made on an individual patient basis in accordance with the MDT assessment of hydration status. This procedure aims to provide a framework for Trust practitioners to administer subcutaneous fluids safely for the purpose of correcting mild hydration in adult patients receiving end of life care where it is deemed beneficial and with agreement with the MDT, the patient and their family/carers.

2.0 Procedure Details

2.1 Identifying the need for subcutaneous fluids

A dying person’s hydration status must be assessed by the MDT regularly, preferably daily and reviewed for the possibility of starting artificial hydration (NICE Guidelines 31). This assessment must take into consideration:-

• Dehydration contributing to poor renal clearance of opioids which are causing symptoms of toxicity.

• Dehydration due to reversible causes (e.g. infection). • Inability to swallow e.g. advanced head and neck tumour. • Where confusion and restlessness is aggravated by dehydration. • To prevent dehydration in those who have excessive fluid loss from

vomiting and / or diarrhoea. • Transfer of care - If a patient has already commenced on a

subcutaneous infusion in the hospital or hospice and wish for their

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preferred place of care to be the home. • If a patient fulfils all the relevant clinical requirements and has

carers in place for 24 hours each day.

2.2 Signs and Symptoms of Dehydration

• Poor oral intake over the previous 48 hours of less than 1 litre per day

• Dry mucous membranes • Dry chapped lips • Dry, loose skin with lack of elasticity • Sunken features especially eyes • Clammy hands and feet • Headaches • Light headedness • Dizziness • Tiredness • Low urine output • Concentrated dark urine with a strong odour • Tachycardia

2.3 Cautions and Contraindications

• Major bleeding or coagulation disorders. • If the patient is imminently dying hydration will not improve survival

or symptoms, and may increase the risk of distressing respiratory secretions (Campbell, 2007).

• Patient refusal. • Skin integrity and diminished opportunity to site the cannula in a

safe and comfortable place. • Severe dehydration e.g. those requiring more than 3 litres over a

24 hour period. • Where precise control of volume and rate of infusion is essential

and fluid balance is clinically important. • For patients with severe and unstable cardiac failure or who are

fluid restricted. • For patients with severe renal failure or on haemodialysis. • As a treatment for hypercalcaemia. • Patients with fluid overload or marked oedema. • Severely agitated patients that may cause themselves harm in any

attempt to remove the cannula / dislodge it.

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2.4 Consent, patient and carer information and managing expectations

The patient must be assessed for the potential benefits and risks of clinically assisted hydration and this should be discussed with the patient and family and carers were appropriate (NICE Guidance NG31, December 2015). An individualised approach must be taken, taking into account :-

• The patient’s condition and prognosis • If the patient has expressed a preference for or against clinically

assisted hydration. • If the patient has any cultural, spiritual or religious beliefs that might

affect their preference. • If there is a documented advance statement or advance decision to

refuse treatment

If the patient assessment deems they are likely to benefit from subcutaneous fluids, the process must be explained and discussed with the patient in order to ensure he/she understands and is able to give informed consent. Refer to Trust Consent to Examination and Treatment Policy. This discussion must include:-

• Why subcutaneous fluids are proposed. • Present and future swallowing difficulties • How the underlying disease process will continue and deterioration

in the patient’s condition will be due to this, rather than reduced fluid intake

• How the decision will be made to stop the administration of subcutaneous fluids and who will be involved with that decision.

• Risk of possible peripheral oedema and ascites • Risk of possible increase in airway secretions and/or pulmonary

oedema, • Risk of possible need for a urinary catheter. • The possibility of having a therapeutic trial of subcutaneous fluids to

explore if symptom control (as reported by the patient) can be improved.

• The ‘artificial sense of hope’ that treatment with subcutaneous fluids may bring.

Any concerns raised by the dying person (or those important to them) must be addressed before starting clinically assisted hydration (NICE, 2015).

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2.5 Initiation and administration of the infusion

Patients deemed likely to benefit from subcutaneous fluid infusion must be referred to (if not already) the Community Nursing Team attached to the patient’s registered GP practice. The Community Nursing Team will be involved in the Multi-Disciplinary Team (MDT) on - going reviews of care for end of life patients receiving subcutaneous fluids. At each review the appropriateness of the infusion must be actively considered and the reasons for the decision to be documented. A clinical assessment is advised every 24hours (NICE CG 31, 2015).

2.6 Training and competency assessment

Hypodermoclysis can be undertaken by a registered nurse who must possess confidence and competency in the technique of subcutaneous injections. This includes:

• Assessing the ideal location • Siting a subcutaneous needle • Setting up ( bolus and a gravity infusion drip) • To care for an infusion set and site • Monitoring of the patient • Removing a needle and infusion set. • Documentation and record keeping

These skills are assessed as part of pre-registration nurse training. However, It is recommended that the competency is reviewed at the practitioners annual PDR as part of the competency checklist appraisal, and peer assessed by the District Nurse Team Leader every two years as a minimum. Records of training and competency assessment will be held within the registered nurse’s portfolio on the Trust Oracle Learning Management (OLM) system.

2.7 Prescribing

The prescribing of subcutaneous fluids is an unlicensed indication. Prescribers must be aware of this prior to prescribing and be willing to discuss this with the patient and family/carer. The prescriber will take the clinical responsibility for the review of the patient and ordering any required blood tests. The prescriber will issue a FP10 prescription for the required infusions/injections stating the volume of fluid to be delivered over a specified time period.

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They must also complete the Patient’s Infusion Record (Appendix 2) The fluid of choice is Sodium Chloride 0.9% Injection, given as an infusion or in boluses up to a maximum of 1.5 litres per site ( Pan Birmingham NHS Cancer Network, Wirral Community NHS Trust ) continuously per 24 hour period . The recommended rate to be used in the dying phase is at least one litre over 24 hours. (Cheshire and Mersey Strategic Clinical Network – Hydration Review, November 2015). Maximum Infusion Regimen Maximum Continuous Infusion Rate: Up to 100ml/hour Maximum Infusion Volume: a maximum of 1.5 litres at any one site over 24 hours. Maximum bolus dose: 500ml over one hour

Under no circumstances should any other fluids or medications be administered via this route.

Hyaluronidase

Hyaluronidase is an enzyme, which assists and speeds up the absorption of subcutaneous fluids. Hyaluronidase may be of benefit to patients in whom sites become quickly oedematous.

Hyaluronidase will need to be prescribed.

The use of Hyaluronidase can cause local irritation or systemic allergic reactions.

To use Hyaluronidase, dissolve 1500 units in 1ml of Water for Injection or Sodium Chloride 0.9% and inject subcutaneously directly into the site to be used, then commence the infusion.

2.8 Administration

The subcutaneous preferred infusion sites are:- • Lateral aspects of the upper arms and thighs • Abdomen • Anterior chest below the clavicle, • Occasionally the back. (if confused) • These areas usually have adequate amounts of subcutaneous

tissue and will not interfere with movement. • Sites must be rotated to minimise tissue damage

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Infusion sites to avoid are :-

• Lymphoedematous tissue • Skin recently irradiated • Area with a rash of any type • Sites over bony prominences • Sites near joints • Sites over tumours • Areas of broken, infected or inflamed skin

The subcutaneous needle and line must be sited with an aseptic technique. The infusion site must be covered with a semi-permeable dressing so the exit site is visible (Loveday et al, 2014). Subcutaneous fluids must be gravity fed and regulated using a drip stand, a standard giving set connected to a butterfly needle (or a vialon catheter ( eg. BD Saf –T – Intima) and calculating the drip rate. Fluids must NOT be infused using a pump. The drip rate of the infusion must reflect the instruction on the Subcutaneous Fluid Infusion Record. The infusion giving set packaging will state the number of drops per ml it will deliver. A standard administration set delivers 20 drops per ml. The following formula may be used to calculate the required number of drops per minute.

Number of drops per minute = Volume of fluid (ml) x Number of drops per ml

Duration of Infusion (minutes)

Other fluids or medications must not be administered via this route. For a step by step approach to the administration of subcutaneous fluids clinical procedure see Appendix 1.

2.9 On-going Management and Observations

For patients being started on clinically assisted hydration: • Monitor at least every 12 hours for changes in the symptoms or signs

of dehydration, and for any evidence of benefit or harm. • Continue with clinically assisted hydration if there are signs of clinical

benefit. • Reduce or stop clinically assisted hydration if there are signs of

possible harm to the dying person, such as fluid overload, or if they no longer want it.

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For people already dependent on clinically assisted hydration before the last days of life:- • Review the risks and benefits of continuing clinically assisted hydration

with the person and those important to them. • Consider whether to continue, reduce or stop clinically assisted

hydration as the person nears death.

The infusion to be checked at every visit (minimum every 12 hours - BD visits) for flow rate, site integrity and leakage. Site integrity: The subcutaneous access site must be observed at every visit for signs of

• Inflammation /Redness • Pain/tenderness at the administration site • Oedema /poor absorption (hard subcutaneous swelling) • Blood present in the needle

If any of the above are observed the infusion site must be renewed without delay. All assessment observations to be documented in the Patient’s Infusion Record.

All observations including a Visual Infusion Phlebitis (VIP) see (appendix 3) score must be recorded and signed for as detailed in the Subcutaneous Fluid Infusion (see Appendix 4 ) Record at each visit to reduce the risk of complications.

The subcutaneous needle/ cannula must be rotated a minimum of every three days (72 hours). After 72 hours all equipment and fluids must be changed and this must be documented.

Managing complications – see Appendix 2

2.10 Advice to Patient / Family/ Carer

When administering a subcutaneous infusion in the home it is important to:

• Ensure that the carers are aware they are not responsible for the on-going monitoring and adjustment of the infusion.

• Give advice to the carer about what to do if the infusion finishes early.

• Give advice to the carer about what to do if the infusion becomes dislodged or signs of swelling.

• Follow up the information with a patient information leaflet documenting all the above advice with contact numbers.

• See appendix 5 for Patient Information Leaflet to be utilised.

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3. Monitoring of compliance with this procedure

Minimum requirements to be monitored

Process for monitoring e.g. audit

Responsible individual, group or committee

Frequency of monitoring

Responsible individual, group or committee for review of results

Responsible individual, group or committee for development of action plan

Responsible individual, group or committee for monitoring of action plan

Staff skill competency

PDR competency checklist

Individual, Team leader

Annual Team leader/ operational manager

Team leader/ operational manager

Team Operational Manager

Record keeping audit

Incidents related to Hypodermoclysis

DATIX Quality and Safety

Monthly Quality and Safety

Quality and Safety

Quality and Safety

4. References Campbell, C.( 2007) Artificial Nutrition and Hydration. National Council for Palliative Medicine. London . IN Remington, R. Hultman ,T .(2007) Hypodermoclysis to treat dehydration: A review of the evidence. Journal of American Geriatric Society 55 (12): 2051-2055. Cheshire and Mersey Strategic Clinical Network – Hydration at the end of life review. A systematic literature review and audit of current practice . November 2015 retrieved 17th March 2016 www. Cmscnsenate.nhs.uk Dougherty, L. Lister, S. (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Eighth Edition. Blackwell Publishing. London. GMC (2010) ( retrieved 2016) Guidance Towards End of Life: Good Practice in Decision Making, GMC. Loveday, H. P., Wilson, J.A., Pratt, R.J. et al. (2014) Epic 3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection 86 (Suppl. 1): S1–70. Merseyside and Cheshire Palliative Care Network Audit Group ( MCPCAG) (2010), Standards and Guidelines .4th Edition ( retrieved February 2016).

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National Institute for Health and Care Excellence (NICE) (2015) Care of the Dying Adult. Clinical Guidelines Draft: Methods , Evidence and Recommendations. National Clinical Guideline Centre. NICE Care of the Dying Adults in the last days of life. NICE Guidelines [NG31] Section 1.4 NHS Scotland ( 2015) ( retrieved, March 2016) . Sub Cutaneous Fluids in Palliative Care- Palliative Care Guidelines, www.palliativecare guidelines.scot.nhs.uk Nursing and Midwifery Council (NMC),( 2008) Standards for Medicines Management. NMC. London. Nursing and Midwifery Council (NMC), (2015) . The Code. Standards for conduct, performance and ethics for nurses and midwives. NMC London Nursing and Midwifery Council (NMC), (2009). Record Keeping. Guidance for Nurses and Midwives. NMC London. Pan Birmingham NHS Cancer Network (2015) Guideline for the use of subcutaneous hydration in palliative care ( hypodermoclysis). ( retrieved, February 2016). Smith, J. C., Roberts, A., Moorhead, L., Smith. K., Tate, T. (2010) Guidelines for the use of Hydration in Dying Patients Standards and Guidelines Review : Fourth Edition. Merseyside and Cheshire Palliative Care Network Audit Group . retrieved March 2016 - www.rlbuht.nhs.uk/.../hydration%20advanced%20cancer%20guidance%20word ) St Helens and Knowsley Teaching Hospital (2012) Procedure for the Administration of subcutaneous fluids ( Hypodermoclysis) in Adults. (retrieved February, 2016) . Wirral Community NHS Trust (2012) Procedure for the administration of subcutaneous fluids by community and primary care assessment unit nurses.

5.Associated documents

The Trust’s End of Life Policy The Trust’s End of Life Procedure The Trust’s Medicines Management Policy and Procedures. The Trust’s Infection, Prevention and Control policy

The Trust’s Consent policy NMC (2015) The Code NMC (2008) Guidelines for Records and Record Keeping NMC (2009) Standards for Medicines Management.

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6. Appendices Appendix 1 Administration of Subcutaneous Fluids

Action Rationale Explain the procedure to the patient and/or carer, allowing time for any questions. Ensure they understand that the use of IV Fluids for Subcutaneous use is unlicensed but accepted practice. Discuss expectations.

To ensure patient/family are fully informed and to gain valid consent where appropriate.

Assess the patient for a suitable site To provide a comfortable and safe area for fluid absorption.

Before administering any prescribed fluid check that it is due and has not already been administered.

To protect the patient from harm.

Check the fluid against the prescription chart and ascertain and record the following:-

• The prescription is valid • Fluid name, strength and volume • Batch Number and Expiry Date • Infusion Route and Rate

To ensure the correct type and quantity of fluid are administered by the correct route to protect the patient from harm.

Check integrity of the fluid container and expiry date. Check the fluid for discolouration / crystallization or particulate matter.

To prevent an ineffective or toxic compound being administered to the patient. To check no contamination has occurred.

Prepare the site for the subcutaneous infusion using an aseptic technique

To reduce risk of site contamination.

Introduce the butterfly needle/ peripheral cannula at the angle recommended by the manufacturer. Technique – gently pinch a well-defined amount of tissue between the index finger and thumb and insert the needle into the base of the pinch.

To ensure the needle lies in the subcutaneous space.

If blood appears in the line of insertion of the needle, withdraw immediately and repeat the process in a different site.

To prevent infusion into a blood vessel.

Coil the tubing and secure with a semi-permeable film dressing and ensure exit site is visible. N.B. If the patient is also receiving subcutaneous medication via a syringe driver, it is advisable to mark the lines to differentiate between the two infusions.

To prevent kinking. To secure the line and prevent contamination.

Set the infusion at the prescribed rate. To ensure the fluid is infused correctly. Dispose of sharps safely in accordance with Trust Disposal of Pharmaceutical Waste Procedure.

To prevent needle stick injuries.

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Appendix 2 Monitoring and Managing Complications Monitoring at each visit Action Check the infusion site for signs of redness, swelling, tenderness or leakage around the entry site, VIP score and whether it is appropriate to continue the infusion. Record that you have checked.

If the site is red and inflamed (sign of infection) Re-site immediately and treat the inflammation/infection as appropriate to the patient’s condition. Recording any visual markings within the patient’s documentation. Check for nickel allergy.

If leaking back from the site after removing cannula /needle, monitor - Usually due to the area settling down after rehydration;

If pain at the site, adjust needle slightly to exclude intramuscular or nerve ending placement Re-site if necessary

If local oedema at site, adjust rate. Oedema will absorb naturally Re-site if uncomfortable for the patient. Massage area as oedema will re-absorb.

If bruising at site, monitor site usually settle after needle removed Re-site if possible

Check the volume remaining is (approximately) correct for the prescribed volume and administration rate. Record that you have checked.

If infusion running too slowly:- • Check gravity feed is working • Raise height of bag • Check line regulator • Check lines for occlusion

Check for signs of blood in giving set, cannula or butterfly needle.

If present, stop infusion and remove cannula/needle and document.

Check that fluid is being adequately absorbed.

Consider if Hyaluronidase is appropriate.

Check no bolus injections have been administered accidentally

This rarely occurs and does not require further management, however a delay in the commencement of the next bag of sodium chloride 0.9% will be required to ensure the maximum volume of fluid in 24 hours is not exceeded.

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Appendix 3 Visual Infusion Phlebitis Score

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Appendix 4 – Subcutaneous Fluid Infusion Record

Patient’s Name: …………………………….. NHS No: ……………………………………… GP: ……………………………….

Date Infusion Fluid

Total Volume (ml)

Infusion Rate

Prescribers Name

Prescribers Signature

Batch Number

Expiry Date

Start Time

Site Site Checked VIP score

Infusion Checked

Dressing checked

Time Ended

Comments Initials

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Appendix 5

Patient information leaflet – in progress

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Document PC(07)10

Report to Knowsley Clinical Commissioning Group

Primary Care Committee Date of meeting: 7th July 2016

Report title: Proposed Practice Changes

Report presented by: Clare Barrow, Head of Finance & Contracting

Purpose of the report: The purpose of the report is to seek a decision from the Primary Care Committee in respect of a proposal presented to the CCG by the lead GPs for St John’s Surgery and Aston Healthcare Ltd.

Recommendations:

Action / Decision required

The Primary Care Committee is recommended to:

• Consider the proposal outlined in this report and decide whether to:

a) Approve the proposal and proceed with the appropriate contract changes and patient assignment or

b) Reject the proposal and revert back to the lead GP’s for a decision as to whether they wish to:

1) continue providing services under existing contract arrangements or

2) proceed with their decision to terminate the contracts for St Johns and Page Moss independently of each other

• The decision should be made taking in to consideration the patient feedback outlined in this report and the impact the proposed changes will have on patients, the practices and the CCG.

Delegated Powers:

For decision reports only

N/A

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Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply

1. Patient centred X

2. Safe X

3. High quality X

4. Cost effective X

5. Outcome focused X

6. Closer to home X

7. Affordable X

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PRIMARY CARE COMMITTEE

PROPOSED PRACTICE CHANGES

Executive Summary The purpose of the report is to seek a decision from the Primary Care Committee in respect of a proposal presented to the CCG by the lead GPs for St John’s Surgery and Aston Healthcare Ltd. The proposal would result in a change to service provider at Manor Farm Primary Care Resource Centre and North Huyton Primary Care Resource Centre, although patients would continue to have the ability to access and receive the existing level of primary medical services they do now.

The proposal would result in patients currently registered with St John’s surgery, based at Manor Farm Primary Care Resource Centre (PCRC) being assigned to Aston Healthcare (Manor Farm branch) also located in Manor Farm PCRC; and the patients currently registered with Aston Healthcare (Page Moss branch) based at North Huyton PCRC being assigned to Cornerways Medical Centre also located at North Huyton PCRC in the following manner:

St Johns Surgery, Manor Farm Primary Care Resource Centre (N83612)

St Johns Surgery propose in principal (subject to CCG approval and patient involvement) to close and cease operating as a provider of primary medical services.

Page Moss Surgery (Aston Healthcare branch surgery), North Huyton Primary Care Resource Centre (N83028) Aston Healthcare propose in principal (subject to CCG approval and patient involvement) to close and cease operating as a branch from this site.

Following the closure of both St Johns Surgery and the Page Moss branch of Aston Healthcare the practices propose the patients are subsequently assigned as follows: St Johns Surgery

The patients currently registered with St John’s Surgery (Manor Farm) to be assigned to Aston Healthcare (Manor Farm branch). This would result in approximately 3,000 patients being assigned to Aston Healthcare (Manor Farm branch) taking the registered list size for this practice to approximately 9,500.

Page Moss Surgery (Aston Healthcare branch surgery) The patients currently registered with Page Moss Surgery (North Huyton Primary Care Resource Centre) to be assigned to Cornerways Medical Centre (North Huyton Primary Care Resource Centre). This would result in approximately 2,600 patients being assigned to Aston Healthcare (Manor Farm branch) taking the registered list size for this practice to approximately 9,000.

Following receipt of the proposal, the CCG asked the practices to prepare a case for change detailing the reasons for the proposed changes and the potential benefits this would bring to the

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registered patients and the practice. The CCG also asked the practices to undertake comprehensive patient engagement in line with national guidance. Within the Case for Change the following benefits have been identified by the Practice:-

Benefits to Patients:

a) Patients will experience improved care and outcomes; evidence suggests that practices with larger list sizes deliver increased performance due to a more focused workforce;

b) Patients will continue to receive access to primary care services from the same location but a larger workforce and a workforce with a wider skill mix; resulting in improved continuity of care;

c) Patients will have more flexibility and choice with regards to the clinicians they will have access to: d) Patients will continue to have access to a wide range of clinical services from purpose

built primary care resource centres.

Benefits to Practice(s):

a) The increase in capacity (knowledge and skills) will enable a significant improvement in operational efficiency (i.e. day to day business; management) and improve the quality of care and outcomes for the patient population;

b) There will be a more wide ranging multidisciplinary team (e.g. clinicians with different

skills and special interests) which will only develop the practice in terms of capacity and capability and thus improve performance and outcomes”.

The patient feedback demonstrates that whilst patients are understandably averse to change, the majority would be willing to either follow the existing practice or be assigned as proposed. There will be a one-off cost of approximately £10,000 for IT costs associated with the transfer of patient records and associated clinical system changes which will need to be met from within the GP IT budget. In addition to the benefits outlined in the case for change, the above proposal would also result in freed up space at Manor Farm Primary Care Resource Centre since the space currently occupied by St John’s Surgery would no longer be required. It is worthy of note that a neighbouring practice has recently approached the CCG with a request to move in to Manor Farm PCRC as the building it currently operates from is no longer deemed suitable to operate from. This is separate to and independent of the proposal put forward by the two practices and would be subject to the relevant patient involvement and CCG decision making process. The space freed up by St John’s surgery whilst producing a void cost of £10,500 per annum, could potentially be used to house a neighbouring GP Practice. The CCG would then have the opportunity to move a practice from an old building in to a purpose built Primary Care resource centre at no extra cost and freeing up the rent and rates currently paid to the practice of approximately £14,500 per annum. The Committee is asked to consider the proposal outlined in this report and decide whether to:

b) Approve the proposal and proceed with the appropriate contract changes and patient

assignment

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or

b) Reject the proposal and revert back to the lead GP’s for a decision as to whether they wish to:

1) continue providing services under existing contract arrangements or

2) proceed with their decision to terminate the contracts for St Johns and Page Moss independently of each other.

The decision should be made taking in to consideration the patient feedback outlined in this report and the impact the proposed changes will have on patients, the practices and the CCG.

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1. Purpose of the report 1.1 The purpose of the report is to seek a decision from the Primary Care Committee in respect

of a proposal presented to the CCG by the lead GPs for St John’s Surgery and Aston Healthcare Ltd. The proposal would result in a change to service provider at Manor Farm Primary Care Resource Centre and North Huyton Primary Care Resource Centre, although patients would continue to have the ability to access and receive the existing level of primary medical services they do now.

2. Recommendations

2.1 The Committee is asked to consider the proposal outlined in this report and decide whether

to:

c) Approve the proposal and proceed with the appropriate contract changes and patient assignment

or

b) Reject the proposal and revert back to the lead GP’s for a decision as to whether they wish to:

1) continue providing services under existing contract arrangements or

2) proceed with their decision to terminate the contracts for St Johns and Page Moss independently of each other

2.2 The decision should be made taking in to consideration the patient feedback outlined in this

report and the impact the proposed changes will have on patients, the practices and the CCG.

3. Background 3.1 Aston Healthcare Ltd and St Johns Surgery approached the CCG with a proposal which they

anticipate will improve the efficiency, effectiveness and quality of service they provide to the registered patients of Knowsley CCG.

3.2 St John’s Surgery provide primary medical services under a PMS (Personal Medical

Services) agreement from Manor Farm Primary Care Resource Centre, Manor Farm Road, Huyton, Liverpool, Merseyside, L36 0UB and has a list size of approximately 3,000 patients.

3.3 The contract is held by St Johns Surgery Limited which is a private limited company in which

Dr F Maassarani is the majority shareholder. Dr F Maassarani is also the lead GP for Cornerways Medical Centre (North Huyton), Dr Maassarani & Partners (Tower hill, Kirkby) and Rose heath Surgery (Halewood) under separate contracts serving a combined registered list of approximately 22,500 patients (14% of the CCGs total registered population).

3.4 Aston Healthcare provide primary medical services under a single PMS agreement across a

number of branch sites including Manor Farm Primary Care Resource Centre, Manor Farm Road, Huston, Liverpool, L36 0UB and North Huston Primary Care Resource Centre, Woolfell Heath Avenue, Huyton, Liverpool, L36 3TN, where the Page Moss branch surgery is based. Aston Healthcare has an overall list size of approximately 25,500 (16% of the CCGs total registered population) of which approximately 2,600 are registered with the Page Moss branch and 6,500 with the Manor Farm branch; the remaining patients are registered at other

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Aston branch sites located in Huston, Hale wood and Whist on. The contract is held by Aston Healthcare Limited which is a private limited company in which Dr A Hossain is the majority shareholder.

3.5 Corner ways Medical Centre provide primary medical services under a GMS agreement from

North Huston Primary Care Resource Centre, Woolfell Heath Avenue, Huyton, and Liverpool, L36 3TN and has a list size of 6,200. The contract is held by Cornerways Medical Centre Limited which is a private limited company in which Dr F Maassarani is the majority shareholder. (This practice has merged with Princess Drive Medical Centre in 2015; services provided to patients registered with Cornerways Medical Centre are consistent with local PMS agreements under a separate agreement determined by the CCG.)

4. The Proposal

4.1 The proposal would result in patients currently registered with St John’s surgery, based at

Manor Farm Primary Care Resource Centre (PCRC) being assigned to Aston Healthcare (Manor Farm branch) also located in Manor Farm PCRC; and the patients currently registered with Aston Healthcare (Page Moss branch) based at North Huyton PCRC being assigned to Cornerways Medical Centre also located at North Huyton PCRC in the following manner:

4.2 St Johns Surgery, Manor Farm Primary Care Resource Centre (N83612)

St Johns Surgery proposes in principal (subject to CCG approval and patient involvement) to close and cease operating as a provider of primary medical services.

4.3 Page Moss Surgery (Aston Healthcare branch surgery), North Huyton Primary Care Resource Centre (N83028) Aston Healthcare proposes in principal (subject to CCG approval and patient involvement) to close and cease operating as a branch from this site.

4.4 Following the closure of both St Johns Surgery and the Page Moss branch of Aston Healthcare the practices propose the patients are subsequently assigned as follows:

4.5 St Johns Surgery

The patients currently registered with St John’s Surgery (Manor Farm) to be assigned to Aston Healthcare (Manor Farm branch). This would result in approximately 3,000 patients being assigned to Aston Healthcare (Manor Farm branch) taking the registered list size for this practice to approximately 9,500.

4.6 Page Moss Surgery (Aston Healthcare branch surgery) The patients currently registered with Page Moss Surgery (North Huyton Primary Care Resource Centre) to be assigned to Cornerways Medical Centre (North Huyton Primary Care Resource Centre). This would result in approximately 2,600 patients being assigned to Aston Healthcare (Manor Farm branch) taking the registered list size for this practice to approximately 9,000.

4.7 Following receipt of the proposal, the CCG asked the practices to prepare a case for change detailing the reasons for the proposed changes and the potential benefits this would bring to the registered patients and the practice. The CCG also asked the practices to undertake comprehensive patient engagement in line with national guidance.

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5. Evidence and Consultation/Engagement 5.1 Under the delegated agreement with NHSE, the CCG is responsible for agreeing practice

mergers or closures in the area. In taking a decision of this nature the CCG has a duty to ensure the necessary consultation with patients and wider stakeholders is carried out as set in section 14Z2 of the NHS Act. The consultation should be appropriate and proportionate to the circumstances and include consulting with the local LMC. In addition the CCG has a duty to consult with the local government overview and scrutiny committee in relation to any planned changes or developments on the provision of healthcare.

5.2 In keeping with national guidance and to allow an informed decision to be made by the CCG,

the following key actions have been completed and are summarised in this report:

1) Case for Change 2) Equality Impact Assessment 3) Patient Engagement (including communication plan) 4) Consultation with local Overview & Scrutiny Committee

6. The Case for Change 6.1 The case for change was developed by the practices following a review of their respective

practice service model and infrastructure. A copy of the full case for change which details the benefits and evidence for the proposed changes can be found in Appendix 1.

A summary of the benefits outlined in the report are extracted below:

6.2 Benefits to Patients:

a) Patients will experience improved care and outcomes; evidence suggests that practices with larger list sizes deliver increased performance due to a more focused workforce;

b) Patients will continue to receive access to primary care services from the same location but a larger workforce and a workforce with a wider skill mix; resulting in improved continuity of care;

c) Patients will have more flexibility and choice with regards to the clinicians they will have Access to:

d) Patients will continue to have access to a wide range of clinical services from purpose built primary care resource centres.

6.3 Benefits to Practice(s):

a) The increase in capacity (knowledge and skills) will enable a significant improvement in operational efficiency (i.e. day to day business; management) and improve the quality of care and outcomes for the patient population;

b) There will be a more wide ranging multidisciplinary team (e.g. clinicians with different

skills and special interests) which will only develop the practice in terms of capacity and Capability and thus improve performance and outcomes”.

6.4 In essence the reason for the requested change stems from a need or the practices to

operate in a more effective manner at a scale which is sustainable and future proof. This in turn is intended to improve the accessibility and quality of patient care for the registered patients.

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6.5 The key benefits outlined in the case for change are aligned with the ‘General Practice

Forward View’ published by NHS England in April 2016 https://www.england.nhs.uk/ourwork/gpfv/ which signals the need for practices to work at scale in order to relieve the pressures of growing demand and workforce issues.

6.6 In addition to the benefits outlined in the case for change, the above proposal would also

result in freed up space at Manor Farm Primary Care Resource Centre since the space currently occupied by St John’s Surgery would no longer be required. It is worthy of note that a neighbouring practice has recently approached the CCG with a request to move in to Manor Farm PCRC as the building it currently operates from is no longer deemed suitable to operate from. This is separate to and independent of the proposal put forward by the two practices and would be subject to the relevant patient involvement and CCG decision making process.

7. Equality Impact Assessment

7.1 Prior to commencement of the engagement process, an equality impact assessment was

undertaken to consider the impact on any disadvantaged groups and how this could be mitigated should the proposal be accepted.

7.2 The equality impact assessment is attached in Appendix 2. The assessment concluded that

the only issue is one of “transfer” from one provider to a new provider at the same site. The assessment proposed the following actions be undertaken to mitigate barriers to exclusion:

• Engaging and communication with stakeholders and patients to enable them to

understand when the current arrangements will cease and the new arrangements commence

• Ensure those affected have choice and support to access other GP provision other than the GPs presenting the proposal.

• Ensure patients have access to relevant information to allow them to make an informed choice should they prefer to register elsewhere

• Ensure capacity within the service is in place to meet the demands of increased registration.

7.3 The recommendations outlined in the EIA form a key part of the communication and engagement plan required to evaluate and implement any changes in service provision.

8. Patient Engagement

8.1 A comprehensive engagement plan was developed to ensure the appropriate level of engagement was carried out with patients, the local overview and scrutiny committee (OSC), Health watch and other stakeholders.

8.2 Patients registered with each practice were issued with a letter outlining their practice

proposals and inviting them to attend drop in sessions. In addition, telephone surveys were also conducted to gather more views.

8.3 A copy of the stakeholder engagement report can be found in Appendix 3.

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8.4 In summary, over 5,600 patients collectively were informed of the planned change, 300 patients actively responded which is a 5.5% response rate. A further 450 patients were contacted to take part in a telephone survey and 150 people responded.

8.5 Feedback from St John’s Surgery patients:

A high proportion of patients stated that they are satisfied with their current provision and are averse to change due to established relationships with GP’s and practice staff. The detailed patient feedback can be found in the stakeholder engagement report with the following being a high level summary of patients’ views: • 48% of patients are happy to transfer from St Johns Surgery to Aston Healthcare (Manor

Farm branch) • 41% would prefer to remain with the practice by moving to Cornerways Medical Centre • 10% would choose to transfer to another practice • 34% of those patients surveyed access services by foot • 45% of those patients surveyed are car drivers • 19% of those patients surveyed are bus users (both sites have a direct bus 10b and a the

227 from Huyton Bus Station)

8.6 Feedback from Aston Healthcare patients:

A high proportion of patients stated that they are satisfied with their current provision and are averse to change due to established relationships with GP’s and practice staff. The detailed patient feedback can be found in the stakeholder engagement report with the following being a high level summary of patients’ views: • 39% of patients are happy to transfer from Aston Healthcare (Page Moss branch) and

register with Cornerways Medical Centre • 57% would prefer to remain with the practice by moving to Aston Healthcare (Manor Farm

branch) • 4% would choose to transfer to another practice • 36% of those patients surveyed access services by foot • 40% of those patients surveyed are car drivers • 16% of those patients surveyed are bus users (both sites have a direct bus 10b and a the

227 from Huyton Bus Station) 9. Consultation with Overview & Scrutiny Committee 9.1 A meeting of the overview and scrutiny committee took place on 27th June 2016 and was

attended by representatives from the CCG, the proposing practices and the engagement lead. The case for change along with the patient feedback was presented to the committee to allow them to consider if the proposal constituted a substantial change. Members of the committee reviewed the information presented to them and concluded that the change was not deemed a substantial variation therefore the amount of patient engagement carried out was sufficient to allow an informed decision to be made by the CCG.

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10. Impact on Services to the Population 10.1 The proposal put forward by the lead GPs would result in a change to the provider of

services at Manor Farm and North Huyton Primary Care Resources Centres. Patients who are assigned to the respective practice will continue to receive the services they have traditionally received from the same site but from a different provider.

10.2 Whilst the patient feedback demonstrates that in general patients are opposed to change the engagement process identified that patients are willing and able to follow their existing provider should this be their preference.

10.3 Evidence presented in the case for change suggests practices are able to operate more

effectively and efficiently at a larger scale which in turn improves the quality of care they are able to provide to patients. The change will enable clinicians to work as part of a bigger team allowing for greater peer support and an MDT approach when necessary.

10.4 Should the proposals be accepted, the patients would automatically be transferred to the

respective practices. This would result in the closure of both St John’s Surgery and Aston Healthcare (Page Moss branch) with the patients being assigned to the neighbouring practice at the same site. A provisional date of 1st August 2016 has been reserved by the IT service provider to allow the appropriate transfer of records to take place.

10.5 It is important to note that patients retain the right to choice of provider and can therefore

choose to register with another practice if they prefer. Patients will continue to be kept informed throughout the process.

11. Resource Implications 11.1 Financial

11.1.1 If the proposals are approved, the practices will be paid per registered patient based on their existing contract agreements and there would be no renegotiation of the contract price.

11.1.2 There will be a one-off cost of approximately £10,000 for IT costs associated with the

transfer of patient records and associated clinical system changes which will need to be met from within the GP IT budget.

11.1.3 There is an opportunity cost associated with the space at Manor Farm PCRC being

vacated by St John’s surgery which is outlined in more detail in the Physical Assets section below. Essentially, the CCG will become responsible for picking up the cost of the £10,500 service charge currently paid by the practice until such a time the space can be occupied by a new tenant. There would be an opportunity at this point to house the neighbouring practice which has expressed a desire to move in to Manor Farm at no extra cost to the CCG and the service charge for St John’s of £10,500 would be picked up by the new practice. In addition the CCG would save the cost of reimbursable rent and rates of £14,500 currently incurred for this practice on a recurrent basis

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11.2 Human Resources

11.2.1 There are no Human Resource implications for the CCG as a result of this proposal. 11.2.2 All staff employed by the practices have been informed of the proposals and any

impact this may have on them as employees of the practice. There are likely to be TUPE implications associated with the termination of the contracts which will be managed by the practices as independent providers. It is not envisaged that there will be any redundancies made by either provider as a result of this proposal.

11.3 Technology

11.3.1 The CCG has engaged with the local Health Informatics Service regarding the proposals. The key IT consideration is associated with the transfer of electronic patient records and associated clinical systems. The records transfer has been explored EMIS the GP IT system provider and a provisional date of 1st August 2016 has been secured to transfer patient records should the decision be approved. If the proposals are rejected the date can be cancelled. As stated above, the will be a one-off cost associated with the records transfer of approximately £10,000. There is no requirement for further investment in IT equipment as a result of this proposal.

11.4 Physical Assets

11.4.1 Both practices provide services from purpose built PCRC’s which are owned by Community Health Partnership. Each practice has their own individual lease with the landlord based on floor occupancy. Rent for the space occupied by the practices is reimbursable under the statement of financial entitlements. The service charge associated with maintenance costs is non-reimbursable and payable by the practices

11.4.2 A recent review of the clinical space at Manor Farm and North Huyton PCRC suggests

there is sufficient space to accommodate the increase in the registered list for each practice.

12. Manor Farm PCRC

12.1 If the proposal is approved, the space currently occupied by St John’s surgery would be vacated as Aston Healthcare (Manor Farm branch) have identified sufficient clinical rooms within their existing clinical area to accommodate the maximum increase in patient list size.

12.2 The space feed up by St John’s surgery would then become available for use by either

another GP practice or community service. 12.3 If the space remains vacant the CCG will become responsible for paying the reimbursable

rent and rates (as it currently does) plus the service charge currently paid by the practice, an increase of approximately £10,500 per annum until the space is occupied.

12.4 There would be an opportunity at this point to house the neighbouring practice at no extra

cost to the CCG and the rent and rates currently paid to this practice of £14,500 would be saved on a recurrent basis.

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13. North Huyton PCRC 13.1 If the proposal is approved, the space currently occupied by Aston Health Care (Page Moss

branch) at North Huyton PCRC would need to be retained by Cornerways to accommodate the increase in patient list size. To facilitate the additional space requirements, Aston Healthcare (Page Moss branch) would assign the lease at North Huyton PCRC to Cornerways Medical Centre, freeing up sufficient clinical and admin space to accommodate the increase in patient numbers.

13.2 In this scenario, the total number of patients accessing the building for primary medical

services would not increase. There would be no increase in the reimbursable rent payable by the practice, however, Cornerways Medical Centre would be required to take on the service charges associated with the existing Aston Healthcare (Page Moss branch) part of the building which has been discussed and accepted by both parties.

14. Risk Assessment 14.1 The key risks to the CCG which may arise should the proposal be approved by the

Committee relate to patient experience and access to primary care services. There is a risk that the change in provider of Primary Care services for patients remaining registered at their current GP practice site will result in a lack of continuity of care and patient experience. Conversely, there is a risk that patients transferring registration to remain with their current provider of Primary Care services at a different site will need to travel further to access primary care. In both cases the providers have set out mitigating actions to both minimise the impact on patient care and experience and ensure that continuity of care is enhanced for patients in the medium/longer term

14.2 Should this proposal be rejected, there is a risk that the providers are unable to progress with

plans for their consolidation of Primary Care provision within the borough which may, in turn impact on future provider sustainability. A further risk identified as potentially arising from rejection of this proposal is that the two providers may feel that the CCG is not supporting Primary Care provider development and therefore become disengaged with the broader strategy and plans of the CCG. For the former the impact for the CCG is not assessed as being significant as rejection of this proposal will not constrain either provider from seeking to consolidate services by alternative means. For the latter the likelihood of occurrence is assessed to be low given the support provided by the CCG to both providers in developing these proposals.

15. Summary

15.1 In summary, the committee is asked to consider the proposals presented by the practices and decide whether to approve or reject the proposed assignment of patients to Aston Healthcare (Manor Farm branch) from St Johns Surgery and Cornerways from Aston Healthcare (Page Moss branch) taking in to account the patient feedback and risks summarised in this report.

Managerial Lead – Clare Barrow Head of Finance & Contracts

Signatory details: Clare Barrow, Head of Finance &

Contracts, clare.barrow@knowsleyccg.nhs,uk 0151 244 3361

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Appendices:

Appendix 1 – Case for Change

Appendix 2 – Equality Impact Assessment

Appendix 3 – Stakeholder Engagement Report

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Appendix 1

St Johns Surgery and Aston Healthcare Joint Case for Change

1. Background

General Practice has seen a significant increase in the amount of work during recent years which has and will continue to place added pressure on the delivery of high quality patient care and patient related outcomes. Major changes to core practice business (i.e. QOF and local contracting), transition within the local healthcare system and the introduction of a regulatory body (i.e. CQC) have provided primary care with a greater challenge; therefore, it is imperative that individual practices assess their current infrastructure, systems and processes to ensure they are ‘fit for purpose’.

Following a comprehensive internal review of their current practice, and taking into consideration the aforementioned factors, two member practices within Knowsley CCG would like to propose the following two independent business changes that they firmly believe will enable operational efficiency and improve the quality of care and outcomes for their respective patient populations:

St Johns Surgery, Manor Farm Primary Care Resource Centre (N83612)

St Johns Surgery (“SJS”) propose in principal (and subject to CCG agreement and patient involvement) to close and cease operating as a provider.

Page Moss Surgery (Aston Healthcare), North Huyton Primary Care Resource Centre (N83028)

Aston Healthcare (“AH”) propose in principal (and subject to CCG agreement and patient involvement) to close their Page Moss Surgery Branch site.

The purpose of this document is to provide Knowsley CCG with a brief proposal relating to the case for change for the two practices, with a view to receiving support and agreement to proceed.

The partners of SJS and AH strongly believe that the proposed changes will bring about significant benefits to general practice, patients and the local healthcare system.

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2. Overview of the GP Practices

The following information aims to provide a brief overview of each practice in terms of their current infrastructure, e.g. business partners, staffing and premises:

St Johns Surgery

Location

SJS is located within a state of the art purpose built premises located within Manor Farm Primary Care Resource Centre, Manor Farm Road, Huyton, Liverpool, Mersesyide, L36 0UB

Business Partners

The practice is a Private Limited Company1 and has one partner: Dr Faisal Maassarani.

Practice Population

As of 1st April 2016 the total practice population was 3,049.

Contract

The practice is a member of Knowsley CCG and provides services via a PMS+ contract The practice actively engages in the delivery of DES and LES contracts to improve patient care.

Staff

The practice currently employs a total of 11 staff and these include the following;

3 x GPs (1.6 WTE) 1 x Practice Manager (1.0 WTE) 1 x Practice Nurse (0.5 WTE) 1 x Nurse Clinician (0.1 WTE) 5 x Administrators (3.1 WTE)

In addition, the practice contract Spectra Health Ltd to provide a medicines management service to support work mainly in relation to the primary care quality initiative, the standards within the PMS+ contract and medicines optimisation in general.

1 Company No. 05781396– registered in England

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With regards to TUPE and whether this applies, legal advice is currently being sought.

Page Moss Surgery

Location

Page Moss Surgery is located within a state of the art purpose built premises located within North Huyton Primary Care Resource Centre, Woolfall Heath Avenue, Huyton, Liverpool, L36 3TN.

Business Partners

The practice is a branch surgery of Aston Healthcare Ltd, a Private Limited Company2 and has 3 shareholders: Dr Aftab Hossain, Dr K Sandeep and Dr J Benton

Practice Population

As of 1st April 2016 the total practice population was 2675

Contract

The practice is a member of Knowsley CCG and provides services within the framework of the PMS+ contract. The practice actively engages in the delivery of DES and LES contracts to improve patient care.

Staff

The practice currently employs a total of 8 staff and these include the following;

1 GPs (1.0 WTE) 1 Clinician (0.4 WTE) 1 Practice Office Manager (1.0 WTE) 1 Practice Nurse (0.6 WTE) 4 Administrators (4.0 WTE)

3. The Case for Change

National Context

General Practice is a vital component of the NHS; good access to high quality primary care is essential for a cost effective, high quality NHS that meets the needs of the population. 2 Company No. 04159048– registered in England

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General practices are typically small organisations, working in relative isolation from one another, with the exception of involvement in clinical commissioning. It could be argued that small sized practices present challenges to ensuring a high quality NHS, these include enabling full use of a multidisciplinary team, having the necessary resource to fund extended primary care, and lacking management and leadership capacity for service and organisational development.

General practice has seen a significant increase in the amount of work during recent years which has and will continue to place added pressure on the delivery of high quality service provision, especially to smaller size practices. Coupled with the increase in workload is the added challenge presented by patients, in that their demands for healthcare and expectations of the way healthcare is structured and delivered has increased. According to the Royal College of General Practitioners3, patients want:

greater responsiveness from GP practices; better co-ordination, extra services and greater emphasis on health promotion; the GP practice to be the basic unit of care; to protect the special relationship that exists between a patient and a GP who knows them.

In addition, major transitional changes with the healthcare system (i.e. from PCT to CCG and NHSE) and the introduction of a regulatory body (i.e. CQC) have provided primary care with a significant challenge. The NHS reorganisation has placed extra pressures on practices, financial pressures due to reductions in contractual income and capacity pressures due to the workload in preparing for and meeting the recently introduced Care Quality Commission (CQC) standards. Furthermore, in the near future the Government also want practices to extend their opening hours, proposing a change from the current Monday to Friday (office type) hours to seven days a week, 8am to 8pm. This initiative is currently being trialled; however, if extended hours are enforced on general practice then this could have a significant impact on GP workloads, create capacity issues and therefore affect quality and outcomes.

One quite recent major change that has had an impact on general practice is the formation of Clinical Commissioning Groups (CCGs) and NHS England (NHSE). GP practices are now members of CCGs and accountable to NHSE for the delivery of general medical services.

Though CCGs have a responsibility for commissioning community and secondary care services, they also have an important role in supporting quality improvement in general practice. It is extremely difficult to commission efficient secondary care activity without considering the way in which (a) primary care is structured and delivered and (b) the way in which patients are supported within primary care.

There are a number of solutions that GP practices, particularly those that are smaller in size (such as St Johns Surgery and Page Moss Surgery), could take in order to meet the various demands and the current and future challenges. For example, a high number of practices across England have either closed, federated under separate legal entities (i.e. GP Federations) or have formally merged with other practices to share and/or optimise resource to deliver their contractual responsibilities. 3 Royal College of General Practitioners 2007b

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The concept of larger practices has been supported by the Centre for Workforce Intelligence (CfWI)4 who reported that primary care commissioners (CCGs and NHSE) would seek better coordinated patient care through effective use of skill mix in multidisciplinary teams. The CfWI suggested that general practice would benefit from practices adopting a different skill mix, more effective demand management and measures to improve operational efficiency and productivity and thus predicted that there would be greater numbers of larger GP practices.

In addition, a recent report by the King’s Fund and the Nuffield Trust acknowledges that increasingly larger scale primary care provision is emerging5.

Larger practices offer a wider range of opportunities including:

career development for professional and other staff, (e.g. developing specialist clinical roles, commissioning involvement etc.);

enhanced peer review and clinical governance; the introduction of an extended range of services with access to specialist advice; professional human resource, financial and leadership capacity career development and support for professional staff.

Local Context

Knowsley CCG was established in April 2013 and is the third most deprived CCG in England.

The need for change for (the population and) providers has been identified as a key requirement for the CCGs transformation programme. One of the aims of this programme is ‘to move services closer to people’s homes - providing high quality services in a more sustainable and cost effective way…’ A key element of the CCGs strategic vision is to ensure that services are integrated and appear seamless from a patient’s perspective. The CCG has made significant progress in developing and (together with its key partners) commissioning an infrastructure within the Borough that has contributed towards a more robust and fit for purpose’ primary care system. For example, the CCG have previously invested in a ‘winter service’ that increased capacity (more GP appointments) meaning that more people were able to access timely primary and community care rather than accessing A&E facilities, thus reducing emergency activity and the associated costs. The CCG have also invested in (award winning) consultant-led initiatives for diabetes, COPD and CVD; these services are being provided within state of the art primary care resource centres across Knowsley which presents a unique opportunity for general practitioners to (a) refer their patients for specialist advice in a timely manner and (b) form and develop relationships with expert providers for continued professional development and service improvement.

4 Centre for Workforce Intelligence (2013). GP in-depth review: Preliminary findings. March 2013. http://www.cfwi.org.uk/our-work/publications/gp-in-depth-review-preliminary-findings 5 The King’s Fund and Nuffield Trust (2013) Securing the Future of General Practice: New Models of Primary Care. Website. 18 July 2013. http://www.nuffieldtrust.org.uk/publications/securing-future-general-practice

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More recently, Knowsley CCG have taken on greater responsibility for the commissioning of primary medical services (general practice), through a delegated arrangement. NHS England (NHSE) have also stated that, where applicable, ‘primary care services should be universally accessible, whilst ensuring that patients receive care in a coordinated and cohesive manner’6.

NHSE Merseyside Area Team have a vision to seek to commission a primary care system that:

Delivers an increased range of services from a primary care setting and reduce the need to refer patients to hospital,

Improves access and choice for patients, Ensures that providers are supported through a period of change, Delivers services from fit-for-purpose premises or access points, Addresses health inequalities, Delivers high quality services through a range of providers, Prevents ill health, Effectively uses NHS resources, Seeks to continually improve patient experience and service development.

5. Proposed Change

SJS and AH would like to seek agreement, in principle, for the following changes to take effect:

Aston Healthcare

AH to give notice to the CCG that it wishes to close itsPage Moss branch surgery and for the patients to be reassigned to Cornerways Medical Centre;

The current sub-leasing arrangement between Aston Healthcare and Community Health Partnerships for North Huyton PCRC will need to transferred from Aston Healthcare to Cornerways Medical Centre.

St Johns Surgery

SJS to cease operating as a provider from and for the patients to be reassigned to Aston Healthcare – Manor Farm PCRC,

SJS to give notice to the CCG to terminate its PMS contract The current sub-leasing arrangement between St Johns Surgery and Community Health

Partnership at Manor Farm PCRC will need to cease

6 NHS England Plan 2013-14. Merseyside Area Team.

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6. Benefits

The following benefits are believed to be brought about as a result of the proposed changes for the two practices:

Benefits to Patients

• Patients will experience improved care and outcomes; evidence suggests that practices with larger list sizes deliver increased performance due to a more focused workforce4;

• Patients will continue to receive access to primary care services from the same location but a larger workforce and a workforce with a wider skill mix resulting in greater continuity of care;

• Patients will have more flexibility and choice with regards to the clinicians they will have access to; • Patients will continue to have access to a wide range of clinical services.

Benefits to Practice(s)

• The increase in, and cross fertilisation of, capacity (knowledge and skills) will enable a significant improvement in operational efficiency (i.e. day to day business management) and improve the quality of care and outcomes for the patient population;

• There will be a more wide ranging multidisciplinary team (e.g. clinicians with different skills and special interests) which will only develop the practice in terms of capacity and capability and thus improve performance and outcomes;

• An increased resource/capacity will support organisational development in a number of areas; • Operational, financial and patient safety risks will be mitigated by working with a larger workforce,

e.g. there will be more staff to cover for sickness and absence, the practice will be more financially viable in its day to day operations etc.

Benefits to the Local Healthcare System

There will be an improved continuity of care within the practice population; this has strategic relevance and links to Knowsley CCGs planned and unplanned care agenda;

There will be a reduced number of practices to support from an NHS England, Knowsley CCG and Operations Merseyside perspective (as well as other healthcare related commissioners and providers);

The closure of SJS will allow increased estate capacity and will provide an option for neighbouring practices to move into, therefore improving the quality of estates and facilities for a greater patient population within Knowsley;

By enabling neighbouring practices to move into the vacant estate, this will support the CCG and NHSE strategic plans for an improved primary care system as other practices will be enabled to deliver services from fit-for-purpose premises or access points;

The propose changes will contribute towards improving patient experience and service development.

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7. Financial Implications

Both practices:

acknowledge and accept the risk that not all patients will want to receive their primary care/GP services from the proposed providers who they will be reassigned to, and therefore there will be a potential reduction in practice revenue.

acknowledge that the following aspects will have an impact (negative or positive) on their finances as a result of the proposed changes:

- Legal advice/instruction; - Staffing; - Premises - Insurance/Indemnity

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1

Appendix 2

(DRAFT) Equality Analysis Report Knowsley CCG Changing GP patient registration services

Date: Start date: 20.4.2016 Date: Date: Date: Signature: Andy Woods-Senior governance manager Details of service / function Primary Care : Changing GP patient registration services at:

1. Terminate Dr Maassarani’s St Johns PMS contract at Manor Farm and assign patients to the Aston Healthcare Ltd branch at Manor Farm.

2. Assign the patients from Aston Healthcare Ltd branch at North Huyton PCRC to Cornerways Medical centre, North Huyton PCRC

Aston Healthcare Manor Farm, Aston Healthcare Pagemoss, St. Johns Surgery and Cornerways Medical Centre are all member practices of NHS Knowsley Clinical Commissioning Group. All four of the practices provide primary care services in Huyton, Knowsley: Aston Healthcare Pagemoss and Cornerways Medical Centre within North Huyton Primary Care Resource Centre (NHPCRC) and Aston Healthcare Manor Farm and St. Johns Surgery based at Manor Farm Primary Care Resource Centre (MFPCRC)

Reasons for the change proposed

• In recent years General Practice has seen a significant increase in the amount of work which has, and will continue to place, added pressure on the delivery of high quality patient care and patient related outcomes.

• These changes to core practice business, the transition within the local

healthcare system, and the introduction of the CQC as a regulatory body, have provided primary care with an even greater challenge.

• It is therefore imperative that individual practices assess their current

infrastructure, systems and processes to ensure they are ‘fit for purpose’, future proofed to meet the changing needs of communities, equipped to meet the increasing financial challenges ahead and ensure their service models are robust and sustainable to provide the necessary healthcare provision to their

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local patient population The evidence for change is detailed within the practices “Case for Change” document which is underpinned and endorsed in a series of NHS guidance:-

A Fresh Start for the Regulation and Inspection of GP practices and GP out of hours services (CQC 2013)

Transforming Primary Care - safe, proactive, personalised care for those who need it most DH (2014)

• Further evidence and support can be identified in arrange of national reports

Change to service

Primary Care : Changing GP patient registration services at:

• Terminate Dr Maassarani’s St Johns PMS contract at Manor Farm and assign patients to the Aston Healthcare Ltd branch at Manor Farm. This will mean an additional 3049 registered patients.

• Assign the patients from Aston Healthcare Ltd branch at North Huyton PCRC to Cornerways Medical centre, North Huyton PCRC. This will mean an additional 2674 patients and will create a total registered list at North Huyton PCRC OF 9,088 individual patients.

This assessment is concerned with the ‘transfer of services from two providers at one location to one provider at the same one location and any potential barriers’ that this may create for different protected characteristics. (see chart below)

The delivery of the service and the service itself has no change to the criteria or threshold of those who which to use the service and /or entitled to use the service. Therefore there is no relocation of the service provision and or no change in the criteria to access the service. All patients will be able to access GP services.

Only change for patients effected is registration to a new GP practise, operating at the same

location Does this service go the heart of enabling a protected characteristic to access health

and wellbeing services?

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Yes- Public Sector equality Duty engaged. Primary care services are an integral part of healthcare.

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Barriers relevant to the protected characteristics ( where are the disadvantages) Including the change to the service

The only issue is one of ‘transfer’ from one provider to a new provider at the same site. As

such items that need to be understood as ‘may cause barriers’ are:

• Engaging and communications with stakeholders and patients to enable them to understanding when the old arrangements will occur and the new arrangement at the same location will start.

o Ensure those affected have choice and support to access other GP provision other than the GP’s outlined above (assigned GP services). Please note In addition to this service provider change, patient choice is paramount and consequently robust communication and engagement is required to explain the purpose of the change to ensure patients have a full insight of the current and planned services, any changes to service delivery, the benefits and purpose of the change, and where, if they wish, understand how patients can register with and alternative provider of their choice.

o Ensure capacity within the single service can meet the demands of increased registration

Protected characteristic Issue linked to travel and familiarisation

Comment /mitigation

age Young and older patients need to be engaged and informed of proposed new arrangements

Parents of young children need to be notified of changes in good time

Young people, Working age and Older patients notified of changes and offered choice to access other GP services other than those assigned

GP to ensure receptionists and other operational communication functions inform patients over the transition period Work with local Healthwatch organisations for guidance and distribution across

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Voluntary sector

GPs and practise to identify patients that may need support. GPs to contact patients with support plan.

disability Severely disabled may be assisted by carers.

Disability-sensory impairments leaning disability and mental health (including frail elderly, dementia etc.)

Notify carers in good time of changes

Identify best method of communicating. Further support on with engaging, and communicating In line with the Accessible information Standard.

GP to ensure New telephone number is communicated to patients with language needs

Work with local Healthwatch and Voluntary organisations for guidance.

GPs to identify patients that may need support with communication needs and choice. GPs to contact patients with support plan.

GP to ensure receptionists and other operational communication functions inform patients of move over the transition period

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Gender reassignment Limited impact GPs ensure they have a good knowledge of Gender identify requirements

Pregnancy & maternity Notify in good time of changes –

race Spoken /written language Ensure letters and information is given to different communities, consider different language formats

GP to identify and target patients with language needs

GP to ensure New telephone number is communicated to patients with language needs

GPs to utilise NHSE commissioned services include a telephone interpreting service (Language Line) and face to face interpreting service from Global Accent, during transition period

Religion& belief No impact

Sex (M/F) Male /female – other than the above categorises – no specific impact

Sexual Orientation No Impact

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Consultation: As the main aspect is ‘transfer of service from one provider to another, with the location

remaining the same , then it would be appropriate to ‘inform and support’ patients with details of the transfer any associated issue arising from their Protected characteristics highlighted in the above chart.

Is there evidence that the Public Sector Equality Duties will be met

(a) Eliminate discrimination. –

YES: new service will continue to meet need. Transfer process will take in to account any difficulties linked with protected characteristics above

(b) Advance equality of opportunity

YES: new service continues to meet need and helps facilitate and develop services. Support plans to help with ‘transfer’ have identified younger ( children) older patients , Black minority and ethnic patients and disabled patients that may need to be provided with particular information or with particular help and support to aid the transition.

C Foster good relations between different protected characteristics-

Not engaged.

PSED is met by ensuring patients fully understand when the change will take place, the difference in the new services available. The material should be available in different formats and the Voluntary sector is part of the process of informing and supporting patients with particular needs.

To mitigate risk : Actions: Please note some action are for communication and engagement activity and day to day GP operational activity Ensure that the following Actions take place:

• Patients receive appropriate letter (delivered directly to each household). This information needs to be accessible and targeted to specific communities as above

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• Hold drop in engagement sessions – provide additional transport and bus information / details of when and how the new service will run

• Posters displayed in the practice

• Offered choice and support if necessary with access to other GP services

• Utilising partner/3rd sector channels to ensure patients/carers are aware of the move and they know who to speak to for further info

• GPs identify patients that may need additional support to help them understand and cope with transfer as outlined in the tables above.

• GP to use receptionist and other operational communication mechanisms to inform patients over the transition period

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NHS Knowsley Clinical Commissioning Group

Proposed Changes to GP Practices

Aston Healthcare (Page Moss) and St Johns Surgery

Stakeholder Engagement Report

May 2016

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1. Background

2. Context for changes in primary care provision

2.1 National Context

2.2 Local Context

3. Introduction

3.1 NHS Guidance and supporting research on transforming primary care services

3.2 The fresh start for the regulatory and inspection of GP practices and GP ‘out of

hours’ service (2013)

3.3 Transforming primary care (2014)

3.4 NHS England Plan (2013-14)

3.5 Kings Fund & Nuffield Trust report (2013)

3.6 Centre for workforce development (2014)

3.7 REFORM research – The future of General Practice (2016)

4. Legal and statutory duties

4.1 NHS Act 2006

4.2 Health and Social Care Act (2012)

4.3 Public Sector Equality Duty (2010)

4.4 Transforming Participation in Health and Care (2013)

4.5 Everyone Counts – Planning for patients (2013-2019)

4.6 Standard Operating Policies and Procedures for Primary Care (2013)

4.7 Bite Size Guides for Public Participation (2014)

5. Framework for communication and engagement activity

5.1 Aims of the engagement

5.2 Format for engagement

5.2.1 Target audiences

5.2.2 Engagement channels

5.2.3 Key messages

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5.2.4 Format for patient information

5.2.5 Format for the public drop-in events

5.2.6 Format for stakeholder groups

5.2.7 Format for patient participation groups

6. Qualitative and Quantative Findings – Key Stakeholders

6.1 Equality impact assessment

6.2 Patient Participation Groups

6.2.1 St Johns Surgery

6.2.2 Aston Healthcare Page Moss

6.2.3 Cornerways Medical Centre

6.2.4 Aston Healthcare Manor Farm

6.3 Huyton Health Forum

6.4 Healthwatch Knowsley

6.5 Letters and patient enquiries

6.6 Information to GP members

6.7 Information to “Ward” councilors and Local Authority Scrutiny Committee

7. Patient survey responses

7.1 St Johns Surgery – drop-in events

7.2 St Johns Surgery – telephone survey

7.3 St Johns Surgery – total respondent data

7.4 Aston Healthcare Page Moss – drop-in events

7.5 Aston Healthcare Page Moss – telephone survey

7.6 Aston Healthcare Page Moss – total respondent data

8. Summary of findings and key points for consideration

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Appendices

Appendix 1 - Key Milestones

Appendix 2 - Healthwatch Questions

Appendix 3 - Demographic Breakdown of St Johns Surgery Respondents

Appendix 4 - Demographic Breakdown of Aston Healthcare Page Moss Respondents

Appendix 5 - Patient Letters and Emails Received

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1. Background

Knowsley Clinical Commissioning Group (CCG) is an NHS organisation that brings together local GPs (doctors), nurses and other healthcare professionals from across Knowsley, to assess the health needs of the local population, and then plan, buy and monitor the delivery of the required healthcare services. Knowsley Clinical Commissioning Group (CCG) received a joint proposal from two GP providers: Aston Healthcare (Page Moss branch) provided at North Huyton Primary Care Resource Centre (PCRC), Huyton, Knowsley, and St. Johns Surgery provided at Manor Farm Primary Care Resource Centre, Huyton, Knowsley. The proposal presented to Knowsley CCG outlined the GP practices aspiration to change service delivery which was identified following a comprehensive review undertaken by the GPs which specifically addressed their respective practice service delivery model and infrastructure. The review also took into consideration the increasing challenges on primary care providers to sustain high quality services to their registered patients. Within the GP providers case for change is stated that “General Practice has seen a significant increase in the amount of work during recent years which has and will continue to place added pressure on the delivery of high quality patient care and patient related outcomes. Major changes to core practice business (i.e. QOF and local contracting), transition within the local healthcare system and the introduction of a regulatory body (i.e. CQC) have provided primary care with a greater challenge; therefore, it is imperative that individual practices assess their current infrastructure, systems and processes to ensure they are ‘fit for purpose’.” Both practices see one of their key priorities is to provide their patients with high quality care and good results. Their proposal for change in responding to the fact that the NHS needs to change in order to continue providing the best possible healthcare it can to patients, means providing more services in a primary care setting, such as the GP surgery. Each practice has stated that they wish to ensure that they are fit to deliver 21st Century medical services for local people in Knowsley and that their patients receive the services they need, within a community setting. In order to achieve this, both practices wish to scale up one practice base and both Aston Healthcare and St John’s Surgery anticipate their proposed changes will positively improve the efficiency, effectiveness and quality of service they provide. It is reported in the case for change that larger practices offer a wider range of opportunities including:

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career development for professional and other staff, (e.g. developing specialist

clinical roles, commissioning involvement etc.); enhanced peer review and clinical governance; the introduction of an extended range of services with access to specialist advice; professional human resource, financial and leadership capacity career development and support for professional staff. Benefits to Patients Patients will experience improved care and outcomes; evidence within Centre for

Workforce Intelligence (2013). GP in-depth review: Preliminary findings suggests that practices with larger list sizes deliver increased performance due to a more focused workforce;

Patients will continue to receive access to primary care services from the same location but a larger workforce and a workforce with a wider skill mix;

Patients will have more flexibility and choice with regards to the clinicians they will have access to;

Patients may have access to a wider range of clinical services, depending on their choice of practice.

Benefits to Practice(s) The increase in, and cross fertilisation of, capacity (knowledge and skills) will

enable a significant improvement in operational efficiency (i.e. day to day business management) and improve the quality of care and outcomes for the patient population;

There will be a wider ranging multidisciplinary team (e.g. clinicians with different skills and special interests) which will only develop the practice in terms of capacity and capability and thus improve performance and outcomes;

An increased resource/capacity will support organisational development in a number of areas;

Operational, financial and patient safety risks will be mitigated by working with a larger workforce, e.g. there will be more staff to cover for sickness and absence, the practice will be more financially viable in its day to day operations etc.

An increased resource/capacity will support organisational development in a number of areas Therefore, the joint proposal outlined within the case for change identified how they wish to deliver their primary care services in the future and how this would alter where the GP service would be provided from; subject to patient and public involvement and Knowsley Clinical Commissioning Group’s approval.

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The proposal was outlined as follows:

a) St Johns Surgery, Manor Farm PCRC - St John’s Surgery propose in principal (subject to CCG agreement and patient involvement) to close and cease operating as a provider.

b) Page Moss Surgery (Aston Healthcare branch surgery) - North Huyton

PCRC, Aston Healthcare propose in principal (subject to CCG agreement and patient involvement) to close and cease operating as a branch surgery.

Following the closure of both St John’s Surgery and the Page Moss branch of Aston Healthcare the practices propose the patients are subsequently assigned as follows:

Terminate Dr Maassarani’ St Johns PMS contract at Manor Farm PCRC and

assign patients to the Aston Healthcare Ltd Manor Farm branch which has approximately 6,500 patients at Manor Farm PCRC. This could mean an additional 3,049 registered patients, bringing the practice to over 10,500 registered patients.

Assign the patients from Aston Healthcare Ltd branch at North Huyton PCRC to Cornerways Medical Centre, North Huyton PCRC. This will mean an additional 2,674 patients and will create a potential total registered list at North Huyton PCRC to over 9,000 individual patients.

The above changes would result in there being a single provider of primary medical services operating from both Manor Farm Primary Care Resource Centre and North Huyton Primary Care Resource Centre.

In addition to this service provider change, patient choice is paramount and consequently communication and engagement was planned to explain the purpose of the change and ensure patients have a full insight of the current and planned services; any changes to service delivery; the benefits and purpose of the change; and where, if they wish, understand how patients can register with and alternative provider of their choice.

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2. Context for Changes to Primary Care Provision

2.1 National Context General Practice is a vital component of the NHS; good access to high quality

primary care is essential for a cost effective, high quality NHS that meets the needs of the population.

General practices are typically small organisations, working in relative isolation

from one another, with the exception of involvement in clinical commissioning. It could be argued that small sized practices present challenges to ensuring a high quality NHS, these include enabling full use of a multidisciplinary team, having the necessary resource to fund extended primary care, and lacking management and leadership capacity for service and organisational development.

General practice has seen a significant increase in the amount of work during

recent years which has and will continue to place added pressure on the delivery of high quality service provision, especially to smaller size practices. Coupled with the increase in workload is the added challenge presented by patients, in that their demands for healthcare and expectations of the way healthcare is structured and delivered has increased. According to the Royal College of General Practitioners1, patients want:

o A greater responsiveness from GP practices; o Better co-ordination, extra services and greater emphasis on health

promotion; o The GP practice to be the basic unit of care; o To protect the special relationship that exists between a patient and a

GP who knows them.

In addition, major transitional changes with the healthcare system (i.e. from PCT to CCG and NHSE) and the introduction of a regulatory body (i.e. CQC) have provided primary care with a significant challenge. The NHS reorganisation has placed extra pressures on practices, financial pressures due to reductions in contractual income and capacity pressures due to the workload in preparing for and meeting the recently introduced Care Quality Commission (CQC) standards. Furthermore, in the near future the Government also want practices to extend their opening hours, proposing a change from the current Monday to Friday (office type) hours to seven days a week, 8am to 8pm. This initiative is currently being trialled; however, if extended hours are enforced on general practice then this could have a significant impact on GP workloads, create capacity issues and therefore affect quality and outcomes.

1

Royal College of General Practitioners 2007b

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One quite recent major change that has had an impact on general practice is the formation of Clinical Commissioning Groups (CCGs) and NHS England (NHSE). GP practices are now members of CCGs and accountable to NHSE for the delivery of general medical services. Though CCGs have a responsibility for commissioning community and secondary care services, and more recently in 2016, NHS Knowsley CCG now holds responsibility for co-commissioning GP primary care services. It is extremely difficult to commission efficient secondary care activity without considering the way in which (a) primary care is structured and delivered and (b) the way in which patients are supported within primary care. There are a number of solutions that GP practices, particularly those that are smaller in size (such as St Johns Surgery and Page Moss Surgery), could take in order to meet the various demands and the current and future challenges. For example, a large number of practices across England have either closed, federated under separate legal entities (i.e. GP Federations) or have formally merged with other practices to share and/or optimise resource to deliver their contractual responsibilities.

2.2 Local Context

Knowsley CCG was established in April 2013 and is the third most deprived CCG in England. The need for change for (the population and) providers has been identified as a key requirement for the CCGs transformation programme. One of the aims of this programme is ‘to move services closer to people’s homes - providing high quality services in a more sustainable and cost effective way…’ A key element of the CCGs strategic vision is to ensure that services are integrated and appear seamless from a patient’s perspective. The CCG has made significant progress in developing and (together with its key partners) commissioning an infrastructure within the Borough that has contributed towards a more robust and fit for purpose’ primary care system. For example, the CCG have previously invested in a ‘winter service’ that increased capacity (more GP appointments) meaning that more people were able to access timely primary and community care rather than accessing A&E facilities, thus reducing emergency activity and the associated costs. The CCG have also invested in (award winning) consultant-led initiatives for diabetes, COPD and CVD; these services are being provided within state of the art primary care resource centres across Knowsley which presents a unique opportunity for general practitioners to (a) refer their patients for specialist advice in a timely manner and (b) form and develop relationships with expert providers for continued professional development and service improvement.

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More recently, Knowsley CCG have taken on greater responsibility for the commissioning of primary medical services (general practice), through a delegated arrangement. NHS England (NHSE) have also stated that, where applicable, ‘primary care services should be universally accessible, whilst ensuring that patients receive care in a coordinated and cohesive manner’

2. NHSE Merseyside Area Team have a vision to seek to commission a primary care system that:

Delivers an increased range of services from a primary care setting and reduce the need to refer patients to hospital,

Improves access and choice for patients, Ensures that providers are supported through a period of change, Delivers services from fit-for-purpose premises or access points, Addresses health inequalities, Delivers high quality services through a range of providers, Prevents ill health, Effectively uses NHS resources, Seeks to continually improve patient experience and service development.

2

NHS England Plan 2013-14. Merseyside Area Team.

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3. Introduction

In recent years General Practice has seen a significant increase in the amount of work which has, and will continue to place, added pressure on the delivery of high quality patient care and patient related outcomes. These changes to core practice business, the transition within the local healthcare system, and the introduction of the CQC as a regulatory body, have provided primary care with an even greater challenge. It is, therefore, imperative that individual practices assess their current infrastructure, systems and presses to ensure they are ‘fit for purpose’, future proofed to meet the changing needs of communities; equipped to meet the increasing financial challenges ahead and ensure their service models are robust and sustainable to provide the necessary healthcare provision to their local patient population, in this case, patients residing in North Huyton, Knowsley, Merseyside.

3.1 NHS Guidance and supporting research on Transforming Primary Care

Services

The evidence for change is detailed within the practices “Case for Change” document is underpinned and endorsed in a series of NHS guidance:

3.2 A Fresh Start for the Regulation and Inspection of GP practices and GP out of hours’ services (CQC 2013)

3.3 Transforming Primary Care - safe, proactive, personalised care for those who

need it most DH (2014)

3.4 NHS England Plan 2013 – 2014 - Merseyside Area Team

The NHS guidance documents outline key areas for consideration for any GP practice, which include:

Delivering an increased range of services from a primary care setting and reducing the need to refer patients to hospital;

Improving access and choice for patients;

Delivering services from fit for purpose premises or access points;

Effectively using NHS resources;

Seeking to continually improve patient experience and service development;

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3.5 Kings Fund and Nuffield Trust Report July 2013

A recent report by the King’s Fund and the Nuffield Trust, (Securing the Future

of General Practice; new models of primary care) also acknowledges that larger scale primary care provision is an emerging feature of the NHS landscape and states that larger practices offer a wider range of opportunities including:

Career development for professional and other staff, (e.g. developing

specialist clinical roles, commissioning involvement etc.); Enhanced peer review and clinical governance; The introduction of an extended range of services with access to

specialist advice; Professional human resource, financial and leadership capacity;

3.6 Centre for Workforce Intelligence July 2014

The concept of increasing GP practice sizes to help improve services and

access is supported by the Centre for Workforce Intelligence (CfWI), in their report: In-depth review of the General Practitioner workforce July 2014, which stated that:

Primary Care Commissioners would seek better co-ordinated patient

care through more collaborative delivery and effective use of skill mix in multi-disciplinary teams;

General practice would benefit from practices adopting a different skill

mix, more effective demand management and measures to improve operational efficiency and productivity;

There will be greater numbers of larger GP practices;

3.7 REFORM Research April 2016

Who Cares – The Future of General Practice, April 2016, by REFORM

http://www.reform.uk/wpcontent/uploads/2016/04/Reform_who_cares_the_future_of_general_practice.pdf

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Reform is an independent, non-party think tank which produces research on the core issues of the economy, health, education, welfare, and criminal justice, and on the right balance between government and the individual. The report states:

“To deliver these services most effectively, (GP) providers will need to operate

at much larger scale. Providers offering best practice in England and elsewhere

hold patient lists at least ten times larger than today’s average list size of 7,400

patients; many aspire to operate at multiples of that. This affords providers the

size to invest in front-end change and exploit back-end efficiencies, including

making the most of technology”.

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4. Legal and Statutory Duties

Legal and statutory duties

NHS Knowsley CCG has fully complied with their legal and statutory duty to engage stakeholders in plans for the proposed changes to local primary care services. The relevant duties are detailed below:

4.1 NHS Act 2006

Section 242 of 2006 NHS Act is the legal duty to involve current and potential service users or their representatives in everything to do with planning, provision and delivery of NHS services. The duty specifically applies where there are

changes proposed in the manner in which services are delivered or in the range

of services made available.

Sections 13C and 14P - Duty to promote the NHS Constitution

Sections 13I and 14V - Promotion of patient choice

Section.14T of the NHS Act 2006 (CCGs) have a duty to “have regard to the

need to reduce inequalities”.

4.2 Health & Social Care Act 2012

Section.14Z2 Public involvement and consultation by clinical commissioning groups and Section.13Q of the Act – Public involvement and consultation by the Board

1) This section applies to any health services which are, or are to be, provided pursuant to arrangements made by a clinical commissioning group in the exercise of its functions (‘commissioning arrangements’).

2) The clinical commissioning group must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other

ways): –

a) in the planning of the commissioning arrangements by the group,

b) in the development and consideration or proposals by the group for

changes in the commissioning arrangements where the implementation

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of the proposals would have an impact on the manner in which the

services are delivered to the individuals or the range of health services available to them, and

c) in decisions of the group affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.

4.3 Public Sector Equality Duty 2010

4.4 Transforming Participation in Health and Care 2013, NHS England

4.5 Everyone Counts: Planning for Patients 2013/14 to 2018/19, NHS England

4.6 Standard Operating Policies and Procedures for Primary Care, managing regulatory and contract variations, June 2013

4.7 Bite-Size Guides to patient and public participation, February 2014

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5. Framework for Communication and Engagement Activity

5.1 Aims of the engagement

Strategically, NHS Knowsley Clinical Commissioning Group through its stakeholder engagement and communication activity aimed to ensure: An equality impact assessment was undertaken to consider any

disadvantaged groups and consider mitigating the impact of change should the proposal be accepted.

That all patient and stakeholder feedback is recorded and shared with the CCG to inform their decision making processes.

Feedback would be recorded in the form of patient surveys being hand

written and completed by telephone interviews; a question and answer sessions through attendance at forums or planned stakeholder meetings and responding directly to letters and emails following specific patient and stakeholder enquiries.

That Knowsley patients had the necessary information on the planned changes, its impact to current service provision, and informed on how to transfer to another practice if they do not wish to transfer to the proposed practice.

The purpose of engagement with patients in regard to the proposed service change was to enable patients to make comment on their preferred choice, which would primarily fall into four categories:

1. Keeping the existing provision in place without any change. 2. Continue with the proposed change but register with alternative

provider at the same site. 3. Continue with the proposed change, but patients moving with existing

GP provider on their consolidated practice, e.g. moving from Aston Healthcare Page Moss to register at Aston Healthcare Manor Farm, or move from St Johns Surgery and register at Cornerways Medical Centre.

4. Continue with the proposed change but register with another GP

outside of the existing site.

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5.2 Format for engagement Illustrated within Appendix 1 highlights key milestones in regard to how; where; when and with whom; the communication and engagement operational leads, and each respective GP practice staff worked with patients and key stakeholders to deliver timely and robust information on the plans. Each partner supported and facilitated access to the new provider and broader community services to allow patients to meet practice staff and see the surgery facility, inform them on other health provision in the centre, and offer information on wider community health services. 5.2.1 Target Audience

The approach to communication and engagement aimed to be comprehensive and robust. The aim was to also work closely with partner organisations that can easily communicate with a range of people who may be affected by the change, as follows:

Patients Carers Voluntary Patient Groups Community nursing service Knowsley Healthwatch Third sector provider’s/support organisations Knowsley Borough Council “Ward” councillors CCG Governing Body Board NHS England North (Cheshire and Merseyside)

5.2.2 Engagement Channels

Stakeholder engagement was carried out through a range of channels to promote and explain the purpose of the planned service change, including:

Targeted letters to every registered patient at the practices; Frequently asked question and answer factsheets; Easy read formats to support patients with literacy and/or a learning

disability; Poster information in practices at both Primary Care Resource Centres

promoting the open events in May 2016. Discussion with PPGs at all four practices; Meeting with members of Knowsley Healthwatch; Meeting with Huyton Health Forum Drop-in events at each primary care resource centre;

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Survey of patient views sought at events; A market stall information event at both Primary Care Resource Centre

premises to enable people to learn more about what services are available and primary and community service level with the specific inclusion of vulnerable/underrepresented groups;

Direct telephone contact with practice manager, reception staff and/or engagement lead;

Patient telephone interviews to target working population and gain a balanced demographic of respondents for both practices;

Web-based information on CCG website;

5.2.3 Key Messages

All practice staff were provided with internal communication to support them in responding to patient enquiries, this included understanding their role and responsibilities to support the engagement process, that they were clear and consistent in informing patients and their families enquiring about changes that “no decision had been made” and that this

is a proposal for change which their views would be used to inform the CCG. All staff was provided with copies of the patient letter, the frequently asked question factsheet ahead of information being posted to patients to guarantee consistent information was shared with patient and families. A consistent set of key messages were provided by the lead GPs during the open drop-in events and translated during informal conversations with patients and practice staff. The providers at St Johns Surgery and Aston Healthcare Page Moss,

strongly believe that the proposed changes will bring about significant benefits to general practice, patients and the local healthcare system.

Continue to focus on making sure patients receive high quality care

that supports them to stay healthy. That the changes will improve patient experience by having wider

choice doctors and clinicians, extended and increased number of appointments and access to more community based services.

That patients will have the right to choose whether to be reassigned

to the new proposed provider, or decide to change practice altogether.

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5.2.4 Format for patient information

Every registered patient received an information letter outlining the proposed changes and this included question and answer factsheet. The information was offered on request in a range of alternative language and other formats and a contact number was provided to request this directly. An easy read version of the factsheet was also produced and sent to every registered patient listed within each practice as having a learning disability. Patients could contact the surgery practice manager for more information, or speak to the engagement lead working on behalf of Knowsley CCG.

5.2.5 Format for the public drop-in events

All registered patients were invited to attend a public drop-in event which was held at the practice for ease of access to allow patients to speak directly to clinicians and reception staff. Local community support services also attended the drop-in events to inform patients on local support services, e.g. district nurses, learning disability support services, mental health nurse, Knowsley Ethnic Minority Support Group, Knowsley/St Helens Accommodation Supported Housing Project (SHAP), Knowsley Healthwatch, Smoking Cessation Support, Knowsley Carers Centre, Knowsley Pensioners Advocacy Information Service, Sexual health services, Integrated Wellness Team for lifestyle changes. The practice making the proposal for change gave an overview on why this was being suggested and what they feel will be the benefits to patients, staff, the practice and the wider health economy.

The alternative GP provider on the same site that patients could be assigned to then explained their current services and the range of services their practice refers into within each respective primary care resource centre. Patients were invited to speak to clinicians and practice staff to get responses to their specific questions. Patients were provided with a survey to complete and feedback their views to the proposal for change.

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Key questions covered:

Patient Information

o What GP are you registered with?

Patient Experience

o What matters most to you about the care you receive?

Patient Choice

o Are you happy to continue to use this healthcare facility? o Would you wish to transfer with your current GP? o If you are not happy, would you choose another GP in the local

area? o Do you have any objections to the changes and why?

Travel

o Are you prepared to travel further to access GP services? o How do you travel – Bus, Car, Taxi, Bike, On Foot?

The engagement events provided GP’s, practice managers and their staff

with an opportunity to test patient opinion about the current services that are provided and gauge patient views on how the practice can continue to improve upon this moving forward. The engagement activity provided patients with information on other local practices available to register with as part of their Patient Choice as an NHS consumer. This list was extended to also include moving with the practice as this had been initially omitted as an option.

5.2.6 Format for stakeholder groups

An overview of the proposal for change was shared with both groups and how this is a request from the practice not the commissioners. Information on the national evidence for change was shared but explained this did not specifically relate to local changes but helped contextually to see the direction of travel for primary care services increasing the practice lists. Huyton Health Forum holds bi-monthly meetings which are comprised of local Huyton residents and supported by a community development worker from The 5 Borough Partnership NHS Trust.

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The lead for engagement requested attendance to share the proposal and seek the views of the Forum members. Knowsley Healthwatch called a coffee morning for their members to attend and input their views as stakeholders.

5.2.7 Format with patient participation groups

An overview of the proposal for change was shared with PPG groups and how this is a request from the practice not the commissioners. Information on the national evidence for change was shared but explained this did not specifically relate to local changes but helped contextually to see the direction of travel for primary care services increasing the practice lists. Each practice has a local patient group and the practices called a specific meeting to discuss the proposed changes. The meeting was also attended by practice staff.

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6. Quantative and Qualitative Findings - Key Stakeholders

6.1 Equality Impact Assessment

The equality impact assessment identified that the only issue is one of “transfer”

from one provider to a new provider at the same site. As such, items that need to be understood as ‘may cause barriers’ are:

Engaging and communication with stakeholders and patients to enable them to understand when the old arrangements will occur and when the new arrangements at the same location will start.

Ensure those affected have choice and support to access other GP provision other than the GPs outlined above, (assigned GP services). In addition to this service provider change, patient choice is paramount and consequently communication and engagement is required to explain the purpose of the change to ensure patients have full insight of the current and planned services, any changes to service delivery, the benefits and purpose of the change, and where, if they wish, understand how patients can register with an alternative provider of choice.

Ensure capacity within the service is in place to meet the demands of increased registration.

6.2 Patient Participation Groups

Relevant questions in the survey were also used to guide the PPG discussions and to enable a consistent format of feedback to be achieved. The focus groups and meetings are qualitative and the surveys returned via events or following telephone survey discussions are both qualitative and quantative.

6.2.1 St Johns Surgery

The patient group was in general not supportive of this planned change going forward as they are happy with their current provision of healthcare.

The group was concerned they may not have the choice to follow the practice to the Page Moss based practice. Once this was communicated this would be an option some were satisfied but not sufficiently to support closing the practice.

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Patients want reassurance that there will be enough GPs and staff capacity in place to manage the transfer of patients. There are concerns that Aston Healthcare in Manor Farm does not have enough GPs.

Some would travel further to access GP services but highlighted that transport and a patient’s mobility could restrict this option for some. There was a split of 60% who are car drivers and 40% who access the practice on foot.

Some felt their patient experience would determine whether they moved out of Manor Farm.

The key issues raised in terms of what matters most to patients about the care they receive included:

o The continuity of GP and the staff and the important relationship that is built up.

o Ease of access for GP appointments. o Access to other healthcare facilities in premises. o Closeness/distance of travel to access your GP. o Support for minority and/or vulnerable groups to have healthcare.

6.2.2 Aston Healthcare Page Moss

The PPG patients questioned the purpose of the change and expressed how valued the GP is and that it seemed unfair he would be moving as they are happy with the current arrangements.

One patient was particularly concerned in regard to the impact on continuity of patient care if patients have to move practices.

There were objections to the planned change because of the inconvenience of change but stated they would transfer with the practice to Manor Farm if the proposal went forward and were satisfied this was an option.

Both patients access service by car.

The key issues raised in terms of what matters most to patients about the care they receive included:

o Range of appointments. o More choice. o Local facilities.

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The patients wished it to be stated how clear and transparent the communication of the planned change was conducted which they felt has helped ease any concerns they had by being involved in the PPG discussion.

6.2.3 Cornerways Medical Centre

The PPG members supported the planned changes and they felt it was good that the PPG was being asked to input into the planned changes but acknowledged they are a small number of respondents.

The patients want assurance that the practice will be sufficiently staff with clinical and non-clinical staff to meet the demand of new patients.

The key issues raised in terms of what matters most to patients about the care they receive included:

o Stability of the service and practice. o Reduction in running costs. o Local “all-encompassing facilities” on one site. o Being known by the staff.

6.2.4 Aston Healthcare Manor Farm

The PPG members supported the proposed changes.

They felt transport and access will be important to patients when deciding to move with their existing practice or remain in Manor Farm as a patient with Aston Healthcare.

Overall they felt it was a good idea and the key issues raised in terms of what matters most to patients about the care they receive included:

o Good appointment service. o Having back-up GPs for Out of Hours provision. o Having other services in the same building.

6.3 Huyton Health Forum

This forum was not well attended and the coordinator was unsure why people had not attended their meeting. However, the resident who did attend made key points in regard to what matters to patients about the care they receive:

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Having a practices close to where people live. Access for people who have mobility problems – e.g. lifts. Having services in one place saves travelling time and expense to patients. Having a GP who knows you is important. Pensioners bus passes start late and appointments need to accommodate

this. Public transport can be unreliable which can make patients late for appointments. If people are transferring the bus routes and frequency of the service will be important.

Taxis are not an affordable option for many.

6.4 Knowsley Healthwatch

The members raised a series of questions rather than commenting on whether they agreed with the proposed changes.

There were some members who are patients and had also attended the practice PPG meeting.

The questions covered:

o Information to patients o Capacity of practices o Service changes o Transport o Decision making process

The response to the questions was populated by Knowsley CCG, Aston Healthcare and Dr. Maassarani and Partners. The responses to the questions will be shared with Healthwatch to share with their members. A full transcript is contained within Appendix 2.

6.5 Letters and patient enquiries received

Aston Healthcare Page Moss

Aston Healthcare received 4 emails two with specific questions which were responded to via the CCG as they were copied in. Two emails were also received with patients expressing their objection to the proposal be noted. Four letters all of which object to the proposed change. Copies of emails and letters and responses within Appendix 5 in this report.

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Approximately 200 phone calls from patients have been received by Aston Healthcare. The practice manager reported the key issues was responding to enquiries regarding why the change is happening; where the current GP was moving to; how to get to Manor Farm practice; if staff jobs were at risk.

56 patients called in person to reception and 43 of the total enquiries of 276 enquired about the time of the drop-in event.

The engagement lead was asked to contact two patients and both patients were not supporting the proposed change as they wish to remain with Dr. Sandeep.

St Johns Surgery

The practice has received one email which they replied directly to the patient’s

enquiry. A copy of the email and response is appended to this report.

There were 27 telephone calls and 53 patients called in person to the practice. The enquiries mainly focused on what was happening with the staff; would patients be able to transfer to Cornerways; where else outside of Aston Healthcare at Manor Farm was available for patients to transfer to.

The practice manager has reported that overall their patients have been supportive of the change once explanations on why the change is happening and what choices patients have should the proposal be supported.

6.6 Information to GP members

The CCG issued internal communications to GP members and those indicated within the public documentation as having open lists. This is to be reviewed following some omissions from the list printed.

6.7 Information to “Ward” Councillors/Local Authority Scrutiny Committee

The elected local authority councilors covering the wards where Manor Farm and North Huyton Primary Care Centres are based were invited directly through the CCG to attend the public events.

The scrutiny committee for health and wellbeing had disbanded due to purdah and the local elections. Democratic services were informed the engagement activity would take place and the CCG has presented the background documentation to democratic services to share with newly elected committee members and requested a meeting to discuss the engagement and seek their input and advice.

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7. Patient Survey Responses

Patient surveys responses following drop-in events – St Johns Surgery

Patients completed surveys at the drop-in events and this was then expanded with a telephone survey to target age groups who did not attend the drop-in events.

The demographic of the respondents attending the events was narrow and the telephone survey which followed attempted to reach a similar number of respondents to those who attended the events but targeted across a wider age range to give a balance of opinions across all ages.

The telephone surveys were conducted in the morning an evening to compliment the active engagement events which were held in the afternoon. This model was adopted to reach people who are unable to attend events, or maybe working, have childcare commitments etc.

The drop in event attracted over 50 patients and a total number of 48 patients completed the surveys at the event. The summary of this is detailed in the graphs and feedback below. The demographic breakdown is within Appendix 3.

7.1 Patient Experience – What matters most to you about the care you receive

“You have a number of choices about how you receive primary GP care,

can you tell us what is important to you?”

o Accessible GP appointments without long waiting times

o Appointments that fit in with working hours

o Online prescription service

o Being seen by the same practice nurse

o Consistency of GP

o Relationship with staff, GP, nurses and receptionists

o Close proximity to home

o Seeing a doctor who knows me and my condition

o Other services available on same site

o Close proximity for patients who have mobility problems

o GPs who know your health issues, which patients then don’t have to

repeatedly go over their condition

o Helpful, friendly reception staff who know you.

o Support for diabetes from nurses.

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Patient Choice – Please tick your preferred choice?

Are you happy to continue using this healthcare facility?”

Yes (I would be happy to transfer to Aston Healthcare Manor

Farm).

No (I would prefer to transfer with my current practice to

Cornerways Medical Centre).

I would prefer to choose another GP in the local area.

Answer choices Responses

Yes 53.33% 24

No 40.00% 18

I would prefer to choose another GP in the local area 6.67% 3

Total 100.00% 45

Yes

No

I would prefer to choose another GP in the local area

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%

Are you happy to continue to use this healthcare facility?

Answered: 45 Skipped: 3

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Patient Choice - “Do you have any objections to the planned changes and

why?”

Answer choices Responses

Yes 75.00% 30

No 25.00% 10

Total 100.00% 40

Feedback comments:

o Reassurance there are enough GPs to meet the demand of the transfer of patients choosing to transfer to alternative suggested GP practice. The current Aston practice does not appear to have enough doctors.

o Not happy we need to travel to stay with practice. o Happy with services as they are. o Not happy Cornerways was not highlighted as an option of transfer in the patient

information. o We know the GP and travel is difficult.

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00%

Do you have any objections to the planned changes?

Answered: 40 Skipped: 8

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o Don’t want to change to another doctor as we are happy we see the same doctor now and this wasn’t our previous experience at Aston Manor Farm and it was the reason we moved practice.

o I am local and known at this practice. o Close to home and we know all the doctors. o It is inconvenient and I would choose another GP in the area as Aston Manor

Farm is a training practice so you don’t get to see the same GP. o Not happy to move, I have heard Aston uses locum GPs. o I want a doctor who knows me and I feel comfortable with and I have this now. o I will have difficulties finding buses to reach surgeries which will mean I won’t

see my usual nurse. o The practice will be too big. o Communication with patients and the reason for this planned change not

explained. o As a registered blind person, I have a relationship with staff which has

developed over years and prefer this to continue. o Prefer to stay at St Johns Surgery but will transfer to Aston as it is near me. o My surgery is very good and the staff and doctors are very caring. o I travel far enough o Need reassurance if I stay at Manor Farm I can see the same doctor. St Johns

Surgery staff know their patients individually. o Never get the same doctor at Aston and different doctors don’t know your

problems and if you are anxious anyway, this is very stressful. o I prefer the practice not to move.

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Travel - “Are you prepared to travel further to access GP services?”

Answer choices Responses

Yes 27.27% 12

No 72.73% 32

100.00% 44

Whilst over 70% of respondents do not wish to travel further to access GP services and over a quarter of respondents are willing to travel further, this is not aligned to those who have selected they remain at the current site, move with the practice or would transfer to another GP.

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00%

Are you prepared to travel further to access GP services?

Answered: 44 Skipped: 4

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Travel - “How do you travel to access GP service?”

Answer choices Responses

Bus 20.83% 10

Car 47.92% 23

Taxi 2.08% 1

Bike 0.00% 0

On foot 29.17% 14

Total 100.00% 48

Feedback comments:

Of those who travel by bus: o Their choice would depend upon distance. o If they have health problems which could restrict them. o A small number reported difficulties with public transport to reach

surgeries would be a barrier. Of those who travel by car they stated:

o They would travel if needed but would prefer the practice to remain. o They would travel to a surgery of their choice and the best GP to meet

their needs.

Bus

Car

Taxi

Bike

On foot

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%

Do you travel by

Answered: 48 Skipped: 0

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o Some would be reliant on others taking them by car to access GP services.

o Some patients in poor health will in the future not be able to drive. Of those who reported using taxi services:

o This related to disability rather than distance of travel. Of those who access the services on foot:

o The close proximity to their homes was convenient to many. This was highlighted as a particular need for older patients whose mobility may be restricted. Many patients are also not car owner/drivers.

7.2 Patient survey responses to telephone survey - St Johns Surgery

“You have a number of choices about how you receive primary GP care,

can you tell us what is important to you?”

o Seeing the same doctor.

o Having a choice of female doctor.

o Accessible GP appointments.

o Consistency of GP and not having to retell your history

o GPs who know you.

o Close to where you live

o Quick appointments without long waiting periods

o Appointments available when I need them, especially for working people.

o Don’t use locum GPs

o Getting into your appointment at the appointed time

o Having faith in the GP

o Staff that are excellent and our GP practice staff are.

o Easier appointments for work and not having to call at 8am or wait for a

week

o GPs and nurses that are very helpful

o Feeling comfortable with current GP and staff who are all amazing.

o Seeing a GP who understands your needs and has time for you.

o Love all the staff but need a local GP

o Staff who know your condition.

o Length of appointments are too short.

o Good communication and teamwork at the practice.

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Patient Choice – Please tick your preferred choice?

Are you happy to continue using this healthcare facility?”

Yes (I would be happy to transfer to Aston Healthcare Manor

Farm).

No (I would prefer to transfer with my current practice to

Cornerways Medical Centre).

I would prefer to choose another GP in the local area.

Answer choices Responses

Yes 42.86% 18

No 42.85% 18

I would prefer to choose another GP in the local area 14.29% 6

Total 100.00% 42

Yes

No

I would prefer to choose another GP in the local area

0.00% 10.00% 20.00% 30.00% 40.00% 50.00%

Are you happy to continue to use this healthcare facility?

Answered: 42 Skipped: 0

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Patient Choice - “Do you have any objections to the planned changes and why?”

Answer choices Responses

Yes 55.00% 22

No 45.00% 18

Total 100.00% 40

Feedback comments:

o Prefer not to move practice and also have female GP. o Low income estates will be a problem for people to travel. o Don’t feel we should have to move off Manor Farm area, there are a lot of older

people who can’t travel. o This is close to where we live, it is inconvenient to move.

o We have a long standing relationship with the practice and prefer things to stay as they are.

o Makes sense amalgamating but it means people travelling. o They are only doing this to save money. o Not happy with the change, I am very happy with the current GP.

o This is the third time we have moved, we want a surgery who knows you and understands you. We would love Dr. Sarker back if possible.

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%

Do you have any objections to the planned changes?

Answered: 40 Skipped: 2

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o I would have trouble building trust elsewhere but I would have to stay at Manor Farm as travel to Page Moss is a problem. I want St Johns to stay the staff are lovely and do their best.

o I couldn’t move to Aston I have had a previous bad experience so would follow St Johns or go to Dr. Johnson if they are still in the area.

o The GP understands me and wants to help me. I would sing the praises of the practice, the care is better here and the staff know me, I would move with St Johns practice.

o This location is more convenient and there is not much transport between here and Page Moss, but I would move to Page Moss.

o I wish it could stay as it is. o Want a female GP back at the practice. o Don’t feel Aston is run as a family practice, more a private business. o Those on committees in the backroom are faceless and don’t care about the

“man in the street” in this case it’s the patient. If they do care they should stand up and be counted.

o I find change for the sake of change is not always for the better. I will now have to try and get rapport with new people. It is important to stay with same GP for attitude and mind.

Travel - “Are you prepared to travel further to access GP services?”

Answer choices Responses

Yes 54.76% 23

No 45.24% 19

100.00% 42

Over 50% are willing to travel, a similar amount is also willing to stay. This is similar in choice to move with the practice or stay at Manor Farm site.

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%

Are you prepared to travel further to access GP services?

Answered: 42 Skipped: 0

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Travel - “How do you travel to access GP service?”

Answer choices Responses

Bus 17.50% 7

Car 42.50% 17

Taxi 0.00% 0

Bike 0.00% 0

On foot 40.00% 16

Total 100.00% 40

Feedback comments:

Of those who travel by bus: o I need a local GP practice. o There isn’t much transport between Page Moss and Manor Farm. o A low income estate will be hard for people to travel.

Of those who travel by car:

o There will be a lot of older people who can’t travel. o It is inconvenient to have to move don’t think we should have to travel. o Will choose another GP in area as don’t want to stay at Manor Farm. o I will follow the practice to Page Moss, but I am worried when the GP is not

nearby what will I do when I am unwell. o I don’t want to stay at Manor Farm so will choose a GP in the local area. o I have poor mobility and when not able to drive will get a taxi and won’t move

practice because of this will stay at Manor Farm. o The new practice premise is actually closer to where I live’

Bus

Car

Taxi

Bike

On foot

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00%

Do you travel by

Answered: 40 Skipped: 2

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Of those who access the service on foot: o Travel a problem due to personal circumstances. o I want a local service and I will see what the new practice is like. o Ease of access and being seen quickly has been a key reason for many people.

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7.3 Total patient respondents’ data – St Johns Surgery

Answer Choices Responses

Yes 48.00% 42

No 41.50% 36

I would prefer to choose another GP in the local area 10.50% 9

Total 100.00% 87

Yes

No

I would prefer to choose another GP in the local area

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%

Are you happy to continue to use this healthcare facility?

Answered: 87 Skipped: 3

The response rate has decreased from 53.33% happy to stay at Manor Farm to 48.00%.

Those who wish to move with the GP practice to Page Moss “Cornerways Medical

Centre” has slightly increased from 40% to 41.5%.

Those who wish to change to an another GP has increased from 6.67% to 10.5%.

This is possibly due to the wider range of respondents who were mixed ages and more mobile via use of car, public transport.

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Answer choices Responses

Yes 65.00% 52

No 35.00% 28

Total 100.00% 80

The objections have decreased from 75% to 65% The number of people who now do not object has risen from 25% to 35%.

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

Do you have any objections to the planned changes?

Answered: 80 Skipped: 10

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Answer choices Responses

Yes 40.70% 35

No 59.30% 51

100.00% 86

Of those who are prepared to travel to access GP services has increased from 27.27% to 40.70%. Of those who are not prepared to travel has decreased from 72.73% to 59.30%. This is possibly due to the wider range of respondents who were mixed ages and more mobile via use of car, public transport.

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

Are you prepared to travel further to access GP services?

Answered: 86 Skipped: 4

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Answer choices Responses

Bus 19.30% 17

Car 45.50% 40

Taxi 1.10% 1

Bike 0.00% 0

On foot 34.10% 30

Total 100.00% 88

The number of people travelling by bus decreased slightly from 20.83% to 19.3%. Those travelling by car also decreased slightly from 47.92% to 45.50%. Taxi users slightly decreased from 2.08% to 1.10%. There are no bicycle user respondents to the survey. Those who access services on foot has increased from 29.17% to 34.10%. This maybe attributable to the different age range respondents in the telephone survey.

Bus

Car

Taxi

Bike

On foot

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% 50.00%

Do you travel by

Answered: 88 Skipped: 2

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Total demographic breakdown of 90 respondents – St Johns Surgery

Answer choices Responses

16-25 7.90% 7

26-35 13.50% 12

36-45 4.50% 4

46-55 14.60% 13

55-65 18.00% 16

65+ 41.50% 37

Total 100.00% 89

16-25

26-35

36-45

46-55

55-65

65+

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00%

What is your age group Answered: 89 Skipped: 1

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Answer choices Responses

Male 32.20% 29

Female 65.50% 59

Transgender 0.00% 0

Prefer not to say 2.30% 2

Total 100.00% 90

Male

Female

Transgender

Prefer not to say

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

Sex Answered: 90 Skipped: 0

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Answer choices Responses

Yes 37.00% 33

No 63.00% 56

Total 100.00% 89

Yes

No

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

Do you consider yourself to be disabled? Answered: 89 Skipped: 1

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Answer choices Responses

Hetrosexual 83.40% 75

Homosexual 0.00% 0

Bi-sexual 1.10% 1

Prefer not to say 15.50% 14

Total 100.00% 90

Hetrosexual

Homosexual

Bi-sexual

Prefer not to say

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00%

Sexual Orientation Answered: 90 Skipped: 0

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White British

White English

White Irish

White Scotish

White Welsh

White Polish

White Latvian

White Gypsy/Traveller

Other white background (specify if you wish)

Asian British

Asian Indian

Asian Bangladeshi

Asian Pakistani

Asian Chinese

Asian Japanese

Asian Vietnamese

Other Asian background (specify if you wish)

Black British

Black African

Black Caribbean

Other Black background (specify if you wish)

Mixed ethnic background Asian and White

Mixed ethnic background Black African and …

Mixed ethnic background Black Caribbean …

Other mixed background (specify if you wish)

0.00% 20.00% 40.00% 60.00% 80.00%

Ethnicity - do you identify yourself as... Answered: 48 Skipped: 0

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7.4 Patient surveys responses following drop-in events – Aston Healthcare

Page Moss

Patients completed surveys at the drop-in events and this was then expanded with a telephone survey to target age groups who did not attend the drop-in events.

The demographic of the respondents attending the events was narrow and the telephone survey which followed attempted to reach a similar number of respondents to those who attended the events but targeted across a wider age range to give a balance of opinions across all ages.

The telephone surveys were conducted in the morning an evening to compliment the active engagement events which were held in the afternoon. This model was adopted to reach people who are unable to attend events, or maybe working, have childcare commitments etc.

Aston Healthcare Page Moss – North Huyton Primary Care Resource

Centre

The drop in event attracted over 100 patients and a total number of 96 patients completed the surveys at the event. The summary of this is detailed in the graphs and feedback below. The demographic breakdown is within Appendix 3.

Patient Experience – What matters most to you about the care you receive

“You have a number of choices about how you receive primary GP care,

can you tell us what is important to you?”

o Local consistent GP which we have now. o Appointments when needed, on the same day and which are also flexible. o Consistent GP, nurses, reception staff who I have confidence in. o Mental health awareness. o Knowing your GP well. o Sign interpreters for deaf patients o Availability of emergency appointments. o Ability to get appointments can be difficult. o Repeat prescription service. o Good relationship with GP who knows their patients. o Services close to where I live. o Seeing the same doctor. o Local facilities and accessible services. o Consistent nursing services o People who listen and look after us. o Having confidence and trust in your GP. o Access via public transport. o Access for community wide and elderly.

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o Helpful and cheerful staff. o Nurses who know your condition e.g. COPD, diabetes. o Pharmacy on site. o Understanding and caring staff. o Sympathetic doctor and staff. o Doctors who I can depend on. o Physio and counselling on the same site. o Stability. o Location. o Range of services and more choice.

Patient Choice – Please tick your preferred choice?

Are you happy to continue using this healthcare facility?”

Yes (I would be happy to transfer to Aston Healthcare Manor Farm).

No (I would prefer to transfer with my current practice to Cornerways

Medical Centre).

I would prefer to choose another GP in the local area.

Answer choices Responses

Yes 33.70% 31

No 63.04% 58

I would prefer to choose another GP in the local area 3.26% 3

Total 100.00% 92

Yes

No

I would prefer to choose another GP in the local area

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

Are you happy to continue to use this healthcare facility?

Answered: 92 Skipped: 4

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Patient Choice - “Do you have any objections to the planned changes and

why?”

Answer choices Responses

Yes 88.10% 74

No 11.90% 10

Total 100.00% 84

Feedback comments:

o I would still prefer to stay with Aston because I believe big is not always better and I myself prefer a small surgery. In a surgery of approximately 2,500 people have difficulty getting appointments to see Doctor. What change is a surgery of 8,000. Because it’s a small surgery I know the doctor, nurse, and chemist and have had no difficulty seeing a specialist with aliments once I have seen the doctor.

o It is unsettling to change from one GP to another. I was in this situation in 2014 having had to move from another practice because of closure. I have only just got used to coming here and I like Dr. Sandeep.

o Accessibility via public transport is excellent. Moving will impact on patients not keeping appointments due to bus route off arterial road and inaccessible for other probable change of address.

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00%

Do you have any objections to the planned changes?

Answered: 84 Skipped: 12

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o Dr. Sandeep is an excellent doctor who patients wish to continue to receive care from (this has been a universal comment through most responses).

o I strongly object to any proposals of change to the doctors and surgery. (this response was received 6 times).

o Very, very happy with Dr. Sandeep, our nurses & our lovely helpful receptionists in Page Moss Healthcare.

o Good family doctor with helpful receptionists doing the best for us all. o Good central surgery for everyone. o This is important as I have mental health issues and the medication I

have been taking for 30 years is about to change and I could do without the problems of the GP closing.

o The trust I have for the GP has taken years to gain. o Service is perfect why change. o Inconvenience of change, but I would rather stay with my practice. o I prefer no change to happen, but I live close to Manor Farm so I can

access it and stay with my current GP who understands my care. o Used to same GP who understands complex medical history. o It’s hard to get an appointment now, so it will become harder and my

doctor is really good and the receptionists are helpful, all of this I don’t want to lose.

o It is sad to move the practice but I will follow Dr. Sandeep.

o I feel that this proposal is wrong as the doctor at Cornerways will benefit as a business (Dr. Maassarani) as he is a member of the CCG. I do not want to lose my doctor and I will follow him wherever he goes.

o Doctors are aware of the problems I have had for a long time. o Prefer services to remain as they are with same GP. o Disruption to doctor/patient care. o I need to deal with someone who knows my medical condition o Closing a surgery so another can include in its numbers, where is the

patient care. o Have no knowledge of where Aston Healthcare would be situated and

were Dr. Sandeep would be located. o Continuity of being served brilliantly for 45 years by the practice. o I have received fantastic service for over 50 years. o I want to continue my care with the practice that know me. o I look after my dad and work full-time and I get on with the staff. They

are lovely people I don’t want to move. o Having a consistent GP "Dr. Sandeep" who I have come to love & trust

with whole of family. Excellent appointment service, receptionists very good at what they do, "professional", Dione the nurse deals with my COPD and also my husband’s diabetes & blood pressure. We just have been so happy with this service.

o No other staff can replace or are good enough to take the place of Aston staff.

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o I may consider it if Dr. Sandeep’s practice is not too far to travel to. When my previous GP closed in 2014, I came to this building in Page Moss and was told by Cornerways that I could not register as I live just beyond the practice boundary, in L14, yet Aston was able to accept me.

o Could Aston take on another GP, if more than one is required? (It may be two buses to another practice)

o Don’t want to have to join another practice and start all over again, why when the surgery runs perfectly well.

o Live 5 minutes away but would travel to stay with Aston. o Myself and my mum are deaf BSL users and feel, finally, we are getting a

good service from doctor, nurse and reception staff who know us. If its new staff we will have to go through it all again.

o Ideal surgery location with pharmacy. o If you increase the amount of patients it will be harder to get an

appointment. o Will other doctors be able to manage extra patients. o Excellent service all-round, very unhappy indeed. o I have bipolar and going to another practice will cause me stress and

anxiety. o If Aston is committed to providing me with high quality of care you must

leave it as Aston Care I do not want to go elsewhere. o I am happy to stay in Page Moss, but I am concerned that if I need an

appointment I will be able to get one. o I have complete confidence in Dr. Sandeep. o Not sure about proposed changes – as long as new doctors listen and

appointments are available quickly, not in weeks, things should be ok. I would rather keep it the same.

o This is convenient place, with great bus service to access it. I don’t want any change, we have everything available to us, why close our surgery down.

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Travel - “Are you prepared to travel further to access GP services?”

Answer choices Responses

Yes 26.51% 22

No 61.00% 61

100.00% 83

Whilst 61% do not wish to travel further to access GP services and over a quarter of respondents are willing to travel further, this is not aligned to those who have selected they remain at the current site, move with the practice or would transfer to another GP.

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

Are you prepared to travel further to access GP services?

Answered: 83 Skipped: 13

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Travel – “How do you travel to access GP service?”

Answer choices Responses

Bus 21.69% 18

Car 38.55% 32

Taxi 10.84% 9

Bike 0.00% 0

On foot 28.92% 24

Total 100.00% 83

Feedback comments:

For those who travel by bus: o I already travel from Whiston sometimes two buses. o May consider it if Dr. Sandeep is not too far away. o I am in poor health and bus route access to Page Moss is excellent. o Several areas use this centre because it is central to old bus terminus. o We use public transport because it is convenient and helps us to be on

time for appointments as we know the times and the bus routes. o This centre is on a direct bus route. o I am disabled and travelling to another GP will be a problem for me.

Bus

Car

Taxi

Bike

On foot

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00%

Do you travel by Answered: 83 Skipped: 13

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For those who travel by car: o I can access other services. o Prefer to stay with present GP. o Due to my medical condition my GP understands and I am 90 years of

age and don’t want another GP. o I would prefer to choose another GP in local area. o Health reasons restrict my travelling (this was mentioned a number of

times by other respondents) o I am registered disabled. o Having services close are important I can’t travel. o Small number of patients use mobility scooter.

For those who travel by taxi:

o If the practice moves I will have to get a taxi. o I will travel to see Dr. Sandeep without doubt he saved my life. o We have a convenient site for our surgery and a great bus route so I

would need to use a taxi. o Due to being disabled some patients use a taxi service. o Due to poor health cannot walk far so uses taxi service.

For those who access the service on foot:

o I access service on foot now but would travel to see GP. o The practice is on my doorstep. o I live locally. o Surgery is within walking distance. o Not aware of public transport, have no car, travel with carer. o I want to keep my present surgery open. o I don’t want to change and not happy to move. o Very happy at current practice. o Walking is difficult when inflammation is up so want practice to stay.

7.5 Patient survey responses to telephone survey – Aston Healthcare Page Moss

Patient Experience – What matters most to you about the care you receive

“You have a number of choices about how you receive primary GP care,

can you tell us what is important to you?”

o 1:1 relationship with GP and practice staff o Staff are good as are the reception and pharmacy o A simple straightforward service which I have now. o Local to where we live o Easy access I don’t want to travel on a bus when unwell. o Consistent GP o Local consistent GP which we have now. o All the services together.

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o Local services available in one place with GP. o Flexible appointments for working people and families. o GP who knows me and he is a current doctor is very good. (stated

multiple times). o Knowing our condition is important. o Current GP is good and want to stay with him (stated multiple times). o Knowing our history as a family. o Convenience and accessibility. o My doctor knows me, which I value, he understands me. o Quality of care I receive. o Access to appointments. o Being seen quickly. o A doctor I can trust. o Location and relationship with staff and Dr. o Continuity of care. o Access to early appointments. o Having telephone consultations. o Appointments when needed. o Seeing GP who knows my background, mental health, and building up

that trust is important. o Evening surgery. o More emergency appointments, they are often all gone after 8am. o Quick appointments that fit in with my working hours. o Having home visits for housebound patients. o Trust in GP and knows me and my family. o Doesn’t bother me a long as I get seen to. o Competency of the GP and the practice. o Some reception staff are unhelpful for patients who are working and have

no understanding, but some of the staff are nice. Only reason we are still registered is because of Dr. Sandeep.

Patient Choice – Please tick your preferred choice?

Are you happy to continue using this healthcare facility?”

Yes (I would be happy to transfer to Aston Healthcare Manor Farm).

No (I would prefer to transfer with my current practice to Cornerways

Medical Centre).

I would prefer to choose another GP in the local area.

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Answer choices Responses

Yes 44.57% 41

No 51.09% 47

I would prefer to choose another GP in the local area 4.35% 4

Total 100.01% 92

Yes

No

I would prefer to choose another GP in the local area

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%

Are you happy to continue to use this healthcare facility?

Answered: 92 Skipped: 4

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Patient Choice - “Do you have any objections to the planned changes and

why?”

Answer choices Responses

Yes 58.62% 51

No 41.38% 36

Total 100.00% 87

Feedback comments:

o Like things to stay as they are, but would move with the practice. o Happy with current service, but would prefer to use same premises because it is

close to where we live. o I have a brilliant doctor I want to go with my GP. o Don’t want the surgery to move and stay as it is. o Prefer not to change but would stay at North Huyton centre. o Because it’s easy to get to, but would like it to stay the same, but will remain in

same building because it is more convenient. o Rather no change, but will follow the practice. o Prefer change not to happen but need somewhere close to where I live. o Many respondents replied “will move with GP”.

YES

NO

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

Do you have any objections to the planned changes?

Answered:87 Skipped: 9

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o The practice is local on my doorstep. o If I move to Manor Farm and I live outside the area can I still change will be my

concern. I would rather stay and not move. o Don’t want to start from scratch with a new GP therefore I will transfer. o Staff really nice and know you personally, would rather it didn’t happen. o Happy where it is staff know me and my medication (stated 4 times). o Been happy with the staff who are pleasant and helpful (stated 5 times) o I am very disabled and cannot walk and need home visits to continue so I would

not like it to change. o The care I receive off GP is so supportive why would I have to move, but I would

prefer not to move at all. o It’s a shame to have to move. o Not in agreement because getting to Manor Farm is inconvenient for me using

public transport. Also have good relationship with nurses/GP/staff. Feel like it is ripping the heart out of the community.

o I don’t want to go to Cornerways. Staff and nurses lovely at the practice but I can’t move to Manor Farm it’s too difficult to travel on two buses.

o Having to travel further which isn’t on a direct bus route. o More driven by finance rather than benefits to the welfare of the patients. o Inconvenience of change and having to go to a new doctor. o Travelling to a new practice as a non-driver and the time this takes as a working

person. o Understand why this is happening but distance and accessibility over GP is not

a comparison, so I will move with the practice. o Undecided at the moment about whether to move with the practice or not. I

would have a problem getting to Manor Farm. Things are running smoothly at the moment so don’t want changes if possible.

o I have been a patient since a child. Inconvenient for family to go through changes but we understand why. Would rather it stay as it is. Difficulty for our daughter to travel there. Stayed because of Dr. Sandeep.

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Travel - “Are you prepared to travel further to access GP services?”

Answer choices Responses

Yes 53.13% 51

No 46.87% 45

Total 100.00% 96

The 51% of people who selected to move with their existing practice/or access another GP broadly correlates with the amount of people who are prepared to travel at 53%. The figure for those who wish to stay at Page Moss center 44% broadly aligns to those who are not prepared to travel.

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%

Are you prepared to travel further to access GP services?

Answered: 96 Skipped: 0

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Travel - “How do you travel to access GP services?”

Answer choices Responses

Bus 10.75% 10

Car 40.86% 38

Taxi 5.38% 5

Bike 0.00% 0

On foot 43.01% 40

Total 100.00% 93

Feedback comments:

Of those who travel by bus: o Don’t want to travel by bus further when I am unwell. o Don’t want to travel further with my children, so will move to Cornerways surgery. o As a non-driver travelling further takes more time as a working person.

Of those who travel by car: o I live outside of the area; I want to move with the practice. I have concerns I can

still do this. o Prepared to travel further as distance and accessibility over GP consistency is

no comparison. o Would need to travel by car as it is not on a direct bus route. o The existing practice is in an ideal location, but I would move with GP.

Bus

Car

Taxi

Bike

On foot

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% 50.00%

Do you travel by

Answered: 93 Skipped: 3

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o The quality of the care I receive I will move with the practice. o Will travel further because value relationship with practice.

Of those who travel by taxi:

o I am very disabled and cannot walk so use taxi or home visits. o Prefer things to stay as they are but will move with the practice.

Of those who access the services on foot: o Will stay at Huyton premises it is close to where we live. o I will move with the practice because of GP. o I don’t want the surgery to move. o Because I don’t have transport I will stay at North Huyton centre. o Too difficult to travel on two buses. o Not viable to move to another practice.

7.6 Total patient respondents’ data – Aston Healthcare Page Moss

Answer choices Responses

Yes 39.10% 72

No 57.10% 105

I would prefer to choose another GP in the local area 3.80% 7

Total 100.00% 184

Yes

No

I would prefer to choose another GP in the local area

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%

Are you happy to continue to use this healthcare facility?

Answered: 184 Skipped: 12

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The response rate has increased from 33.7% happy to remain at North Huyton to 39.10%.

Those who wish to move with the GP practice to Aston Healthcare at Manor Farm has slightly decreased from 63.04% to 57.10%.

Those who wish to change to another GP practice has increased very slightly from 3.26% to 3.8%

This change is possibly due to the wider range of respondents who were mixed ages and more mobile via use of a car, public transport.

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Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00%

Do you have any objections to the planned changes?

Answered: 165 Skipped: 31

The objections have increased from 75% to 88%

The number of people who do not object has decreased from 25% to 11%

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Answer choices Responses

Yes 40.00% 73

No 60.00% 106

100.00% 179

For those who are prepared to travel to access GP services has increased from 26.69% to 40%.

This is possibly due to more people confirming they will move with the practice to Manor Farm.

Of those who are not prepared to travel this has decreased very slightly from 61% to 60%.

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

Are you prepared to travel further to access GP services?

Answered: 179 Skipped: 17

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Answer choices Responses

Bus 16.00% 28

Car 40.00% 70

Taxi 8.00% 14

Bike 0.00% 0

On foot 36.00% 64

Total 100.00% 176

The number of people travelling by bus has decreased from 21.69% to 16%

The number of people travelling by car has slightly increased from 38.5% to 40%.

Taxi usage has decreased from 10.8% to 8%.

There are no bicycle user respondents to this survey.

Those who access services on foot as decreased from 29% to 36%.

This change in those accessing the service by foot could be attributable to the different age range respondents in the telephone survey who have access to a car.

Bus

Car

Taxi

Bike

On foot

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00%

Do you travel by

Answered: 176 Skipped: 20

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Total demographic breakdown of 196 respondents – Aston Healthcare Page Moss

Answer choices Responses

16-25 12.00% 23

26-35 13.5% 26

36-45 12.5% 24

46-55 18.5% 35

55-65 15.5% 30

65+ 28.00% 54

Total 100.00% 192

16-25

26-35

36-45

46-55

55-65

65+

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%

What is your age group Answered: 192 Skipped: 0

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Answer choices Responses

Male 39.22% 71

Female 60.23% 109

Transgender 0.00% 0

Prefer not to say 0.55% 1

Total 100.00% 181

Answer choices Responses

Yes 39.00% 72

No 61.00% 116

Total 100.00% 188

Male

Female

Transgender

Prefer not to say

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

Sex Answered: 181 Skipped: 11

Yes

No

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00%

Do you consider yourself to be disabled? Answered: 188 Skipped: 4

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Answer choices Responses

Hetrosexual 88.00% 154

Homosexual 2.00% 3

Bi-sexual 2.00% 3

Prefer not to say 8.00% 15

Total 100.00% 175

Hetrosexual

Homosexual

Bi-sexual

Prefer not to say

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

Sexual Orientation Answered: 175 Skipped: 17

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White British

White English

White Irish

White Scotish

White Welsh

White Polish

White Latvian

White Gypsy/Traveller

Other white background (specify if you wish)

Asian British

Asian Indian

Asian Bangladeshi

Asian Pakistani

Asian Chinese

Asian Japanese

Asian Vietnamese

Other Asian background (specify if you wish)

Black British

Black African

Black Caribbean

Other Black background (specify if you wish)

Mixed ethnic background Asian and White

Mixed ethnic background Black African and …

Mixed ethnic background Black Caribbean …

Other mixed background (specify if you wish)

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

Ethnicity - do you identify yourself as... Answered: 192 Skipped: 0

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8. Summary of findings and key points for consideration

In general, patients from both practices are very satisfied with their current service and do not want to have the inconvenience of change. Most patients stating that building of new relationships with staff they have received a valuable service from isn’t something

they would choose as a proactive option. However, many are prepared to follow the existing practice (St Johns Surgery to Cornerways at North Huyton Primary Care Centre) and

Patients local stakeholder groups (Healthwatch and GP Patient Participation Groups) have raised helpful and insightful questions all of which have been responded to directly with input from both GP providers and Knowsley Clinical Commissioning Group.

The equality impact assessment identified that the only issue is one of “transfer” from one provider to a new provider at the same site. As such, items that need to be understood as ‘may cause barriers’ are:

o Engaging and communication with stakeholders and patients to enable them to understand when the old arrangements will occur and when the new arrangements at the same location will start.

o Ensure those affected have choice and support to access other GP provision other than the GPs outlined above, (assigned GP services). In addition to this service provider change, patient choice is paramount and consequently communication and engagement is required to explain the purpose of the change to ensure patients have full insight of the current and planned services, any changes to service delivery, the benefits and purpose of the change, and where, if they wish, understand how patients can register with an alternative provider of choice.

o Ensure capacity within the service is in place to meet the demands of increased registration.

Healthwatch raised a series of questions all of which have been responded to and shared with Healthwatch members. The questions covered the following topics:

o Information to patients o Capacity of practices o Service changes o Transport o Decision making process

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Huyton Health Forum highlighted what mattered most to patients is:

o Having a practices close to where people live. o Access for people who have mobility problems – e.g. lifts. o Having services in one place saves travelling time and expense to patients. o Having a GP who knows you is important. o Pensioners bus passes start late and appointments need to accommodate this.

Public transport can be unreliable which can make patients late for appointments. If people are transferring the bus routes and frequency of the service will be important.

o Taxis are not an affordable option for many

In summary the feedback from patients registered with St Johns Surgery is: -

St Johns Surgery Patient Participation Group members are generally not supportive of the planned change, mainly because they are happy with their current service and do not want to move. They were not informed they could transfer with the practice to Cornerways Medical Centre. Once informed this is an option it made a positive difference to some. The patient group want reassurance that Cornerways practice and Aston Healthcare Manor Farm will have sufficient capacity of clinical and administrative staff to support a patient transfer and that wider practice lists where patients may register is fully communicated to all patients if the decision is made to support the proposal.

Cornerways Medical Centre Patient Participation Group members, who as a result of planned change could potentially see the increase in patient registrations are fully supportive of the proposal for change. The PPG also want confirmation of staff numbers being augmented to manage the increased demand for appointments. They wanted to ensure stability in the service and agreed with the principle of a reduction in running costs.

Both PPGs felt having services and facilities on one site is beneficial to patients.

Both practice PPGs feel that relationships with GPs and staff members are very important along with continuity of care, availability of appointments and locally accessible service for patients to access.

Following open events and undertaking patient surveys, 91 patients have shared written responses.

A high percentage of respondents praised the GP and staff at St Johns Surgery and emphasised the importance they place on their relationship with their GP and practice staff which patient’s buildup over many years.

90 survey questions which elicited qualitative responses:

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“What matters most to you about the care you receive?”

o Accessible GP appointments. o Being seen by practice nurse staff who know your condition. o Other health services available on the same site. o Flexible appointments particularly for those who are working. o Proximity of services, particularly for those with mobility restrictions. o Consistency of GP and not having to repeat your history. o Having access to female GPs. o Feeling comfortable with current GP and staff. o Seeing GPs who understand and listen to patients. o Good communication and teamwork at practice. o Relationship with staff, nurses, GPs and also pharmacy services on site.

“Do you have objections to the planned change?”

o Patients are satisfied with current provision and do not want to move practice. o Inconvenience of change. o Consideration that extra travel may have financial impact and the area has many

people living on low incomes. o Concern that practice may become too large and that reassurance would need to

communicated that there are enough GPs and staff to manage the transfer of patients and that it does not negatively impact access to appointments.

o Lack of information on primary care choices – e.g. that patients can move with the practice, this includes patients who as a result would fall out of area but wish to maintain their relationship with their existing GP and staff.

o Patients could see the sense of amalgamating the practice, but highlighted for many, the inconvenience of travelling further.

A rounded percentage of responses stated:

o 48% are happy to transfer from St Johns Surgery to Aston Healthcare Manor Farm.

o 41% wish to move with St Johns Surgery and register at Cornerways Medical Centre.

o 10% would chose to register with a new GP provider in the local area. o 65% do object to the planned change. o 35% do not object to the planned change. o 40% will travel further to access GP services. o 59% are not prepared to travel further to access GP services o 19% access services by bus. o 45% are car drivers. o 1% use taxi services. o 34% access services on foot.

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In summary the feedback from Aston Healthcare Page Moss is:

Aston Healthcare Page Moss Patient Participation Group members questioned the purpose of the planned change and felt that it seemed unfair to move the practice as patients are satisfied with the service they receive. They raised concerns regarding the continuity of care and the impact of change. Other issues they considered which would be important for patients is that there is patient choice; a range of appointment options; having accessible local facilities which patients currently have within North Huyton Primary Care Centre.

The patient group wished it to be formally noted how clear and transparent the communication of planned changes was conducted and which they felt helped ease any concerns they had by being involved in the PPG discussion.

Aston Healthcare Manor Farm Patient Participation Group felt the amalgamated service was a good idea. They felt transport and access are important to patients when deciding to move practices. Other issues of relevant importance were: having a good appointment service; having back up for GP Out of Hours service provision; and having other services available in the same building.

Following open events, patient surveys, 200 patients have shared written responses.

A very high percentage of respondents praised the GP (Dr. Sandeep) and staff at the practice and the importance they place on their relationship with them which has been built up over numerous years.

196 survey questions elicited qualitative responses:

“What matters most to you about the care you receive?”

o Consistent GP. o Sign interpreters for deaf patients. o Repeat prescription service. o Services close to where I live. o Access via public transport. o Understanding and caring staff. o Suitable location. o 1:1 relationship with GP and practice staff. o All services together. o Flexible appointments for working people and families. o Quality of care. o Having telephone consultations. o Fast appointments. o Competency of GP and the practice. o Having staff who know you and your medication.

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“Do you have objections to the planned change?”

o Don’t want the surgery to move and wish it to stay where it is. o I live outside the area and I don’t know if I can move with the practice. o Getting to Manor Farm is inconvenient. o As a non-driver, travelling to the practice takes more time for me as a working

person. o Inconvenient for my family to go through changes, we understand why, but

would rather the practice stays where it is. o Happy with current service but would prefer to use premises and transfer GP

because it is close to where I live. o Having to travel further, it is not on a direct bus route. o I believe big is not always better, I prefer a small surgery. o It is unsettling to change from one GP to another. o Accessibility via public transport to North Huyton centre is excellent, moving will

impact on patients not keeping appointments due to bus route off arterial road. o I trust the GP and this takes years to gain. o Disruption to doctor/patient care. o Could Aston not bring in another GP to Huyton if more are required. o I would rather have no change happen at all (this was stated by high majority of

people opposed to the change) o If you increase the amount of patients it will be harder to get an appointment. o Will other doctors be able to manage the extra patients. o Not sure about proposed changes? as long as new doctors listen and

appointments are available quickly, not in weeks, it should be ok.

A rounded percentage of responses stated:

o 39% are happy to transfer from Aston Healthcare Page Moss to Cornerways Medical Centre.

o 57% wish to move with Aston Healthcare Page Moss and register at Aston Healthcare Manor Farm.

o 4% would chose to register with a new GP provider in the local area. o 88% do object to the planned change. o 11% do not object to the planned change. o 40% will travel further to access GP services. o 60% are not prepared to travel further to access GP services o 16% access services by bus o 40% are car drivers. o 8% use taxi services. o 36% access services on foot.

Therefore, how the decision has been reached will need to be communicated to all patients irrespective of the decision to support or decline the request. This will need to

Page 105 of 106

76 | P a g e

go via letter from each practice with clarity on their position along with additional internal communication in practices, on websites and via staff briefings.

The communication plan post decision is important as it may not meet everyone’s

needs and therefore to mitigate this a clear translation of what the decision is, what this means, (assuming the proposal is supported) where can patients register with another practice; how to get more support to do this; who can patients speak to regarding transferring to practices; etc. will need to be fully supported by GP practices and their staff.

Key comments for consideration:

Following a number of patient enquiries, a review of all local practices with open registration lists, within a 2.5 radius will be included should the proposal for change be supported and communicated to all registered patients to support patient choice. Key comments for commissioner consideration:

o Cornerways Medical Centre and Aston Healthcare patients will need written as-surance that there will be capacity to copy with a transfer of patients from Aston Page Moss and St Johns surgery. This includes, GPs, clinical staff and backroom function staff.

o CCG and practices need to ensure that patients are supported to understand how to make a change of GP.

o There needs to be a robust communication plan in place if this change goes forward to ensure people know the transport routes, the patient choice available to them, access routes to alternative providers.

o Healthwatch members felt that patients need to be informed that Aston Healthcare runs a training GP practice whose doctors move regularly. It was felt this may impact on patient choice and therefore patients need to be in-formed in advance of making a decision about their future care.

o Engaging and communication with stakeholders and patients to enable them to understand when the old arrangements will continue until and when the new ar-rangements at the same location will start.

Page 106 of 106

1

Document PC(07)11

KNOWSLEY STRATEGIC ESTATES GROUP

KEY ISSUES

11th May 2016

Key Issues

• The Primary Care Transformation Fund is now called the Estates and Technical Transformation Fund and the portal for bids is due to open on 2nd June 2016. The CCG is not expected to put in a bid for any large estates schemes but bids for technology will be made.

• An update on the Pilch Lane development has been received from NHS England. The site the NHS has (old boundary pub site) is too big for the planned NHS facility for the 2 Practices. As part of the ongoing planning NHS Property Services (NHSPS) has been discussing with Knowsley Council any requirements they might have for this surplus space before NHSPS simply dispose of it via other routes. Also NHSPS and the Council are working on resolving some local access issues for the School on Pilch Lane to be part of the project. NHS England has kept the Practices and their respective Patient Participation Groups appraised as to progress and a meeting with the Roby PPG took place last month. Plans remain on track against original timing expectations, i.e. FBC completion during this summer 2016 with hopeful final approval and physical commencement Autumn 2016

• A strategic estates action plan/tracker has been produced. • A number of potential GP Practice and 5BPFT staff moves are being progressed. A

meeting to discuss joint room use by social work and health staff is to be held. • There are rent increases at a number of NHS Property Services properties due to the

move to market rents. It was confirmed by CHP that there was no similar increase in LIFT building rents.

1

Document PC(07)12

MEDICINES MANAGEMENT SUB-COMMITTEE

KEY ISSUES

1st June 2016

Key Issues

Review of Committee Effectiveness

• A review of Committee Effectiveness took place. E-Cigarettes

• Talks on e-cigarettes are still in discussion and therefore remain as not being approved for prescribing at present.

• A report highlighting key issues relating to e-cigarettes and outlining key recommendations was referred to, with the outcome being that the C&M Directors of PH have asked for progress

o Follow PHE advice with regards the use of Electronic Cigarettes as an aid to quitting smoking.

o Stop smoking services should support smokers using EC to quite by offering them behavioural support.

o Develop a draft protocol across Cheshire and Merseyside on the use (or otherwise) of E-cigarettes as a form of NRT.

o Request CM Tobacco Commissioners in collaboration with Tobacco Free Future and PHE to develop a CM position statement in relation to e-cigs and smoke free environment policies.

Repeat Prescribing Working Group Mark advised that the first meeting had taken place and that an update will be provided at the next meeting. Prescribing for Transgender patients Mark advised he and a small group has been tasked to look at a local solution. There is a requirement to get a solution within 4 weeks so it will go to the next Governing Body. Current Position of Dietetic reviews of sip feeds and paths

• Maria Morris, Team Leader in the Community Dietetic Service at 5BP gave a presentation

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on the current position of the Dietetic reviews of sip feeds and paths; • Nursing Homes requesting changes to sip feeds in the middle of the month are

contributing to waste of up to a whole months worth of feeds, it was suggested that patients should be advised by the dietician to finish the course and then do the switch the following month;

• Dieticians always use a food first approach and Nursing Home referrals are often returned asking them to follow the food first guidelines before referring into the service;

• Enquiries are ongoing with StHK over supplements they provide in the Hospital; • Problems with supplements being prescribed, is often due a lack of understanding as to

why they are prescribed. Information will be provided as a guide for this; • Of the supplements prescribed, 95% of them can be changed to the less expensive

equivalent.

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Document PC(07)13

Ratified

PART A

Quality Committee

Notes of Meeting; Tuesday 29th March 2016 1:00pm Nutgrove Villa, Boardroom

Doc Ref 03(05)01

Present Apology MEMBERS

Peter Murphy Chair of the Committee – Registered Nurse Dr Paul Conway Clinical Lead for Quality & Safety Dianne Johnson Chair of the Committee - Accountable Officer,

Knowsley CCG

Helen Smith Safeguarding Service Representative Dr David Stokoe Clinical Lead for Primary Care Quality Helen Meredith Chief Nurse Philip Thomas Commissioning Director

IN ATTENDANCE

Mark Lammas Acting Quality and Safety Operational Manager Ian Stewardson Director of Strategy and Performance Alistair MacFarlane Head of Commissioning Paul Mavers Healthwatch Knowsley Paul Coogan Healthwatch Knowsley Mark Pilling Interim Head of Medicines Management Rajesh Karimbath Quality and Safety Programme Manager Ann Dunne Head of Safeguarding (Children) Neil Rotherham Primary Care Quality Manager Kendra Waring Programme Manager Dawn Boyer Head of Corporate Services Dr Ronnie Thong Knowsley GP Alison Van Dessel Quality & Safety Programme Manager Paul Melia Lay Member, Patient & Public Engagement Dianne Goncalves Designated Nurse Safeguarding Adults Debbie Spruce Designated Safeguarding (Children) Sarah McNulty Knowsley Council (Public Health) Clare Barrow Head of Finance & Contracts Jane Uglow Programme Manager Anne-Marie Dibble Note Taker

ACTION

1 WELCOME & INTRODUCTIONS & APOLOGIES FOR ABSENCE

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Dianne Johnson, The Chair in the absence of Peter Murphy, welcomed all those present to the meeting and round-the-table introductions took place. Paul Coogan nominated Paul Mavers to represent him at this meeting. Apologies for absence were received from Peter Murphy, Dianne Goncalves, Ann Dunne, Ian Stewardson, Dawn Boyer, Helen Meredith, Helen Smith and Paul Coogan.

2 DECLARATIONS OF INTEREST

There were no declarations of interest from the Committee.

3

MINUTES AND MATTERS ARISING

The minutes of the last meeting held on 19th January 2016 were accepted as an accurate record subject to the following amendments; Page 1, Members register: No recording of Dianne Johnson being present at the Committee. Action: Anne-Marie Dibble to add Dianne Johnson’s attendance at the Committee.

AMD

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REVIEW OF ACTION LOG

Matters arising and review of action log; 3rd July 2015, Item 6, Patient Experience Group (PEG) Sub Group Report, Page 6 – The committee is asked to approve the PEG Work Plan and Terms of Reference for the Quality Committee in September 2015 when a more detailed report and work plan incorporating the Committee’s comments are brought back. Mark Lammas to present paper with a series of proposals regarding future patient experience work. Action: This action has been superseded by a review of the way that the CCG obtains Patient Experience information. Mark Lammas to lead on the review, and write a paper for EMT to consider, and bring back to the Quality Committee in July or September 2016. 10th September 2015, Item 7, Agenda Item 9 Incident Management - Training dates to be set. Action: Date has been set for RCA training of 24 May 2016. Action Closed. 10th September 2015, Item 8, Agenda Item 9, Serious Incident Management - Feedback to the CSU SI Team the positive comments from the Quality Committee. Action: Mark Lammas fed back positive comments to the CSU SI team. Action Closed. 10th September 2015, Item 17, Agenda Item 12, HCAI Sub Group - Share learning in detail from the MRSA case with the Quality Committee. Mark Lammas to pick up if this has been circulated. Action: This is being managed by the HCAI sub-group who are in dialogue with Aintree regarding this issue. Action Closed.

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10th September 2015, Item 21, Primary Care Quality - GP survey is published and can be circulated, key themes to be included in the next report. Action: This will form the a part of the Primary Care quality reporting review. Action Closed. 10th September 2015, Item 23, Agenda Item 17, Mersey Care Quality Improvement Visit - Safeguarding concerns appear to have been missed in a case discussed Safeguarding team to follow up with the provider. Safeguarding to check and feedback to the Quality Committee. Action: Completed. Action Closed. 10th September 2015, Item 28, Agenda Item A.O.B. - All Clinical Leads to be written to and asked to present their papers at the Committee. Action: Dianne Johnson confirmed that this has been written into the new Clinical Lead job descriptions. Action Closed. 12th November 2015, Item 31, Agenda Item A.O.B. - Patient Choice and Transfer of Care Policy to be circulated. Ian Stewardson to chase this up. Action: Anne-Marie Dibble to chase up with Ian Stewardson and distribute the Cheshire and Merseyside policy. 19th January 2016, Item 29, Agenda Item 5 - To set up small meeting to look at Quality and Safety report. Action: Meeting took place on 5th April 2016. Action Closed. 19th January 2016, Item 30, Agenda Item 5 – To discuss areas for KPI’s with Primary Care Team. Action: This has been covered on Action 19. 19th January 2016, Item 31, Agenda Item 6 – To request initial HCAI action plan be updated and presented to the Quality Committee and the Governing Body. Action: Dianne Johnson clarified it was an evaluation of the Action Plan. This has been presented to the Quality Committee and Governing Body. Action Closed. 19th January 2016, Item 32, Agenda Item 8 – To send Mike Kenny the details for the GP Forum/Mental Health meetings. Action: Alistair MacFarlane to pick up CRG meetings for the 17th May 2016 Quality Committee. Action Closed. 19th January 2016, Item 33, Agenda Item 8 – Kendra Waring to lead with Dawn Boyer about informing practices about the process of shredding documents whilst the Goddard Inquiry is on-going. Action: The scanning / shredding issue is in hand and is being addressed. Action Closed. 19th January 2016, Item 34, Agenda Item 8 – To check the nursing homes suspension status and feedback to this Committee. Action: Included on agenda this agenda at 29th March 2016 Quality Committee. Action Closed. 19th January 2016, Item 35, Agenda Item 8 – Produce a plan regarding medication reviews for patients with learning disabilities. Action: All patients with learning disabilities at both Mill Brook and Dinas Lane Practices have had their medications reviewed. Action Closed. 19th January 2016, Item 36, Agenda Item 9 – Paul Conway to meet with Mark Pilling to discuss a follow up visit to St Helens and Knowsley Hospital (STHK) to review Pharmacy processes relating to patient discharge. Action: Paul Conway and Mark Pilling visited STHK to look at the role of pharmacy within patient discharges. A pilot scheme is underway and is working well. The electronic prescribing

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was not done electronically which caused delays. STHK Pharmacy team will be going to the Trust Board to request to roll out the pilot throughout the Trust. Action Closed. 19th January 2016, Item 37, Agenda Item Any Other Business – The Committee to give any feedback from the items of receipt to The Chair, Peter Murphy.

5 CLINICAL EFFECTIVENESS QUALITY & SAFETY REPORT BY EXCEPTION INCLUDING:

Acute Services Quality Community Health Services Quality Dr Paul Conway explained there were 16 areas making up the Quality and Safety Report 2015/16 update. Paul Conway highlighted within Appendix 1 (Knowsley CCG Quality & Safety Report; summary & Exception Report) 1 Mixed Six Accommodation (MSA) breach and 1 Health Acquired MRSA breach. VTE Risk Assessments figures were commented upon. Specialist Community Services Key Performance Indicators (KPIs) were also discussed. The committee were invited to comment, Philip Thomas mentioned page 6 of 57 and questions around the detail of the Healthcare Associated Infections (HCAI). FFT performance from 2015/16 is shown on page 49 of 57 some Practices do and some don’t have a score, some are persistently near the bottom. Paul Conway commented about the submission process (as Dr Thong had mentioned in the previous Quality Committee meeting). Neil Rotherham said Practices do get reminders but if Practices get a low response then the data is not submitted. Action: Primary Care FFT data to include both the number of responses and the % recommended scores. Mark Lammas to lead on this.

ML

Mental Health & Learning Disability Dr Ronnie Thong updated the Committee regarding the IAPT service and the fact that some patients are being discharged, and not being seen. There are also issues with different counties in regards to patients with alcohol and drug issues.

Primary Care Quality Dr David Stokoe gave the Committee an update of the CQC process, and how this information can be used in tandem with other Primary Care information, such as FFT to measure Primary Care Quality.

Primary Care Quality Premium Neil Rotherham informed the Committee part of CCG work proposal was approved by the Governing Body in October 2014 with the proposed premium containing three elements:

Practice Quality Improvement (£3 per patient) Prescribing (£2 per patient) Support for the Accountable GP for patients aged 75 and over £5 per patient)

Practices were asked to choose 3 areas to focus on during the period 2015/16. In the operating plan guidance, GPs were asked to spend £5 per patient for the over 75 years old. The Primary Care Quality Premium Specification covering 2014 to 2016 (Appendix 2) was noted by the Committee. All practices signed up to this

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The remaining £5 per head will be discussed at the Locality Peer Review meeting in March 2016. Following the latest round of meetings in January 2016, one practice has now failed to attend the quarterly review meetings on 2 occasions, with discussions are on-going between the CCG and the practice to determine whether funding should continue. The practice has been issued payment in this instance. The practices have all received correspondence from the Accountable Officer reminding them that attendance is an important part of the governance arrangements for the PCQP and is a requirement in the specification which was approved by the Governing Body. The 2015/16 practice audits have been taking place. Full 2015/16 evidence is due in by the middle of April 2016. Dianne Johnson asked for the GPs on this Committee to comment on the Primary Care Quality Premium. Paul Conway commented it depends what options are selected by Practices, with the over 75 years’ admission avoidance option mentioned. Practices can have younger and more affluent patients, where this option is easily achieved, but conversely some Practices may look after substantial numbers of care home patients and a turnaround in admissions in one year is difficult to achieve. Neil Rotherham commented that the PCQP does encourage small practices to work together. The Chair asked the Committee for any other feedback to be given to Neil Rotherham.

6 SUB GROUPS:

Health Care Acquired Infection (HCAI) Issues Dr David Stokoe gave the Committee an update regarding HCAI issues. Mark Pilling commented the HCAI Action Plan and Evaluation (Appendix 2) had been put in place in 2013. The organisation would have systems to prevent and act on HCAI. D-Difficile has seen a clear reduction from 2008 and 2010. Education was highlighted with engagement with General Practices. The action plan gives assurances that those activities take place, as an example Proton Pump Inhibitor (PPI), continues to be monitored and evaluated. HCAI Sub Group regularly meet to discuss issues. Sarah McNulty commented that we should ensure that other HCAIs are also monitored. David.Stokoe confirmed that E-Coli is looked at in the Sub Group. The HCAI Working Group meetings are held bi-monthly but the attendances are low due to infection control staff sickness. David Stokoe confirmed that documentation / lessons learned from the single MRSA infection at Aintree in 2015/16 have yet to be shared with the CCG, as the HCAI sub-group is still in dialogue with Aintree regarding this issue.

7 PATIENT EXPERIENCE:

Patient Story (Verbal) Paul Mavers shared with the Committee a patient story focusing on the pre-op clinic. The case study was e-mailed to Healthwatch Knowsley on 16th February 2016 with the incident involved a female between 55 to 64 years of age. The patient story

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focuses on waiting times for a pre-op assessment and also mentioned a 71 year old female who had a similar experience. On 6th April 2016 this issue will be presented to the Patient Experience Council. David Stokoe commented that pre op is badly designed.

St Helens and Knowsley Teaching Hospitals NHS Trust Healthwatch Knowsley Report: Q3 2015/16 Paul Mavers provided an update on the work relating to the Q3 2015/16 report submitted on 19th January 2016 at St Helens and Knowsley Teaching Hospitals NHS Trust. Any concerns will be flagged in the action plan. The key concern on page 13 about a patient being discharged and a family member being asked to remove there catheter whilst at home. A similar incident took place in Aintree Hospital, with a different patient.

8 SAFETY:

Safeguarding (Adults and Children) Debbie Spruce presented the Safeguarding Update (Adults and Children) to the Committee. Q3 2015/16 KPI performance demonstrated reasonable assurance for Adults and Children from 5 Boroughs Partnership NHS Foundation Trust, St Helens and Knowsley Teaching Hospital NHS Trust and Mersey Care with concerns around no data submitted regarding Deprivation of Liberty Safeguards (DoLs) services and referrals. Aintree has reasonable assurance. Liverpool Heart and Chest Hospital Trust require further assurance around their current stance on PREVENT and training compliance has reduced for MCA. The policies need to be reviewed in line with new legislation. The Committee was given an update regarding care homes (Adults). Haven Lee Residential Home is currently under management review and has a full suspension on new placements. A breach of contract notice has been sent to the Provider and 5 Boroughs Medication Management Service continues to provide support. Hillside (BUPA) remains on management review with a number of concerns being raised about the Rowen unit relating to falls. A medication audit has been completed with concerns identified around the administration and recording of medication. An emergency link meeting was held. Dianne Johnson commented on the wording about the registered manager being off sick and may not return. This should not in the report details. Arncliffe Court (BUPA) remains on management review and continues to show good improvements. Philip Thomas mentioned Arncliffe Court (BUPA) is moving over to Hillside (BUPA) so there is a risk of Hillside Court (BUPA) deteriorating. Serious Incidents (Sis) out of area were also discussed. Dianne Johnson commented that any personal identifiable details do not need to be in the report. Debbie Spruce presented the Safeguarding Publication of Lampard Report (Savile Inquiry (an appendix to the Safeguarding update). Since the update from November 2015 very little has changed. A self-assessment audit took place with the Providers. A Q4 2015/16 update has been asked for from the Providers. The update highlights difficulty with the 3 year DBS checks. The summary was highlighted to the Committee.

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CCG Clinical Supervision Policy An overview of the Clinical Supervision Policy was presented by Rajesh Karimbath. The Committee noted and approved the Clinical Supervision Policy. Philip Thomas commented that an AHP position statement was this part of the policy. This will be looked into. Action: Mark Lammas to ensure that AHP position statement is included in the policy and then arrange for the policy to be presented to the Governing Body for approval. Dianne Johnson said in relation to forward planning the CCG needs to be aware of all policies requiring review, and the date that this is required.

ML

Serious Incidents (SIs) Update: Rajesh Karibath gave the Committee an update of Serious Incidents (SIs). The contents of the SI update was noted by the Committee. From a NHS Knowsley CCG point of view there has been an increase in the reporting of pressure ulcers. The 2 key themes from SIs are the below:

Apparent/actual/suspected self-inflicted harm Unexpected death of community patient (in receipt)

The Committee was informed that RCA reports are being received on time in a lot of cases; and that this is an improvement in practice by providers, particularly 5BP.

Merseyside Quality Surveillance Group Update Rajesh Karimbath gave the Committee an update on the Merseyside Quality Surveillance Group meeting held on 3rd March 2016. The contents of this update were noted by the Committee. The NHS England transforming care implementation of national plans across Cheshire and Merseyside was highlighted. Paul Conway commented that the 5BP key lines of inquiry have been open for a significant period and that there are to be reviewed in the next 2 months. The next 5BP CQPG is being held on 26th April 2016 to discuss the 5BP enhanced surveillance staus. Dianne Johnson requested the CCG to meet and discuss this issue prior to the next 5BP CQPG. Dianne volunteered Mark Lammas to set up the pre-meeting. Action: Mark Lammas to co-ordinate a CCG internal meeting to discuss 5BPs enhanced surveillance status prior to the next meeting 5BP CQPG on 26th April 2016.

ML

9 GOVERNANCE

Assurance Framework & Risk Register Dianne Johnson presented to the Committee this report, in the absence of Dawn Boyer. The Committee noted the report. The Chair asked for any comments / feedback to be sent to Dawn Boyer.

Individual Exceptional Funding Request Service Report October – December 2015

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The Committee noted the report for information only. The paper is being deferred to 17th May 2016 Quality Committee. Action: Paper deferred to 17th May 2016 Quality Committee.

AM

Review of Committee Effectiveness MIAA presented to the Committee a review of Committee Effectiveness.

10 ANY OTHER BUSINESS

The Committee was asked to feedback any comments relating to the items of receipt to The Chair, Peter Murphy. Action: The Committee to give any feedback from the items for receipt to the Chair, Peter Murphy.

ALL

DATE AND TIME OF NEXT MEETING

The next meeting will be held on Tuesday 17th May 2016, 1pm – 4pm. Boardroom, 1st Floor, Nutgrove Villa, Westmorland Road, Huyton, L36 6GA.

1

Document PC(07)14

NOTES OF THE FINANCE & PERFORMANCE COMMITTEE

held on Wednesday, 27th April 2016 in the Boardroom, Nutgrove Villa

Document FP(06)01 Present Apology

MEMBERS Lorraine Hannon F&P Committee Chair/Lay Member –

Audit & Governance

Dianne Johnson Accountable Officer Dr Andrew Pryce CCG Chair Dr Ronnie Thong GP/Clinical Lead – Planned Care &

Patient Engagement

Dr Simon Perritt GP/Clinical Lead – Unplanned Care Paul Brickwood Chief Finance Officer Clare Barrow Head of Finance & Contracts Ian Stewardson Director of Strategy & Performance Andrew Thomas Head of Planning and Performance Craig Porter Interim Director of Service Redesign and

Improvement

IN ATTENDANCE Richard Holford Head of Public Health Strategy and

Intelligence

Julie Moss Director of Integrated Services, KMBC Stephen Mann Finance Manager, Knowsley MBC Karen Connor Principal Accountant, Knowsley MBC Ian Campbell Associate Director - Contracting Michelle Clunie CCG Accountant Dawn Boyer Head of Corporate Services Lorraine Frodsham Note Taker Action 1. Apologies for Absence

Apologies for absence were received from Julie Moss, Stephen Mann, Clare Barrow and Julie Tierney.

2. Declarations of Interest The Chair asked if any further declarations needed to be made.

Ian Stewardson declared an interest as he is currently on secondment to the CCG and his substantive role is as an employee of a local provider, St.Helens & Knowsley Hospitals Trust.

3. Minutes of the Meeting Held on 24th February 2016

2

The minutes of the meeting held on 24th February 2016 were accepted as a true and accurate record.

4. Review of Action Log/Matters Arising Analysis of referrals by Practice for the Spire Hospital’s

activity – Ian Campbell had provided this information which had been circulated to the Committee. The Chair asked if the Practice weighted populations could be added and this was agreed. It was noted that one of the Practices appeared to be a limited company and requested more information on this. Dianne Johnson said there were a number of these and the Primary Care Team will provide this information to the Chair. This item to remain on the log. Written response to be shared with the Committee in relation to change of treatment setting identified at Whiston Hospital – A response is awaited from StHK Trust. The response had been delayed due to the recent contract negotiations taking place which needed to take priority. This item to remain on the log. Referral data comparison to be shared at the next meeting –This information has been circulated to the Committee. Action closed. StHK presentation on PLCP exercise –The Trust had been unable to attend the meeting although details of the exercise undertaken and the findings have been circulated to the Committee. The report indicates that the problem relates to lack of information provided by GPs to the Consultants with regard to PLCP decision making. It was agreed that a referral management system/ triage process needs to be put in place in order to ensure that all relevant information was captured. Ian Campbell informed that St.Helens CCG is going live with a referral management system on the 1st July 2016. Knowsley CCG are currently exploring options for a referral management system and it was suggested that we see how the St.Helens system is operating after it has been live 3 months to see if this is something Knowsley wish to consider. Action closed. Publication of contractual sanctions on the website – Ian Stewardson reported that this action was not yet completed as providers remained in negotiation with regard to contract breaches. Action will be taken once this has been completed. Reports will be published on a quarterly basis. Action closed.

3

Context in relation to catchment KPI breach ‘groin hernia’ to be provided –This information has been circulated to the Committee. Action closed. Terms of Reference and log of Declarations of Interest to be provided to the Chair at each meeting – Done. Action closed. Previous experience and lessons learned regarding CHC and the Broadcare system to be shared –This information has been circulated to the Committee. Action closed. Meeting to take place with Chair to discuss queries relating to the Contract Performance report – Ian Campbell had met with the Chair prior to the commencement of the meeting. Action closed. Information on questions included in the GP patient survey to be provided to the Chair – Done. Action closed. The lack of attendance by Council colleagues was noted and the Chair agreed to speak to Council colleagues about this.

Chair

5. Planning Update – Delivering the Forward View Andrew Thomas reported that the CCG is working to contribute

to a system wide five year Sustainability and Transformation Plan (STP) The deadline for completion this is the end of June 2016 It has also produced a one year Operational Plan for 2016/17 at CCG level. This consists of Finance, Activity, QIPP and a narrative. Following submission, NHS England requested some changes to be made and these have resulted in the unidentified QIPP gap rising from £1.1 million to £1.9 million. The Finance & Performance Committee noted the content of this report.

6. Commissioning/Programme Management – Delivering the Operational Plan

Andrew Thomas reported upon the arrangements for taking forward the implementation of the Operational Plan for 2016/17. A CCG Workplan Steering Group has been established to bring together the key players within the CCG and three business critical pieces of work will be taken forward:-

• Locality model for integrated health and social care • Improving support to people in nursing homes

4

• Referral support. These now need to become mainstream activities and a PMO approach will be used to ensure delivery. Dianne Johnson said that an enormous amount of work had been put in by the team as this was a very big task and she wish to record her thanks for their efforts. The Chair said that, on behalf of the Committee, she would also like to add thanks. The Finance & Performance Committee noted the content of the report.

7. Budget Book Paul Brickwood explained that the Budget Book showed how the

CCG planned to spend money to deliver its plans and commission services for the people of Knowsley. He said the CCG needs to deploy its resources and prioritise where money is spent. Knowsley CCG’s budget is approved by the Clinical Membership Group. The budgets are built based on a range of assumptions on contracts and the level of in-year pressures which may be experienced against these contracts. The budgets also reflect the expectations about whether any additional resources may be forthcoming later in the year. Paul Brickwood said that this budget had probably been one of the toughest that Knowsley CCG has had in years as the CCG was required to maintain the 1% carry forward surplus and set aside 1% of the budget which can only be used on approval by the Treasury. He said the Finance Team will continue to monitor budgets and free up resources as they occur. The Chair said that on page E1 relating to Community Services budgets, Specsavers hearing tests were mentioned, and she queried how this worked. Paul Brickwood said that Specsavers put themselves forward to do NHS work around hearing tests under the Any Qualified Provider (AQP) initiative whereby CCGs allow a range of providers to do certain services on the basis that any provider who has the relevant experience and expertise can do the activity. Referrals to the Specsavers services can be done through the GP and self-referrals are also allowed. Dr Thong said that the bulk of referrals were done through the GP and that this service was only for people aged 55 and over. Also on page E1, the Reader Organisation was mentioned and the Chair queried what this was. Craig Porter agreed to provide her with more information regarding this. Ian Campbell also agreed to provide information.

5

Dianne Johnson said she had a couple of queries relating to staff grades contained in the Budget Book but these were very minor. Paul Brickwood said that the budgets can change within the year for various reasons and it was a dynamic document. Action : Information to be provided to the Chair on the Reader Organisation. The Finance & Performance Committee noted the content of the Budget Book and Commentary and that minor amendments relating to staff grades may be required.

CP/IC

8. Finance Report (including QIPP) – Month 12 Michelle Clunie presented this report which summarised the year-

end financial outturn for 2015/16. The CCG has delivered the planned surplus target of £2.78 million in 2015/16, including a minor contribution of £0.1 million from running costs. The surplus will be returned to the CCG in addition to its notified allocation and will be used to pre-provide for the 1% surplus target required by NHS England in 2016/17. The CCG fully delivered the overall QIPP plan of £11.7 million which was delivered through tariff efficiency and prescribing budget savings of £7.4 million, plus a further £4.3 million from demand management schemes and other efficiency savings. However, it should be noted that £2.8 million was achieved non-recurrently and the CCG will be required to deliver this amount of savings as a minimum next year recurrently in order to keep its current plans in balance for 2016/17. As reported throughout the financial year, the most significant area of overspend in 2015/16 was within Acute contracts (£1,541,000 before deployment of reserves) mainly due to over-performance at Spire, St.Helens & Knowsley Hospitals Trust and Southport & Ormskirk Hospitals Trust. There has been an overspend of £833,000 before deployment of reserves in Primary Care mainly due to an over-performance in prescribing of £1,316,000. Dianne Johnson said that earlier in the year the pooled budgets were heading for an overspend position but the report states that the underspend has now increased. Michelle Clunie said this related to care packages for a variety of reasons – direct payments, initial expectations that Mental Health cases would come back into the Borough which did not happen because of delays in finding suitable accommodation etc. Discussion took place and Dianne Johnson said it might be interesting for the Committee to look at CHC/Complex Care Mental Health and the

6

number of people in long-term care as these cases are very expensive. The Finance & Performance Committee noted the content of this report.

9. Contract Negotiations Ian Campbell said that since the paper had been written things

had moved on slightly. A joint dispute and resolution policy was issued which stated that if all contracts were not signed off by 25th April 2016 this would trigger arbitration at a cost of £100,000 per item so the CCG had been working hard to achieve sign off and, therefore, avoid these costs. Regarding StHK Trust, the contract had been signed on Monday. All the items mentioned in the report on pages 2, 3 and 4 have now been resolved. A Memorandum of Agreement has been issued with regard to the 5BP contract and Monitor is happy with this approach. Paul Brickwood said the two areas of particular significance were PbR for Mental Health where work is continuing but this will not be live in 2016/17. The other issue is the Tony Ryan review and how to reflect this in contractual arrangements and in particular relating to out of borough Mental Health placements and risk sharing arrangements around this. Alder Hey is in mediation. Because they are a Foundation Trust they cannot be forced into arbitration. Aintree is in formal arbitration and there are no problems with Liverpool Heart & Chest Hospital contract and the Liverpool Women’s contract. The Royal Liverpool & Broadgreen University Hospitals Trust is in formal arbitration. The Finance & Performance Committee noted the content of this report.

10. Contract Performance – Month 10 Ian Campbell said that as previously requested, a key to the

different rag ratings included in the report had been included. At month 10 the CCG was £916,000 overspent on acute contracts. The main areas of overspend were at the Spire Hospital £427,000 and Royal Liverpool £207,000.

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Regarding A&E waiting times, cumulative performance at the end of January was 93.4% against a target of 95%. Month 10 performance was 87.7% and this is the fifth month the 95% target has not been met. Knowsley CCG failed the target in January relating to cancer 2 week waits for breast symptoms but is achieving the year to date target of 93%. Regarding Category A emergency ambulance response time, overall performance in January was 61.2% but the CCG is failing the 75% target YTD with 73.9%. There were three new cases of CDiff in January. This brings the year to date total to 39, below the year to date plan of 40. There were no new cases of MRSA reported in January 2016. Dr Thong said that an overspend was showing in relation to cardiology and geriatric medicine and queried why and what the overspend actually related to. Ian Campbell said the case-mix in cardiology has been richer with more expensive interventions. However, Paul Brickwood said the information shown in the table relating to cardiology was incorrect and there is not an overspend in this area. Ian Campbell said he would reissue the report with the correct information but Paul Brickwood said to just correct the table for the month 12 report. The Finance & Performance Committee noted the content of this report.

11. GBAF and Committee Risks Dawn Boyer presented this report which set out the risks which

are the responsibility of the Finance & Performance Committee. The quarter 3 Assurance Framework was also included in the report. The risk of collaborative and partnership commissioning arrangements not being effective in delivering Knowsley CCG’s priorities is currently rated as extreme due to a significant increase in the proportion of the BCF being required to maintain social care eligibility criteria which is likely to result in failure to deliver other elements of the BCF plan. The Section 75 agreement with the Council has now been revised to include the BCF and was signed off in March 2016, and includes agreed risk sharing arrangements and mitigation. The existing agreement has been extended to June pending completion of the updated BCF plan for 2016/17. An updated agreement for 2016/17 and

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beyond is currently in draft form. Gaps or delays in the availability and quality of data, information and intelligence which results in a reduction in effective performance management is rated as high. The replacement contract commenced on 1st March 2016 and a Collaborative Contract Management Forum has been established with other Merseyside CCGs. The business intelligence system has been implemented smoothly ensuring business continuity and delivery of efficiency improvements. Further benefits are anticipated as this is rolled out more widely in the coming months. The risk in respect of Council financial pressures adversely impacting on BCF outcomes previously rated as extreme has been revised to moderate as targets for 2015/16 have been achieved The Finance & Performance Committee noted the content of this report.

12. Minutes from Contract Review Boards The minutes of the 5BP, Aintree, Liverpool Women’s, RLBUHT,

and StHK Contract Review Boards were received by the Committee. The Finance & Performance Committee noted the content of these minutes.

13. Review of Meeting The Chair asked if everyone felt that sufficient detail had been

provided in the reports and that enough time had been allocated to discussions. All agreed. Dianne Johnson said it would be useful to make sure that Council colleagues did attend the meetings and she also thought it would be better for Dawn Boyer to present her item at the beginning of the meeting so the Committee is aware of the risks it has responsibility for to inform discussions on the other items on the agenda. Dianne Johnson said that a report should be provided on QIPP at each meeting and could be included in delivery of the plan. Action : GBAF and Committee Risks to be on agenda at the beginning of the meeting. Action : QIPP to be included in future reports regarding delivery of the plan.

IS/LF

AT

14. Date and Time of Next Meeting 29th June 2016 at 1.00 p.m. in the Boardroom, Nutgrove Villa.

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Andrea.Kelly

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Document PC(07)15